NHS HIGHLAND RESPONSE TO SCOTTISH AMBULANCE SERVICE: OUR FUTURE STRATEGY. Discussion with partners

Transcription

1 NHS HIGHLAND RESPONSE TO SCOTTISH AMBULANCE SERVICE: OUR FUTURE STRATEGY Discussion with partners 1

2 1. PREAMBLE We wish to compliment SAS on the document, which is easy to read and clear about the issues. We welcome the SAS commitment to work in partnership with territorial Boards to deliver their services and contribute to Better Health, Better Care for the people of Scotland. Our experience is that the way the SAS is structured has not always resulted in effective local partnership working. Too often we find that local managers through whom we liaise are not in a position to commit the SAS in the ways necessary to improve patient care. We would suggest that the SAS considers how it wishes to establish effective liaison arrangements with territorial Boards at senior level to ensure speedy and effective decision making and implementation. We would recommend that SAS should have a named senior officer locally to ensure active involvement at senior level for engagement with Boards on Strategic Planning and Local Delivery Plans. This would go some way to addressing the perception that SAS are currently failing to respond to the needs of local populations. We welcome the SAS aspiration to broaden its remit and to be seen as a clinical service rather than just an emergency service providing life support and transport. However we believe that the SAS should be absolutely clear as to the delivery of its core role and remit in respect of unscheduled and scheduled care before it diversifies resources into other areas. In many parts of NHS Highland there remain significant concerns about the performance of SAS in respect of these core duties and we are keen to work in collaboration with the SAS Board to see these addressed as a priority. We are aware that SAS have undertaken a number of pilots throughout Scotland on potential service redesigns and we would welcome a report on the outcome of these as a means of identifying which proposals are potentially viable. 2. FEEDBACK ON SAS DISCUSSION DOCUMENT The SAS document was widely circulated within NHS Highland as part of this consultation exercise. Some general points on the four key issues outlined within the SAS document are made below, with more specific comments attached at appendix Accessing the right help in an emergency We are thoughtful about the proposed common assessment system for emergency and out of hours healthcare. At the moment an emergency 999 call requiring ambulance dispatch is activated with immediate effect. We would want to be assured that any common system which amalgamates emergency response with out of hours care would not result in a delay to the current 999 response. It is crucial that all calls are dealt with in the same way to avoid long, bureaucratic and challenging responses to emergency calls - this is particularly important in the remote and rural areas. We welcome the suggested model where patients receive emergency treatment before being transported to an appropriated healthcare centre e.g. community hospital, as opposed to being transported direct to the nearest A&E department. This will be hugely beneficial in rural areas and we would welcome the opportunity to take this forward with SAS. 2.2 Delivering for remote and rural health care We are delighted to see the emphasis on remote and rural healthcare in the SAS strategy. We are very pleased to see the SAS commitment that the quality of the service received from SAS should not be affected by where they live. The work of RRIG is acknowledged and the possible models of care included in the strategy. It would have been reassuring to see the SAS acknowledgment of the Service Standards developed by RRIG for emergency response in remote and rural Scotland as well. These are important in so far as they indicate how that commitment to equality of service quality can be translated in reality in the remote and rural setting. 2

