Framework For A High Performing

Transcription

1 Framework For A High Performing Report of the Air Ambulance Working Group Final Report July 2008

2

3 1.1 Clinical Care The NHS Ambulance Service Air Ambulance Services Regional Trauma Centres Air Ambulances in The Future The Air Ambulance Working Group The Air Ambulance Sector Overview Funding Models Services Provided by Air Ambulances Clinical Staffing of Aircraft The Legal and Regulatory Environment The Charity Commission Aviation Regulation The Healthcare Commission Governance of Charities Trustees Responsibilities of Trustees Joint Responsibility and Joint and Several Liability Trustee Discretion Delegation Conflict of Interest Governance Arrangements and Responsibilities Relationship With Third Parties Principles Aircraft Contractors NHS Ambulance Services Comparative Performance Measures Clinical Governance Arrangements UK National Clinical Advisory Group Local Clinical Advisory Groups Risk Management, Clinical Audit and Complaints Risk Management Clinical Audit Complaints Information Medical Indemnity Insurance Accreditation, Peer Review and Regulation Standard Operating Procedures 25

4 5.1 Crew Resource Management Landing Sites Mutual Aid Agreements Major Incidents Handover and Shift Start Standard Operating Procedures Health and Safety Tasking The Importance of Good Tasking Tasking Responsibilities Principles and Criteria Quality of Tasking Stand Down Restrictions on Mission Types Hours of Operation Night Flying Weather Restrictions Servicing of Aircraft Transfers Staffing of Air Ambulances HEMS Crewmembers Clinical Advice to Crews Medical Passengers Aircraft Dispatchers Observers Selection of Staff, Training and CPD Clinical Competencies Selection of Doctors Employment of Paramedics Trainees Induction In Service Training Training Records 45 Appendices A. Outline Job Descriptions 49 B. External Review Proforma 51 C. Minimum Crewing of Aircraft 52 D. List of Standard Operating Procedures 54 E. List of People Consulted 55 F. References 56 G. AAWG Sub Group Members 58

5 elicopters have been involved in the delivery of health care in the UK for many years flying primary missions to provide clinical care to patients and to assist ambulance services and acute trusts through undertaking secondary transfers. The number of charity financed Helicopter Emergency Medical Services (HEMS) in England and Wales has increased steadily over the last ten years reflecting the public s perception of the importance of helicopters in pre-hospital care. The charities and NHS ambulance services providing HEMS services play an increasingly important role in patients with major trauma and those who are seriously ill to ensure that these patients are treated quickly and transported to the most appropriate hospital. We must of course acknowledge the enormous contribution made by the air ambulance charities and all who support them. Without their efforts there would be no HEMS operating in England and Wales today. To succeed as the air ambulance charities have done is an achievement to be highly commended. At the heart of the air ambulance charities and air ambulance services is an aspiration for clinical and operational excellence, uniformity of clinical practice and sound underpinning governance. Experience indicates that much of the work of helicopter air ambulances is highly predictable, easy to train for and ideally suited to adopt many of the standards of governance that exist in hospital and in non emergency situations. All organisations where the regulations are relevant have to comply with the new Charities Act 2006, the Companies Act 2006, Civil Contingencies Act 2004 and the Corporate Manslaughter and Corporate Homicide Act These new laws and reports, areas of responsibility, accountability, communications and contractual obligations must be reviewed to ensure effective cooperation in the future. This Framework aims to provide a structure through which Air Ambulance Services and NHS Ambulance Trusts with whom they work can deliver a high and consistent standard of operational management and clinical care. The Framework does not advocate a specific staffing model, recognising that different services and locations will have different requirements. It provides examples of good practice to which Air Ambulance Services can aspire and sets out ambitious improvements to support Charities, Ambulance Services and Staff deliver world class care for patients. I wish to record my thanks to all those colleagues listed in Appendix G for their hard work and contribution to the development and production of this Framework.

