Y UR AMBULANCE SERVICE Operating Plan 2015/16 Saving lives, caring for you 1 09/06/2015 09:06
Contents INTRODUCTION...3 YORKSHIRE AMBULANCE SERVICE: WHAT WE DO...4 OUR SERVICES... 4 2014/15 PERFORMANCE REVIEW...6 A&E RESPONSE PERFORMANCE... 6 AMBULANCE QUALITY INDICATORS (AQIS)... 7 PATIENT TRANSPORT SERVICE (PTS) PERFORMANCE... 8 NHS 111 PERFORMANCE... 8 FINANCIAL PERFORMANCE REVIEW... 9 STRATEGIC CONTEXT...9 STRATEGIC VISION... 10 OUR STRATEGIC AIMS, OBJECTIVES AND PRIORITIES... 11 ACCESS, ASSESSMENT AND TRIAGE... 19 TREATING SERIOUSLY ILL AND INJURED PATIENTS... 20 ENABLING STRATEGIES AND PLANS... 21 SERVICE DEVELOPMENTS... 23 SERVICE REDESIGN... 24 WORKFORCE AND ORGANISATIONAL DEVELOPMENT... 25 OTHER DEVELOPMENTS... 26 FUTURE PERFORMANCE... 27 FOUNDATION TRUST (FT) ASPIRATIONS AND RATIONALE... 28 EXTERNAL STAKEHOLDER ENGAGEMENT... 29 WORKING IN PARTNERSHIP WITH COMMISSIONERS AND PROVIDERS... 29 ENGAGEMENT IN SERVICE DEVELOPMENTS... 29 FOUNDATIONS FOR GOOD ENGAGEMENT... 30 COMMUNITY ENGAGEMENT... 30 QUALITY AND SAFETY... 30 QUALITY GOVERNANCE... 30 OUR PATIENTS... 31 RISK MANAGEMENT... 31 BOARD LEADERSHIP... 32 CLINICAL QUALITY STRATEGY... 33 WORKFORCE... 34 INTRODUCTION... 34 OUR WORKFORCE PLANS... 35 FINANCIAL PLAN... 41 OUR FINANCIAL STRATEGY... 41 OUR COST IMPROVEMENT PROGRAMME... 42 OUR FINANCIAL PLAN... 43 OUR CAPITAL PLANS... 43 KEY FINANCIAL RISKS... 44 1
RISK... 45 SUMMARY... 47 APPENDIX 1 - AMBULANCE QUALITY INDICATORS... 48 2
Introduction In recent years Yorkshire Ambulance Service NHS Trust (YAS) has demonstrated a strong track record of improving patient care across all of our services. A key part of that success now and in the future is our willingness to look forward, anticipate change and adapt our services to better meet the needs of our patients. We are a knowledge-based service that relies on the competence, commitment and enthusiasm of our staff to continue to innovate and deliver service excellence and our strategy sets out our ambitious plans for the future for both patients and staff. At the heart of our culture are the NHS shared values based upon commitment, openness and trust, both inside the organisation, with our partner NHS organisations and emergency services, our suppliers and most importantly the patients and communities we serve. Our operating plan for 2015/16 identifies the key priorities, risks and milestones for YAS over the next year. It also provides the foundation for a refresh of our five-year Integrated Business Plan, which will be produced later in 2015, reflecting our aims and ambitions to further improve the services and care we provide to our patients: We will achieve this by: Our Vision Providing world class care for the local communities we serve Our Mission Your Ambulance Service, Saving lives, caring for you Continually improving patient care; Setting high standards of performance; Always learning; Spending public money wisely. Our plans have been developed through a process of continual engagement with internal and external stakeholder groups including service leads, patient representatives, staff, commissioners and healthcare partners. They provide clear and direct commitments to our Membership, commissioners, regulating authorities, staff and most importantly the public we serve. In 2015/16 we will specifically advance our ambitions to provide world class care by: Expanding cardio pulmonary resuscitation (CPR) training, clinical supervision and adoption of heart compression technology to improve rates of survival from out of hospital cardiac arrest in Yorkshire and the Humber closer to the best in the world. Growing our expertise in remote clinical advice by expanding numbers of specialist clinical advisors in NHS 111 and expanding the use of technology to create virtual working environments. Adopting world class support service models by progressing plans for a new Hub and Spoke estate model and Make Ready vehicle preparation. Achieving ISO 22301 standards in business continuity in our ICT, PTS, NHS 111 and EOC (Emergency Operations Centre) functions. 3
Our Values Our values are fundamental to our strategy and future direction, given that it is the actions, behaviours and the day-to-day culture that we adopt which enhance patient outcomes and experiences. Our values are: Working together for patients We work with others to give the best care we can Everyone counts We act with openness, honesty and integrity - listening to and acting on feedback from patients, staff and partners Commitment to quality of care We always give the highest level of clinical care Always compassionate Our staff are professional, dedicated and caring Respect and dignity We treat everyone with dignity, courtesy and respect Enhancing and improving lives We continuously seek out improvements We have worked hard to make sure that our values are complementary to those reflected across the NHS, in the NHS Constitution, and are transparent and reflective of YAS as a service provider and employer. Yorkshire Ambulance Service: What we do We are a successful integrated provider of emergency and urgent care and patient transport services. Our core skills and competencies include emergency and urgent care triage and response, clinical pathways design and management, healthcare technology, resilience and logistics. We now employ over 4,500 staff who, together with over 1,000 volunteers provide services to a population of more than five million people. We respond to over 700,000 emergency 999 and urgent calls and undertake a further one million patient transport journeys per year across the region. Our NHS 111 service for less urgent calls handles over 1.4m calls per year across Yorkshire and the Humber, Bassetlaw, North Lincolnshire and North East Lincolnshire. We also provide a region-wide major incident response and resilience planning capability, medical and first aid cover for large-scale sporting events and festivals, commercial training and fleet and logistics services across an area of over 6,000 square miles. Our Services 4
A&E Operations, Urgent Care Practitioners, Air Ambulance We deliver an Accident and Emergency (A&E) service in response to 999 calls, providing the most appropriate clinical response for patients with emergency and urgent conditions using transport activated by our Emergency Operations Centre (EOC) or via further assessment through the Clinical Hub. Clinically-trained staff assess and treat patients at the scene and, where necessary, transport them to an emergency department or another NHS facility such as a walk-in centre or minor injuries unit for further assessment and treatment. We are implementing urgent care practitioner (UCP) schemes in a number of areas across Yorkshire, whereby paramedics with enhanced clinical skills work alongside GPs and other primary care providers to support and manage patient care within their local communities to avoid unnecessary admissions to hospital. We continue to work in partnership with the Yorkshire Air Ambulance (YAA) charity to provide clinicians for an airborne response to serious emergencies and where casualties are in a difficult location. The two YAA helicopters are based at Nostell Priory near Wakefield and Topcliffe in North Yorkshire. Patient Transport Service (PTS) and Urgent and Inter-facility Transport The current Patient Transport Service (PTS) represents a significant part of our operations. This involves the transport of patients who have been referred for treatment to hospital outpatient departments or other treatment centres and are unable to use other transport options due to their medical condition. It also provides non-urgent patient transfers between hospitals and other healthcare providers. Our PTS is operated by staff who have been trained in first aid, moving and handling techniques and specialist driving skills. We have responded to recent requests from commissioners and acute providers by increasing our provision of weekend and evening urgent transport cover and we will seek to expand this further to take pressure off 999 ambulance resources and support the national drive for seven-day services. NHS 111 and Care Coordination We operate the NHS 111 service across Yorkshire and the Humber, Bassetlaw, North Lincolnshire and North East Lincolnshire. This is a service for patients whose condition is not life-threatening, but who require urgent care and includes telephone advice and signposting to various parts of the health system to deliver the right care for patients. We also hold the contract for the West Yorkshire (in-hours and out-of-hours) Urgent Care Service and provide call-taking support to other GP out-of-hours (OOH) services. Over the life of this plan we will be seeking to make the most of our skills and infrastructure by offering our capabilities to other local health communities to assist them in operating their own local care coordination programmes. Resilience Our Resilience and Special Services team plans the Trust s response to major incidents within the region. Examples include flooding, public transport incidents, pandemic flu, and chemical, biological, radiological and nuclear (CBRN) incidents. Our Hazardous Area Response Team (HART) provides a clinical response within the immediate area of an emergency incident known as the inner cordon, particularly where there are mass casualties. An element of the HART is our Urban Search and Rescue (USAR) team which can respond to incidents involving entrapments at height, underground, in collapsed structures and other places that are difficult to reach. Community, Volunteer and Apprenticeship Schemes We receive the invaluable support of many community-based volunteers; these include Community First Responders who have been trained by the Trust to assist in our response to certain medical emergencies. Although these volunteers are always backed up by ambulance professionals, there is no doubt that their early intervention has saved many lives. We also have a number of volunteer car drivers who support the delivery of our PTS. In addition we also have an award-winning apprenticeship scheme which plays an important part of our commitment to developing the skills and future prospects of younger people within our communities. 5