3 NHS Highland is committed to working with SAS to ensure a comprehensive emergency response can be provided across Highland in line with the standards and utilising the RRIG models. Key to this work will be the Memorandum of Understanding of the respective roles and responsibilities of SAS and territorial Boards in this regard. This will allow a firm basis of that necessary collaboration and we look forward to the SG publishing the MoU shortly. 2.3 Getting Patients to and from Hospital There are a number of real practical issues that impact on patient care as a result of the criteria SAS applies in respect of patient transport, e.g. only deliver patients to hospitals; only provide transport within certain times, etc. There are also many examples of SAS cancelling booked journeys at very short notice leaving the NHS with the cost of taxis we would suggest that SAS make immediate arrangements to meet the cost of alternative transport e.g. taxis, for any patient who meets the eligibility criteria but for whom SAS cannot provide appropriate transport. Failings within the current PTS have a significant impact on the management of waiting times when appointments have to be cancelled or patients DNA as a result of being unable to reorganise their transport in time. It is crucial that any redesign of the current PTS results in a good service being provided to all those who need it, when they need it. Clearly, access to hospital is only one purpose for which healthcare transport is required people also need to attend their GP, optician, chiropodist, day care centre, etc. NHS Highland would be keen to work with SAS and other transport partners to develop an integrated transport strategy that addresses the principles within Better Health, Better Care and looks sympathetically and meaningfully at how any eligibility criteria should be structured. 2.4 Enhancing the care we provide As previously mentioned, we applaud SAS s aspiration to broaden its remit and make a significant contribution to the provision of scheduled healthcare. However we are keen to work in collaboration with the SAS Board to see the effective delivery of its core role and remit in respect of emergency response and transport before exploring how resources might be diversified into other areas. 3. CONCLUSION In conclusion, this document has been well received within NHS Highland and clearly outlines the key challenges and opportunities. Moving forward requires collaboration - no single agency can re-design without direct involvement of partners and the consistent roll out of redesign in rural areas will be a key starting point. NHS Highland is keen to work in collaboration with SAS to ensure that local needs are met through combined workforce and service delivery planning to ensure the SAS proposals complement local NHS services and thus avoid any duplication. We also need to ensure that unplanned care complements planned care and ensure assumptions about local NHSH services are checked out during the process of SAS redesign. ROGER GIBBINS Chief Executive, NHS Highland 3

4 Appendix 1 SPECIFIC COMMENTS ON SAS DISCUSSION DOCUMENT ACCESSING THE RIGHT HELP IN AN EMERGENCY SAS Questions 1. How can we work together to improve patient access to the right emergency help? 2. How can we better share resources? 3. What are the practical considerations for implementation? NHSH Comments The SAS EMDC and NHS 24 hubs should be co-located and serve coterminous areas. We can work together in terms of better and integrated strategic planning based on the needs of the Health Board population and defined roles and responsibilities. The development of a single point assessment for triage is a gold standard although it must avoid a bureaucratic long and challenging response as is sometimes seen by NHS 24. This is especially important in the remote and rural areas when there is a locality. Perhaps what is needed is not one central access point but a number based in each region. E-health should be utilised in the availability of Health Information electronically. This would entail not only an emergency care summary, but a summary of a patient including long term conditions and ongoing health conditions such as palliative care. There needs to be joint planning between SAS regions, Health Boards and an integrated response to unscheduled care including NHS 24, Out of Hours services, A&E and General Practitioner s - especially within the remote and rural settings. The concept of central triage is commendable, however, we are unclear how this would work in locations where NHS24 isn't used and GPs provide the local on-call service. SAS and territorial Boards should explore emergency medical retrieval services, utilising helicopters/fixed wing planes. Emergency" does not have the same meaning throughout the NHS and SAS. "Un-scheduled care" is used within the NHS to cover a lot of unplanned activity, some of which may relate to emergencies i.e. emergency transfer from community or RGH hospitals which is compromised by 999 calls taking priority even though call may not be life threatening. Definitions need to be shared throughout the NHS including SAS, and the public educated as to what this really means.. The sharing of resources should be based on need and an open and honestly in planning. The practical considerations are the integrated response to Strategic Planning, the definition of need, and a joint action plan with accountability. By co-location & cross referencing e.g. NHS 24 callers with chest pain get passed to a dual or SAS response at an early point in the call - but there should be cross trading of calls to NHS 24 of others which do not require an ambulance response - this would be helped if only one number was used to call either/both.!"! #$ %# 4