6 It is now well recognised that pre-hospital emergency care is emerging as a medical speciality within its own right. At the time of its inception in the late 1970s, patients encountering serious or life-threatening injuries were reliant upon the local ambulance service and enthusiastic General Practitioners. Over subsequent years, the care delivered was gained experientially or through limited pre-hospital training in the rudimentary aspects of major trauma management. The introduction of paramedics and their use of extended skills, meant that the old school medical pre-hospital practitioner has had little to offer in terms of additional advanced skills except that of sedation for extrication. More recently the introduction of physicians onto some aircraft and ambulances has further increased the clinical capabilities of teams at the scene of the incident. There is a moral and legal duty for ambulance services to recognise that provision of early, expert, advanced critical care and interventions at the road side in seriously injured patients has a significant effect on patient outcome (McKenzie R and Bevan 2005). This may be in terms of survival, morbidity (Coats T, 1997) (Cowley RA, 1976) or indeed in ease of suffering and reduction in long-term psychological problems associated with the patient s journey. For patients who have serious traumatic or life-threatening injuries or for those who are immediately recognised as being seriously ill, or are potentially seriously injured, having high level clinical care at the scene is vital if the complex nature of trauma-related pathophysiology and its early signs are to be identified (Little et al, 1995). In addition, there are a larger proportion of patients who may (or may not) have serious life- or limb-threatening injuries but require advanced analgesia or sedation to ease their suffering. As the role of the air and land ambulance services continue to develop, it is important that responses to incidents are by clinical staff with the training appropriate to the incident and with the authority and skills to administer the appropriate drugs. Ambulance services are expected to provide a consistently high level of emergency care to all members of the population exhibiting a wide range of medical problems. Using Computer Aided Dispatch (CAD) systems, the service will have to provide a suitable response to all calls from Cat A to Cat C whilst meeting national standards. Included within these will be seriously ill or injured patients requiring early and judicious management and transport to central specialist centres, rather than nearby emergency departments (LSIWG, 2001); (McGuffie AC et al, 2005). For example a patient with unstable angina progressing to a myocardial infarction and requiring Primary Coronary Angioplasty (PCA), or a haemodynamically unstable patient with multiple serious injuries (polytrauma) requiring delivery to a trauma centre will require different pre hospital care. Ambulance service personnel will need to spend additional time on-scene or en-route in order to accurately assess and stabilise clinically complex patients. Time spent and appropriate interventions undertaken at this stage will help to minimise secondary physiological injuries (McGuffie AC et al, 2005). This sounds simple but requires excellent clinical insight and awareness of the pathophysiological processes occurring at that time. It also requires ambulance personnel to predict complications and act accordingly. The wider role and scope of care offered by ambulance services together with the need to balance financial constraints and meet national targets in terms of response times has led to ambulance services developing a range of responses to a particular incident or casualty. Whatever the constraints or target, the needs of the patient need to be paramount: Although the targets are important, the ultimate aim is to improve patient experience and clinical outcomes. It is vital that this aim remains at the centre of all decision making (Sir Alberti G, Bradley P, Cooke M, 2004).

7 In order to ensure that incidents are responded to as soon as possible, many ambulance services are providing Fast Response Unit cars, staffed with individual paramedics, technicians and/or civilian first aid trained first responders equipped with an automatic defibrillator. This response is appropriate for some incidents but this will not replace the need for road ambulances or speed up patient delivery to hospital from the scene. Some ambulance services are also looking at ways of extending the remit of their paramedics. Currently, university-led programmes are being developed and trialled to train paramedics to undertake a critical care role. This could enable these paramedics to transfer some critically ill patients between hospitals without the need for nurse (or even medical) escorts. Some colleagues from the medical profession have expressed caution and argue that whilst certain techniques can be taught, skill in other areas are based on years of medical training and the development of clinical acumen. Further research and work is needed in this area. Whilst ambulance services strive to develop newer, more extended skills for their paramedics, it is vital that core paramedic and recognised extended skills continue to be developed. (Hussain LM and Redmond AD, 1994) (NCEPOD, 2007) (Dunford et al, 2003). Physicians attending major trauma patients at the scene of the incident have been developed in several road-based schemes. As the population become more aware of the different responses, expectations of patients and the public as to the level of medical care at the scene will increase. A failure to ensure that there is appropriate medical input at the scene raises the possibility of litigation and in extreme cases, prosecution under the new Corporate Manslaughter and Corporate Homicide Act In late 2007, Trauma: Who Cares? a report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) was delivered to the NHS. It highlighted the current situation of trauma management across England, Wales, Northern Ireland and the offshore islands. It confirmed that pre-hospital physicians should have a range of skills and the focus should be on continuing to improve standards in pre-hospital care. A strategic review of NHS ambulance services proposed major changes in the way that NHS ambulance services are organised and an increasing role for ambulance services in pre hospital care ( Taking Healthcare to the Patient: Transforming NHS Ambulance Services, 2005). One of the most significant conclusions from that report was a reduction in the number of NHS ambulance services. The introduction of air ambulances in 1987 was a major development in getting to, and treating, patients quickly. Aircraft with two paramedics is still the most common staffing method and can, in some situations, bring clinical care to the patient more quickly than a road ambulance. The principle of a doctor-paramedic team was first used by the London HEMS. This fundamental break from the usual paramedic only model radically changed the dynamics of the crew and the level of care available to patients in the prehospital environment. In 2003, the Great North Air Ambulance undertook the integration of physicians into their team. At the time of writing, several Air Ambulance Services are utilising this approach to pre-hospital care including Kent, Surrey & Sussex, East of England and West Midlands. With the development of the Helicopter Emergency Medical Service (HEMS) in London in 1988 and a body of trained practitioners elsewhere, the delivery of care at the point of injury improved markedly, and has been shown to significantly decrease patient mortality and morbidity within an overall system involving the chain of survival and culminating in definitive hospital treatment. (Coats T, 1997); (Mckenzie R and Bevan D, 2005); (Baxt WG and Moody P, 1987); (Deakin C and Davies G, 1994); (Anderson I et al, 1988); (Lee A et al, 2003); (NCEPOD, 2007)

