Clinical Strategy

Transcription

1 Clinical Strategy x Page 1 of 44

2 Version Number 01 Document Author Medical Director and Consultant Paramedic Lead Executive Director Sponsor Medical Director Ratifying Committee Board Date Ratified Click here to enter a date. Date Policy Effective From Click here to enter a date. Next Review Date 31 January 2020 Keywords : Page 2 of 44

3 All changes to the document must be recorded within the Table of Revisions. Version number Document section/ number page Description of change and reason (e.g. initial review by author/ requested at approval group Author/ Reviewer Date revised 01 Whole document New document Medical Director 07 April 2016 Page 3 of 44

4 MEDICAL DIRECTOR AND CONSULTANT PARAMEDIC FOREWORD We are proud to present the Clinical Strategy for the North East Ambulance Service NHS F o u n d a t i o n T r u s t. This strategy presents an exciting vision for the services provided by our Trust, and importantly, work is already taking place to turn this vision into reality. This strategy links with the Trusts overall strategic aims and to the Quality Strategy. We are driven by one overarching ambition which is to deliver the best possible service to our patients. Our aims are to: provide the best care in all our services provide care based on the patient s individual needs make it easier, as well as quicker, to access emergency and urgent care to get the right balance between highly specialist care where it is needed and more local care where appropriate play our role in encouraging healthier communities and individuals The focus on quality and clinical care gives us the opportunity and the challenge to articulate what we do. This will become even more important in the current financial context and the increasing emphasis on transparency in quality and outcomes. This means questioning how we do things, thinking in more innovative ways to support better clinical outcomes, while focusing on promoting and maintaining health and well-being, as well as on prevention. The Clinical Strategy helps the Trust and our teams to understand the agenda we face going forward. Quality is always going to be a key priority for our services, focusing on patients and their health needs, working across pathways and working with other clinical colleagues and partners. This strategy is designed in line with the national direction of travel from the urgent and emergency view as well as the five year forward view. Our staff are close to our patients, so can see how they can change things to enhance the care we provide for our service users. We look forward to working with you the staff to provide the safe and high quality care for our communities. Over the forthcoming months we will develop local action plans to realise the clinical strategy and to ensure that changes taking place within commissioning and provider organisations. Page 4 of 44

5 ACKNOWLEDGEMENTS The authors are grateful to the assistance of their teams in the production of this Clinical Strategy, and also to the help that was willingly given to the project by the members of other directorates who provided assistance with areas in which they were key experts. They are also grateful to those involved in proof reading at various stages. Grateful thanks also go to the Trust Board for their support for this concept and for their constructive feedback. EXECUTIVE SUMMARY The Clinical Strategy has been produced by the Medical Director and Consultant Paramedic with contribution from the Director of Clinical Care and Patient Safety as well as other directorates. Its aim is to identify the key clinical principles that underpin the Trusts Strategy and from these to build a clear and cohesive approach to delivering the highest quality clinical care to the patients of the North East England locality. The approach taken in this document has been to break the delivery of high quality clinical care into distinct steps, starting with the clinical concept and the context in which healthcare is delivered by North East Ambulance Service NHS Foundation Trust, and then in the following chapters elaborating on the individual steps which are necessary to provide high quality care defining, developing, delivering and evidencing the care given. Throughout this Clinical Strategy a series of Strategy Pledges have been made to our patients. These will, for the next five years, form the basis of developments and evidencing of high quality clinical care. These pledges are brought together at the end of the document in Appendix A, with executive leads identified for each pledge. This table will be used when developing the annual plans to ensure the development and delivery of all pledges, which in turn will ensure all aspects required to deliver high quality care receive equal focus and the Trust can be assured that appropriate processes are in place. Mr. Kyee Han, Medical Director Mr. Paul Aitken-Fell, Consultant Paramedic Page 5 of 44

6 CONTENTS Medical Director And Consultant Paramedic Foreword... 4 Acknowledgements... 5 Executive Summary... 5 Contents Chapter One- Clinical Concept Of Operations Chapter Two- Contextualising Chapter Three- Defining Care Chapter Four- Developing Care Chapter Five - Delivering Care Chapter Six - Evidencing Care References Glossary Appendix A: Summary Of Strategy Pledges Page 6 of 44

