GREATER MANCHESTER JOINT HEALTH SCRUTINY COMMITTEE

8 GREATER MANCHESTER JOINT HEALTH SCRUTINY COMMITTEE Date: 11 January 2017 Subject: Report of: Ambulance Performance across GM Derek Cartwright, Chief Executive North West Ambulance Service and Stuart North, Chief Officer, Bury Clinical Commissioning Group PURPOSE OF REPORT: This briefing has been provided to update the members of the Greater Manchester Joint Health Scrutiny Committee on the position regarding Ambulance performance across the Greater Manchester area. The briefing focuses primarily on the Paramedic Emergency Services (PES) provided by North West Ambulance Service NHS Trust (NWAS), but references other on-going work to support performance of the service at a time when it is under continued pressure. NHS 111 and Patient Transport Services (PTS) are described below as they are part of the overall package of services delivered by NWAS, but they are not covered by the scope of this brief. RECOMMENDATIONS: Members are asked to note the contents of this briefing, which will be expanded upon at the Joint Health Scrutiny Committee meeting with a presentation made by NWAS and Commissioner Leads. CONTACT OFFICER: Chris O Neill Senior Ambulance Commissioning Manager Chris.O Neill@blackpool.nhs.uk Page 1 of 13

1. Introduction This briefing has been provided to update the members of the Greater Manchester Health Overview and Scrutiny Committee on the position regarding Ambulance performance across the Greater Manchester area. The briefing focuses primarily on the Paramedic Emergency Services (PES) provided by North West Ambulance Service NHS Trust (NWAS), but references other on-going work to support performance of the service at a time when it is under continued pressure. NHS 111 and Patient Transport Services (PTS) are described below as they are part of the overall package of services delivered by NWAS, but they are not covered by the scope of this brief. 2. Background There are 3 services provided by NWAS to Greater Manchester Clinical Commissioning Groups (CCGs): PES o PTS o These are Paramedic Emergency Services, recognised as the blue light ambulances responding to patients in need of urgent care and attention. This is the Non-Emergency Patient Transport Service, which transports eligible patients to and from routine outpatient appointments, patient discharges, transfers between healthcare facilities; and Healthcare Professional requested transport for patients in the community who need to be transported to hospital at short notice. NHS 111 o This is the NHS telephone service provided to allow patients to access advice or medical/urgent care treatment quickly, but where the situation is not an emergency. The NHS 111 service also provides information to patients on local services provided near to a patient s home that is part of the Directory of Services. The PES and NHS 111 services are provided as part of an overall collaborative contract on behalf of the 33 North West CCGs while the PTS service is a dedicated Greater Manchester service for the 12 Greater Manchester CCGs. The 3 services are managed by the Ambulance Commissioning Team, hosted by Blackpool CCG as Coordinating Commissioner, working on behalf of all 33 North West CCGs. Contract Costs: The total cost of delivering PES, PTS and NHS 111 across the North West is circa 300m each year. Of this Greater Manchester CCGs contribute circa 100m split as follows:- PES 80.7m Page 2 of 13

PTS 13.3m NHS 111 7.1m Governance Arrangements Governance for the 3 contracts is delivered at North West level through the NWAS Strategic Partnership Board (SPB), which comprises CCG Chief Officer and Clinical Lead representation from each of the five County areas. The SPB also has representation from the NWAS Executive team and the Ambulance Commissioning Team. Within the overall governance framework there are a number of other groups that support the strategic direction set by the SPB. There are also strong links with the Urgent & Emergency Care Networks, NHS England / NHS Improvement and the A&E Delivery Boards (System Resilience Groups). The full governance structure for the delivery of the contract is shown at Appendix 1. 3. Paramedic Emergency Services (PES) The PES service responds to patients with serious or life-threatening conditions. Patients calling 999 are triaged according to their need and the nature of their condition. NWAS allocate the nature of the patient s condition to one of 35 main disposition codes ( Cardiac/Respiratory Arrest, Breathing Problems, Falls etc.) and a dispatch priority is allocated which identifies how quickly a response is needed. Dispatch Priorities are set out below: Red 1 these are the most seriously ill patients, those in a cardiac arrest or a state of peri-arrest, who require a response at scene of the incident within 8 minutes. Red 2 these are patients with life-threatening conditions that are less time-critical than those categorised as a Red 1. These patients also require an emergency response arriving at the scene of the incident within 8 minutes. Green patients whose conditions are less acute are coded as Green 1 to Green 4. These patients may still need a response at scene or may be managed over the phone with clinical advice. There are no national targets for Green calls but local target times for these patients across the North West are: o Green 1 20 minutes o Green 2 30 minutes o Green 3 3 Hours o Green 4 4 Hours National targets are defined for Red coded patients as follows:- Red 1 incidents: presenting conditions which may be immediately life-threatening require an emergency response within 8 minutes in 75% of cases. The clock for the 8 minutes starts at the point the call is connected to the Emergency Operations Centre (EOC) telephony switch. Page 3 of 13

