Argyll & Bute CHP Committee Date of Meeting: 27 October 2010 Item No: 11.3 UPDATE ON STRATEGIC OPTIONS FRAMEWORK FOR EMERGENCY AND URGENT RESPONSE IN REMOTE AND RURAL COMMUNITIES AND MEMORANDUM OF UNDERSTANDING WITH SCOTTISH AMBULANCE SERVICE Update Report by Milne Weir, General Manager, North Division, Scottish Ambulance Service, and Gill McVicar, General Manager, Mid Highland CHP on behalf Pauline Howie, Chief Executive, SAS and Roger Gibbins, Chief Executive, NHS Highland The Board is asked to: Note performance against the 30 minute standard for SAS call outs broken down by category of calls across NHS Highland Board area Note plans to address the priority areas identified in the June and August Board papers including timescales for delivery 1 Background and Summary CEL 21 (2010) issued in June 2010 sets out the framework through which the Scottish Ambulance Service and NHS territorial Boards can ensure that there are robust and responsive systems in place within remote and rural communities to respond in emergency or urgent situations. The Scottish Ambulance Service and NHS Highland seek to deliver the best outcome for patients by working collectively and collaboratively with partners and local communities to clearly define appropriate emergency and urgent responses; to make the best use of existing resources; and to explore opportunities for enhancing skills and sharing resources. This work is underpinned by NHS Scotland s Quality Strategy which puts the patient, patient safety and clinical excellence at the heart of healthcare delivery. Implementation of the Strategic Options Framework has been identified as one of the early activities in support of the Healthcare Quality Strategy for NHS Scotland. The final report of the Remote and Rural Implementation Group outlines that delivering for remote and rural healthcare extends across the continuum of care, from the need for community resilience and integration between health and social care through to the role of hospitals, workforce, transport and technological solutions that are required to sustain appropriate local access to care. Good communication between NHS partners is helping to overcome some of the challenges of delivering services to remote and rural communities, using evidence based practice to route patients to the most appropriate referral pathways for the most appropriate care. Ongoing work is required to bring together the full range of services, ensuring patients get the best pre hospital treatment and are taken directly to the care they need. Referral pathways are helping to provide a focus on clinical outcomes as well as response times. 1
2 A common triage and assessment tool, national standards for out of hours care, anticipatory care planning, shared information systems, access to advice from other professionals and the delivery of more care at home to patients, reducing unnecessary admissions to hospital, will not only improve the patient experience but will deliver greater financial and resource efficiencies for the whole system. Partners and remote and rural communities will require to jointly explore how existing resources can be used to deliver safe, sustainable and affordable models of care in the future. This paper will review performance against the 30 minute standard for SAS call outs broken down by category of calls across NHS Highland Board area. 2 Strategic Options Framework Standards for Emergency and Urgent Response The SAS is required by Scottish Government to achieve certain targets for emergency and urgent response. These are time based targets and are as follows: 75% of Category A calls to be responded to within 8 minutes (mainland NHS Boards areas) 95% of Category B calls to be responded to within 14/19/21 minutes (depending on population density) 53% of all emergencies (includes category A and B calls) to be responded to within 8 minutes (target for Island NHS Board areas) These national response targets apply equally to remote and rural communities. It was noted that response times are monitored at NHS Board level and this can mean that within an individual area, the targets are not met, even when achieved for the NHS Board as a whole. The Remote and Rural Implementation Group identified there was a need to set additional standards, with the specific aim of ensuring that patients in remote and rural communities experience an equitable clinical outcome to that experienced by their urban counterparts. This focussed on developing standards that would improve patient clinical outcomes which would mean that response times were less critical. The additional standards included in the Strategic Options Framework are outlined below and attached in further detail in appendix one. Standard 1 : Accessibility and Availability Standard 2 : Safe and Effective Care Standard 3 : Audit, Monitoring and Reporting Standard One outlines that patients should not have to wait longer than 30 minutes for the arrival of a member of the community emergency response team, although it is recognised that there will be exceptional circumstances where this may occur and there should be a system of recording these. Appendix two set out a range of emergency and urgent responses for remote and rural communities included in the strategic options framework. These settings include Island with no resident professional Island with resident doctor Island with resident other health care professional Very remote rural defined as settlements of less than 3,000 people and with a drive time of over 60 minutes to a settlement of 10,000 or more 2