8 The paramedic-physician concept has been the subject of much debate over recent years but is now consistently demonstrating increased survival rates and decreased morbidity in regions where it is in use (Mckenzie R and Bevan D, 2005). Correctly utilised HEMS operations target the most seriously ill or injured patients and those likely to benefit most from early medical input regarding; scene management, triage, treatment and transfer. Other benefits can be recognised in providing rapid, controlled and skilled secondary transfers to tertiary centres for further specialist input after initial resuscitation in a non-specialist hospital. Despite controversial earlier research which seemed to imply there was no need for regional specialist trauma centres (Nicholl J and Turner J, 1997), more recent studies have shown significant benefits in patient outcome who are treated in specialist centres. NCEPOD have supported the development of regional trauma centres, stating that in hospitals where large numbers of seriously injured or ill patients are received, their care and outcomes are consistently higher when compared to non-specialist establishments (NCEPOD, 2007) (Mackenzie E et al, 2006). The comparison defines a specialist trauma centre as one where over 1,000 patients with an Injury Severity Score of more than 15 are treated per year. The Royal College of Surgeons of England have proposed the placement of major trauma centres across the UK, stating that As a minimum, major trauma centres should admit more than 250 critically injured patients per year (RCS Eng, 2007) equating this to one major trauma centre for every 3-4 million people. Those emergency departments remaining outside of specialist trauma centre model will, as a result, become less experienced in dealing with major trauma with a possibility of increased mortality and morbidity in those who they do treat. There is likely to be an increase in tertiary referrals to trauma centres. As such the onus upon the ambulance service will be to change their current policies when treating this type of patient (RCS Eng, 1988). Taking Healthcare to the Patient: Transforming NHS Ambulance Services highlighted the increasing role that ambulance services should take in pre hospital care. The air ambulance service has an important role to play in taking forward this strategy. The deployment of physicians on aircraft is likely to be a feature of more air ambulance services so increasing the clinical ability at the scene of an accident. Increasingly patients who are seriously ill or injured are being treated in specialist centres. These patients include those with serious trauma injuries as well as patients who have suffered a stroke or a major heart attack. The development of major trauma and specialist centres will result in an increase in tertiary referrals and require air ambulance services to work closely with the centres to ensure that patients are taken to the correct place from the scene of the incident. The Scottish Ambulance Service has been flying 24 hrs per day since 1999 and has developed significant experience in delivering an integrated Air Ambulance service that provides HEMS and Air Ambulance capability. Some English Air Ambulance services have recently begun to explore the possibility of flying missions at night. These and other changes will take place within an increasingly regulatory regime and with increasing expectations by patients. Both air and land based ambulance services will need to ensure that they have in place staff with the relevant clinical training and systems and procedures which ensure that care is given by the right people at the right time and in the right place.

9 The core issues of governance, clinical care and operational effectiveness (targeting and dispatch) have been debated for many years demonstrating a wide variety of opinions but without resolution. Although we have seen a steady increase in the number of air ambulance helicopters there is little evidence to indicate a corresponding improvement in clinical and operational effectiveness of this essentially free (to the NHS) resource. Nicholl stated: [Hospital Emergency Air Ambulance Services] bear little resemblance to one another. The helicopters used (Bolkow 105, Squirrel, Dauphin) their ownership (leased, bought), crews (paramedical, medical), funding (public subscription, private sponsorship, central funding), operators (health authority, ambulance services, police authorities, hospital trusts), operational basis (targeted at trauma only, or all emergencies), and operating environment (metropolitan, urban, rural) show such diversity that questions need to be raised about the appropriateness and cost-effectiveness of the services (Nicholl J, 1995). A Situation Audit of Air Ambulance Services 1 has shown that this wide variation in models of care and the way in which HEMS provide care to the patient continues. Examples of where practice varies include: In 2007 an Air Ambulance Working Group (AAWG) was set up to consider future air ambulance practice and procedure and provide a means of reaching agreement on issues in accordance with the following terms of reference: These agreements are to serve as a basis for the development of air ambulance services with a view to providing a level of consistency while at the same time retaining the flexibility to suit specific local requirements. In September 2007, the Situation Audit was discussed at a workshop of all stakeholders. Feedback from the workshop was discussed at a meeting of the AAWG sub committee and a group was appointed to develop A Framework for a High Performing Air Ambulance Service 2. Air ambulance services in England are funded through 17 charities of which the majority are independent charities with the others being NHS Corporate Trustees or independent charities with NHS representation on their Boards. The air ambulance services are managed either by the charity in collaboration with the NHS or by the NHS. The location of the air ambulance services are shown overleaf.