Red 2 incidents: presenting conditions that are less time critical than Red 1, requiring an emergency response arriving at the scene of the incident within 8 minutes in 75% of cases. The clock start for the 8 minutes is the earliest of: o The call being coded as a Red 2 having established the chief complaint or disposition; o The first responding resource being assigned or; o 60 seconds from the point that the call is connected to the Emergency Operations Centre (EOC) telephony switch. Red 19 minute response: the total number of Red 1 and Red 2 incidents resulting in a fully equipped ambulance able to transport a patient, in a clinically safe manner, arriving at the scene of the incident, within 19 minutes in 95% of cases. NWAS are required to deliver the national performance targets at the North West Regional level, although the Trust makes best endeavours to also deliver the targets at the County level. 4. Current NWAS Activity & Performance against National Standards: NWAS is currently not meeting the national performance targets with cumulative performance at the end of November shown below: Cumulative Nov-16 R1 R2 All Reds Nov-16 Nov-16 Nov-16 R1 R2 All Reds Activity 8 mins % Activity 8 mins % Activity 19 mins % NHS Cumbria CCG 1,189 61.69% 20,040 60.95% 21,229 81.12% Lancashire 3,921 68.04% 67,962 62.12% 71,883 87.77% Cheshire 2,715 68.66% 47,330 65.79% 50,045 93.88% Merseyside 3,512 73.18% 55,697 67.00% 59,209 92.15% Greater Manchester 7,511 72.18% 128,171 63.70% 135,682 90.08% NWAS 18,860 70.34% 319,401 64.07% 338,261 89.95% There has also been a significant growth in both the volume and acuity of incidents presenting to the system. For 2016-17, Commissioners included an additional 2.5% in the contract to allow for growth in activity, which in recent years has been between 2% and 3% each year. At the end of November, the total number of incidents responded to by NWAS was 5.1% more than expected activity (or circa 7.6% more than in 2015-16). Of more concern is the continued high number of Red incidents being seen, which at the end of November was 8.1% more than expected (or circa 10.6% more than in 2015-16). Over the last 3 years NWAS has seen the total volume of activity increase by more than 22% from around 1m incidents seen in 2013-14 to an expected volume in the current year of 1.23m incidents. At the same time, the balance between Red and Green incidents has also moved such that, at the end of 2013-14, activity was circa 39% Red : 61% Green, compared with an Page 4 of 13

expected 43% Red : 57% Green in the current year reflecting the change in acuity of patients being seen. Whilst this may seem like a small movement in percentage terms, it puts additional pressure on the service through the need to respond to an additional 135,000 patients within the 8 minute timescale. More detailed information is provided in Appendix 2 regarding activity and performance variations for each of the CCGs across Greater Manchester, along with information on the year on year growth seen by NWAS and across the Greater Manchester area. Ensuring the Safety of Patients Whilst performance is not meeting the national targets, it is important to ensure that patients are not waiting for unacceptably long times. These are referred to as response tails. NWAS and Commissioners monitor the length of these tails. At the end of November, the Red 1 target of 75% was achieved at 9:45 seconds, and the Red 2 of 75% target was achieved at 11 minutes. National Performance: Performance at the national level is also not meeting performance targets. Following the rollout of the Dispatch on Disposition pilots as part of the Ambulance Response Programme, comparative data across all the Ambulance Trusts is not readily available as several Trusts are now piloting the new clinical code sets (expected to be rolled out nationally in Spring 2017). The latest information available shows the performance for those Trusts, not included in the pilots, as at the 18 th December. This shows that NWAS are the 3 rd highest performer against the Red 1 standard and the 4 th highest performer against the Red 2 standard. RED1 RED2 Red in 19 WC_12/12/2016 YTD Performance YTD Performance YTD Performance East of England 68.23% 60.91% 90.37% East Midlands 68.95% 57.21% 84.57% London 69.62% 65.23% 93.47% North East 66.00% 65.00% 90.59% North West 69.26% 63.23% 89.40% South Central 72.23% 72.87% 94.55% South East Coast 64.3% 54.1% 89.9% Commissioners served NWAS with a Contract Performance Notice in mid-november in view of the on-going performance concerns, whilst recognising that a number of the issues require system change to deliver sustainable performance improvements. Work is now underway with the NWAS Director of Operations to develop and implement a Remedial Action Plan to recover performance against the national standards. Page 5 of 13