Argyll & Bute CHP Committee Date of Meeting: 27 October 2010 Item No: 11.3 Remote rural defined as settlements of less than 3,000 people and with a drive time of between 30 and 60 minutes to a settlement of 10,000 or more Accessible rural defined as settlements of less than 3,000 people and within a 30 minute drive time to a settlement of 10,000 or more 3 How are 999 calls dispatched under the priority based approach? Each incoming 999 call is handled by a call taker and a dispatcher working in one of the SAS Emergency Medical Dispatch Centres (EMDC). The call taker asks the caller a series of questions, guided by clinically approved screen based software in order to very quickly establish the location of the incident, the chief complaint, and the seriousness of the call. As soon as the location of the incident is identified, the dispatcher will dispatch an emergency ambulance. Based on the responses of the caller, the software will then assign a call a response category. Category A is clinically defined as immediately life threatening (e.g cardiac arrest). The dispatcher would deploy the fastest, most appropriate available response. This might involve supplementing the emergency ambulance (road and/or air) already deployed with community first responders, BASICs Doctors, General Practitioners and Community Nurses. Category B is clinically defined as not life threatening but still serious (e.g limb fracture). The emergency ambulance (road and/or air) already dispatched would continue to the incident under blue lights and siren conditions. Category C is defined as alternative responses (e.g backache). The call handler would arrange to : deploy an emergency ambulance (cold response i.e not under blue light and sirens). The dispatcher would advise the emergency ambulance already deployed to continue cold to the incident pass the call to NHS24, the 24 hour NHS advice line give advice to the caller Urgent Calls are defined as Calls received from General Practitioners and the response time is provided by the GP based on clinical need. This is normally defined as an urgent response within 1 hour, 2 hours, 3 hours and 4 hours. Across Scotland, more than 1 in 10 people attended by 999 crews last year were treated in their homes, under the SAS See and Treat Initiative. Epilepsy sufferers recovering from fits, diabetic patients recovering from low blood sugar episodes, people with minor nose bleeds are among those who no longer need to be taken to hospital. Dr George Crooks, Medical Director of the Scottish Ambulance Service said what we will never do is leave a patient at home where there is a potential risk that the underlying illness may deteriorate or they have sustained an accident or injury where there is a chance their condition may deteriorate insidiously over time. The rise of See and Treat was detailed at the annual review of the SAS in September 2010. It is important that 999 crews respond to appropriate emergency and urgent responses as this will improve the patient experience and ensure that accident and emergency vehicles are not taken out of location from remote and rural communities, when a hospital admission is unnecessary. This requires joint working between the SAS, primary care teams and local communities, to provide the most appropriate response for the patient. 3
4 4 Delivering appropriate Emergency and Urgent Responses across NHS Highland The Scottish Ambulance Service and NHS Highland have a long history of joint working with remote and rural communities. There is good evidence that joint working can improve outcomes for patients in remote and rural communities. In recent years a number of initiatives have been introduced to improve emergency and urgent responses to remote and rural communities including Community First Responder Schemes Innovative work with Strathclyde Fire and Rescue Service in Argyll and Bute to have an ambulance vehicle available when the air ambulance attends an emergency on the Islands Integrated working with primary care teams Extended role of Paramedics to see and treat patients within their own homes reducing the number of unnecessary admissions to hospitals. BASICs Clinicians responding to urgent and emergency incidents in remote and rural communities in partnership with the Scottish Ambulance Service Paramedics working jointly with Primary Care Teams to deliver Anticipatory Care. This is a pilot scheme and will commence shortly in Lairg and Bonar Bridge. Effective use of telemetry for stroke and cardiac patients. This links ambulance crews up to stroke and cardiac specialists in hospital who can provide advice and guidance Ambulance Care Assistants being trained up to first person on scene (FPOS) level with the ability to respond at an FPOS level to appropriate incidents in remote and rural communities. This does not replace an Accident and Emergency vehicle but provides additional resilience to remote and rural communities. Increasing use of telemedicine for professional decision support routing patients to the most appropriate referral pathway Air Ambulance Service and the introduction of the Emergency Medical Retrieval Service (EMRS) Integrated working between SAS Emergency Medical Dispatch Centre (EMDC), NHS Highland Hub and NHS24 New Defibrillators being rolled out to all A&E Ambulances across Scotland New Airwave Radio Communications being installed in every A&E Vehicle across Scotland Releasing patient transport service capacity through the application of clinical eligibility criteria and reinvesting this into the urgent tier service 5 Case Study : Delivering Emergency and Urgent Responses in Ardnamurchan Over the last six months, the Scottish Ambulance Service has been working closely with the primary care team and local communities in the Ardnamurchan area to map out emergency and urgent service provision; to identify the gaps; to develop detailed implementation plans; and to monitor progress in achieving the standards The steps outlined above are set out in the strategic options framework and are seen as a way of making progress towards sustaining emergency and urgent responses in remote and rural communities. Appendix 3 provides an overview of current emergency and urgent service provision in the Ardnamurchan area. Appendix 4 provides an overview of all incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area from September 2009 to August 2010. 4