As part of our commitment to supporting and raising the profile of health issues affecting the people of Yorkshire we work extensively with schools and communities, providing life-saving training and equipment. We also support the work of local charity groups such as MacMillan Cancer Support and Yorkshire and Humber Dementia Action Alliance. Events and Commercial Services, Sporting and Events Cover, Private Ambulance Service Another important part of our service is the provision of clinical cover at sporting events and festivals. YAS provides paramedic support to football and rugby league clubs within Yorkshire, county and international cricket matches and horse racing events. We also provide First Aid and other training to clubs, companies and community groups and actively promote life support in schools, clubs and voluntary groups through our community defibrillator programme. Information and Communication Technology (ICT) Our ICT department supports all of our key service lines with a range of advanced telephony and IT systems along with communications platforms. It is leading the way in developing new integrated systems such as ResWeb which is a multi-agency hosted site for sharing crucial information in realtime. With our IT Help Desk and on-call teams, we are able to provide services to external partners as well as our internal services. Working closely with the IT teams are the Business Intelligence teams who are developing a data warehouse and self-service approach to reporting to meet the many information requirements of staff across the organisation. The ICT team provides support to a number of GP OOH services and develops and maintains e-learning and web facilities for a number of other healthcare organisations. 2014/15 Performance Review A&E Response Performance During 2014/15 delivery of the A&E Red 1 and Red 2 performance standards posed a significant challenge. We saw unprecedented levels of demand for the A&E service, particularly for those patients who were most seriously ill or injured. The introduction of new rota patterns at the beginning of the year did not have the impact that we anticipated and, with a changing demand level, is being revisited to establish the optimum staffing levels and working patterns to meet the increase in activity. An A&E Operations taskforce was introduced in Quarter 2 to identify key areas for improvement, an initial improvement in September and October was not realised in future months; A refreshed performance improvement plan was produced in Quarter 4 with immediate, medium, and long-term actions; An advanced despatch module was introduced in Quarter 4 to assist identifying potential Red emergencies earlier in the call cycle and allowing an earlier despatch to those patients; There was an improvement in Red 1 performance during January to March 2015; Three key pieces of work around resource management, call cycle efficiency and a review of the establishment and its utilisation have been commissioned. Closer working across the 999 and NHS 111 services has led to better management of the transfer of workload between the two services. Emergency Response Performance Category Standard 2013/14 2014/15 2015/16 YAS YAS National YAS Forecast Red 1 75.0% 77.4% 69.9% 71.9% 76.8% Red 2 75.0% 75.1% 69.3% 69.1% 74.6% Red 19-minute response 95.0% 97.3% 95.7% 93.9% 95.0% 6
Ambulance Quality Indicators (AQIs) From April 2011 we have been measured against a combination of national system indicators and quality criteria. There are 11 indicators which are used to benchmark between ambulance trusts, to promote best practice and provide a framework for us to demonstrate and effectively plan for continuous service improvement. The Ambulance Quality Indicators (AQIs) focus on three key areas of quality: Effectiveness, Patient Experience and Safety across five domains. The table below details our performance. The full table of AQIs is attached at Appendix 1 Upper Quartile Achievement Ambulance Quality Indicator Units YAS Rank National Av YTD Recontact 24hrs on Scene % 3.7 1 5.4 Feb-15 Cardiac - STD % 11 2 8.7 Nov-14 Cardiac - STD Utstein 38.4 1 26.3 Stroke - Care % 97.8 5 97.1 Nov-14 Lower Quartile Achievement Ambulance Quality Indicator Units YAS Rank National Av YTD Red 8 minute response - RED 1 % 69.6 8 71.1 Red 8 minute response - RED 2 69.0 8 69.1 Feb-15 ROSC % 23.1 9 27.5 ROSC - Utstein 50 5 49.9 Nov-14 Non A&E % 32.8 7 37.1 Feb-15 STEMI - 150 % 85.7 8 87.2 Nov-14 Upper Quartile Achievement Recontact on Scene the use of National Early Warning Scores (NEWS) and appropriate referral to other Health Care Providers has seen improvements in patient safety, and a reduction in the need to recontact 999. This gives a good measure of safety in clinical decision making at scene. Survival to Discharge (STD) a patient being fit enough to leave hospital after suffering a cardiac arrest is the most important quality indicator in resuscitation. Improvements in cardiac arrest management have included, improved training in Immediate Life Support, clinician post-event feedback and changes in the telephone support for cardiac arrest patients. During 2013/14 the Trust completed a Red Arrest pilot programme in Hull to improve adherence to Resuscitation Council guidelines for CPR and to establish the impact of the presence of a clinical supervisor at all pre-hospital cardiac arrests. With the success of this pilot in improving local STD following out-of-hospital cardiac arrest this approach has been rolled out across other areas of Yorkshire and the Humber including Doncaster, Harrogate, Bradford and Wakefield. In addition, the Trust trialled the use of adrenaline to support blood pressure following Return Of Spontaneous Circulation (ROSC) and external chest compression devices to assist in the safe transport of suitable patients still in cardiac arrest. These are being supplemented by the ongoing expansion of numbers of Community First Responder schemes and static defibrillators located in public places which have resulted in YAS having some of the best STD rates in England. As well as these measures, YAS has been instrumental in the training of thousands of school children in CPR techniques as part of the Restart a Heart campaign. This year s campaign aims to teach Basic Life Support to over 20,000 more children in over 90 schools. 7
Stroke Care the clinical care given to stroke patients is defined by the stoke care bundle improvements have been made through staff awareness and training, and feedback from clinical audit. However the Stroke 60 Ambulance Clinical Quality Indicator (ACQI), which measures the number of suspected stroke patients reaching definitive hospital care at a specialist unit within 60 minutes of an ambulance being requested, is becoming increasingly challenging to deliver as the rationalisation of acute stroke services reduces the number of receiving centres and therefore increases journey times. Discussions are ongoing at a national level with a view to improving this situation. Lower Quartile Achievement Red 8 minute response delivery of the A&E Red 1 and Red 2 performance standards has been a significant challenge with unprecedented levels of demand. Our actions to improve response are clearly documented elsewhere in this plan. ROSC the return of spontaneous circulation (pulse) following a cardiac arrest is the least important indicator in cardiac arrest survival and is influenced by drugs such as adrenaline. Improvements in STD are more clinically relevant. Non-Conveyance to A&E the pilot of Paramedic Pathfinder, a clinical support tool has seen an increase in appropriate and safe non-conveyance. Paramedic Pathfinder is being rolled out wider as part of a locally agreed CQUIN (Commissioning for Quality and Innovation) scheme. There has also been an increase in clinical input into EOC (eg mental health nurses and frequent caller management) which we will continue to expand upon this year. STEMI 150 this measures the proportion of confirmed ST elevation heart attack patients undergoing treatment in specialist coronary care units within 150 minutes of an ambulance being requested and is monitored by the regional cardiac network. Every breach is reviewed and the cause identified, demonstrating that YAS is only able to influence a very small proportion of the breaches with the majority due to factors outside our control. Patient Transport Service (PTS) Performance Considerable work has been completed over the past year in relation to better matching our demand and our operational capacity through a significant rota design programme. This has allowed us to maintain performance levels against our Key Performance Indicators (KPIs), despite some major changes in our demand profile linked to an increasing patient complexity and associated higher level of support being required to carry out these journeys safely. We successfully completed a review of our communications and scheduling functions and have implemented a regional model of operations, with centres located in West, South and East Yorkshire. In addition to this we have introduced a new scheduling role and successfully rolled this out across PTS. We continue to seek and receive patient and stakeholder feedback on our performance and this is overwhelmingly positive. However, we have recently made some changes to how we deliver our renal services in West Yorkshire linked to feedback from patients and healthcare professionals and improved our service performance as a consequence. NHS 111 Performance Our NHS 111 service received over 1.4m calls during 2014/15, and is expected to rise to 1.5m calls per year in future years and is the largest single NHS 111 contract. Call response performance was particularly challenged over winter 2014/15, with rises in call volumes nationally significantly above the predicted levels. In spite of this, performance across the year compares favourably with other services around the country. 8
Key KPIs Abandoned calls (after 30 seconds waiting time) Total answered calls within 60 seconds Warm transfers (from call handler direct to clinician) Q1 Q2 Q3 Q4 YTD YAS Nat l Avg YAS Nat l Avg YAS Nat l Avg YAS Nat l Avg YAS Nat l Avg 1.0 1.2 1.0 0.9 3.4 3.4 0.9 N/A 1.7 N/A 95.2 93.6 95.5 95.5 85.1 87.5 95.9 N/A 92.7 N/A 32.6 57.3 32.7 61.0 26.9 53.0 28.6 N/A 29.3 N/A Whilst there is a national warm transfer target (which we understand is under review) this is not applicable in our region as we agreed with our commissioners in 2014/15 a formal contract to manage clinical calls within two hours and currently performance stands at 91%. The NHS 111 team manages all clinical calls, which are not warm transferred on a clinically prioritised call-back basis, to ensure that patients receive a safe and effective service. Financial Performance Review We have continued to strengthen our financial performance and financial governance arrangements during the year, which has enabled us to deliver our statutory financial targets in each of the last three years. We have delivered our planned surplus of 2.9m for the year. Despite the challenges faced by many organisations in the health sector during 2014/15 we delivered 102% of our cost improvement and service efficiency targets. Summary of Financial Review Key Statistic 2013/14 2014/15 2015/16 Forecast EBITDA (Earnings Before Interest, 13,640 13,419 13,438 Taxes, Depreciation and Amortisation) 000 Surplus/(deficit) 000 2,771 2,991 1,154 % of CIP delivered 97.6% 102% 100% CIP 000 10,643 10,545 8,786 Cash 000 10,142 13,427 13,602 Financial Risk Rating** 4 4 - Continuity of Service Rating* - 4 4 *Where 4 is the lowest risk and 1 the highest **Where 5 is the lowest risk and 1 the highest NB. The financial risk rating was replaced by the continuity of services risk rating in 2013/14 in line with guidance from Monitor Strategic Context The NHS faces ever more challenging times. Unprecedented rise in demand for urgent and emergency care services seen during 2014/15 has placed additional pressures across the whole healthcare system. The Five-Year Forward View (5YFV) was published in October 2014 setting out a vision for the future of the NHS, developed by the partner organisations that deliver and oversee health and care services including NHS England, Public Health England, Monitor, Health Education England, the Care Quality Commission and the NHS Trust Development Authority (TDA). This strategy underpins planning guidance for 2015/16 issued by The NHS TDA 1 and NHS England 2. 1 Delivering in a challenging environment: Refreshed plans for 2015/16, NHS Trust Development Authority, December 2014 2 The Forward View Into Action: Planning for 2015/16, NHS England, December 2014 9
