East Midlands Ambulance Service NHS Trust Service Delivery Model EXECUTIVE SUMMARY This paper outlines the new service operating model proposed for East Midlands Ambulance Service NHS Trust which has the ultimate goal of being an excellent, high performing provider of Emergency and Urgent Healthcare. The Trust s current service model must change to provide a sustainable performance improvement and achievement, manage increasing demand more effectively and align with the new commissioning agenda. The current service model always deploys either a Paramedic or Emergency Care Practitioner (ECP) to patients who require an ambulance vehicle response, even if the patient does not require that level of clinical skill. The proposed new service operating model has a distinct urban and rural model that is underpinned in both types of geographical area by an urgent care tier: Urban Response Model Paramedic Fast Response Vehicle (FRV) or Double Crewed Ambulance (DCA) staffed by a Paramedic and ECA/Technician for patients who require an immediate response and/or conveyance in an urban area Rural Response Model Predominantly Community Based FRV (ECP or Paramedic) that are based in smaller towns and integrated into local health care communities. Support is provided from appropriately deployed DCA as per urban response Urgent Care Tier Urgent Care Ambulance crewed by Emergency Care Assistants (ECA) for patients who require conveyance but do not have a life-threatening condition This model deploys EMAS staff more effectively to ensure that patients receive treatment that is most suitable for their clinical requirements in an appropriately timely manner. 1
Introduction As part of the Operations Strategy and to support Better Patient Care the Trust is planning to implement a new three tiered service delivery model to support delivery of national performance targets and to improve the quality of care delivered to patients. Background The current service delivery model is based on Fast Response Vehicles (FRV s), Double Crewed Paramedic Ambulances (DCPA s) and Urgent Ambulances. Within these three groups there are a number of different types of resource: FRV s staffed by Emergency Care Practitioners used to respond to all call types FRV s staffed by Community Paramedics used to respond to all call types DCPA s staffed by a Paramedics and a Technician or by Paramedic and Emergency Care Assistant (ECA) Urgent Ambulance staffed by a Technician and ECA or by two ECA s In addition the Trust provides a number of other specialist resources for example the Falls Vehicle in Nottingham staffed by a EMAS Paramedic and an Associate Practitioner for Crisis Falls Team, the PolAmb vehicle staffed with a Paramedic and Police Officer and GP Urgent Ambulance in Derby staffed with two ECA s. The current service model also relies heavily on support from 3 rd party providers such as St John Ambulance and Amvale. This is for a number of reasons, which include changing demand patterns which mean the rota s do not always meet predicted demand. St John ambulance presently provides the core of Urgent Ambulances dispatched by the urgent desk. Current roles Emergency Care Practitioners At the present time there are approximately 60 ECP s in the Trust, Process Evolution indicated that around 99 are required in the future. The main issue for EMAS ECP s is skill erosion this is partially due to EMAS responding ECP s to all categories of call and not targeting them where their skills could be used to the greatest benefit but also because some skills they were trained to use such as catheterisation have been removed from their skill set, which has resulted in patients being transported unnecessarily to A&E. These issues have led to low morale and many ECP s leaving the service. Community Paramedics/Paramedics At the present time the majority of paramedics in the Trust have completed a further module in addition to the basic paramedic training and have become Community Paramedics. This module was originally designed for FRV paramedics and focussed on better history taking, diagnosis, assessment and access to alternative care pathways. All paramedics are now trained to the same level whether working on a DCA or an FRV. More recently a new Community Paramedic concept emerged based on the West Midlands Ambulance Service model of delivery. This role is not specifically about the Paramedics clinical skills but about the way they operate. This Community Paramedic role relates to the Zonal FRV s which is also known as the elastic band principle. 2
Technicians There are now just over 200 Technicians left in the Trust, with no new Technicians being trained for approximately seven years in EMAS. The Technician role predates the Paramedic role originally starting in the late 1970 s with the Paramedic role introduced nationally in the early 1990 s. Technicians are not recognised by the Health Care Professionals Council (HCPC) however a number of ambulance services nationally do still train Technicians to varying levels. Technicians do not currently work on FRV s. Emergency Care Assistants The Emergency Care Assistants (ECA s) role was introduced nationally as the Technician training was phased out. ECA s currently undertake three weeks emergency driver training followed by a clinical training support course to allow them to work with Paramedics and Technicians on a DCA. Many ECA s are frustrated at the lack of opportunity to develop themselves and train as Paramedics. Proposed Service Delivery Model The proposed new service model is based on three levels of response and has the