Argyll & Bute CHP Committee Date of Meeting: 27 October 2010 Item No: 11.3 Appendix 5 provides an overview of all category A incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area from September 2009 to August 2010. Appendix 6 provides an overview of all category B incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area from September 2009 to August 2010. The mapping and modelling work set out in appendix 4 to appendix 6 identifies the number of calls made to the Scottish Ambulance Service in the Ardnamurchan area by category of call and location. The time of response is also available for each patient. It is important to note that the dots are aligned to post code areas and not specific addresses, but these are available for all incidents. Each incident will have an individual patient record form which is completed by staff from the SAS. Given the size of the population, there will be variations in the number and locations of the category A and category B calls in the Ardnamuchan area therefore flexibility is required around emergency and urgent responses. This will be achieved through joint working with the primary care team and local communities. A Community First Responder scheme has recently been set up in Kilchoan and further discussions will take place with other communities in the Ardnamuchan area about setting up community first responder schemes. This will help to ensure that patients have access to immediate help and support and will assist with meeting the 30 minute response time set in the strategic options framework. Two Ambulance Technicians have also been successfully appointed to vacant posts at Strontian. They will complete their ambulance technician training in December 2010. There is also exploration of the possibility of creating joint posts that would introduce practitioners with generic skills to support remote communities. Meetings between NHS Highland, the Scottish Ambulance Service, partners and local communities are ongoing to review gaps in existing emergency and urgent service provision, and to capitalise on the available resources and skills in the Ardnamurchan area. The outcome of these meetings will be a finalised implementation plan. 6 Performance against the 30 minute standard for SAS call outs broken down by category of calls across NHS Highland Board area Table One sets out the performance against the 30 minute standard for SAS call outs broken down by category A and category B call across NHS Highland Board area. Table One Performance against the 30 minute standard for SAS call outs during 2009/10 NHS Highland 2009/10 Cat A Cat B All calls 8,101 13,567 < 8 mins 67% 55% < 21 mins 90% 90% > 30 mins 0.02% 0.04% 5
6 This analysis identifies the following areas as priorities for further work the Helensburgh area, which has seen an increase in demand Argyll area linked to the increase in inter hospital transfers which take ambulances out of area A9 Corridor particularly around Tain North of Skye Areas around Ardnamuchan and Lochalsh 7 Communication and Engagement The provision of emergency and urgent services to remote and rural communities is of great interest to those communities. A considerable amount of engagement work has happened over the last few years when changes have been required and it is important that this continues in a systematic way. In our case study area, the Ardnamurchan Peninsula, the Mid Highland Community Health Partnership supported a Knowledge Transfer Partnership led by the University of the Highland and Islands Millenium Institute, The Remote Services Futures: Health Care Service Design with Communities. This was an action research initiative which facilitated people in local communities to get involved in designing services, to create a potentially useable health care design for their area that fitted their needs and budget. This was an inclusive process that proved to be effective if people truly engaged in all aspects and was useful in building trust between the communities and service providers. There were key success factors including the need for the participants to be highly informed, for all to have constructive attitudes, for their to be flexibility and for there to be a neutral mediator. Community engagement around the Strategic Options Framework and wider unscheduled care provision will adopt the recommendations contained in the above mentioned report and also the community engagement toolkit currently being developed by SAS and their Partners. The researchers in the Remote Services Futures work believe there to be the following Indicators of Successful Community Engagement:- Increased trust between stakeholders Shifting community attitudes towards involvement Increased community awareness of healthcare issues Increased stakeholder awareness of contextual issues in the community Improved communication between stakeholders Successful involvement of hard to reach stakeholders Project overcoming obstacles such as agency resistance Creation of useable healthcare plans jointly with communities and services Meaningful participation of community members Participants felt able to contribute Reaching consensus on goals Community participants taking some ownership and carrying forward To that end, community engagement events will be held in each of the priority areas and the draft programme for these is contained in appendix 7. It is recognised that there will require to be ongoing work and this will be agreed with participants at the events. In addition to the involvement of local communities it is envisaged that other voluntary and statutory agencies such as Fire and Rescue Service, Coast Guard, RNLI, Red Cross and St John s Ambulance will be included. 6