7 1. CHAPTER ONE- CLINICAL CONCEPT OF OPERATIONS 1.1 What we Want the Ambulance Service to Look Like In 2016, patients contact the ambulance services in the United Kingdom with a much wider variety of care needs than in the past, and our staff must be able to recognise and meet these needs, either alone or as part of a multiprofessional, multi-location team. In alignment with the vision of CQC we aspire to deliver a caring, responsive, efficient and effective service which is well led and governed The pillars in the NHS Mandate and the direction in the operating framework continue to inform how North East Ambulance Service NHS Foundation Trust (NEAS/the Trust) enhances and promotes quality care for patients:- a) Through better commissioning, improve local and national health outcomes, particularly by addressing poor outcomes and inequalities. b) To help create the safest, highest quality health and care service. c) To lead a step change in the NHS in preventing ill health and supporting people to live healthier lives. d) To improve out-of-hospital care. e) To support research, innovation and growth Care needs range from specialist pathways for high acuity treatment at a specialised centre, such as a Major Trauma Centre, Hyperacute Stroke Units, and PPCI Centres; bespoke pathways for on-going lower acuity care in the community, to patients who will travel between high and low acuity settings at points along their clinical journey. We will strive to match the needs of all these patients with the right care, in the right place at the right time. Our commitment to change embraces the mission to provide safe effective and responsive care to all with a vision to provide unmatched quality of care every time we touch lives. 1.2 To do this, our workforce will need to develop. It will become increasingly professional, with degree-level paramedic practice at the core, and increasingly multi professional, with the use of nurses, advanced practitioners and medical professionals bringing their own expertise and supporting our core staff. 1.3 Roles will diversify: our paramedic workforce will undertake specialisation enabling them to deliver more bespoke care to both high and low acuity patients, including providing care advice remotely without themselves attending the patient in person. These developments will increasingly enable paramedics and Allied Health Professionals to meet their full potential as specialised Page 7 of 44

8 healthcare professionals, and allow them to make full use of developments in technology and changes in the way care can be delivered. To recruit, develop and retain good quality staff there is a need for a clear career progression pathway to enable staff to thrive and enjoy working for NEAS and ultimately delivering unrivalled quality care to patients. A. STRATEGY PLEDGE: NEAS will continue to promote high quality care for patients, and ensure its workforce is placed to meet increasingly complex a n d d i f f e r i n g h ealthcare needs DELIVERING RIGHT CARE RIGHT PLACE RIGHT TIME 1.4 NEAS will strive to match the needs of the patient with the correct response, correct decision-making, correct treatment in the right place with appropriate onward review. In alignment with the vision for the ambulance service: 2020 and beyond we will aspire to evolve into a mobile healthcare provider across a range of services and settings. 1.5 Planning To Meet Demand - Ambulance services have traditionally used a number of methods to plan operational delivery. NEAS has had a challenging period of time with regard to current performance but has been a high-performing Trust in this regard. However, we must now also ensure that the current needs of individual patients are considered i n more depth and if possible anticipate and forecast the future as well. This will be as important as the total volume of 999 and 111 calls. The impact of all pathways on patient's ability to access care, both the 999 and 111 services, the use of walk-in u r g e n t c a r e centres and out-of-hours doctors services are part of the whole. No one element can be understood in isolation from the others and the urgent and emergency care network needs concerning both social and health care requirements must be taken into account. 1.6 Hear and Treat - Some patients ringing the 999 service as well as the 111 service can have their care needs managed entirely over the telephone. This is called "hear & treat". Typically, these patients are those with minor or self-limiting illnesses, who will receive advice on managing their symptoms and what to do if they deteriorate. They may also ring for healthcare-related information, which we can provide over the telephone. NEAS uses the NHS Pathways system to manage calls, with a team of paramedic and nurse Clinical Supervisors within the clinical hub to provide enhanced care over the telephone for patients who are suitable for this type of advice. B. STRATEGY PLEDGE: NEAS will strive to safely increase hear and treat rates in the 999 and 111 services. 1.7 See and Treat - The majority of patients who ring 999 will require a face to face assessment from a NEAS clinician. Clinicians assess and treat the patient, then decide on the best next steps for the patient. Since 2012, NEAS has introduced Enhanced Care Paramedics and as from 2015 Advanced Practitioners Page 8 of 44

9 (APs) who are able to diagnose and treat a range of conditions in the community using an extended range of medicines, and skills, enabling patients to be treated on scene or at home. Some elements of point of care testing have been evaluated and are to be implemented which will allow our Advanced Practitioners to perform screening tests in the patient's home, only needing to travel to hospital if the results indicate this is needed. The Transforming Urgent and Emergency Care services in England refer to the Emergency ambulance services as a mobile urgent treatment service. C. STRATEGY PLEDGE: NEAS will continue to develop specialist paramedics and advanced practitioners to ensure that more patients can be treated in the community and avoid attending A&E where this is not appropriate. To enable this, NEAS will also continue to develop the clinical hub in the 999 and 111 contact centres using clinicians from an agile work force to align the skills of the responder to the needs of the patient. 1.8 See and Convey - NEAS has been working to safely reduce the number of patients taken to hospital, but there will still be some patients for whom hospital care is necessary. The majority of patients will be taken to the nearest A&E department but some patients will need more specialist care at regional centres of excellence. NEAS supports the development of specialist clinical networks to ensure that all patients with specialist needs follow a pathway that delivers the best possible clinical outcomes and is integral to development and implementation of the agreed patient pathways. 1.9 For patients with high acuity, life threatening conditions, H A R T a n d S p e c i a l i s t Paramedics (SPs) provide enhanced assessment and treatment, and also provide senior clinical leadership at incidents working collaboratively with the GNAAS and BANE teams with medically qualified staff. Following the success with CARU, the introduction of Critical Care Paramedics (CCP) is being explored As clinical care advances internationally, new medicines and techniques become part of the standard of best practice. NEAS will ensure emerging best practice is included in the routine care of our patients. D. STRATEGY PLEDGE: NEAS will continue to develop specialist paramedics and advanced practitioners to deliver specialised pathways of care, ensuring patients get specialist care at the right time and in the right place. Page 9 of 44