5. Supporting Ambulance Performance Despite the increases seen in acuity and volume of activity, the number of patients being taken to hospital has only increased over the last 3 years by 3% (2.5% across Greater Manchester). 2013-14 saw circa 800,000 patients taken to hospitals across the North West, and this is expected to be in the region of 824,000 at the end of 2016-17. This is due to Commissioners working closely with NWAS over recent years to deflect activity away from hospitals where there are safe alternatives that can manage patients needs, and has resulted in significant increases in the number of patients being managed through Hear & Treat and See & Treat. Over the course of the last 3 years, the number of patients managed through Hear & Treat (incidents resolved without requiring the dispatch of an ambulance) has increased from 2% of total incidents in 2013-14 to over 11% of total incidents expected at the end of 2016-17. The number of patients managed through See & Treat (incidents managed without requiring the patient to be taken to A&E) has also increased from a position of 18% of incidents in 2013-14 to over 21% of incidents expected at the end of 2016-17. This is significant, as it means that the number of patients being conveyed to hospital, as a proportion of the total volume of incidents, has reduced from around 80% at the end of 2013-14 to around 67% at the end of 2016-17. Further detailed activity information showing the increases in the use of Hear & Treat and See & Treat, and the corresponding reduction in patients taken to hospital is shown at Appendix 3. This reflects the on-going work with NWAS to manage patients over the phone, or at scene, without taking patients to hospital. Much of this has been possible through the use of the NWAS Paramedic Pathfinder tool that allows patients to be deflected into safe kite marked local services avoiding the need to take the patient to hospital unnecessarily, and has been supported by Commissioners through the use of CQUIN funding. The number of patients being deflected away from hospital also reflects the work that has taken place through the CCGs in providing suitable alternative primary care facilities that can manage patients safely. This includes services that have been put in place such as the GP Acute Visiting Schemes where NWAS can refer patients onto Out of Hours services for a patient to be seen by a GP where this is appropriate. 6. Development of the Clinical Hubs A key development that is being implemented as part of the overall approach to delivering Integrated Urgent Care is the development of the Clinical Hubs. This work, taking place through the NHS 111 service, looks to divert patients that would normally result in an ambulance dispatch being deflected into Out of Hours Providers for the purposes of receiving an enhanced clinical triage. This was implemented in Cumbria at the beginning of September with a limited number of dispositions that could be referred to the Out of Hours Provider. This was subsequently extended at the beginning to a Page 6 of 13