10 The first service became operational in 1987 and the latest in Together the air ambulance service in England contracted in, leased or owned 24 aircraft in 2006/07, flew nearly 19,000 missions per year and served 177 emergency departments (2006/07). In the last year for which published accounts are available, the service as a whole spent 19.4 millions and held 32.6 millions in reserves. It is estimated that the 14 charities included in the 2007 Situation Audit flew some 18,850 missions with Primary HEMS accounting for just over 70% of these and a further 26% aborted or stood down. The range of reported missions that were aborted or stood down varied considerably. Transfers of patient accounted for 2.5% of missions with six charities accounting for nearly 90% of transfers. There are a number of different funding and operational models of air ambulance services throughout England. The NHS usually meet the costs of ambulance personnel (Technicians and/or Paramedics) who work on Air Ambulance. The two dominant models reflect the relationship between the funding Charity and the Ambulance Services. Specifically: Owner / Operator Charities. These charities provide the Air Ambulance Service and support the NHS Ambulance Services Grant Giving Charities are essentially those that provide the funding for the service but the operational and clinical management responsibilities are the responsibility of the NHS Ambulance Service In both models there should be a documented Memorandum of Understanding between the Charity and the participating NHS Ambulance Service(s). The memorandum should define the roles and responsibilities of all members of the parties and the reporting and communication arrangements. An annual review of the memorandum should be undertaken.

11 Circles represent 10 minute flying times from aircraft bases.

12 Base1: RAF St Mawgan nr Newquay, Cornwall Helicopter Type1 : Eurocopter EC135 Contractor: Bond Air Services Base1: DCAE Cosford, Albrighton, Shropshire Helicopter Type1: Eurocopter EC135 Base2: Helicopter Type2: Stensham Services, M5 North, Worcestershire Eurocopter EC135 Base3: Helicopter Type3: Contractor: Tatenhill Airfield, Needwood, Staffordshire Eurocopter EC135 Bond Air Services Base1: Police ASU, Middlemoor, Exeter, Devon Helicopter Type1 : Eurocopter EC135 Base2: Helicopter Type2: Contractor: Eaglescott Airfield, nr Umberleigh, Devon Bolkow 105dbs Bond Air Services Base1: Henstridge Airfield, Templecombe, Dorset Helicopter Type1 : Eurocopter EC135 Contractor: Bond Air Services Base1: RAF Wyton, St Ives, Cambridgeshire Helicopter Type1 : Eurocopter BK117 Base2: Helicopter Type2: Contractor: Norwich Airport, Norfolk, locates to RAF Honnington Eurocopter BK117 Sterling Helicopters Base1: Boreham Airfield, nr Chelmsford, Essex Helicopter Type1: Eurocopter EC135 Contractor: Bond Air Services

13 Base1: Penrith, Cumbria Helicopter Type1: Aerospatiale AS365 Dauphin Base2: Helicopter Type2: Durham Tees Valley Airport, Darlington, Teeside McDonnell Douglas MD902 Base3: Helicopter Type3: Contractor: Otterburn, Northumberland Bolkow 105dbs PDG Helicopters/Medical Aviation Services Base1: Filton Airport, Bristol, Avon Helicopter Type1 : Eurocopter EC135 Contractor: Bond Air Services Base1: Thruxton Air Base, Andover, Hampshire Helicopter Type1 : Bolkow 105dbs Contractor: Bond Air Services Base1: Marden Airfield, nr Maidstone, Kent Helicopter Type1 : McDonnell Douglas MD902 Base2: Helicopter Type2: Contractor: Dunsford Park, Cranleigh, Surrey McDonnell Douglas MD902 Medical Aviation Services Base1: RAF Waddington, Lincolnshire Helicopter Type1 : McDonnell Douglas MD902 Contractor: Medical Aviation Services Base1: The Royal London Hospital, Whitechapel, London Helicopter Type1 : McDonnell Douglas MD902 Contractor: Medical Aviation Services Base1: Blackpool Airport, Blackpool, Lancashire Helicopter Type1 : Eurocopter EC135 Contractor: Bond Air Services

14 Base1: RAF Benson, Wallingford, Oxfordshire Helicopter Type1 : Eurocopter EC135 Contractor: Bond Air Services Base1: Coventry Airport, Warwickshire Helicopter Type1 : Augusta 109 Base2: East Midlands Airport, Derby Helicopter Type2: Agusta 109 Contractor: Sloane Helicopters Base1: Wiltshire Police HQ, Devizes, Wiltshire Helicopter Type1 : McDonnell Douglas MD902 Contractor: Police Aviation Service Base1: Leeds/Bradford Airport, Leeds, Yorkshire Helicopter Type1 : McDonnell Douglas MD902 Base2: Helicopter Type2: Contractor: Sheffield City Heliport, Sheffield, Yorkshire McDonnell Douglas MD902 Medical Aviation Services