The 5YFV sets out the challenges ahead, identifying the three key areas of increased demand, funding constraints and the need for improved efficiency. A greater emphasis on prevention and care delivered outside of hospital, together with a more engaged relationship with carers, patients and communities are identified as central in meeting this challenge. Increased collaboration between providers of emergency and urgent care and primary and community care services remains essential to providing responsive, effective and personalised services outside of hospital for those people with urgent but non-life-threatening conditions. The 5YFV and subsequent Dalton Review 3 propose several new models of care for local adoption to support delivery of this aim including Multispecialty Community Providers (MCPs), Primary and Acute Care Systems (PACS), Enhanced Health in Care Homes and the development of local System Resilience Groups into Urgent and Emergency Care Networks. A number of local health economies within Yorkshire and the Humber have submitted Vanguard applications seeking additional funding to implement new models of health and social care integration and YAS is an active participant in the adoption of innovative models of care. The 5YFV and other planning guidance underlines the importance of technology in assisting the delivery of change, including adoption of a shared digital patient record across all settings of care (with the NHS number as the primary patient identifier). The introduction of fully interoperable digital records within local health economies is essential in ensuring patients and healthcare providers have access to key information to inform decisions. Other priorities include enhancing access to mental health care, including the provision of mental health support as an integral part of NHS 111 services and expanding the use of personalised care plans such as end-of-life care and ensuring organisations have appropriate systems in place for listening and responding to patient complaints. Provider organisations will face another challenging year with the requirement to deliver efficiency gains of 3.5% under the Enhanced Tariff Option (ETO). This will place greater demands for assurance that plans are robust and adequately balance service capacity, quality, activity and finance. Strategic Vision When developing our strategy we have drawn upon the key themes within local and national strategies that are relevant to our services, people and communities. This includes joint planning guidance: the (Five-Year) Forward View Into Action and the NHS TDA Delivering in a challenging environment. Our plans and mission Saving lives, caring for you focus on our commitment to quality and ensure we deliver safe, effective, caring, well-led and responsive services to the communities we serve. Our supporting strategies, including workforce, clinical quality, information technology, fleet and estate, provide the necessary drivers to deliver the best possible care for our patients and support the concept of working in new ways to deliver the highest quality services. This will be achieved by continuing to progress improvements in frontline clinical skills, engaging with local health communities in developing services and care pathways, giving clinical staff access to advice, technology and information to aid decision-making and ensuring that our estate and fleet guarantee that patients have timely access to services in a safe and clean environment. The frontline A&E workforce is adapting to the changing needs of patients and this is reflected in the Trust s new A&E workforce proposals. This will see a new role of paramedic plus developed which will provide paramedics with additional knowledge and skills to make some of the non-conveyance decisions that are now necessary to manage patients at or closer to their home. Within the context of a national shortage of paramedics, the workforce proposal aims to establish a clear pipeline for paramedic recruitment and training. This will ensure that the Trust has sufficient clinical staff to operate across Yorkshire and the Humber. As paramedic education becomes increasingly focused on undergraduate higher education there will be a key requirement for frontline experience to complement their academic exposure. Those individuals identified as our paramedics of the future will gain this vital experience from the start of their employment in A&E Operations until they complete their paramedic training. 3 The Dalton Review: Options for Providers of NHS Care, Department of Health, December 2014 10
Our clinical capability has improved dramatically in recent years with staff now administering many treatments at the scene of an incident which would previously only have been carried out in a hospital setting. Through the 999 and NHS 111 services we are the largest single gateway to healthcare services across Yorkshire and the Humber. This places us in a leading position to support the transformation, integration and alignment of healthcare services across the region to ensure patients are managed in the most appropriate setting. To support this we are actively engaged with local System Resilience Groups and other community forums, for example Healthwatch, to make certain the services we provide are tailored to meet the specific needs of the local communities we serve. Our Strategic Aims, Objectives and Priorities Our strategic aims reflect our commitment to provide clinical excellence, patient-focused care and a timely 24/7 response. Where appropriate, we will develop new partnerships with public, private and third sector providers, to support innovative approaches to delivery. Our strategic objectives outline what we need to do to support achievement of our aims, with priority actions underpinning each of our strategic objectives. These objectives are discussed in the table overleaf. 11
Strategic Objective Priority Actions Improve survival to discharge (STD) rates for cardiac arrest. Expand use of Red Arrest Teams (RATs) to further support clinicians in Advanced Life Support. Where appropriate, employ external compression equipment to allow ease of conveyance of patients in cardiac arrest. Re-launch the Restart a Heart campaign for 2015 to train 20,000 pupils in Basic Life Support in over 90 schools across Yorkshire and the Humber. Reduce mortality from major trauma. Reinforcing the use of the decision tree to inform bypass to Major Trauma Centres. Improving trauma training for frontline clinicians. 1. Improve clinical outcomes for key conditions Improve management of patients suffering from stroke and heart attack (Myocardial Infarction - MI). Improve effectiveness and patient experience in relation to the assessment and management of pain. Clinical Development Managers work plan is aligned to the Clinical Audit cycle to deliver actions targeting the specific elements of clinical performance indicators requiring improvement through multi-modal delivery methods. Undertake a review of current pain assessment tools and options for acute pain relief to inform changes to practices. This will be specifically in relation to the potential to introduce middle range analgesia. Implement best practice care bundle with recording of pre and post analgesia pain scores with evaluation of patient experience. Implement the priorities in our Sign up to Safety plan. Increase early recognition and treatment of the deteriorating adult and child. This will include embedding the use of the National Early Warning Score (NEWS) best practice care bundle during 2015/16. As part of the 2015/6 CQUIN scheme a care bundle for the management of patients with suspected sepsis will be implemented this year. This will be delivered collaboratively with a number of acute providers. Reduce harm from falls by developing a best model of falls prevention in partnership with other health agencies. Improving safety within the EOC by undertaking a study and education programme into the impact of stress on human behaviour. 12
Strategic Objective Priority Actions YAS Operating Plan 2015/16 final Implement recommendations from national reports including Hard Truths and other quality and safety publications. Implement relevant recommendations within the Lampard Report (February 2015) into matters relating to Savile. Review of Trust process for communicating and managing staff concerns, in light of the Freedom to Speak Up, including involvement of trade unions. Ensure our fleet and estates meet the needs of a modern service. Development of the Outline Business Case for Hub and Spoke and Make Ready service models. Completion of South Leeds Make Ready proof of concept. 2. Provide clinicallyeffective services which meet regulatory and legislative standards Through the Clinical Quality Strategy 2015/18, implement improvements in patient safety, clinical effectiveness, and patient experience. Implementation of 2015/18 Clinical Quality Strategy including: i) Measuring and reducing harm through the embedding of quality indicator dashboards ii) Standardised process for the roll-out of new equipment iii) Embedding and continuing the roll-out of Paramedic Pathfinder iv) Improvement action plans for the ACQIs specifically rolling out best practice deployment models Trust-wide v) Increased visibility of patient feedback vi) Improvement action plan through the CQUIN schedule for mental health care pathways and patients at point of crisis (section 136) vii) A range of methodologies to listen to staff and take action on what is learned viii) Implement and embed standardised clinical supervision arrangements for all professional staff ix) A robust and effective communication plan for the Clinical Quality Strategy x) A robust reporting framework for the Clinical Quality Indicators. Alignment to the CQCs five domains in the regulation framework. Strengthen and increase assurance in relation to safe staffing methodology. Implementation of plans to address any issues identified in the Chief Inspector of Hospitals report. 13