wider code set. This has resulted in circa 75% of the calls that are referred to the Out of Hours provider being deflected away from A&E departments. A significant amount of work has taken place with one of the Out of Hours Providers in the Greater Manchester area, and a similar scheme is due to go live across part of Greater Manchester in early January, with phased plans to roll this out across the wider Greater Manchester area before April 2017. All of the code-sets for the schemes have been reviewed by the Clinical Leads to ensure that patients safety remains paramount. 7. Handover & Turnaround at Hospital One of the key factors affecting ambulance performance is Handover & Turnaround, where ambulances are delayed at hospital sites for significant periods of time. This period should be around 30 minutes where there is a 15 minute clinical handover of the patient from ambulance crew to acute staff followed by a 15 minute period where the crew cleans and re-stocks the vehicle, completes the necessary paperwork and are then ready to respond to the next incident. Consequently the total turnaround time of the ambulance at hospital should be around 30 minutes. From July 2015 onwards there has been a steady rise in the total length of time it is taking to get ambulances away from hospital, to the point where the average turnaround time for all incidents in the North West is nearly 36 minutes at the end of November. Within this there are variances by time of day, day of the week and across hospital sites. The table at Appendix 4 shows the average Handover & Turnaround times across both the North West and across the Greater Manchester area since July 2015, showing an increase from 27:13 in July to 35:48 in November. Whilst this may not seem significant, the additional 9 minute on the average turnaround time represents around 9,000 lost ambulance hours per month. This is the same as losing 13 24-hour ambulances across the system, with a financial cost around 7m annually. There has been a substantial amount of work that has taken place with Acute Trusts and NWAS, facilitated by NHS England and NHS Improvement. This has included the development of Handover & Turnaround concordat agreements across the system with pledges made on cooperative working to resolve the issue, but further work and focus is required. 8. Conclusion Ambulance performance across the North West and Greater Manchester is not performing in line with the national expected targets. This is due to increases in both the volume of activity being seen and in the acuity of the activity with sicker patients presenting to the system. A Contract Performance Notice has been served on NWAS Page 7 of 13

with work underway to develop recovery trajectories to address the performance being seen. National performance is likewise not meeting the national targets, and NWAS are one of the better performing Ambulance Trusts in this regard. Handover & Turnaround issues at specific hospital sites are compounding the issues associated with the additional growth in activity and patient acuity, which urgently needs to be addressed through work being done by Commissioners and NWAS through A&E Delivery Boards. Wherever possible, NWAS is working with Commissioners to deflect activity through Hear & Treat, or through early transfer of calls to Out of Hours Providers from the NHS 111 service to prevent patients being unnecessarily conveyed to hospital, and significant numbers of patients are being managed without the need to convey them to hospital. The development of the Clinical Hubs will see this progress further. NWAS are also managing a significant number of patients via See & Treat, or through the use of the GP Acute Visiting Schemes that CCGs have implemented, again to prevent patients being unnecessarily conveyed to hospital. 9. Recommendations Members are asked to note the contents of this briefing, which will be expanded upon at the Joint Health Scrutiny Committee meeting with a presentation made by NWAS and Commissioner Leads. Page 8 of 13

