East Midlands Ambulance Service

Transcription

1 Appendix 1 East Midlands Ambulance Service New Service Delivery Model Summary Document Trust Executive Board 05 April 2012

2 Contents Introduction The Strategic Context Overview Objectives Next Steps High Level Workforce Transition Plan Year 1 (2012/2013)

3 Introduction The East Midlands Ambulance Service as an aspirational Foundation Trust is embarking upon a significant programme of transformation which will ultimately see a change to the way in which it provides unscheduled health care to the population of the East Midlands. The existing model of service delivery is not clinically led and focussed on the highest standards of clinical excellence and quality as it is designed with the primary focus of achieving performance standards. The Secretary of State announced in December 2010 the introduction of the Clinical Quality Indicators for the ambulance service which came in to effect from April This set of 11 indicators replaced the Category B, 19-minute response time target and supported a move to measure the performance of the ambulance service on what matters most to patients quality and patient outcomes. The existing very traditional model of delivery lacks the required versatility and to continue with the concept of sending any type of resource to an emergency call is not clinically appropriate nor is it affordable with high staff and vehicular costs. Alongside a traditional model of service delivery the divisional management teams are primarily operationally focussed and do not focus sufficiently on clinical leadership or staff welfare. To support a new model of operational delivery the development of an Urgent Care Hub within the Emergency Operations Centre linked through a single point of access is pivotal to the success factor of the transformation programme. Within the Emergency Operations Centre a growth within our clinical assessment ability will support service provision through numbers of patients assessed and discharged over the phone (Hear & Treat) and a significant number of patients referred to alternative care providers (Hear & Refer). The relative reduction in response volumes required will allow the most appropriate resource to be sent to the patient supporting the ethos of Right Care, Right Time, Right Place whilst allowing the Ambulance Service to develop its service model around the requirements of its service users. Critical success factors will need to be achieved to support to new service delivery model including;- Increasing productivity through reduced call cycle times Reducing sickness absence levels Full rota review to create UCA crews and flexibility through 8, 10 &12 hour rota s Benefit realisation of the Resource Management Centre Getting the best leaders that can transact the change Communications and engagement with staff Reviewing the existing estates footprint to develop a new Hub and Spoke model. Reviewing the types and numbers of Trust response vehicles including where appropriate, vehicles which can carry multiple patients. Delivery of performance and quality targets 3

4 1. The Strategic Context 1.1 National Context The Government has embarked on a fundamental reform of the NHS, which will see the responsibility for the commissioning of ambulance services transfer from primary care trusts to GP consortia. These reforms are being introduced at a time when the NHS faces the tightest financial settlement in many years and when the Government aims to deliver up to 20 billion of efficiency savings in the NHS by the end of The ambulance service is expected to play a part in achieving these savings by identifying a minimum of 4 per cent efficiency savings within its budget (around 75 million per year). The ambulance service provides a life-saving service to some patients, is highly regarded by the public, and rightly remains committed to providing a rapid response to urgent and emergency calls at a time of steadily growing call volumes. But, until April 2011, the Department s emphasis on response time as a measure of performance rather than on a more rounded view of clinical outcomes, meant that the incentive structure did not encourage resource optimisation which resulted in little change to the traditional model of service delivery. A number of government plans require the contribution of ambulance services to meet NHS system-wide objectives. Examples include the Government s 10 year NHS Plan published in 2000, the NHS planning and governance framework Standards for Better Health published in July 2004, the Department of Health s National Ambulance Review Taking Healthcare to the Patient: Transforming NHS Ambulance Services published in June 2005 (and 2011) and the Health White Paper Our Health, Our Care, Our Say published in February The follow up review to Taking Healthcare to the Patient National Strategy for Ambulance Services, published in 2011, provided further recommendations, including:- Developing more visible, clinical leadership to support the more complex clinical challenges and an increase in hear and treat and see and treat are supported through high quality clinical leadership and mentoring. Adjusting the Category A target to allow time to gather key patient condition information before dispatching a resource, whilst at the same time protecting existing world class 999 call answering times. Maintaining national compliance with performance measuring whilst ensuring calls to cardiac arrests are singled out to receive the absolute fastest response. On 1 April 2011 new national targets were introduced with the emphasis no longer solely on speed of response. The key national target for Ambulance Trusts remains as maintaining response time performance of reaching 75% of patients with conditions prioritised as Category A within 8 minutes and providing a transport resource to patients within 19 minutes. EMAS must work with their patients and the public to ensure that the services can respond appropriately to all patients. This will require a revised approach to the traditional operational service delivery models. 4