Strategic Objective Priority Actions 3. Develop culture, systems and processes to support continuous improvement and innovation 4. Be at the forefront of healthcare resilience and public health improvement Support cultural change among existing service leaders and managers to improve healthcare delivery. Faster adoption of innovative technologies and techniques. Improve access to continuing professional development (CPD) for frontline operational staff. Work in partnership with commissioners and other providers to use YAS information and data to improve service design and commissioning. Improve business continuity management systems across the Trust. Continue to raise the profile of Yorkshire Ambulance Service as the regional lead for healthcare resilience. YAS Operating Plan 2015/16 final Embed a structured Trust-wide management and leadership development programme. Embed service line management across PTS and A&E. Develop an effective Aspiring Leaders programme which supports equality of access to opportunity. Establish closer links with research, education industry partners to ensure early implementation of equipment and best practice. Develop a CPD programme including delivery by external clinical experts. All CPD sessions will be available through the YAS intranet. Participation in the AHSN Urgent and Emergency Care initiative. Joint YAS/CCG 3-5 year YAS commissioning strategy. Expand scope of ISO 22301 certification to EOC, PTS, NHS 111 and ICT. Expand planning and medical support for large scale public events eg Tour de Yorkshire cycle race and other major sporting events. Review of MERIT (medical emergency response incident team) training - development of enhanced care teams to complement casualty clearing stations staffed by hospital MERIT teams. Make every contact count. Work with partners to use the high profile nature of our vehicles to adopt public health messaging across the A&E and PTS fleet aligned to local priorities. Expand the use of community medical units (CMUs) in delivery of public health education and advice. Utilise safeguarding practices where necessary to raise concerns about patient welfare/social matters when in attendance as a result of PTS transport, urgent admission or a 999 call. Improve public training in CPR. Restart a Heart campaign teaching CPR to schoolchildren across the region. Develop proposals for CPR training facilities. 14
Strategic Objective Priority Actions YAS Operating Plan 2015/16 final Support health economy plans for delivering care closer to home. Introduction of mental health nurses into EOC and NHS 111. Expansion of community-based urgent care practitioners and advanced paramedics. Telecare. Implement a pendant alarm service. 5. Deliver timely emergency and urgent care in the most appropriate setting Support greater integration through the development of NHS 111. Increase number of clinical floor walkers in NHS 111 to further support call handling staff. Closer integration of clinical advisor functions across 999 and NHS 111 services to facilitate seamless service delivery, staff supervision and support. Develop a model to support a single point of access (SPA) to services. Deliver Red 1 and Red 2 response time standards on a consistent basis by the end of quarter 1 and for the rest of the financial year. Further develop care pathways for frequent callers. Dedicated urgent care transport fleet. Implementation of the A&E Workforce Plan. Review of A&E rosters in line with outcomes from demand modelling. Continue the development and roll-out of eprf and Paramedic Pathfinder. 15
Strategic Objective Priority Actions YAS Operating Plan 2015/16 final Improve engagement with patients, the public, clinical commissioning groups and other key stakeholders. Further development of YAS Forum. Develop account manager roles. Improve patient involvement and experience. Implementation of the Friends and Family Test. Greater engagement of patients in focus groups and developmental initiatives. Improvement of the quality and timeliness of complaint responses. 6. Provide services which exceed patient and commissioners expectations Develop services in partnership with others. Support local Vanguard applicants in providing enhanced health in nursing homes. Support local care integration. Implement plans to improve patient experience and financial sustainability of PTS. Expand the use of on-day text messaging and telephone calls to provide patients with up-to-date journey information. Continue fleet modernisation programme and rationalisation of vehicle types. Utilise telematics and auto-scheduling technology to improve patient journeys and fuel use. Embed dedicated renal and oncology services to improve timely patient arrival and departures. 16
Strategic Objective Priority Actions Further improve staff engagement. Respond positively to the results of our cultural audit leading to a significant improvement in the annual staff survey results. Review the delivery of YAS Teambrief to increase coverage. Implement YAS TV across all ambulance stations. Implement Employee Wellbeing Strategy. YAS Operating Plan 2015/16 final Develop a vibrant career framework which will create a pipeline of future talent, ensuring we are better able to manage the impact of increasing demand. Complete consultation on A&E Workforce Plan. Establish a clear training programme for workforce progression. Develop and implement a talent management and succession process. Develop and support staff. Implementation of living wage. 7. Create, attract and retain an enhanced and skilled workforce to meet service needs now and in the future Review of Clinical Supervisor role. Ensure revised rosters enhance availability for training. Expand geographical access to training. Create a virtual workplace, where appropriate, to support flexible working (e.g. NHS 111 telephone triage). Support the development of our nursing staff. Through the established multi-disciplinary steering group review recruitment, induction, education and training and appraisal processes to enable nurse revalidation from April 2016. Implement and bring to life the new Workforce Race Equality Standard, ensuring that we grow into an organisation that is truly representative of the communities that we serve. Develop and deliver effective CPD opportunities for nurses in YAS. Empowering the BME (black and minority ethnic) staff group to assist with developments in diversity issues across the organisation. Identify and eliminate barriers to progression. Increase BME representation on recruitment panels. Introduce targeted recruitment campaigns. Utilise YAS Forum membership to further develop community engagement. 17
Strategic Objective Priority Actions YAS Operating Plan 2015/16 final Agree a 3-5 year service strategy with commissioners for A&E and PTS. Strengthen service strategies and pricing models for A&E, PTS, and NHS 111 with commissioners. 8. Provide costeffective services that contribute to the objectives of the wider health economy Continue to deliver Monitor s continuity of services rating of 4 (lowest risk). Deliver cost improvement programme of 8.8m. Deliver a financial surplus of 1.15m. Improve financial sustainability of service lines. Implement service line management (SLM) and Service Line Reporting (SLR) to enable leaders to better understand and thus better manage the true cost of services to ensure more effective use of resources. 18
Access, Assessment and Triage NHS 111 has been introduced across England as the easy to remember, Freephone number for urgent healthcare services. The NHS 111 service is designed to provide consistent clinical assessment at the first point of contact and direct people to the right service, first time. This builds on our expertise in clinical call centre environments with the rapid and appropriate management of calls to direct patients to the best point of definitive care. It also provides greater opportunity for the regional coordination of access and referral to emergency and urgent care. The NHS 111 service and further development of our team of clinical advisors based within the 999 EOC (the Clinical Hub) who provide support for patients with non-life threatening conditions will enable us to: increase the number of patients whose call is resolved with appropriate advice over the phone ( hear and treat ); increase the decision support provided to clinicians during face-to-face assessments offering a greater range of treatments and interventions directly to patients, resulting in fewer avoidable conveyances to A&E departments by ambulance ( see, treat and convey ); provide alternative transport for patients who require further face-to-face clinical assessment by another healthcare professional. Being the largest gateway to emergency and urgent care across Yorkshire and the Humber has brought development opportunities including: Provision of care co-ordination for patients with long-term conditions or special patient notes, ensuring that these patients receive their planned individualised care when they access 999 or NHS 111; Expansion of the frequent caller case management function which identifies frequent callers to the emergency ambulance service who require help, but not necessarily assistance from our A&E staff; Greater links between the Clinical Hub and emergency care, expanding the co-ordination of emergency care beyond major trauma to cardiac arrest management and the provision of senior clinical advice for emergency conditions; Provision of specialist clinical advice and support in EOC, utilising mental health nurses, to ensure that patients receive the most appropriate response for their needs; Clinical pathways advisors to identify gaps in current community and specialist care pathways and work with health and social care partners to develop alternative pathways of care for conditions such as falls, diabetes, respiratory conditions and end-of-life care that can be managed at or closer to home; Specialist nurses and paramedics working with nursing and residential homes to develop care plans to reduce unnecessary 999 and NHS 111 calls and inappropriate attendance at hospital emergency departments; Home visits by specialist nurses and paramedics on behalf of GPs in primary care both in-hours with YAS clinicians embedded in community healthcare facilities and out-of-hours working alongside GP OOH services; Provision of tele-care monitoring (eg pendant alarm schemes for the frail elderly) and the development of falls service provision working in partnership with Third Sector agencies to provide social care support; Developing urgent care practitioner schemes, where paramedics with enhanced clinical skills work alongside GPs and other primary care providers to support and manage patients care within their local communities, avoiding unnecessary admissions to hospital; Building a case for the invest to save opportunities for clinical commissioning groups (CCGs) in the future, through reduction in emergency department and primary care attendances and admissions. 19