5 DELIVERING FOR REMOTE AND RURAL HEALTHCARE 1. How can we develop our current To develop the current role one has to identify what the current role in the provision of emergency care? role is. What is the SAS role and responsibilities in remote and rural areas? Based on needs of a population and what is available the SAS needs to be actively involved in Strategic Planning and bringing together all the possible models of care. There requires to be a lead agency for accountability i.e. whose responsibility it is. We already have the provision of community CPR training and the development of first responders but these need to be under an accountable body. Within the remote and rural setting a retained ambulance service similar to the existing retained fire service, or amalgamating with it, would be useful. There is some uncertainty as to whether a retained driver service to support GP s or Nurses responding to emergency calls would be appropriate in the remote and rural area. However, there is a view that a fully trained ambulance service response unit providing 24 hour care directly within rural communities is a standard that we should strive for, supported by unscheduled healthcare. As a simple and obvious principle in rural areas NHS 24 & SAS should co-locate, and on an operational level, ambulance stations/day time manned ambulances should be co-located and the workforce integrated in either community hospitals or GP practices. This to include where the staff are deployed e.g. ambulance staff could be on base & see patients in A&E or doctors surgery but with the understanding that they might have to leave quickly. This requires an active and joint manpower and capital development plan to implement. 2. Given the unique challenges faced by remote and rural communities, how can we share resources to improve emergency care services? If we develop an extended community practitioner s service where existing GP s provide a greater response to calls in the Highland communities and remote and rural areas, this will entail more manpower with ongoing and sustainable training, skills and competence needs. There should be the possibility of an augmented air ambulance service providing direct care as apposed to just a retrieval service. This may be along the lines of the Hems in England whereby there is an emergency team that goes out and actively assesses and responds to care and retrieves to secondary care when appropriate. &%' # (% # $' ( % ) % % $ **%* %*+, 5

6 3. How can we share resources to deliver integrated non emergency care? 4. How do we involve communities better in the planning and delivery of services? In terms of non-emergency health care, there should be the identified need of unscheduled care which may well be based around the long term conditions and on-going chronic needs of the patient. This would require Strategic Planning between SAS personnel and local community services in the development of a long term conditions strategy. This, with the development of protocols and e-health software for the management of long term conditions, could easily be developed including the use of some diagnostic tools such as pulmonary peak flow, ECG etc. Correct application of the PTS eligibility criteria should result in a service for patients at the moment this doesn t always happen as SAS cancels booked PTS journeys at very short notice without any apparent regard for the impact on patients or the health service. If SAS want to continue providing the PTS, then they must do so efficiently and effectively this must include an absolute commitment to get patients to where they need to be. Therefore, if patients meet the eligibility criteria and SAS cannot provide the service for any given reason, then SAS pay for alternative transport e.g. taxi not the NHS. If SAS cannot provide a good PTS to those who need it, then the PTS budget should be taken from SAS and given to an alternative provider. The key area absent here is the 3 rd sector. Why does the SAS have to deliver PTS services in its current configuration. There are clearly alternative options which could offer better value and better focus for patient transport. For example, renal transport services - this is identified as a specialist need - so why can t it be offered to alternative providers. Similarly in rural areas PTS services may be best delivered by community initiatives derived from 2 above. Access to hospital healthcare is only one purpose for which transport is required in rural communities people also require to attend their GP, lunch club, optician, chiropodist, day care centre, etc. People need to feel independent and have responsibility for their own arrangements a community car which transports someone to the nearest public transport access point ten miles away might be viewed of equal value to being transported 100 miles direct to the healthcare facility. Perhaps the most efficient model would be total integration of existing transport operators with an effective booking and scheduling system that has an open approach to the use of all vehicles. The current strict eligibility criteria would therefore not be required. In this way, scare resources in all communities (but especially those that are remote and rural) could be used to their fullest potential. This model would aid capacity building within all communities; help local businesses and support the active travel agenda. The SAS and Health Boards need to jointly and comprehensively involve the public in the planning and delivery of service. Exercises such as this consultation are a starting point but each design will be individual to a locale and take time to develop. There should be an immediate moratorium on closure & downgrading on any existing ambulance stations & irrespective of current service model, every area should look initially to build links with existing health care providers - this is a much bigger & wider issue than mere "emergencies". 6