same resource elements as the current service model, however the new model will have different numbers of ECP s, DCA s, FRV s and Urgent ambulances and these resources will be used more effectively and more appropriately. The model will be implemented within the available financial envelope. Urban Response Model The urban response model has two principal elements. The first is the Fast Response Vehicle (FRV), which is crewed either by a solo Emergency Care Practitioner or Paramedic providing an immediate response to lifethreatening calls. Second is the Paramedic Ambulance, crewed by a Paramedic and ECA or Technician, and designed to respond to patients who require a Paramedic and conveyance to hospital. The urban FRV will assess patient s on-scene to determine the most appropriate care pathway, which includes see and treat, see and refer including referral to another ambulance vehicle response. It is anticipated that urban FRVs will primarily respond to the most life-threatening (red) calls. The emphasis of the urban FRV is to ensure that patients with the greatest need receive a rapid response. Urban FRVs provide a dynamic response within urban areas with their current response location actively managed by the EOC in line with the System Status Plan (SSP) demand forecast or specific operating principle within a defined area. Urban FRV s will book on and off duty either at a designated Hub site or Community Ambulance Station as required. Throughout the duration of their shift they may operate in a distinct way to suit the urban environment and density of population and activity: From a predetermined hub and providing a dynamic response within urban areas in response to activity and managed by the EOC in line with the current SSP demand forecast. Once deployed from the hub providing a response from a number of Community Ambulance Station Response Posts (CAS RPs) within a given area or sector to maximise the geographical response footprint 3
The second element of the urban response model is the A&E DCA which is crewed by a HCPC Registered Paramedic and either an Ambulance Technician or ECA. DCA s are primarily designated as 999 response and transport vehicles that are deployed directly by the EOCs to emergency and non-emergency cases or to provide back up to the urban FRVs. DCAs will be allocated to response posts as required by the EOC SSP and provide emergency call responses as necessary. DCAs are fully equipped emergency ambulances and are able to respond to the full range of emergency calls; they will respond either under emergency or non-emergency conditions as dictated by the EOCs. The Region s rotary winged aircraft (helicopters) are staffed by Critical Care Paramedics and Doctors that are specially trained in in-flight patient care and support. Helicopters provide a rapid emergency response and transport facility irrespective of terrain or geography. They operate out of the Trust s designated helicopter sites and abide by Civil Aviation Authority rules and regulations Community Response is an important and integral part of ensuring that EMAS is able to provide a timely response in all areas. The introduction of community response has provided a facility whereby community volunteers may be nearer to an incident. These schemes when available reduce some of the long distances that previously resulted from tasking vehicles from distant stations or response posts with a consequent reduction in response times and patient care. Whilst urban based CFRs are available due to the density of population they are more inclined to operate in rural areas. Rural Response Model Similarly to the urban response model the rural response model has two main elements that is supported by a third element. The first is the Fast Response Vehicle (FRV), which is crewed either by a solo Emergency Care Practitioner or Paramedic providing an immediate response to life-threatening calls. Second is the Paramedic Ambulance, crewed by a Paramedic and ECA or Technician, and designed to respond to patients who require a Paramedic and conveyance to hospital. The third element is the network of Community First Responder and Co-Responder groups. Rural FRVs will be predominantly sited within market towns of rural communities and have a specific role in providing an initial response to emergency calls, but more crucially integrating within the local community and fostering a link between primary, secondary and emergency care within the community. Rural FRVs will usually provide a 24/7 vehicle that books on and off duty from a Community Ambulance Station Reporting Post (CAS RP) and are not dynamically managed within the EOC System Status Plan in the same way as their urban counterparts are. They operate on an Elastic Band principle, which means that should the Rural FRV respond to an incident outside of the designated market town the post will not be backfilled ordinarily with another resource. However, on completion of the case the Rural FRV will return to the designated static response post. Rural FRVs will have boundaries that support the surrounding area and villages. 4