10 2. CHAPTER TWO- CONTEXTUALISING 2.1 External Landscape and Context Costs of healthcare are rising above the rate of inflation due to advances in treatments and the changing demographics of the population. Whilst the government seeks to protect clinical services, health funding is coming under increasing pressure as the available government budget shrinks relative to costs Along with less central n a t i o n a l policy direction there is increased locally derived patient involvement, and the public has more appetite to hold public bodies to account, which makes us more determined to optimise all aspects of our service. Within the UK and Europe, ambulance services are still fragmented in their approach with differing models of care delivery. NEAS has the opportunity to become an exemplar of a clinically effective-cost efficient approach to delivering an increasing proportion of the population's healthcare needs Recent changes to the structure of the NHS in particular to commissioning arrangements, where more local Clinical Commissioning Groups have replaced larger Primary Care Trusts, as well as the delivery of healthcare education through the Local Education and Training Boards, create a challenge in ensuring our workforce is of high quality, but also prompts us to focus better on what is vital in terms of investment goals and to identify the critical successes that will evidence our effectiveness as a provider of clinical care Cost effective healthcare requires embracing innovation, and by strengthening the professional identity of our paramedics we can provide more opportunities for our patients to have the best outcome in a cost effective way. There is currently a relatively weak evidence base in prehospital care and we can be instrumental in strengthening this by promoting research, audit and innovation As a Foundation Trust, we are able to determine and respond to the local needs of our population and we will develop effective new models of care, which may mean challenging professional and role boundaries More recently, there are changes in the commissioning landscape with the introduction of Accountable Care Organisation (ACO) and Place based systems of care for health and social needs. NEAS aspires to be actively involved in the development of systems which will ensure best care for the local population they represent according to the JSNA (Joint Strategic Needs Assessment). E. STRATEGY PLEDGE: NEAS will strive to focus on the financial imperative, but not at the expense of reduced quality of care High quality care can drive up productivity and be more cost effective and we will continue to look for the best way to convert every available pound into care. Page 10 of 44

11 2.1.7 Where are we now and what do we want to look like in 2020? NEAS recognises that in order to meet patient demand and provide high quality care, it must plan for the future. Between now and 2020, we will be working on the following areas of work and developments. Page 11 of 44

12 Business Area 2016 Milestones, achievements and work in progress 2021 Why Ensure that there are continued developments, including work with partner emergency services to develop joint strategies and responding to improve out of hospital cardiac arrest survival. Work has started with the four regional Fire Services Co responding is live across all four areas from selected stations; develop co-responding to cardiac arrests and trauma. Further develop the coresponding to develop a full region wide service To enhance the patient experience and outcome ensuring a timely response for the most critically ill or injured patient Ensure patients with vascular emergencies (including ruptured abdominal aortic aneurysms) are assessed, treated and conveyed to the most appropriate facility to manage their care. This will include working with our partners as further reconfigurations of services take place Consider the use of a standard pre hospital warning score-such as the National Early Warning Score for use in both adults and children. Work has already started across the North East looking at a Vascular Emergencies Pathfinder algorithm All staff have access to the NEWS score via the pocket book there is an increase in nursing homes and GP s using this system. Continued work with the NE cardiovascular network to ensure the delivery of a regional wide vascular service Pilot of the Paramedic Pathfinder in Sunderland using the NEWS score To have in place a robust system to ensure patients are transported to definitive care If the pilot is successful then a rollout across the region for Paramedic Pathfinder To ensure the patient receives definitive care at the earliest opportunity to increase the survival rate. Standardisation of care is paramount to ensure the safety of patients and to ensure the patient is treated appropriately Enable ambulance clinicians to have comprehensive access to special patient notes with one system across whole health communities so ambulance services see the same message about a patient s special situation as NHS 111, out of hours primary care, emergency department etc. Ensure that there is generic documentation around do not resuscitate orders and when and when not to resuscitate policies and that this information is accessible by NEAS staff. There is limited access to clinicians as part of a trial for mobile DOS and for access to the national spine All staff have been trained in DNACPR and the documentation that is used within the North East. Through Vanguard there is an application to bring the regional special patient notes and the spine access together and to allow NEAS staff access to these notes NEAS have to be able to access this information electronically and frontline crews need the information in a timely manner. Development through Vanguard for special patient notes. To have a regional electronic system in place that enable access by staff on the front line. All operational staff have instant access to this information when remotely on scene with a patient. This would enable access to individual care plans, end of life plans, records of DNACPR forms, mental health plans and violent patient warnings to ensure the patient is treated appropriately. To allow the patient to receive the right care when they and their family are at the most vulnerable Page 12 of 44