5 1.2 Regional Context The East Midlands Ambulance Service (EMAS) provides emergency and urgent care, patient transport, call handling and clinical assessment services for 4.8 million people in an area covering approximately 6,425 square miles across the six counties of Derbyshire, Nottinghamshire, Lincolnshire, Northamptonshire, Leicestershire and Rutland. EMAS operate a fleet of around 780 vehicles, including emergency ambulances, fast response cars, specialised vehicles and patient transport vehicles. Our overall annual budget is 158 million. Every day, around 2,000 calls from members of the public calling 999 are received. In November, December 2010 and periods within January 2011, the region experienced dramatic and severe weather conditions and a significant increase in demand due to flulike symptoms which affected many people across the region. As a result of these events, and despite urgent management action, EMAS failed to achieve national performance targets for the year. Beyond the Trust s immediate urgent and emergency market exists a wider local health economy, which must be understood not only to realise the Trust s business position in its healthcare market, but also to understand the impact that the local health economy has on demand for Ambulance services. Firstly, in order to establish what encompasses the Trust s local healthcare economy, the Trust s current service provision is considered. The majority of EMAS services are provided for the East Midlands, excluding some mobile healthcare and specialist services which can cross regional boundaries. Therefore, the Trust s local health economy is considered to be the East Midlands, covering the six counties of Derbyshire, Leicestershire, Lincolnshire, Nottinghamshire, Northamptonshire and Rutland. The six East Midlands counties that EMAS serves currently have their healthcare services commissioned by six PCT clusters, made up of eleven PCTs. Whilst these commissioning organisations include NHS Milton Keynes as a member of the Northamptonshire and Milton Keynes Cluster, EMAS does not provide an emergency service to Milton Keynes and so this area is excluded from further regional consideration. Bearing this in mind, healthcare services within the EMAS region are provided by eleven acute trusts, seven mental health trusts and a large number of GP practices and community health providers (eight of these organisations are foundation trusts). Each organisation and the county in which it sits has its own identity and aims to address its own local healthcare agenda. This diversity of agendas adds to the complexity of requirements that EMAS fulfils. At present the Trust s requirements are also very dynamic due to the changing commissioner landscape in the region, and the resultant development of twenty six Clinical Commissioning Groups (CCGs) across the region, including North and North East Lincolnshire PCTs and excluding Milton Keynes PCT. The full impact of these new CCGs is yet to be realised as they are still very much at the development stage. However, the CCGs will bring a great variety of differing perspectives and levels of understanding regarding EMAS services, meaning that the Trust must continue to engage with and educate these new organisations. Furthermore, the CCGs are likely to create a more localised commissioning environment, which may change the way that EMAS promotes its services to increase its market share. To manage the regional commissioning transition and to provide some consistency of engagement with the emerging commissioners, the regional business hub has been replaced with the East Midlands Procurement and Collaborative Transformation team (EMPACT). EMPACT was established in 2010 and serves the East Midlands 11 PCTs. 5

6 This organisation has acted on behalf of the East Midlands commissioners to procure the regional non emergency patient transport services and manage the transactional contract for 999 emergency services. The regional commissioning landscape is also changing further due to the increased role that local authorities will have in terms of public health. The introduction of local health and wellbeing boards will bring together commissioner interests across the NHS, public health and social care. As such, EMAS will have to engage with a wider pool of commissioners and satisfy a broader range of interests. With regards to the population living in the region that the Trust primarily serves, the East Midlands is characterised by a generally poor level of health when compared with the rest of England, based on the most recent relevant health indicators from the UK Public Health Observatories (Reference: Within the East Midlands there are some areas of severe deprivation and significant resultant health needs, which may dictate some of the demand for EMAS services. Aside from the general health profile of the East Midlands population, other factors that will affect EMAS service demand are population growth and age. The East Midlands population is growing and an increasingly greater proportion of that population is of an older age, both of these factors will contribute to urgent and emergency service demand at EMAS. 2.3 Trust Strategic Context East Midlands Ambulance Service failed to achieve national ambulance response targets for the period 2009/10 and 2010/11 for Category A8 and B19 calls. In addition EMAS has also faced significant challenges in meeting clinical quality standards and maintaining a healthy financial balance. In the performance year 2011/12 EMAS is on target to achieve its A8 performance standard but will not achieve its A19 standard. Sub-standard performance is unacceptable to a Trust which aspires to achieve Foundation Trust status and deliver the highest quality care possible. The current service delivery model structure is based upon historic principles of ambulance service delivery. As a result of the higher volume of calls and transformations of NHS services, the current model is no longer offering value for money or achieving performance standards. EMAS recognises that it needs to significantly change its approach to the way in which it serves the region and as such is now commencing a significant programme of transformation starting with a change to its service delivery model. 6