Treating Seriously Ill and Injured Patients In the future we intend to save more lives and improve clinical outcomes for patients, particularly those suffering from cardiac arrest, myocardial infarction ( heart attack ), stroke, major trauma or vascular emergencies. Patients will receive gold standard pre-hospital care and increasing numbers will be taken directly to specialist centres to receive timely definitive care. Cardiac Arrest We will continue our work to examine and implement those aspects of cardiac arrest management which have the greatest effect on patient outcome including: training all paramedics in Immediate Life Support; ensuring that a resuscitation team leader attends all cardiac arrests; the provision of a debrief immediately following resuscitation attempts; the use of post-resuscitation drugs and external chest compression devices where clinically indicated; increasing the number of members of public who are trained in Basic Life Support. Major Trauma Significant evidence collated over the last 30 years demonstrates that substantial improvements are required across the UK in care of patients with serious injuries, within all sectors of the NHS. Working with our healthcare partners we have delivered an integrated major trauma service across Yorkshire and the Humber. This means the most severely injured patients are transported directly to major trauma centres rather than to general hospitals. This also means we drive patients further to achieve improved outcomes. Our interventions make a positive impact on patient survival and improve the speed and extent of recovery. We continue to work closely with the Yorkshire Air Ambulance (YAA) charity, providing the clinicians for the two air ambulances based in Yorkshire, and arrange their dispatch to appropriate incidents. In 2015/16 we will develop the operational and governance structures to support the provision of prehospital care doctors on the aircraft, teaming up with our Helicopter Emergency Medical Service (HEMS) paramedics to form an Enhanced Care Team to attend to the most critically-injured patients. Developing Different Models of Care We are actively expanding the numbers and role of paramedics to meet current and future challenges. During 2014 we introduced a number of urgent care practitioner schemes across Yorkshire to work closely with other healthcare partner organisations with the aim of improving management of patients within the community. This work will continue to evolve to include the development of a more multi-professional workforce to strengthen clinical skills and knowledge. It will also include introducing new service models for different areas including rural, inner city and areas with diverse ethnic populations or specific healthcare needs. Our workforce plan supports the continued development of an appropriately-skilled workforce, with advanced grades of clinicians targeted for the greatest clinical impact. Extensive rota reconfiguration has enabled resources to be available at times of greatest demand ensuring patients receive timely and appropriate care. Paramedic Pathfinder All our paramedics are being trained in the use of the clinical decision support tools such as the National Early Warning Score (NEWS) as a component of the Paramedic Pathfinder system. The guidance provided to our clinicians on accessing alternatives to emergency department attendance will be developed to clarify pathway options and instil confidence that these options are safe and appropriate for the patient. 20
We will work with other providers and commissioners to identify gaps in provision and lead the development of new patient pathways for emergency and urgent care conditions, which focus on the delivery of safe, timely care at a patient s home or incident scene. Patient Transport Service and Urgent Transport Good PTS and urgent transport is essential to support high quality patient care and the efficient use of capacity in hospital and community settings. Our ambition is to develop a sustainable integrated urgent and scheduled transport service which meets the needs of patients and healthcare professionals and is aligned to the efficient delivery of our emergency 999 service. We recognise that our PTS has high visibility across Yorkshire and the Humber, with more patient contact than other services we provide. With numerous daily interactions with patients our PTS staff can play an important role in the early identification of health and social care needs, ensuring that every contact counts and making a significant contribution to the wider public health strategy. Beyond this, we recognise that the scale of our operations and geographic spread offer opportunities for us to expand into areas such as unscheduled and social care transport, and the distribution of medical consumables and equipment. PTS works closely with our 999 service to ensure that key services continue to be delivered to patients with time-critical needs during periods of adverse weather or other disruption. Community Level Performance As part of our commitment to improving availability of ambulance services at peak times of demand and in more rural areas we have recently introduced new operational rotas across Yorkshire and the Humber. Aligned to this we are increasing the number of defibrillators located in public areas and establishing a number of Community First Responder schemes, including emergency responder schemes with staff from other health and emergency services. Public Health We have developed a Public Health Strategy to maximise YAS s contribution to wider health promotion initiatives across the region. This will focus on alcohol, smoking, diet and accident avoidance thereby contributing to the reduction in patients suffering from the key life-threatening conditions described above. The development of health information for patients and the public is a key element, including a drive to increase awareness of cardiopulmonary resuscitation (CPR) techniques to help improve cardiac arrest survival rates. This was achieved in 2014/15 with Restart a Heart Day involving the training of nearly 12,000 schoolchildren in Basic Life Support. There are plans to repeat the initiative in 2015/16 with the longer-term aim of training one million members of the public in Yorkshire and the Humber. Recognition of previously unidentified conditions, such as irregular heart rhythms or undiagnosed high blood sugar, is important in preventing the progression of disease. Ambulance clinicians have a unique opportunity to refer patients to ongoing care when these incidental findings are discovered. In addition, identifying patients who may be struggling to cope in their home environments may facilitate the early diagnosis of dementia. Enabling Strategies and Plans A number of broader enabling strategies and plans also underpin the delivery of key service developments. The Urgent and Emergency Care Strategy informs developments in the Urgent and Emergency Care Delivery Model, associated Education and Development and other workstreams. Other strategies and plans relating to Communications and Engagement, Workforce, Transformative ICT and Commercial development will also heavily underpin the delivery of the key workstreams. 21
Our Fleet 2015/16 sees the third year of significant investment in our A&E and PTS fleet which is significantly improving the average age and reliability of our vehicles. We have worked with Leeds University, industry and our own clinicians to design lighter, more fuel-efficient vehicles that comply with latest safety requirements and reduce our carbon footprint. Aligned to this we are also reviewing our internal fleet operational hours and practices to provide flexible and responsive maintenance to reduce the time our vehicles spend off the road. Our Buildings and Facilities In 2012 the Trust approved a five-year Estates Strategy to move towards a Hub and Spoke estate model whereby community-based response facilities will be supported by larger locality hub facilities with dedicated training and fleet maintenance facilities, vehicle cleaning and Make Ready staff and clinical stores. These new facilities will ensure clinicians have immediate access to clean, well maintained and equipped vehicles and spend the maximum possible time focused on patient care. Upon successful trialling of this concept this new estate model will be rolled out over the next eight to ten years. We are exploring opportunities to co-locate facilities with other health and emergency service organisations where we operate from similar locations to get the best use from resources ensuring we can invest the maximum funding into patient care. 22
Service Developments Key service developments are prioritised and managed under a co-ordinated Service Transformation Programme to ensure coherence of the overall change agenda, consistency of approach, rigour in the deployment of resources and delivery of desired benefits. Discussions in Board and Trust Executive Group have highlighted the scale of transformation required by the Trust in the coming years. Our YAS Forum, introduced in May 2014 and comprising public, staff and appointed members, has also contributed. The programme has therefore been expanded for 2015/16, to ensure full alignment with strategic priorities, underpinned by appropriately strengthened programme and project support. Figure 1 below summarises the proposed outline programme for 2015/16 and further detail is provided in the paragraphs below. 23