13 Business Area 2016 Milestones, achievements and work in progress 2021 Why The future clinical models for ambulance services and NHS 111 could include increasing the clinical input and the development and provision of a clinical care coordination service or central care advice and support centre that could be for specific groups of patients such as: Patients at the end of life Frail elderly Patients with mental health needs including place of safety Patients requiring urgent dental advice Work has begun in NEAS to develop a robust clinical hub this development is now a major part of the Vanguard application Some recruitment has taken place for the clinical hub and Vanguard are now working with NEAS on this development To have a fully integrated Clinical Hub to co-ordinate services and offer centralized clinical support To ensure the patient gets the right advice at the time of call ensuring the patient experiences an appropriate response to their needs Health records and patient data Patient outcome - meeting and exceeding national and international best practice Contract coming to an end on current e- PRF system 90% compliant with e-prf 10% compliant with paper based and scanned. No whole system data sharing. Very little data is available easily for NEAS patient outcomes E-PRF project. A&E data feeds Major Trauma TARN. Cardiac arrest survival to discharge data. A&E data feeds for admission data Electronic clinical records. Seamless data transfer. Anticipatory care planning. Electronic reporting. Paperlight clinical systems Patient dispositions and outcomes available for analysis from all health partners Clinical data is essential in planning services, educating staff and measuring performance. The move from response times only to a range of clinical performance measures will require good data access. NEAS aspires to being the best it can be, and this requires comparison with the best EMS systems in the world such as Australia and parts of Europe. Advanced practice As at December 2015 we have 15 Advanced Practitioners. Advanced Paramedic education from Define role of Critical Care Paramedics Increased numbers of Advanced Practitioners and Clinical Hub in line with workforce plan Introduce Critical Care Paramedics. It is vital that clinicians are effectively supervised and supported, and that they have a clear career framework to aspire to. Page 13 of 44

14 Business Area 2016 Milestones, achievements and work in progress 2021 Why ICaT Integrated Care & Transport Single Service Model Supporting intelligent dispatch Clinical Hub Urgent transport e.g. End of Life Collaboration with Fire and Police other blue light services Mobile healthcare provider with multitude roles including navigation;coordination;diagnostics; treatment; transport in a range of settings New model of care enabled by technological development, increasing use of tele-health care Health Promotion This is a model which will be in line with the landscape set by NHS England to transform urgent and emergency care services in England. NEAS aspires to be the hub of the urgent and emergency care networks in the North East. To ensure the right resource is being sent to the right patient, ensuring that those with a complex need receive the correct care at the first contact with NEAS. Scope of practice and clinical standards of Trust paramedics Scope of practice in NEAS is no longer the most extended in the UK e.g. surgical airway capability, chemical restraint Investing in CCP scope of practice being developedskills, treatments and medicines. Paramedics and APs delivering NICE- Recommended treatments. Scope of practice equivalent to best EMS systems achieved in all areas of care - introduced safely with care and caution Patient demand is more than just volume of calls. Patients fall in categories based on severity and complexity, and the workforce must develop accordingly Embedding of staff in local health economies AP placements in primary and Urgent care. GP H E N E facilitated AP placements. Developing and Training CCP (Critical Care Paramedic). Exploration of rural community based AP pilots. Community based APs and paramedics - linked with local CCG. CCPs having more central role in critical care and trauma networks Ambulance services must be embedded in local and regional health services in order to minimise hand over of patients, to enable data sharing and to drive up quality- all within a cost effective financial envelope. Page 14 of 44

15 Business Area 2016 Milestones, achievements and work in progress 2021 Why Technology, Innovation and horizon scanning. Some point of care testing. Extensive innovation with slow adoption Point of care testing for PPs- Hb, WBC, FEV, Lactate. Blood testing for CARU. Fully integrated point of care testing facility. Rapid adoption of best practice innovation. Research & Development agenda expanded within NEAS Adoption of innovation in ambulance services can be slow due to a range of issues. Where innovation clearly promotes safety and/or reduces costs (NEAS or whole system), funding must be rapidly made available through commissioning or other research and development funding Research and Development Active R&D Group. Small number of studies undertaken within NEAS- Involvement in several key projects, such as PARAMEDIC2 trial, adrenaline vs placebo in out of hospital cardiac arrest. One of five ambulance services taking part, due to finish in POD Pilot, pilot project for ResQpod device with a view to apply for funding to roll out the trial nationally. Career framework adopted and ensures that advanced and consultant paramedic drive research and development of evidence base Ambulance services have been slow to embrace research and NEAS needs to drive sector specific evidence in order to develop safe and appropriate services. Career Framework New senior clinical roles in line with College of Paramedics Framework. Specialist practice currently extends to level 6 and 7 (postgraduate). NEAS staff to be given opportunities and encouragement to progress in areas of clinical practice, Education Management and Research in line with recommendations of the College of Paramedics Increased numbers of specialist advanced, paramedic practitionerswith prescribing ability and additional Consultant Paramedics. Medicine, Nursing and most allied professions have fully formed career frameworks from registration to consultant level. Senior clinical leaders promote standards and drive research, education and service developments. Page 15 of 44