Appendix 1 Governance Structure Page 9 of 13

Appendix 2 Greater Manchester Activity & Performance Year to date activity & performance across NWAS and Greater Manchester Cumulative Nov-16 R1 R2 All Reds Green Nov-16 Nov-16 Nov-16 Nov-16 All Incidents R1 Variation R2 Variation All Reds Variation All Green Variation Total Variation Activity 8 mins % % Activity 8 mins % % Activity 19 mins % % Activity % Activity % NHS Cumbria CCG 1,189 61.69% 7.7% 20,040 60.95% 16.3% 21,229 81.12% 15.8% 31,490 11.0% 52,899 12.6% Lancashire 3,921 68.04% (4.6%) 67,962 62.12% 6.9% 71,883 87.77% 6.2% 95,962 1.5% 169,206 4.0% Cheshire 2,715 68.66% (5.7%) 47,330 65.79% 9.2% 50,045 93.88% 8.3% 70,475 6.6% 122,109 6.8% Merseyside 3,512 73.18% (2.1%) 55,697 67.00% 7.5% 59,209 92.15% 6.9% 76,005 0.4% 137,792 2.8% NHS Bolton CCG 752 73.47% (6.8%) 12,198 64.74% 10.6% 12,950 90.31% 9.5% 16,337 2.5% 29,549 5.3% NHS Bury CCG 425 70.55% (2.2%) 8,257 63.67% 8.5% 8,682 87.81% 7.9% 13,221 5.5% 21,962 6.1% NHS Central Manchester CCG 477 76.37% (1.0%) 8,384 67.73% 6.9% 8,861 92.85% 6.4% 12,838 2.8% 21,799 4.0% NHS Heywood Middleton & Rochdale CCG 607 72.88% 0.2% 9,911 63.09% 11.2% 10,518 89.35% 10.5% 14,332 3.5% 24,877 6.3% NHS North Manchester CCG 972 78.20% 14.5% 12,551 71.23% 10.4% 13,523 91.64% 10.7% 17,054 3.3% 30,632 6.2% NHS Oldham CCG 646 75.00% 4.3% 10,500 63.13% 14.2% 11,146 90.71% 13.5% 16,085 9.1% 27,330 9.9% NHS Salford CCG 665 72.84% (0.0%) 10,838 60.19% 1.7% 11,503 90.10% 1.6% 17,548 1.3% 29,326 1.1% NHS South Manchester CCG 381 75.79% (6.8%) 9,522 72.49% 12.7% 9,903 92.86% 11.8% 11,078 2.2% 21,079 6.0% NHS Stockport CCG 630 63.94% 4.5% 12,557 58.85% 12.8% 13,187 90.25% 12.4% 17,743 7.8% 31,316 9.4% NHS Tameside and Glossop CCG 671 69.61% (4.4%) 11,636 60.60% 9.9% 12,307 88.83% 9.0% 16,905 2.5% 29,300 5.1% NHS Trafford CCG 416 64.32% (11.8%) 8,443 56.46% 3.2% 8,859 87.59% 2.3% 11,922 0.4% 20,805 1.3% NHS Wigan Borough CCG 869 69.91% (7.8%) 13,374 62.28% 11.1% 14,243 88.61% 9.7% 18,659 2.6% 32,939 5.5% Greater Manchester 7,511 72.18% (1.0%) 128,171 63.70% 9.5% 135,682 90.08% 8.9% 183,722 3.7% 320,914 5.6% NWAS 18,860 70.34% (2.2%) 319,401 64.07% 8.7% 338,261 89.95% 8.1% 459,474 3.3% 805,076 5.1% Nov-16 Page 10 of 13

Year on Year Activity Growth across NWAS Actual Activity Volumes Activity Movement Year on Year Growth across Greater Manchester Actual Activity Volumes R1 Vol R2 Vol Red Vol Green Vol Total Vol 2013-2014 NWAS 29,265 359,123 388,388 599,400 1,001,594 2014-2015 NWAS 29,733 401,214 430,947 598,873 1,041,040 2015-2016 NWAS 28,984 452,121 481,105 670,580 1,163,288 2016-2017 NWAS (to 30/11) 19,278 319,401 338,679 459,474 805,076 2016-2017 NWAS (Projected) 28,632 494,923 523,555 690,089 1,225,324 R1 Vol R2 Vol Red Vol Green Vol Total Vol 2014-2015 NWAS 1.6% 11.7% 11.0% -0.1% 3.9% 2015-2016 NWAS -2.5% 12.7% 11.6% 12.0% 11.7% 2016-2017 NWAS (Projected) -1.2% 9.5% 8.8% 2.9% 5.3% R1 Vol R2 Vol Red Vol Green Vol Total Vol 2013-2014 GM 11,529 147,183 158,712 232,126 393,579 2014-2015 GM 11,854 162,652 174,506 234,112 411,321 2015-2016 GM 11,409 180,500 191,909 267,125 461,956 2016-2017 GM (to 30/11) 7,511 128,171 135,682 183,722 320,914 2016-2017 GM (Projected) 11,318 197,903 209,221 276,506 487,979 Activity Movement R1 Vol R2 Vol Red Vol Green Vol Total Vol 2014-2015 GM 2.8% 10.5% 10.0% 0.9% 4.5% 2015-2016 GM -3.8% 11.0% 10.0% 14.1% 12.3% 2016-2017 GM (Projected) -0.8% 9.6% 9.0% 3.5% 5.6% Page 11 of 13