Rural FRV the Elastic Band principle The Rural FRV provides a strategic Mobile Health Care systems approach which is fully integrated with both primary and secondary care within the community and operate closely with the EOC s to provide as much care as possible in the home thus ensuring access to the full range of NHS services where possible. In addition, due to the small locality of deployment of the Rural FRV the opportunity for return visits is possible, enabling close monitoring of patients and assistance with such tasks as monitoring observations and assistance with medications. Such tasks often require hospital admission in an acute bed. Rural FRVs work with local health economy partners in order to establish effective patient pathways that cut across all health and social care systems and can meet patient s needs 24hours a day, seven days a week. Rural FRV staff will also provide clinical and operational support to EMAS s Community First Responder schemes that operate in their locality. DCAs that operate in rural areas are primarily designated as transport vehicles that are deployed directly by the EOCs to emergency and non-emergency cases or to provide back up to the rural FRVs. When, and as required, DCAs will also respond to emergency calls as a primary response. CFRs are most often deployed in rural areas that EMAS is challenged in providing a timely response due to the presenting rurality. CFRs provide a significant community resource for achieving performance standards and patient care support irrespective of location. CFR schemes will be organized into car schemes that will operate on a 24/7 basis to ensure consistent and reliable CFR resource availability. The location of CFR car schemes will be determined by data supplied by the EMAS Performance Management Intelligence Unit. CFR car schemes will be self-supporting in terms of funding; however EMAS will provide support in terms of provision of appropriate communications, training and governance support. CFRs will be supported by Rural FRV staff who will oversee and support volunteers in the delivery of patient care within their designated market town and peripheral area. 5
In all cases, CFRs are backed up by an EMAS resource as soon as practicable. Medical First Responder schemes are EMAS staff (generally ECPs and Paramedics) that respond within the community in their own time. These schemes will be enhanced to provide far reaching support to the emergency and urgent service in both rural and urban areas. They will provide a significant community resource for meeting performance standards and patient care support irrespective of location. Public Access Defibrillators (PADs) are placed in high footfall areas and known areas of incidence of cardiac arrest and emergency calls. PADs are available for suitably trained members of the public to use, or in sites where staff have been trained in their use. Volunteers at PAD sites are trained to deliver basic life-saving skills for deliver initial Basic Life Support (BLS) and defibrillation skills where clinically qualified back up will arrive within a relatively short time scale. Urgent Care Tier The urgent care tier will provide transport for patients who do not require Paramedic care but do need transporting to hospital or another healthcare facility within timescales agreed by a Healthcare Professional (e.g. Doctor, ECP, Nurse or Paramedic). The Urgent Care Ambulance (UCA) will be staffed by ECA s and possibly Ambulance Technicians. They will be equipped with automated external defibrillators (AED s) and other basic medical supplies, providing transport for those patients clinically assessed as safe to do so. This will free Paramedics and ECPs to attend the most seriously ill or injured patients. ECA s involved in the urgent care tier will be given role-specific training to fully equip them to respond without the direct support of a Paramedic. The Trust is currently exploring the use of multi-person Ambulance Support Vehicles (ASVs) for this level of response. ASVs are capable of carrying up to six walking patients at a time and are currently being piloted by 6
EMAS in Leicestershire. This pilot has found that ASVs transport more patients per shift than a standard DCA, freeing up other ambulance vehicles, and can better support large-scale incidents that require multiple patient transports, such as road traffic accidents. The plan for acquiring and commissioning ASVs will be detailed in the Trust s Fleet Strategy. Benefits of the modified service delivery model More appropriate response to patients by targeting the right resource first time to a patients need Increased response availability through technician FRV s Opportunity for all staff to use their skills more appropriately Opportunity for staff to progress and develop themselves More effective use of CAT deploying ECP s and Urgent ambulances Provides more effective safety netting through the deployment of the right resource first time More flexible model giving dispatchers a range of options not presently available Reduce reliance on third party support More likely to cover more core shifts by having roles more clearly defined Improved morale Integrates with the Urgent Care Hub in the Emergency Operations Centre Future Workforce Requirements Emergency Care Practitioners: The Trust needs to increase the numbers of ECP s, which will include the need to review their banding in line with other NHS organisations and develop a modular training package so paramedics internally can up skill to this role. Community Paramedics: The Trust needs to review the current Community Paramedic training to ensure it meets the needs contained within the modified service model, especially focussing skills on See and Treat, See and Refer. Technicians: Consider the re-introduction of Technician training as a stepping stone towards becoming a Paramedic. Review existing technician skills in line with a potential Technician FRV. Emergency Care Assistants: Scope further the opportunities for ECA s to progress to Technician and Paramedic grades. 7