16 Business Area 2016 Milestones, achievements and work in progress 2021 Why Extending MERIT service to all times when GNAAS helicopter is not operational Comprehensive CARU response in all 3 divisions of NEAS Clinical leadership of paramedics on duty Cover is only partial for major incidents 24/7 and weekends only for major trauma. Currently covers only 19 min radius from HQ On call senior staff and ECCMs Ongoing planning and discussion with commissioners and GNAAS as providers Ongoing support for BANE to become active in Tees Division Increasing number Of ECCMS available to staff. 24/7 effective cover with fast response times to all areas for very high level capability when needed CARU response in all three divisions Paramedics to access ECCMs on call. Senior Paramedic on call to support ECCM on duty. To reduce time to definitive care giving the patient the best chance for survival and good outcome To improve outcome from cardiac arrests and support front line staff with extended capability Provides two levels of support for the front line paramedic Centre of Excellence for Training Following a review the weaknesses in the structure and function of the training department is being addressed with new job plans to recruit trainers who are clinically current and remunerated appropriately Successful delivery of the foundation program with Sunderland university. Successful delivery of annual mandatory training using simulation to maximum potential Good CPD program m e.g. ITLS AMLS In addition to in house training to capitalise on external training needs of other EMS and CFRs This is an integral part of NEAS which will ensure recruitment, staff development and retention of clinicians. Will also generate income for the trust Mental Health, Substance overuse and Dementia care National initiative to improve care for the patient groups who have received sub optimal care for various reasons Work in progress to streamline responses to call for help starting with expertise in the contact centre, increased awareness and training of staff and collaborative response with other blue light agencies Provide seamless care and transport for these patients to the right destination other than A&E for ongoing care This will result in good outcomes and minimize repeated and frequent calls for help from acute crises Page 16 of 44

17 F. STRATEGY PLEDGE: NEAS will work towards goals that will give our population a caring responsive effective well led and safe ambulance service within a framework of effectiveness, clinical leadership, and development. 2.2 Direction of travel of the NHS The Keogh review (2103) continues the theme of moving clinical care into the community with ambulance services and paramedics playing increasingly important roles, both in the provision of clinical care and in gate keeping. North East locality commissioners recognise and support this direction. A capacity and skill mix review provided for the Trust and the Commissioners is recommended. The NHS is in a period of revolutionary change which will result in large scale system change compounded by the prevailing political landscape The greatest risks to our organisation are a reduction in funding, inability to compete on costs, and how replicable our business might become. One risk for existing statutory provider organisations within the NHS is that the private and charitable sectors will position themselves to take over contracts. Private providers are able to run a very low-cost transport based model of care, this lacks infrastructure, which in turn keeps their costs low We must articulate our understanding of the complexities of patient demand and flow; show that we really understand our demography and geography, and provide compelling evidence that we can convert this expertise into a predictable, high quality service which will have significant demonstrable downstream and whole system financial benefits within an affordable contract cost. NEAS is already ahead of the curve with the ICaT initiative. G. STRATEGY PLEDGE: NEAS aspires to remain as the only comprehensive provider of emergency ambulance and 111 services in the North East locality. We will deliver value for money and demonstrate our knowledge and acumen for the urgent and emergency care sector to our Commissioners. 2.3 Health Economy Strategy and Driving Factors The biggest challenge for all healthcare providers is to ensure that high quality services are maintained within an increasingly constrained financial envelope. It is also true that health is no longer the only victim of a tighter public purse; and the public have seen first-hand how other sectors have (or have not) maintained safe, high quality services. This means providers with a responsibility for services across a wide area may have a very different view of priorities to their local populations. Decision-making can therefore be slow and complex any compromise can lead to an eventual Page 17 of 44