15 The sector distinguishes between a Helicopter Emergency Medical Service (HEMS) flights and air ambulance missions. A HEMS flight is a mission carried out by a helicopter operating under a HEMS approval and aims to facilitate emergency medical assistance where immediate and rapid transportation is essential, by carrying: Deployment under HEMS is therefore governed solely by medical need. An air ambulance mission by contrast is one where the aircraft is used as an extension of the ambulance service land vehicles for the transfer of patients from / to hospital or from land vehicles to hospital. HEMS missions see the aircraft flying directly to the scene and taking an unstable casualty as quickly as possible to the nearest appropriate hospital, before the condition overwhelms the patient. There are a number of potential advantages of primary HEMS, including: reducing delays associated with road crews attempting to get to the patient patho-physiological effects across all age ranges (e.g. an agitated child with a severe head injury, a flail chest, ruptured spleen and multiple long-bone fractures or an elderly patient with severe burns to head and body) receiving hospital have been placed on Alert and so hospital staff are prepared to receive the patient hand-over without delay, this usually reflects the patients clinical condition as well regional centre Air Ambulance missions, usually planned in advance, can provide for the subsequent transfer for patients delivered initially to a local emergency department by a road crew. The transfer is undertaken in order to expedite their ongoing care to a specialist unit such as a burns, spinal injuries or paediatric intensive care. For the ambulance service, this diminishes the costs of a lengthy transfer by road by utilising charity transport and maintains local emergency coverage by not committing resources to out-of-area transfers. Air Ambulance missions can also be employed in the more rural services where a land vehicle may be tasked to uplift the patient from a scene and rendezvous with an air ambulance at a pre-surveyed approved secondary landing site for onward transfer to hospital. This may negate a lengthy journey by the patient in the land vehicle and can ensure that a land vehicle remains available in the area to ensure continuity of cover. Secondary transfers of seriously ill or injured potentially unstable patients are inherently hazardous. Transfer of these patients by air offers advantages in terms of speed but also results in additional difficulties when compared to traditional road transfers. These include:

16 Some of these risks can be mitigated by the provision of a suitably selected and trained clinical HEMS team. Other risks to the patient can be assessed in terms of a risk-benefit ratio which is best made by a very experienced clinician in consultation with both the referring and receiving hospital teams. Where the number of specialist escorts are reduced or even absent, the emphasis moves to the HEMS team to ensure that they are totally familiar with the patient s condition, the accompanying equipment and drugs, the patient s intended response and possible complications associated. The team also bears responsibility for any escorts that may accompany the patient and for ensuring their safety in the unfamiliar surroundings of a helicopter. It is highly unlikely that a road crew would be expected to manage a critical care transfer single-handedly but it is not uncommon in Air Ambulance operations. It should be apparent that there is a significant risk associated with this for a paramedic-only operation, but less if it falls within the remit of a physician-paramedic team with a critical care background. That said some ambulance services are investigating the proposal of training critical care paramedics. These are often road-based schemes and are in the early stages of development. Assuming that HEMS is now being used effectively, as described above, a simple calculation can determine spare capacity within the system nationally. Based on statistics previously used i.e. 20,000 activations per annum of which 40% appear inappropriate 24 helicopters operating 365 days per year would therefore be averaging 1.4 appropriate tasks per day. This is of course assumptive but it does indicate substantial spare capacity with further additional capacity if one includes night flying. This spare capacity can of course be utilised in: The latter is subject to individual charity trustee board determination in line with their charity s objects and aims and is also dependant on increased income to provide for additional flying time and staff. It is unrealistic to assume that all charities can increase income sufficient to accommodate an increase in activity and activity may need to be commissioned by a Primary Care Trust. Since the first service was established, different staffing models on the helicopters have evolved, reflecting both clinical and financial resources. The two main staffing models are: which is used on some 80% of aircraft. Stateregistered paramedics operate within the standards set by the Joint Royal Colleges Ambulance Service Liaison Committee (JRCALC), whether they operate in road or air ambulances. The speed of response, speed of transfer to appropriate treatment centres as well as the ability of the Air ambulance to access difficult to reach ie rural remote locations and the potential increased skill mix of paramedics to become Advanced Critical Care Practitioners are some of the benefits to patients over a road crew in paramedic only systems. Internationally, it is considered that models such as those used in Maryland and Ontario who use Paramedics supported by strong medical oversight and direction remotely via tele-medicine is argued by them to be the best model. provides a higher level of clinical expertise for patients. Correctly utilised these HEMS operations target the most seriously ill and injured patients most likely to benefit from early advanced medical input normally delivered in a hospital setting. This is the model of care throughout Europe, Scandinavia, Japan and Australasia.