7 2. Overview 2.1 Current The current model offers one level of response to all types of calls, regardless of clinical need. The aim of the current service delivery model is to provide a paramedic on every frontline vehicle, sending the nearest available resource, as fast as possible to deliver patient care. Highly skilled clinical staff are required to deal with routine work which would be more appropriately dealt with by an alternative role which would therefore free up Paramedics to attend only the clinically appropriate calls ensuring that those in need receive the highest level of clinical care. The response includes:- Ambulance that is crewed by a Paramedic and an Ambulance Technician or an Emergency Care Assistant (ECA). Fast Response Vehicles crewed by a Paramedic Fast Response Vehicles crewed by an Emergency Care Practitioner 2.2 Proposed The Trust is proposing a new service delivery model that will be based on three levels of response implemented by 2014 with continued development over the lifetime of the integrated business plan (see table below). Resource Type Skill Level Level 1 Response Urgent Care Ambulance Double Emergency Care Assistant Level 2 Response Level 3 Response Paramedic Fast Response Vehicle Paramedic Ambulance Emergency Care Practitioner Paramedic Paramedic and Emergency Care Assistant/Technician Emergency Care Practitioner The Level 1 response is the Urgent Care Ambulance (UCA) that is crewed by two Emergency Care Assistants (ECA s) and is designed to provide flexible transport for patients who do not require paramedic care but do need transporting to hospital within timescales agreed by a healthcare professional (Doctor, ECP, nurse or paramedic). All UCA s will have a bariatric capability, be able to transport retrieval teams and their equipment and provide an immediate response to life threatening calls. Level 1 vehicles will still have the ability to respond to life threatening category A calls in a first response capacity if they were the nearest available vehicle. 7

8 The Level 2 response has two elements to it, firstly the Paramedic Fast Response Vehicle, which is crewed by a solo Paramedic, providing an immediate response to life threatening calls where the speed of the response is key. The fast response paramedics will assess patients and determine the most appropriate care pathway, which includes See and Treat (SAT), See and Refer (SAR), which includes referral to an Emergency Care Practitioner, and treat and leave at home. It is anticipated that FRV s will primarily respond to Category A calls although as part of an agreed over capacity plan they may be utilised to attend alternative calls. The emphasis of the FRV is to attend the high acuity patients ensuring patients with the greatest need receive a rapid response. The second element is the Paramedic Ambulance, crewed by a paramedic and ECA/Technician, and is designed to respond to 999 calls which require paramedic care. Paramedic ambulances will provide the core response to the majority of 999 calls that are assessed as requiring an immediate response. Paramedics will assess patients and determine the most appropriate care pathway which includes SAT, SAR, and treat and leave at home. The Level 3 response, the Emergency Care Practitioner (ECP), provides a response to calls that have been assessed through the urgent care hub as requiring a response where further clinical assessment is likely, with the intention that patients will be treated at home or appropriately referred to another healthcare professional such as a GP or district nurse. ECP s would still be able to respond to the full range of calls although their primary focus would be around hospital avoidance. The emphasis of mobile healthcare is to send the right resource first time to meet the individual patient s needs with clinical assessment at each stage to determine the most appropriate care pathway and avoid unnecessary attendances at A&E departments and subsequent admissions, with the speed of response and quality of care top priorities. To achieve this staff will have to be matched to the three levels of response. This level of change will require transformation of the existing operational workforce including skill mix ratios of staff to support operational tiers and new operational rotas which are aligned to demand for our services. Technology exists to accurately predict the expected number of calls over a period of time which in conjunction with a unit hour utilisation methodology (UHU) allows the organisation to design a rota system which is flexible to anticipated changes such as seasonal variation. 8