18 agreement that is a poor fit for stakeholders. It is hoped that ACOs and Place based systems of care leaders are sighted on this Long term conditions, which in the past were life shortening, can now be managed effectively, extending lives with good quality but with on-going care needs required over many years. Few patients with long terms conditions have only one disease. Multiple diseases (known as comorbidities) place patients at increased risk of periods of acute ill health. Whilst effective clinical management by GPs and other health professionals in the community can mitigate this in part, patients will still become unwell requiring repeated escalation and de-escalation of their care over a number of months/years. To play a full part in predicting and managing this, the Trust needs to have access to the right information and to work in close partnership with both community and hospital based providers. 2.4 North East Health Economy There are currently eleven Clinical Commissioning Groups in the locality, each with their own population for whose health care needs they hold responsibility. They work within the NHS Operating framework which gives these groups flexibility to determine what services should be commissioned and how. With this local system of commissioning NEAS must retain its local focus giving assurance to patients and their communities about their concerns whilst ensuring all our patients receive a uniform high standard of care regardless of where they live. There is potential merit with the development of ACOs in the north, the Better Health Program in the south and the plan for CCGs coming together in clusters. NEAS must aspire to be actively involved in the changes ahead with a clear vision how we can contribute Increasing clinical quality metrics for acute sector services promoting competition may mean that acute providers specialise more and some services move to specialist centralised locations as in major trauma, vascular emergencies and stroke care. This will impact on the clinical care that NEAS delivers to patients and also on the resources required for longer journeys to centres of specialisation. As we are aware, South Tyneside DGH is reconfiguring the services provided locally with Sunderland City Hospital; this will have implications for NEAS. 2.5 Local Commissioners will look to evidence care at a local level, with input into how this is achieved. CQUINs which allow part of annual funding to be delivered only after the achievement of quality markers are likely to become more local and to be more exacting. Commissioners need an awareness of the potential for conflicting quality measures to be imposed by multiple stakeholders, and NEAS needs ensure there is an understanding of the consequences of this by all parties and a joined up approach. Page 18 of 44

19 H. STRATEGY PLEDGE: NEAS will ensure that it remains focussed on meeting the needs of our population keeping a clear focus on quality of care and appropriate conveyance across the health economy. 2.6 Value for Money It is challenging to conclusively evidence and attribute clinical and financial value for money in developments in pre-hospital care. This is because for many patients, their healthcare journey crosses multiple providers under whose care much more time is spent than that spent in ours, therefore the added value to outcome delivered by NEAS is diluted. Similarly many actions and improvements undertaken by NEAS have largely downstream benefits to other providers. We need to develop ways to show the true impact of quality pre-hospital care more easily It is especially important to ensure that we provide evidence that a highly qualified workforce is better for patients, for example by showing that patients with long term conditions are admitted to hospital less frequently. This evidence base will be further developed and strengthened. Higher skilled staff, with access to anticipatory care plans can change the patient journey back to community support rather than to the A&E department The last piece of the value for money jigsaw is investment in technology. Increasing care that can be delivered safely in the community using this effectively makes good economic as well as clinical sense. We must continue to horizon scan for developments in this area. I. STRATEGY PLEDGE: NEAS will continue to convert every pound of income into effective and high quality care. Value for money must be continually reappraised in relation to the changing landscape, and NEAS will continue to scan the horizon for ways to make care safer and more effective. Page 19 of 44

20 3. CHAPTER THREE- DEFINING CARE 3.1 Benchmarking and Best Practice from the UK and Abroad There are key service developments which are essential enablers to achieving our goal of being an ambulance trust meet and exceeds national and international best practice as described in the section entitled Service Development. NEAS is committed to being an organisation at the forefront of excellence in clinical care We achieve this by identifying current best practice worldwide and benchmarking ourselves against it, and by participating in research to further the development of clinical care as part of a systematic and governed research network. J. STRATEGY PLEDGE: The Trust will develop benchmarking tools and use these to map the service against national and international practice. 3.2 National Guidelines Within the UK, there are expert bodies that set standards of care for different conditions and groups of patients relevant to the ambulance service: a) NICE (National Institute for Health and Care Excellence) established in 1999 to harmonise the standards of care delivered by health and social care communities across the UK, as well as to increase access by professionals to the scientific evidence underpinning high quality care. New guidelines are increasingly being developed in conjunction with user groups. We will increase our involvement both in identifying and developing guidance applicable to the Trust to ensure appropriate pre-hospital care, and also identify where innovations can have the greatest impact on patient wellbeing. b) JRCALC (Joint Royal Colleges Ambulance Liaison Committee) publishes guidance on clinical practice for ambulance services. The Trust has staff members on JRCALC working to ensure guidelines are based explicitly on scientific evidence, and applicable to the pre-hospital care setting. c) College of Paramedics Curriculum Framework and Post Registration- Paramedic Career Framework represent important reference p o i n t s. In addition a number of position statements are produced on important clinical topics. d) The Health and C a r e P r o f e s s i o n s C o u n c i l s Standards of P r o f i c i e n c y and Standards of Conduct Performance and Ethics are also key documents that influence paramedic practice nationally. Page 20 of 44