Service Redesign Hub and Spoke and Make Ready The Trust is establishing a business case to implement a Hub and Spoke estate model supported by a Make Ready service. This involves the development of larger stations incorporating services such as fleet maintenance, vehicle cleaning and replenishment to ensure clinical staff time is not tied up on nonclinical duties, thereby increasing time available for patient care and improving vehicle availability. The business case will continue to be developed during 2015/16 and progressed through the Trust s assurance process. Work will also include consideration of the potential for Make Ready Light as an interim stage pending full implementation of the full Make Ready model. Call Centre Developments The Trust holds region-wide contracts for both the 999 and NHS 111 services and is a key gateway to emergency and urgent care. Whilst the services are provided under separate contracts, in practice patients may choose to access care through either route and effective interfaces between, and further integration of the services will deliver potential benefits to patient care and workforce development, whilst reducing overall costs. During 2015/16 the Trust will initiate the call centre integration project, supported by a dedicated project lead and multi-disciplinary project board. The initial focus will be on closer integration of the clinical advisor functions across the two services and opportunities for fluid management of urgent care calls across the call centres and, following further scoping and option appraisal, on the potential for more extensive integration of management and delivery of the services from 2016/17, taking into consideration the complex clinical pathway, technological and workforce implications. In the coming two years we will look to increase the number of calls resolved through telephone advice by expanding the number of clinicians within our Clinical Hub, working with commissioners to further develop the Directory of Services and community-based services, providing ambulance clinicians with decision support tools such as eprf and Paramedic Pathfinder and continuing the development of UCP and advanced paramedic roles. Intelligent Ambulance Technology is also playing an increasingly key role in supporting seamless more integrated care delivery and thereby the delivery of safe effective care. The ambulance of the future aims to provide clinicians with continuous access to key patient information, details of services available within the local heath community and access to on-line training and policy guidance. Our ambulances are equipped with radio and digital technology to guide our clinicians to the patient, notify them of the patient s condition and allow them to communicate with staff based within our EOC. We are now embarking on the next generation of technological development to support improved outcomes for patients. As part of this work between 2014 and 2016 all of our emergency ambulances are being equipped with computer devices to allow our clinicians to access patient records and clinical decision support applications. During 2015/16 we will complete the implementation across Yorkshire of the Paramedic Pathfinder decision support tool and eprf to give our clinicians access to patient records. The potential to share patient records and care plans with other health partners such as hospitals and GPs allows more fully informed clinical decisions to be made regarding the most appropriate pathways of care for patients in the community with urgent care needs. Aligned to this work the national Emergency Services Mobile Communications Programme (ESMCP) is responsible for delivering the next generation of emergency services communications, replacing the existing national radio and communication network currently delivered by Airwave. This new mobile communication network will be utilised by all three emergency services to take advantage of the latest mobile technologies to provide national critical voice and broadband data services. 24
Patient Transport Service (PTS) Transformation Our PTS faces a number of significant challenges with increased expectations from patients and acute hospitals at a time of financial constraint and increasing competition from the independent sector. During 2014 we implemented new staff rosters to better match patient demand, made significant improvements to our performance information systems and expanded the number of volunteer drivers. The focus for 2015/16 will be to continue to develop and improve quality and financial sustainability, through the adoption of planning and scheduling technology, implementation of vehicle telematics devices to improve fleet utilisation and fuel consumption, improving on-day patient communications, fleet modernisation and greater patient engagement. Urgent and Emergency Care Development In 2014/15 the Trust has continued to see an increased demand for urgent and emergency care and has experienced significant challenges in meeting response time targets. A performance improvement plan has been implemented and refined during the year to address this. The Trust also recognises a need to develop its operating model over the medium to long term, to fully reflect changing patient needs and to maximise the role of the Trust as a key gateway into the urgent and emergency care system and provider of care closer to home. We have therefore developed a new Urgent and Emergency Care Strategy, reflecting the changing national and local environment, to provide an overarching vision and framework for the development of urgent and emergency care services over the coming years. The Urgent and Emergency Care Service Delivery Model workstream will therefore focus on the shortterm improvement actions within the updated A&E Improvement Plan, designed to support service delivery and performance, as well as medium to longer-term actions which will enable sustainable service delivery in line with the Trust s strategy. This work will include actions designed to support improved efficiency across the call cycle, developments in the delivery model including improvements to triage, introduction of rapid response vehicle (RRV) conveyance and development of staff responder and co-responder schemes, and modelling and refresh of the A&E Workforce Plan. The developments will seek to integrate learning from pilot urgent care practitioner schemes and other urgent care initiatives in various localities across Yorkshire implemented in 2014/15, to ensure that the future service fully integrates the requirements for both urgent and emergency care into a single, coherent delivery model. Workforce and Organisational Development The developments in the Service Transformation Programme are underpinned by cross-cutting workforce and organisational development workstreams, which are designed to develop the capacity and capability of the organisation in line with the wider strategy, and to support the delivery of sustainable change. Urgent and Emergency Care Workforce Education and Development An Urgent and Emergency Care Workforce Education and Development workstream will focus on development of new education and training programmes to support implementation of the Urgent and Emergency Care Delivery Model. This will include integration of urgent care workforce developments and further development of clinical leadership and supervision models. Organisational Development (OD) and Leadership The OD and Leadership workstream will focus on management and leadership development, career pathways and talent succession planning, as well as reviewing education and training provision more generally, ensuring it is fit-for-purpose for future years. There will be continued development of the Service Improvement Network towards the proposed Service Improvement Academy model to support the generation of greater internal capacity and capability to support change within and across service lines over the longer term. 25
In 2014-15 we began a cultural audit to establish how the organisation can increase staff engagement and improve employee wellbeing, refresh the Trust s values and develop an agreed set of behaviours for the organisation and strengthen leadership. Corporate Developments This workstream will include director level portfolio review and management reviews within each service line, ensuring capability of management teams to operate within a devolved service line management environment. The Trust will continue its implementation of service line management in each of the operational services to provide the environment in which clinicians and managers can better understand how they contribute to the Trust s performance as a whole, and which supports delivery of improvements in quality, productivity and effective use of resources.. Other Developments Mental Health During 2014/15 YAS received non-recurrent System Resilience Funding making it possible to implement new models of care for unplanned/emergency mental health calls to both our NHS 111 and 999 services. Mental health professionals located in our call centres have been able to provide advice to our frontline clinicians treating patients with mental health conditions and provide telephone advice to patients and carers to enable improved management of their care ensuring patients only travel to an emergency department or other healthcare facility if there is a genuine need. Plans for 2015/16 include the continuation of this service and enhancing staff training on Deprivation of Liberties/Safeguarding to ensure our staff have appropriate skills to provide the highest possible standard of care. NHS 111 The Trust has delivered the region-wide NHS 111 service since March 2013. The core service is now well established and is dealing with approximately 1.5 million calls a year, with call volumes continuing to rise as public awareness and confidence in the service grows. The Trust has been innovative in developing its multi-professional workforce, including nurses, paramedics, pharmacists and dental nurses, to better meet the needs of key patient groups accessing the service. In 2015/16 the ambition will be to continue these developments, subject to support from our commissioners, to enable more effective management of a greater proportion of patients at an early stage of the pathway, without the need for 999 referral or Emergency Department attendance. Key developments in 2015/16 aligned to the national strategy could include enhancing the use of pharmacist and pharmacy support staff skills both within the NHS 111 call centres and as a referral end-point, supporting the increase of dental triage for the winter period, improving the value that NHS 111 can provide to palliative care patients and continuing to expand the home-working initiative. We will also continue to develop the interface between NHS 111 and out-of-hours care, particularly in relation to the West Yorkshire service provided by Trust partner Local Care Direct, and development of closer integration with the 999 call centre operation. Development of Volunteer and Co-responder Network Volunteers and partner organisations play an important role in tailoring service models to meet the specific needs of local communities. During 2014 we developed a successful emergency service coresponder scheme with Humberside Fire and Rescue Service to improve service coverage in rural parts of East Riding. We also expanded the numbers of volunteer drivers assisting in the delivery of our Patient Transport Service. During 2015/16 we will seek to expand these service models into other parts of Yorkshire. 26