17 Charities are highly regulated, wholly accountable independent bodies. Governed by the same laws and regulations as all business, charities in addition must comply with Charity Law. Charities are subject to a number of different legal regimes summarised as follows: form what it does There are many different legal regimes that can apply to a charity as a consequence of what it does; in this sense, a charity is in much the same position as any commercial entity operating in a particular area and it is the responsibility of the trustees to ensure compliance. For a body to be a charity, it must be independent. Independence in this context means that the charity must act to carry out its own charitable purposes, not for the purpose of implementing the policies or directions of a governmental authority, or any other bodies. A charity is an institution which: charities. (Charities Act 2006). Charitable purpose is defined by s2 of the Charities Act It is any purpose that falls within a number of descriptions of purposes set out in the Act and is also for Public Benefit. Both requirements must be met. The description under which all the air ambulance charities fall is: The advancement of health or the saving of lives (including the prevention or relief of sickness, disease or human suffering). Public Benefit is the legal requirement that every charitable organisation must be able to demonstrate that its aims are for the public benefit. There are two key principles, both of which must be met, in order to show that an organisation s aims are for the public benefit: are and the benefits must be related to the aims be appropriate to the aims and where the benefit is to a section of the public, the opportunity to benefit must not be unreasonably restricted Existing charities will be required to start reporting, in detail, on public benefit in their trustees annual reports at the end of the 2008/09 financial year. Public perception of what government should provide changes over time, as do relative levels of provision by the charitable and public sectors. Public authorities have taken over responsibility for some services in response to changing public expectations, government policy and statutory duties. More recently, whilst retaining responsibility for the provision (or funding) of services, public authorities have contracted out delivery of some services to private or voluntary sector organisations.

18 There is no general legal prohibition on charities delivering public services under a funding agreement with a public authority or using their own funds to do so. This does not alter the trustees responsibility to comply with charity law and the requirements of the charity s governing document. The following legal rules apply to all charities but are particularly relevant to charities delivering public services: prudently. Charities play an increasingly important role in the supply of services on behalf of local (and, to a lesser extent, national) government. However, for co-operation between charities and the state to be effective, it is important that the framework within which charities operate should be clearly understood. The aviation regulatory authority within the UK is the Civil Aviation Authority (CAA). The CAA is a member of the Joint Aviation Authorities (JAA) which is an associated body of the European Civil Aviation Conference (ECAC), representing the civil aviation regulatory authorities of a number of European States who agreed to co-operate in developing and implementing common safety regulatory standards and procedures. The JAA produced regulations called Joint Aviation Requirements (JAR). JAR Operations 3 (JAR-Ops 3) covered Commercial Air Transportation (Helicopters) and provides the regulatory framework governing helicopter operations in Europe, specifying minimum standards for aircraft, their operation, crewing and the training for crews involved in helicopter operations including Air Ambulance operations. JAR-Ops 3 states that an Air Ambulance can deploy in one of two manners, Air Ambulance or HEMS as defined earlier. In October 2007 an adoption process took place to create the European Aviation Safety Agency (EASA). Many of the JAA s operational requirements are concurrent with the proposed EASA EUOPS requirements. The Healthcare Commission is the independent watchdog for healthcare in England and seeks to promote continuous improvement in the services provided by the NHS and independent healthcare organisations. Whilst the Healthcare Commission regulates the NHS ambulance services, it does not yet regulate air ambulance charities. This means that some air ambulances come under the jurisdiction of the Healthcare Commission (those where the air ambulance is operated by the NHS) whilst others do not (those where the air ambulance is operated by the charity and where the charity employs the clinical staff). However even where the air ambulance service is operated by the charity, the close partnership between the local NHS ambulance service and the charity means that the role of the Healthcare Commission will impact on the charity.

19 This section outlines the governance responsibilities for air ambulance charities. The governance responsibilities and accountabilities for NHS are clearly laid down for all NHS Trusts. The best practice suggested in this section will allow charities to meet their own governance responsibilities whilst ensuring that these are compatible with the NHS. Governance refers to the general management of the charity and the legal framework with which the charities must comply. Anyone who exercises powers in relation to the governance of a charity must act solely in the interests of the charity. Governance responsibilities and requirements for NHS organisations are clearly laid down and must be followed by NHS organisations. With regard to charities, the governance responsibilities will depend on the type of charity they are and their relationship with the NHS ambulance service(s). The responsibility and accountability for the service. Grant Giving Charity Provider/Operator Charity Responsibility Authority Responsibility Authority Governance Can t delegate Unlikely to delegate Can t delegate Unlikely to delegate Clinical None None Can t delegate* Can delegate or Governance integrate Operational None None Can t delegate* Can delegate or Management integrate Governance arrangements are the responsibility of the Trustees and cannot be the responsibility of another organisation such as the host ambulance service that engages with the Charity. Critical to this position was a letter from the Charity Commission (4/12/07) which stated that charities must exist for charitable purposes, not just to carry out another body s policies or instructions. Trustees must have freedom to decide how to use the charity s funds and assets to further its charitable purposes. The Trustees must be informed by, but must not be directed by, the ambulance service. This has significant implications for the role of Trustees within the charity as well as the relationship between firstly ambulance services and air ambulance charities and secondly, air ambulance charities and contractors. There is a need for absolute clarity around the roles and responsibilities of the Trustees and its partner organisations. In the future charities will be expected to provide greater detail as to how they meet the public benefit requirement. Not only are the government and donors increasingly demanding evidence that money is being used effectively by charities, but competition between charitable organisations for funding and contracts is also on the rise. Being able to provide evidence and demonstrate effectiveness is becoming a key priority for the third sector generally.