9 Level 2 Response (FRV/DCA) Immediate Response Hear & Treat Hear & Refer Calls (999) Urgent Care Hub Clinical Assement Level 2 Response (FRV/DCA) Call Closed Through DoS Level 3 Response (ECP) Level 1 Response (UCA) 3. Objectives 3.1 Key Objectives The Key objectives of the proposed service delivery model are:- Sending the most appropriate resource to best meet patient needs To deliver against all performance standards. To constantly achieve the highest standards in Ambulance Quality Indicators To improve systems for inter hospital transfers To treat more patients at home - See and Treat. To refer more patients to other health care professionals such as GPs or district nurses or referring patients for admission using the most appropriate care pathway and avoiding attendance at A&E departments See and Refer. To reduce unnecessary conveyances to A&E To use resources more efficiently providing value for money 9

10 4.2 Benefits Trust Wide NHS & Other Stakeholders Public & Patient Flexible and demand responsive It is clinically focussed and clinically led It is affordable It will deliver performance standards More effective use of ECP s Part of an integrated operations model Reduction in handover times Potential reduction in Journey Times Staff development and motivation Delivering on performance targets Delivering on all quality standards More flexible service delivery model Increased cost efficiency Increased non conveyance to A&E departments Lower cost setting for attendance Reduction in Hospital Admissions It will deliver the highest quality of care Improved patient outcomes More timely response More appropriate response Improved patient experience Care closer to home Improved convenience and choice Shorter treatment times More coordinated patient service Care closer to home 3.2 Conclusion EMAS is on track to deliver Category A8 for the performance year 2011/12. A19 is not achievable this year; however planned improvements will have a significant impact during 2012/13. There will still however be a performance gap, and commissioner support to undertake a joint independent county by county review of demand and capacity to establish a baseline for future commissioning. EMAS has seen a year on year increase in both calls and responses over the past ten years; from 2007/2008 to 2010/2011 EMAS has seen a 21% increase in Category A responses alone with a further 12% increase over the past 12 months. It is anticipated through service changes alongside an increase in clinical assessment of calls that although call volume will continue to rise the actual responses will remain fairly static. 10

11 In terms of Category A volumes the Card 33 changes and then the changes to the national targets on 1 st April 2011 when Category B was removed has meant an increase on average of 2,300 more responses per month than prior to this date. EMAS is also seeing a dramatic change to its activity profile, with Saturday and Sunday now been the busiest days of the week for example the average number of Category A responses per day is between 560 and 590 compared to the average weekend day with 650 to 800 responses. There are clear links to 111 activity which significantly increases at weekends, however further analysis is still required. To ensure the changes are successful a full engagement strategy and planner will need to be put in place. This will be both internal and external facing and to do this effectively a full stakeholder mapping exercise will be completed and linked directly to all communications. Using engagement, all key audiences should develop a comprehensive understanding of the reasoning for change and a focus on the objectives we need to achieve. Proactive communications and presenting the change as a priority which affects everybody will ensure that colleagues will actively engage with the process and in turn make the end result a success. Together with this, the narrative used will be in line with the motivations of the different audiences and expressed in a clear manner, according to shared understanding. We will have open and honest communications on the issues we face whilst maintaining a culture of openness and inclusion. 11

12 4. Next Steps A series of scoping sessions will ensure that the project managers from each individual work streams will be supported to deliver against clear timescales. The flowchart below describes how the individual groups will report in and be accountable to the Transformation Delivery Group which will ensure delivery of the whole programme of transformation. TRANSFORMATION DELIVERY GROUP SINGLE POINT OF ACCESS -Pathways -111 URGENT CARE HUB TELEHEALTH NEW MODEL FLEET WORKFORCE -Professionalism of the workforce ESTATES SERVICE LINE MANAGEMENT -Productivity -CIP The programme of change will commence in April 2012 adhering to structured timescales. Quarter 1 - deliver performance standards linking to the Improving Service Delivery plan. 1 It is imperative that the Trust delivers against its key performance indicators whilst undergoing the change programme, this ensures that we provide the highest standards to our service users. Quarter 1 - Commence consultation on rota reviews to support the new service delivery model whilst ensuring that the levels of required resources accurately reflect the demand profiles of the business. Quarter 1 Alignment of all supporting strategies to the new service delivery model including the Estates and Fleet. Quarter 3 - Commence consultation on management structure changes 1 Tabled at Trust Board April 5 th