21 K. STRATEGY PLEDGE: Continued engagement with NICE and JRCALC to ensure the Trust is sighted on trends in clinical care within the sector and participates in the progression of evidence-based medicine Supported by the Learning and Development Department we will improve engagement of staff in the review, implementation and evaluation of clinical guidance. The processes of systematically evaluating and planning implementation of published clinical guidance and standards will be developed further to embed it across all Directorates of the Trust; enabling us to close the loop, evidence successful engagement and implementation, and where appropriate demonstrate better clinical outcomes and/or patient experience Where guidelines already exist and are implemented, we will ensure they remain pertinent to our organisation and are delivered to the highest standard, through existing and continually improving clinical audit and clinical governance arrangements. L. STRATEGY PLEDGE: Embed the implementation of guidance into normal business for the organisation, and to incorporate evaluation fully into the implementation cycle. 3.3 Stakeholder Involvement As an Emergency a n d U r g e n t service there is a need to ensure resources are not rationed by demand but are apportioned according to clinical need. Ensuring resources are available for patients with serious or life threatening conditions requires us to develop and deliver systems to minimise inappropriate resource usage The political and commissioning direction of providing more care closer to home allows NEAS to engage with other providers in strategic partnerships reducing safely the number of patients conveyed to A&E. M. STRATEGY PLEDGE: The views and opinions of relevant stakeholders will be actively sought with specific reference to patients including hard to reach groups. Page 21 of 44

22 4. CHAPTER FOUR- DEVELOPING CARE 4.1 Education and Training Training, education and development of all staff is a priority for the Trust to equip individuals to give the best possible patient care, and to support the organisation as a provider of high quality healthcare services The Learning and Development team advise our partner Higher Education Institutes (HEI s) on the curricula for both graduate and post graduate paramedic programmes, and a number of NEAS staff are on the faculty of those HEI s as lecturer practitioners. Programmes are developed as the service requires, and are monitored to ensure they give students relevant, appropriate and up to date knowledge and skills. There is representation on the NEAS CAG from Sunderland University which now delivers the foundation degree program Graduates subsequently joining NEAS undertake a preceptorship to help them transfer learning into their role as an autonomous practitioner, responsible for providing the best possible patient care In addition, continuing professional development; Annual Mandatory Training and Appraisal is a cornerstone in the Trust's education and training plan, with dedicated resources to offer skills training in a range of subject areas, and to facilitate personal and professional development opportunities delivered both in-house, and by external providers. This builds on the performance appraisal process, enabling staff and managers to meet any identified needs in patient care, service provision, team leadership, and professional development The yearly Statutory and Mandatory training programme is developed to ensure a balance of clinical updates as well as regular refreshers such as information governance, infection prevention and control, safeguarding along with key skills such as resuscitation and trauma management NEAS recognises that as the workforce becomes increasingly professional and highly skilled, it will also be more mobile, so there will be an ongoing focus on recruitment and retention. This will ensure that NEAS is an employer which attracts the highest quality staff in the sector and they can progress their careers within the organisation in a clinical, teaching or managerial role. N. STRATEGY PLEDGE: To ensure that all staff receive high quality education and training to allow them to maximise their clinical effectiveness. 4.2 Contingency Planning and Resilience Under the Civil Contingencies Act 2004, the Trust has a statutory responsibility along with other Category 1 and 2 responders to participate in national resilience by responding if requested to Mass Casualty or Major Incidents. The management of recent large scale emergencies has come Page 22 of 44

23 under increased scrutiny, and the Trust is required to have and maintain robust contingency planning and systems in place The government oversees events which have a national impact; political reputational and economic via the Cabinet Office Briefing Room (COBR) and has a network of regional Resilience Emergency Division (RED) officers who work with Local Resilience Forums (LRFs) The introduction of Local Health Resilience Partnerships (LHRPs) also requires the Trust to play a key role in the development of local, regional and national Health resilience To maintain core services at times of unplanned or unexpected disruption the enhancement of Business Continuity (BC) arrangements will be a key focus of strategy moving forward. Ensuring that all staff understand their roles and responsibilities within the BC arrangements will enable the Trust to continue to deliver services to our patients, both for impacts which affect the organisation in isolation and those that affect the wider community. a) The Trust will ensure clinical staff understand their role and are practised in responding to Mass Casualty and Major Incidents. b) The Trust will ensure the infrastructure is such that staff will have at their disposal appropriate resources to maintain the highest possible level of clinical care. c) The Trust will ensure those required to undertake a command role during incidents have the pre-requisite skills and competencies. A commitment has been made to ensure that all Gold, S i l v e r and B r o n z e L e v e l m a n a g e r s have u n d e r t a k e n appropriate training courses The Trust will re-evaluate the role of Medical Emergency Response Incident Teams (MERIT) and Medical Incident Advisor (MIA) to better understand how and where MERIT has a role which enhances clinical care whilst at the same time provides best value, and how to ensure clinical effectiveness is maintained. O. STRATEGY PLEDGE: To participate fully in national and local resilience structures and to develop systems that enhances the delivery of care for all patients. 4.3 H.A.R.T The Hazardous Area Response Team (HART) initiative was introduced into NHS Ambulance Trusts in response to the Government's request to provide an ambulance capability within the warm and hot zones at major and Page 23 of 44