20 The South Western Ambulance Service operates four Air Ambulances, funded by three separate Grant Giving charities. Each quarter the three charities, the operational leads from the airbases, SWAST managers, representatives from the medical, training and tasking directorates, (as well as a representative of what was the Public, Patient and Involvement Forum) meet to discuss strategic development, operational commitments, and to review the activity over the previous quarter. These meetings provide the opportunity for open debate on all the issues surrounding the operating of air ambulances, enables the sharing of best practice around the airbases, and facilitates the exchange of information and knowledge between the three charities, and SWAST. They also provide the forum for debating the activity over the previous quarter, allowing issues to be discussed, and if needed joint action plans formed. Charity Trustees are the people who serve on the governing body of a charity and are responsible for controlling the management and administration of the charity. Trustees have and must accept ultimate responsibility for directing the affairs of a charity, and ensuring that it is solvent, wellrun, and delivering the charitable purpose for which it has been set up. Charity trustees must: they exercise any powers or duties Failure to meet the public benefit reporting requirement means that the charity trustees are failing in their statutory duty. If the Trustees act imprudently, or are otherwise in breach of the law or the governing document, they may be personally responsible for liabilities incurred by the charity, or for making good any loss to the charity. Since Trustees act collectively in running a charity, they will usually be collectively responsible to meet any such liability. One of the effects of ambulance service reconfiguration, boundary changes, means that all NHS ambulance trusts now have one or more charities in their newly formed regions with differing governance and service arrangements. Although boundaries changed for the trusts, the area of benefit in the Charity s constitution did not. A charity must apply its objects and resources within its area of benefit and that area cannot be restricted by ambulance service boundaries The role and responsibility of a charity trustee is onerous, without financial reward and carries responsibilities that cannot without consultation be left to others. As the role of air ambulances extends i.e. inter-hospital transfers, night operations and improved levels of clinical care, Trustees have a responsibility to ensure that key decisions are made about the future of their organisations Trustees are jointly responsible for the activities of the charity and must act together. No trustee acting alone can bind his fellow trustees, unless specifically authorized to do so. This does not mean that board decisions must be unanimous; in that case the majority bind the minority.

21 The trustees of a charity are bound to exercise their own discretion in deciding who will benefit from the charity, or precisely what facilities or services should be made available, or when and on what terms the public (or particular sections of the public) should be able to use the charity s facilities or services. Trustees can surrender their discretion to make those decisions only if they have power to delegate them (for example, under the charity s governing document). Where trustees are authorised to delegate, the person who makes the decision has the same duty as the trustees to take into account only considerations that are relevant to the pursuit of the charity s purpose. In the case of continuing decisions (such as the selection of individuals for benefit), allowing the decision to be made by an individual or body with no delegated authority or fiduciary duty to the charity amounts to a surrender of discretion. Trustees must not only avoid surrendering their discretion without proper authority. They must also avoid fettering their discretion (except where the interests of the charity require them to do so). Trustees are required to act in person and decisions affecting the charity must be made by the trustees acting together. Trustees are, however permitted to delegate a wide range of tasks, provided they give clear instruction which define: and the types that must be referred back to the trustees trustees still remains ultimately responsible for all the charity s activities Where there is a relationship between a charity and an authority, a trustee who is an officer of that authority is placed in a position of potential conflict between duty to the charity and loyalty to the authority. Consideration should be given to any trustees who serve on the charity boards that have a direct and corresponding relationship with partner organisations such as co-located ambulance service trust. Where there is a Trustee with a potential conflict of interest, the charity must clearly state the way in which any potential conflicts will be declared and dealt with. Trustees should ensure that they have established appropriate arrangements to satisfy themselves that the Charity is meeting its objects. These arrangements include: law with regard to raising monies and making grants for which they were intended