Appendix 3 Managing Patients Differently NWAS Calls Managed via Hear & Treat or See & Treat Actual Volumes of Calls, Hear & Treat, See & Treat and See & Convey Proportions of Total Activity Calls H&T S&T S&C 2013-2014 NWAS 1,129,225 19,820 181,642 800,132 2014-2015 NWAS 1,187,077 30,976 206,332 803,732 2015-2016 NWAS 1,198,080 121,505 236,599 805,183 2016-2017 NWAS (to 30/11) 817,364 91,184 172,620 541,272 2016-2017 NWAS (Projected) 1,247,829 138,615 262,644 824,065 Calls H&T S&T S&C 2013-2014 NWAS 2.0% 18.1% 79.9% 2014-2015 NWAS 3.0% 19.8% 77.2% 2015-2016 NWAS 10.4% 20.3% 69.2% 2016-2017 NWAS (Projected) 11.3% 21.4% 67.3% Greater Manchester Calls Managed via Hear & Treat or See & Treat Actual Volumes of Calls, Hear & Treat, See & Treat and See & Convey Proportions of Total Activity Calls H&T S&T S&C 2013-2014 GM 451,249 9,384 71,580 312,615 2014-2015 GM 478,744 14,306 81,312 315,703 2015-2016 GM 485,058 52,146 92,413 317,396 2016-2017 GM (to 30/11) 332,418 40,586 69,722 210,606 2016-2017 GM (Projected) 505,722 61,687 106,001 320,291 Calls H&T S&T S&C 2013-2014 GM 2.4% 18.2% 79.4% 2014-2015 GM 3.5% 19.8% 76.8% 2015-2016 GM 11.3% 20.0% 68.7% 2016-2017 GM (Projected) 12.6% 21.7% 65.6% Page 12 of 13

Appendix 4 Handover & Turnaround Times HOSPITAL NAME Avg Overall Arrival to Clear Time all Attends (mm:ss) HospitalArea Hospital Site Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Cheshire & Mersey Total 27:08 26:42 28:46 30:04 30:37 32:45 37:17 38:55 41:52 34:02 33:00 32:50 34:36 34:23 36:56 37:11 36:19 Greater Manchester Fairfield General 23:47 24:22 24:31 25:34 27:04 26:12 30:34 27:04 28:20 27:12 26:46 25:30 25:36 26:44 25:11 27:08 27:54 Manchester Royal Infirmary 29:53 30:06 32:53 32:53 34:21 34:25 36:35 35:15 38:50 36:42 36:13 34:31 36:57 31:47 33:43 36:38 34:31 North Manchester General 26:52 27:39 30:21 30:28 33:29 33:21 41:53 41:07 43:43 32:35 32:45 38:27 37:25 31:46 36:09 36:01 37:32 Royal Bolton 26:15 25:28 26:56 26:45 28:56 29:29 37:18 38:14 46:25 43:30 40:58 35:38 39:30 36:14 37:26 43:26 44:51 Royal Oldham 25:07 26:42 26:06 30:19 33:56 35:05 35:00 39:13 41:15 32:02 28:23 29:39 33:02 30:05 30:54 36:07 36:37 Salford Royal 25:44 25:47 26:42 27:40 27:57 27:20 28:05 28:03 31:12 29:07 27:57 29:04 29:15 29:04 28:40 30:10 31:32 Stepping Hill 29:07 30:16 30:41 30:20 32:26 34:02 35:05 36:42 36:24 32:38 32:25 31:54 34:15 36:19 38:55 36:24 43:23 Tameside General 25:43 25:46 28:16 29:25 29:51 31:14 31:18 31:57 29:10 28:06 28:37 29:56 29:32 29:00 30:47 30:00 29:57 Wigan Infirmary 27:08 29:08 28:17 28:50 29:47 29:34 30:11 28:38 31:15 30:50 33:17 32:06 36:00 33:27 33:01 38:51 40:47 Wythenshawe 28:08 27:32 28:14 28:02 27:58 28:52 30:42 30:12 32:38 30:51 30:35 29:59 28:32 28:00 28:25 28:49 30:02 Greater Manchester Total 26:52 27:20 28:23 29:06 30:38 31:02 33:39 33:41 36:02 32:38 31:57 31:41 33:08 31:19 32:25 34:35 35:54 Cumbria & Lancs Total 27:52 28:31 29:41 30:48 31:20 31:32 34:31 35:00 35:35 32:50 33:22 32:18 34:03 34:40 33:08 34:16 34:57 Grand Total 27:13 27:25 28:50 29:52 30:48 31:45 35:09 35:51 37:56 33:10 32:41 32:15 33:53 33:15 34:11 35:24 35:48 Page 13 of 13