7 5. What additional skills and infrastructure would we need? In terms of the additional skills that will be based on need, it will be important to ensure the sustainability of those skills. Also, the e-health infrastructure will require to be boosted. Education is the key, and the ability to use other existing facilities e.g. in remote & rural areas there is often a paucity of suitable venues for training - schools are not used for education of non-pupils. Co-location as outlined in point 1. We would be keen to work in partnership with SAS around workforce development new roles and role development; and workforce efficiency examining duplication and determining what is required. This would take place across a lot of work streams, but in relation to the strategy, specifically in response to Delivering for Remote and Rural Healthcare and Enhancing the Care sections of the SAS consultation document We propose that NHS Highland and SAS work more collaboratively on workforce planning and development. GETTING PATIENTS TO AND FROM HOSPITAL 1. How do we work with local and regional Transport Co-ordinators to take Key to this is the acceptance by SAS that they are only one small cog in the transport network and what is required is true forward an integrated transport integration of all the key transport strands e.g. road, rail, ferry & strategy? air services. An integrated transport strategy will require true partnership working and involvement of Regional Transport Partnerships 2. The current eligibility criteria is not adhered to across the NHS how do we ensure it is correctly applied? will be key to this. This assumes the validity of "the current eligibility criteria" and the assertion "is not adhered to across the NHS" is a value laden statement which is in complete contrast with the empathy of "given the unique challenges of remote & rural communities. In terms of medical/mobility criteria, these cannot be applied on a blanket basis across Scotland. Someone with the same medical or mobility condition may be perfectly capable of travelling on public transport for a short distance in a city, but that same person could be severely compromised if faced with a tortuous long journey with changes, etc. 3. How can we support NHS Boards in: $ meeting hospital transfer targets? $ meeting the 18 week target? $ meeting the 4 hour target? $ managing the patient discharge process? 4. What services should the PTS deliver? Meeting the 4 hour target. This relates specifically to time spent in A&E. In hospital care this is about patients who need treatment in a different unit - in my area every breach has been due to waiting for ambulance transport to the extent that we now specifically admit patients for transfer to avoid even more paperwork, but in so doing mask the scale of the problem. Discharge. Better co-ordination of SAS vehicles would help to expedite patients discharge e.g. when empty or part empty vehicles are returning to localities, it would be helpful to have a mechanism for checking whether any patients from that area, or enroute to that area, are waiting to be discharged. -, & -! * ) %!.%&$ /,&& % - %%- 0 $,&,& % 1 $. - 0 $ 1 *2*. 1 &!,& % - 0 7

8 ENHANCING THE CARE WE PROVIDE 1. How can we build on the existing This is identified by a needs assessment of scheduled care models of care currently available to and, depending on the need of the population and the patients, e.g. extending the work of availability of personnel, how best to fit services to the patient. community paramedics? This would have to be done on a fairly small scale locality basis. There are numerous models of care as identified in this paper and elsewhere but would require joint planning and sharing of resources. 2. Is there a role for paramedics in the provision of primary care? 3. What role could we have in managing long-term conditions at home? There is a role for paramedics and provisional primary care in a huge range of issues from severe trauma and emergency, to minor injuries in trauma, either in a peripatetic fashion or based round some A&E departments. There is a possibility of paramedic support in Out of Hours Centres and Hubs and there is of course the long term condition support that paramedics may bring. The development of protocols and telehealth for the monitoring of long term conditions that may be based either in the home or utilising e-health through the ambulance. There is a huge area to be explored in terms of long term conditions management and anticipatory care. There is a role but it comes back to communication and integration within Emergency Medical Discharge Centre & information available re options for service. Is this a core remit for SAS? - probably not. 4. What skills do we need to develop? The skills would depend on the identified needs but there would be a need for increased training and education regarding the common chronic disease management processes, the monitoring, the investigation and results interpretation and communication with others within the health provider system. 5. What are your expectations of the Ambulance Service within the wider NHS framework? 6. How can we exploit SAS infrastructure and expertise? 7. How could we support the coordination of all mobile unscheduled care resources? We need to move away from the SAS being a transport agency as opposed to being an integrated partner in care at all levels within the NHS. There may be scope to look at all available drivers, including Out Of Hours drivers. The SAS infrastructure needs to be defined but there is also the possibility that the SAS infrastructure could be more integrated on a locality or Health Board area in terms of management. Local relations between operational SAS staff and NHS front line staff are usually excellent, but there is a sense within the NHS that the SAS as an organisation is insecure & defensive and "prickly" towards people who raise concerns. Is this a reference to the potential for on call GPs to have SAS GPS tracker devices in their cars to show where they are for deployment by SAS in an effort to address SAS difficulties in meeting their own HEAT targets for emergency 999 calls? If this is a development then it requires funding from the SAS and incorporating this as part of its core resource to manage and deploy. 8