22 The auditors should have direct access to the chair of the Trustees if they request it. A service providing charity should also ensure that arrangements are in place to effectively discharge their clinical governance and risk management responsibilities, including: The Medical Director should be the lead director with responsibility for clinical governance. The Trustees of a grant giving charity should ensure that they receive quarterly reports from the local ambulance service committee s governance committee enabling them to assure themselves that the funds granted to the local ambulance service(s) are being used for the purposes for which they were intended. The Medical Director of the local ambulance service(s) should report at least once a year to the Trustee Board. Service providing charities should appoint a Finance Director, a Medical Director and an Operations Director, reporting directly to the Chief Executive/Director of the Charity and through him/her to the Board. A grant giving charity should appoint a Finance Director and Trustee should agree with the local ambulance service(s) responsibilities for the ambulance Medical and Operations Directors regarding their responsibilities in assuring the Trustees that grants made by the Charity are being used for the purposes for which they were intended. It is vital that Governance arrangements of and between Air Ambulance Charities are transparent, robust and constructive to enable both organisations to discharge their responsibilities effectively in the interests of the public and patients. Person specifications for the three Director posts are given in Appendix A. If another authority including a government authority has been given powers under a charities governing document, it is bound to exercise those powers solely in the interests of the charity. It is the duty of all air ambulance charities to ensure that their constitutional document have clear objects and powers of delegation; that Memorandum of Understandings and Service Level Agreements are in place; that the Charity takes independent advice (as recommended by the Charity Commission) and to ensure they are in the best interests of the charity and its beneficiaries. The Air Ambulance Charity will have operational and business arrangements with Ambulance Trusts and a number of third parties. The Trustees should agree principles, codes of conduct, policies and procedures upon which such relationships should be conducted. It is particularly important that: allocation and use of funds and that the allocation and use meets the objectives of the charity been agreed in light of the public benefit reporting requirements within the new Charities Act 2006 responsible for the maintenance of communications between the parties and the dissemination of information to the appropriate person or department within their organisation

23 This document does not seek to prescribe the level of service provision of the operator as minimum operational facilities and pilot qualifications are specified elsewhere. It is advisable that the minimum level of operational performance and pilot qualifications / experience be laid down in the negotiated contracts. Procurement of aircraft and / or accompanying services from aircraft operators (contractors) should be conducted within the Charities best working practices. Regular contract review meetings should be held with all interested parties. Not withstanding the above, there must be a close relationship between each Air Ambulance Service and its local Ambulance Service(s). The resulting arrangement should be a written agreement between the Charity and Trust Board of the host Ambulance Service which indicates where responsibility for the different aspects of management and governance lies. It should take the form of either a written Memorandum of Understanding (MOU) or Service Level Agreement (SLA). The South Western Ambulance Service operates four Air Ambulances, funded by three separate Grant Giving charities. Quarterly joint meeting take place between the charities and SWAST and a partnership arrangement also exists whereby specific projects are managed in a more defined manner. One such example is the current recruitment process. Representatives from each of the three charities, alongside the operational leads from each of the four airbases, and SWAST s air ambulance lead are developing a process which will enable the views and requirements of each party to be incorporated in the process. Where an Air Ambulance Service serves more than one NHS Ambulance Service Trust (or vice versa) one organisation should be identified to take the lead on Governance matters. The relationship should be reflected through joint Clinical Governance Committee meetings, sharing of best practice, lessons learnt from complaints and problematic inquests, patient feedback and suggested changes to standard operating procedures. Each helicopter contract that is held by an NHS Trust is an obligatory liability for that trust, not the funding charity. Consequently if the charity fails to provide sufficient funds by way of grant then the trust is wholly responsible for contractual payments and trusts could find themselves funding part (if not all) of the contract/s they hold. Since a grant is not a contract, a charity is under no obligation to provide full cost recovery for any service, nor can a trust impose a debt of grant on a giving charity if the grant fails to cover the costs incurred. It is, therefore, important that NHS Trust held contracts contain provisions allowing the NHS Trust to terminate the contract in the event of a shortfall in charity funding, to ensure that they are not exposed to undue financial risk. Such arrangements are already in place in the majority of the Air Ambulance contracts held by NHS Trusts in England. If such arrangements are not agreed in the contracts with service providers, the ambulance service could find itself encumbered with the full cost of the HEMS operation or else in breach of contract with the helicopter contractor. On no account should an ambulance service, invoice a charity for a charge it incurs on a contract the trust holds.

24 A grant giving charity is not accountable to an NHS Trust for its financial performance. However a trust, in receipt of a grant payment, must account to the charity for its disbursement and application in line with the charity s objects. Failure to do so could result in a reduced or rejected grant application or in the case of a service provider a reduction in service or charges levied on inappropriate use of the charity s resource. Alternatively if the charity holds the contract for the aircraft the trust incurs no financial liability should the charity fail to raise sufficient funds. In order to support the identification and development of good practice comparative performance measures should be developed. Examples include: and important sub-elements of the mission cycle (for example call connect to airbase receipt, airbase receipt to resource airborne). Other areas for consideration would be: accuracy of mission classification, HEMS vs Air Ambulance; correct identification of most suitable resource type; aircraft availability reports and multidisciplinary dispatch audits. These measures would focus on the quality aspects of the performance, in addition to the currently available mission quantity data being taken to the most suitable treatments centres; and data submission to, and information from, UK Trauma Audit (TARN) secondary responses; percent of missions which are transfers; Service costs; spend per mission and non-availability of Aircraft due to scheduled and unscheduled maintenance