Argyll & Bute CHP Committee Date of Meeting: 27 October 2010 Item No: 11.3 8 Implementation Plans Timelines and key activities for each of the priority areas identified in the June and August Board papers and the priority areas identified from the analysis in section 6 are highlighted below. The joint project team which has been established between the SAS and NHS Highland will monitor delivery against these timescales and report progress back to the parent organisations. 8.1 Ardnamurchan Area Complete detailed gap analysis by end of October 2010 Undertake consultation and engagement work with local communities. This work is ongoing Complete detailed implementation plan by end of January 2011 Monitor progress in achieving the standards. This work is ongoing 8.2 Wester Ross Complete detailed gap analysis by end of November 2010 Undertake consultation and engagement work with local communities from December 2010 to March 2011 Complete detailed implementation plan by end of March 2011 Monitor progress in achieving the standards 8.3 Skye Complete detailed gap analysis by end of October 2010 Undertake consultation and engagement work with local communities from November 2010 to February 2011 Complete detailed implementation plan by end of February 2011 Monitor progress in achieving the standards 8.4 North West Sutherland Complete detailed gap analysis by end of December 2010 Undertake consultation and engagement work with local communities from January 2011 to April 2011 Complete detailed implementation plan by end of April 2011 Monitor progress in achieving the standards 8.5 Lochalsh Complete detailed gap analysis by end of December 2010 Undertake consultation and engagement work with local communities from January 2011 to April 2011 Complete detailed implementation plan by end of April 2011 Monitor progress in achieving the standards 7
8.6 Badenoch and Strathspey to include A9 Corridor 8 Complete detailed gap analysis by end of November 2010 Undertake consultation and engagement work with local communities from January 2011 to April 2011 Complete detailed implementation plan by end of April 2011 Monitor progress in achieving the standards. 8.7 Campbeltown Complete detailed gap analysis by end of November 2010 Undertake consultation and engagement work with local communities from January 2011 to April 2011 Complete detailed implementation plan by end of April 2011 Monitor progress in achieving the standards. 8.8 Dunoon / Cowal and Helensburgh area Complete detailed gap analysis by end of November 2010 Undertake consultation and engagement work with local communities from January 2011 to April 2011 Complete detailed implementation plan by end of April 2011 Monitor progress in achieving the standards. 8.9 Islay Complete detailed gap analysis by end of December 2010 Undertake consultation and engagement work with local communities from January 2011 to April 2011 Complete detailed implementation plan by end of April 2011 Monitor progress in achieving the standards. 8.10 Lochgilphead Complete detailed gap analysis by end of December 2010 Undertake consultation and engagement work with local communities from January 2011 to April 2011 Complete detailed implementation plan by end of April 2011 Monitor progress in achieving the standards. 9 Next Steps The project team will continue to take forward the detailed work outlined in this paper. NHS Highland Board is asked to note progress to date. Milne Weir General Manager North Division Scottish Ambulance Service 5 Oct 2010 Gill McVicar General Manager Mid Highland CHP 8
Argyll & Bute CHP Committee Date of Meeting: 27 October 2010 Item No: 11.3 Encs: Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Strategic Options Framework (SOF) Standards SOF Emergency and Urgent Response Overview of current emergency and urgent service provision in the Ardnamurchan area Overview of all incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area Overview of all category A incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area Overview of all category B incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area Draft Programme for Community Engagement Events 9
10 Appendix 1 SOF Standards 10
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Appendix 2 SOF Options of Emergency and Urgent Responses 15
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Appendix 3 Out of Hours Resources in the Ardnamurchan area 17
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Appendix 4 Overview of all incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area from September 2009 to August 2010 19
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Appendix 5 Overview of Category A incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area from September 2009 to August 2010 21
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Appendix 6 Overview of Category B incidents that the Scottish Ambulance Service responded to in the Ardnamurchan area from September 2009 to August 2010 23
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Appendix 7 Strategic Options Framework Community Engagement Events Draft Programme 1. Welcome and Introductions 2. The National Pespective 3. The Highland Perspective 4. Activity and Cost Information at local level 5. Discussion Groups 6. Market Place Session to include Community First Responders Telehealth demonstration Unscheduled Care Practitioners Community Paramedics BASICs Emergency Medical Retrieval Service Ambulance Care Assistants Airwave communications Defibrillator and other kit demonstrations 7. Discussion Groups 8. Next Steps 25