Frequent Callers YAS has operated a small-scale frequent caller service for a number of years to appropriately manage those individuals who repeatedly call 999. These individuals often have complex health and social circumstances which require us to work closely with other health and social care organisations. During 2014/15 we have worked closely with System Resilience Groups (SRGs) to discuss a more formal approach to managing these vulnerable patients across a number of key health and social care services. The benefits for the patient, and for the whole system, include a reduction in inappropriate ambulance responses and an increase in patients receiving the appropriate care for their needs. Future Performance Within our A&E service our future challenges include sustaining improvements in performance against the emergency response targets to deliver the highest standards of care at all times throughout the week and working with our commissioners to deliver improvements at CCG level. We aspire to achieve upper quartile performance across all of AQIs and ACQIs and to excel in indicators relating to cardiac arrest and major trauma specific to our A&E service. We have described above the measures we will be introducing to improve our response for ROSC (for those patients suffering cardiac arrest) and how we will be seeking to treat more patients at scene or in community settings through improvements to clinical practice and enhancing the skills of our paramedic workforce. As demand for ambulance services continues to rise we will need to provide a flexible response model that manages the demand whilst meeting the needs of patients. Enhancements to our clinical triage process with mental health nurses and additional frequent caller management will allow us to focus ambulance responses on patients that require a face-to-face assessment and/or conveyance to definitive care. A review of our management of resource will focus our forward look based on a more flexible demand forecast to allow dynamic changes to our staffing levels for predictable alterations in activity. A review of the size of the A&E workforce to meet the increase in activity will be fundamental to delivery of the A&E performance standards. In PTS we aim to improve arrival and collection times by reducing time lost through vehicle reliability, automated route planning and on-day patient messaging to improve information for patients and reduce aborted journeys. We intend to improve on current levels of user/patient satisfaction and forge stronger relationships with hospitals and commissioners by improving public information on service improvements and developments, introducing new vehicles into our fleet and using call and text reminders to patients to remind them of journey bookings and provide on-day updates of expected arrival times. Measured against national targets our NHS 111 service has a good call response rate; however there are some periods when patients have to wait for clinical advice in line with our locally agreed two hour KPI. Our focus for 2015/16 will be to maintain call response performance whilst improving our management of patients waiting for clinical advice ahead of a national review of the NHS 111 clinical service specification. Progress against all these deliverables will be monitored by our senior management team and Board through our monthly Integrated Performance Report. Plans and actions are regularly reviewed as part of our annual planning cycle and performance management framework. 27
Foundation Trust (FT) Aspirations and Rationale At the core of our strategy is increasing the public and stakeholder understanding of our services in order to positively influence local improvements and our future direction. We are already taking significant steps to proactively support and be involved in our local communities. Initiatives include community training and awareness programmes with schools and local groups and developing younger people through modern apprenticeship schemes. Our good corporate citizenship and social responsibility initiatives include supporting local suppliers and our award-winning fleet. Foundation Trust (FT) status will enable us to deliver the transformational and cultural change necessary for us to achieve our ambition of becoming a world class provider of emergency and urgent care to the communities we serve. This is because we see the financial and operational freedoms of FT status as key enablers to achieving our vision and strategic objectives listed below. Greater freedom to develop long-term financial and business plans that secure the future of our services in the current challenging financial and commercially competitive environment; More engagement with and accountability to local communities, staff and other stakeholders will enable us to understand their needs and deliver the services they require; Our Council of Governors will be the voice of local people, staff and partner organisations helping us in planning the strategic direction of the Trust; Having greater freedom from central government control will enable us to put new services and innovations into practice at a more rapid pace; The ability to develop partnerships and joint ventures to provide new services for our patients and new service models to expand into additional business areas. We have exceeded our public membership target and now have over 7,000 public members and over 90% of our eligible staff are members. We want our membership to act as ambassadors for the Trust and engage with our network of over 1,000 volunteers and local communities in raising local public health issues. In 2014 we introduced an elected membership body known as the YAS Forum. Forum members are accountable to the Trust Membership by whom they have been elected and includes representatives of public, staff and stakeholders. Their responsibilities include informing and providing insight into the development of Trust strategies and plans through engagement with our membership, the public, staff and partner organisations including local Healthwatch and special interest groups. The YAS Forum will continue to operate until we are in a position to call an election for a (shadow) Council of Governors. The YAS Forum will then be dissolved and new elections held for public and staff representatives. 28
External Stakeholder Engagement Rising to the challenge of meeting patients expectations and increasingly complex urgent and emergency needs across the region s diverse communities, involves engagement, influence and partnership working across a broad stakeholder network. We are commissioned by 23 Clinical Commissioning Groups (CCGs) and work with the 22 acute, community and mental health trusts in our area. We deliver services across 15 local authority areas and 54 parliamentary constituencies. Realising our potential to save more lives and to provide the gateway for patients into urgent and emergency services requires collaboration and partnership at local, regional and national levels. Working in Partnership with Commissioners and Providers Key to fulfilling our potential as a leader in this field is maintaining credibility and the confidence of the CCGs through positive and consistent working relationships. As well as operating as individual CCGs, the role of System Resilience Groups (SRGs) is starting to take shape and gain strategic importance. The responsibilities of the imminent urgent and emergency care networks (UECNs) will be a further driver for integrated working. YAS will be proactive in anticipating the needs of both SRGs and UECNs and playing a key role in their establishment and work. While the increasing complexity of CCG arrangements poses a significant challenge for YAS, the development of regional networks offers an opportunity to develop consistency and coordination. Individuals in external-facing roles will be supported to operate as effective account managers by an internal business development and intelligence management system. Engagement in Service Developments We are committed to proactive stakeholder engagement as a standard part of business planning and service development. This will be built on our engagement principles of: open and transparent, two-way, inclusive, timely, respectful, supporting local leadership, evidence-based and consistent. 29
Foundations for good engagement The relationships described above are built on a platform of: a clear map of Trust stakeholders and their wants and needs; good stakeholder knowledge of YAS, the services we provide and our plans for the future achieved through proactive communications; confidence and trust in YAS achieved through: sharing of the Trust s vision for urgent and emergency care; promotion of Trust developments, capabilities and achievements; and timely response to key issues. Community Engagement At the heart of our mission Saving lives, caring for you is developing the knowledge and resources available within local communities for people to support themselves to stay healthy and access the right care at the right time. Community engagement will focus on building community-wide awareness of YAS and enhancing confidence and trust in the services we provide by: Continuing to grow and engage the YAS membership and YAS Forum; Undertake a monthly Patient Survey; Offering educational resources to schools; Continuing to promote and develop volunteering schemes; Promotion of public health awareness campaigns; Demonstrating YAS support for minority communities ; A visible community presence at public events; Participation in Healthwatch meetings; Promoting careers with YAS. Quality and Safety Quality Governance The Board, Quality Committee and Audit Committee roles, and the underpinning management groups (including Trust Executive Group, Trust Management Group and Clinical Governance Group) provide assurance on the delivery of quality from Board to frontline. The Trust arrangements for quality governance are fully aligned to the requirements of the Foundation Trust Quality Governance Framework and are designed to ensure compliance with the Essential Standards of Quality and Safety and, from February 2015, with the new Fundamental Standards of Care. An inspection of the Trust under the new Chief Inspector of Hospitals regime took place in January 2015. The report is due in June 2015 and will be used to further inform the Trust Quality Governance Development Plan. A detailed review of the recommendations of the public inquiry into Mid Staffordshire Hospitals NHS Foundation Trust was undertaken during April and May 2013 and we have refined and updated our quality governance development plan in the light of this review to ensure that it is fully informed by the learning outcomes of the public inquiry. This plan has been further updated in 2014 in the light of the latest external review of the Quality Governance Framework commissioned by the Trust and other relevant reviews, and is subject to regular review by the Quality Committee. Key elements incorporated into our Trust plans for 2015/16 include: getting the basics right, continuously improving care, professional leadership, safe staffing, training and supervision, staff engagement, raising concerns and learning from adverse events. Continued implementation of the requirements of the Duty of Candour is a key priority. 30