13 5. High Level Workforce Transition Plan Year 1 (2012/2013) The Workforce Transition Plan aims to achieve a full operational management restructure in post by 31 st March The time scale has been proposed to take into account the internal resource capabilities and capacity to deliver change whilst continuing with a management development programme to start to identify talent and embed leadership capabilities across front line and middle manager roles. The scope focuses on the workforce transition that includes: TUPE of PTS staff Reconfiguration of support services in response to the loss of the PTS contract Operational management restructure Operational workforce modelling Key goals of the Work force Strategy are to: Deliver robust and compliant workforce planning to embed a model of organisational development Best practice HRM Excellence in education, training and development Develop talent in our organisation and plan succession into key roles Transformation to a new service model and operational management structure to deliver a culture of staff recognition, supportive management behaviour, positive team working and interpersonal relations; employee involvement and participation, empowered and engaged and well supported staff PHASE ANNUAL PLAN OBJECTIVE WORKFORCE AND FINANCIAL CHANGE April 2012 PHASE 1- PLANNING Deliver a workforce plan to enable transformation to a new service model and operational management structure that ensures business continuity. Commence consultation on operational rota changes which will support the development of 3 tiers of deliver April- 31 st August 2012 PHASE 2- SUPPORT SERVICES AND PTS PHASE 2a- TALENT MANAGEMENT, RESOURCING & EDUCATION TUPE of PTS. Reconfiguration of support service in response to the loss of PTS Develop our people to strengthen our recruitment decision making and ensure that we attract and retain the right people NUMBERS LOSS OF circa 51 support staff TUPE of circa 500 PTS staff FINANCE Financial saving circa 1.5M 13

14 October 2012 PHASE 3 SENIOR MANAGEMENT Consultation Divisional Directors, Paramedic Consultants, Heads of Performance Align the management development education to promote leadership capabilities, staff engagement, talent management and succession planning, increase the quality of appraisal Suggested pool : Existing divisional ADOs, 8b level project managers, other senior level staff. NUMBERS 5 ADO level staff, plus 4 at risk for x3 DD, x3pc, x3 HoP FINANCE Saving circa 140k assuming 5 ADO:3 October 2012 PHASE 4 MIDDLE MANAGEMENT Consultation Locality Managers, Divisional Quality Managers, Service Improvement Manager Align the management development education to promote leadership capabilities, staff engagement, talent management and succession planning, increase the quality of appraisal Suggested pool: Existing SDMs, OSMs NUMBERS 48 staff for 17posts FINANCE saving circa 300k October 2012 PHASE 5 FIRST LINE MANAGER Consultation Team Leaders, Team Mentors Align the management development education to promote leadership capabilities, staff engagement, talent management and succession planning, increase the quality of appraisal Suggested pool: Fall out from phase 4 plus existing PTLs NUMBERS : 31 from phase 4 plus 120 PTLs for 120 posts FINANCE saving circa 1.9m 14

15 Key transition stages showing broad considerations and assumptions PLAN CONSULT SELECTION APPOINTMENT Establish project group and define scope and secure appropriate resources Devise consultation plan Draw up communications plan - internal and external stakeholders Prepare Job Descriptions and indicative bandings Clarify scope of practice/competencies/d ecision making rights required for each role Agree selection pools and processes and anticipate educational requirements by role Take forward consultation process Review and revise job descriptions/ selection criteria/pools as result of consultation Review and /or secure capacity/ resource to deliver (eg assessment centres) Review business continuity plans and risk management Revise and communicate any changes Undertake selection process Confirm successful and unsuccessful appointees Provide support mechanism for displaced staff Confirm suitable alternative arrangements on an individual basis Revise and communicate any changes Transact all employee changes - particular focus for Human Resources, Education and Development Devise individual education plans for new appointees in relation to gaps identified through selection process Revise and communicate any changes Clarification of legal implications Detailed financial modelling Propose what is and is not suitable alternative employment 15

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