24 large scale incidents; particularly where loss of life could be prevented by earlier intervention There are 15 HART teams in England and Wales funded initially by the Department of Health through the National Ambulance Resilience Unit (NARU). After two years initial set-up costs ongoing funding was transferred to commissioning bodies ( 2.2million). The teams are part of the national resilience strategy but work within and provide day to day support for their host ambulance trust. The service specification is set by NARU including details for the fleet, buildings, staffing, recruitment, deployment of resources and funding arrangements. HART is now written into the Governments Contest 2 Strategy along with National Security Strategy (HM Government Oct 2010). Commissioning Bodies "Are to ensure that HART capabilities are maintained to the required specification in accordance with the NHS Standard Contract for Ambulance Services". (NARU 2012) The Trust operates a HART team based at Russell House Monkton in alignment with the Home Office Model Response site requirements. It comprises of 42 operational staff, with a HART Manager, Administrator and HART Training Manager. P. STRATEGY PLEDGE: To develop the HART team further to ensure that it works to its most effective level both at home and abroad. There is merit in integration of the valuable resource into the NEAS clinical workforce alongside with specialist paramedics e.g. Trauma, Critical care paramedics, Advanced Practitioners and Consultant Paramedics. Page 24 of 44

25 4.4 Role Developments and Workforce Redesign The current operational workforce comprises of a range of different clinicians who practice at different levels of the NHS Career Framework with appropriate scopes of practice. Nursing and AHPs are additional and valuable members of the team and integration of their training and development will be aligned with the paramedic, emergency care technician work force. Page 25 of 44

26 a) Emergency Care Assistant (ECA) - Health support workers operating at level 3 of the career framework. ECSWs are trained to provide support to senior staff and are not deployed on their own. b) Ambulance C a r e Technician/Advanced Technician -_Associate practitioners, operating at level 4 of the career framework, usually work on ambulances with a Paramedic, another technician or ECA. Technicians are trained to provide care for a limited range of conditions and can convey patients to A&E or refer them. c) Paramedic - Registered health professionals at level 5 of the career framework, which is the entry level for registered health professionals. Regulated by the Health and Care Professions Council (HCPC). Trained to provide advanced life support and manage a broader range of conditions. d) Specialist Paramedic (Urgent Care) -_Specialist paramedics at level 6 who have undertaken additional education and training to manage patients with minor or longer term conditions such as minor injuries and infections. Liaise w i t h community colleagues to provide care closer to home. e) Specialist Paramedic (Critical Care) - Specialist paramedics at level 6 who have undertaken additional education and training to manage patients with serious and life threatening illness and injury. Support colleagues with the most serious incidents and ensure the patient is stabilised for transit to the most appropriate hospital. f) Specialist Practitioner (Operations Room) - Nurses/Paramedics working in the Operations Centres EOCs) within both the 999 and 111 services to provide support both to staff managing challenging or complex calls, and to staff who are with a patient where care needs are complex. g) Advanced practitioner (APP) at level 7 with advanced clinical or educational knowledge pursuing higher postgraduate degrees. h) Consultant Paramedics at level 8. Minimum 3 one for each division NEAS is expanding and diversifying its workforce in response to changes in service delivery. Hear & Treat and 111 have led to more nurses joining NEAS in the Operations Centres (OC), working alongside increasing number of paramedic colleagues. Staff dispatching ambulances will be developed further to ensure that the correct resource is sent to all cases. A clinical hub is being introduced to support the trained call takers. Page 26 of 44

27 Q. STRATEGY PLEDGE: The skill mix of staff working in all areas of clinical care will be set according to patient need and levels of demand. NEAS will strive to create and maintain a workforce which is highly effective, safe and value for money Clinical Workforce Development Overview: The ten key Roles and Responsibilities for Allied Health Professionals (AHPs) are: a) To be a first point of contact for patient care, including single assessment. b) To diagnose, request and assess diagnostic tests, and prescribe, working with protocols where appropriate. c) To discharge and/or refer patients to other services, working with protocols where appropriate. d) To train and develop, teach and mentor, educate and inform Allied Health Professionals, other health and care professionals, students, patients and carers, including the provision of consultancy support to other roles and services in respect of patient independence and functioning. e) To develop extended clinical and practitioner roles which cross professional and organisational boundaries. f) To manage and lead teams, projects, services and case-loads, providing clinical leadership. g) To develop and apply the best available research evidence and evaluative thinking in all areas of practice. h) To play a central role in the promotion of health and wellbeing. i) To take an active role in strategic planning and policy development for local organisations and services. j) To extend and i m p r o v e c o l l a b o r a t i o n w i t h o t h e r p r o f e s s i o n s a n d s e r v i c e s, including shared working practices and tools By aligning our strategy to the ten key Roles and Responsibilities we can promote and enhance high quality care across the spectrum of patient need and gives our health professionals the opportunity to develop their practice- often as part of a wider health team. Page 27 of 44