Our Patients The Trust is committed to ensuring effective learning from patient experience and to developing our responsiveness to complaints in line with principles from the Clwyd/Hart review. The Trust prioritises promotion of patient dignity via an annual awareness-raising campaign and training materials, and this will be complemented by a Trust-wide staff campaign focused on communication, attitudes and behaviours, drawing on learning from patient feedback. Review of the recommendations of the Winterbourne View Report has supported the Trust s focus on adults with learning disabilities and other vulnerable adults. The Trust will continue to strengthen existing arrangements for safeguarding vulnerable adults in line with new guidance. We will also take forward further developments in our dignity campaign, in training including e-learning and we will work with partner organisations to support the sharing of patient care plans which enable ambulance service clinicians to provide emergency and urgent care which is tailored to the specific needs of patients. The Trust is committed to openness and transparency. In the coming year this will include continued attention to openness with patients and families where harm has been caused as a result of Trust care, further development of the annual Quality Account in line with best practice guidance from NHS England and Monitor, an annual public non-financial annual report covering the key aspects of quality and safety, a programme of pre-board public presentations on important clinical topics, and publication of learning from adverse events and complaints on the Trust s website. The Freedom to Speak Up review published in February 2015 will also be used to inform how we enable staff to voice any concerns about care and the way in which the Trust responds to such concerns. Risk Management In 2014/15 the Trust completed an investigation into the association of Jimmy Savile with the former West Yorkshire Metropolitan Ambulance Service, in line with national developments overseen by the Department of Health Savile Legacy Unit. The current governance arrangements are significantly stronger than those in place in the 1970s-1990s, but the Trust has conducted a further review and refinement of governance arrangements in relation to observers and volunteers in the light of the investigation and other national learning. Further work will be undertaken in early 2015 to reflect learning from the national overview report Themes and Lessons Learnt from the NHS Investigations into Matters Relating to Jimmy Savile. The Trust continues to contribute to the Hillsborough inquests, as one of the successor bodies to the former South Yorkshire Metropolitan Ambulance Service and will ensure that any lessons learned from the inquest process are addressed in future plans. We have considered the implications of the Berwick Report on patient safety (A promise to learn - a commitment to act) and ensured our plans align with recommendations therein. The Trust has committed to engaging with the national Sign up to Safety campaign as part of its ongoing agenda to reduce avoidable harm incidents to patients whilst in our care. In the coming two years we will continue to focus on promotion of a safety culture and learning from adverse events and near misses, identified patient safety improvements informed by local learning and recognised best practice, and aligned to the national campaign. These are key developments incorporated into the Trust s Clinical Quality Strategy. The National Emergency and Urgent Care Review reinforces the Trust s focus on responsiveness and development of urgent care services, including development of NHS 111 as part of the wider clinical service development strategy. This includes significant development and training for the clinical workforce, greater multi-professional working and development of new models of care delivery, both internally and in partnership with other organisations. The Trust s Service Transformation Programme is focused on the priority cross-directorate developments which will bring about step-change as part of the wider Trust strategy. The programme is informed by the CQUIN developments agreed with commissioners and engagement of staff and leaders in innovation and change. Priorities within the programme for 2015/16 include the urgent and emergency care service delivery model and associated workforce development, PTS transformation, development of 31
Hub and Spoke and Make Ready, call centre integration, leadership, management and organisational development and transformative ICT. These initiatives will have a significant impact on quality across emergency and urgent care provision. The Trust has a clearly-defined cost improvement programme quality impact assessment process and arrangements for ongoing monitoring of early warning indicators at corporate and departmental level, and for escalation and action on emerging risk. During 2015/16 there will be a continued challenge to reduce costs whilst maintaining and improving quality of care. The Trust will be implementing large-scale workforce development, changes to operational workforce arrangements and the reconfiguration of its estate and fleet. During this period we will continue to assess new schemes using the quality impact assessment framework and we will monitor impact closely using agreed early warning indicators to ensure the continued delivery of safe care during periods of significant change. Our Clinical Quality Strategy sets out our priorities for clinical quality and this is underpinned by annual implementation plans for each of the key workstreams. Ensuring effective clinical leadership and supervision for staff is a key element of our clinical quality strategy. A new framework for clinical leadership and supervision was implemented across the Trust in August 2012 and further work is continuing to ensure that the new model is fully embedded and that we achieve the intended benefits of improved consistency and quality of clinical practice. This is supported by updated guidance and training to support the quality of the Personal Development Review (PDR) process. Quality is a central element of all Trust Board meetings. The Integrated Performance Report focuses on key quality indicators and this is supplemented by more detailed reports containing both qualitative and quantitative information on specific aspects of clinical quality. Patient stories and briefings on clinical developments are used in the Trust Board meetings, alongside the quantitative data, to ensure a clear patient focus (and a monthly patient experience survey has now been introduced to add a regular realtime view of quality from the patient s perspective. Board Leadership The Trust has a broad programme of clinical and quality audit throughout the year (which is reported to Quality Committee and Board) and the Standards and Compliance Directorate leads a programme of Inspections for Improvement, providing an objective view of quality and safety across the Trust s operational departments, and feedback for managers and the Executive Team on key areas for action. Our Trust Board is actively engaged in reviewing the risks to quality, including the quality impact of cost improvement schemes and other service changes. All cost improvement plans must be quality impact assessed, including sign off by the Executive Medical Director and Executive Director of Standards and Compliance and review by the Quality Committee and Trust Board. Early warning indicators are monitored by the Board and Quality Committee to provide assurance that CIPs are not adversely impacting on quality or safety. Our Executive Team and senior managers are proactive in seeking to engage with frontline staff on issues of safety and quality through a range of both formal and informal methods. The Listening Watch programme is an important element of this activity. This programme is a schedule of structured visits to all parts of the Trust involving all Executive Directors and Associate Directors. This is complemented by a separate engagement programme involving the Chairman and other Non-Executive Directors. Our Executive Team reviews issues arising and implements action as required, reporting to the Board on key issues as part of the regular report from the Trust Executive Group (TEG). Our Quality Committee supports the Trust Board in providing an objective and independent review of quality to support the delivery of safety and excellence in patient care. The Committee enables the Trust Board to obtain assurance that high standards of care are provided and that adequate and appropriate governance structures, processes and controls are in place throughout the Trust to: 32
promote safe, high-quality patient care across all departments; identify, prioritise and manage risk arising from clinical care and service developments; ensure the effective and efficient use of resources through evidence-based clinical practice; ensure that the Trust is aligned to the statutory and regulatory requirements relating to quality and safety; ensure effective supervision and development of the workforce; protect the health and safety of Trust employees; ensure effective information governance across the Trust s functions. The Quality Committee works in liaison with the Audit Committee to provide effective scrutiny of the management of all aspects of clinical governance and quality. The Quality Committee also has a key role in reviewing the quality impact assessments (QIAs) of the CIP schemes and early warning indicators based on reports from the Executive Medical Director and Executive Director of Standards and Compliance and joint meetings with the Finance and Investment Committee enable a rounded view of CIP schemes from both a quality and finance perspective. Clinical Quality Strategy The main themes from the key national reviews relating to patient safety, patient experience and compassion in practice are at the heart of NHS England and NHS TDA planning guidance. The Care Quality Commission (CQC) has also reviewed and developed its approach to the assessment of quality, with the Trust inspection under the new regime completed in January 2015. The Clinical Quality Strategy, underpinned by an annual implementation plan, sets out the key priorities for improving quality of patient care. The current Clinical Quality Strategy reached its conclusion in March 2015 and a full review has therefore been initiated in readiness for the launch of an updated strategy for 2015/2018. This review is drawing on recent national policy and guidance, plus broad consultation with staff, Trust members, commissioners, Healthwatch and other stakeholders. This includes a focus on five key dimensions aligned to the new CQC inspection standards: Safe - patient safety, including cleanliness and infection control, safeguarding, medication safety, safety alerts, learning from adverse events. The Trust has joined the national Sign up to Safety programme and is focusing developments in 2015/16 on the deteriorating patient and use of the National Early Warning Score (NEWS), falls, and the impact of human factors on safety in the Emergency Operations Centre environment. In 2014 we developed and implemented enhanced processes for monitoring of safety, particularly relating to delayed emergency responses. These processes have been shared with other ambulance Trusts via the national Medical Directors group (for which YAS Executive Medical Director is now Chair). In 2015 we will continue to develop these processes, including implementation of a new process for ongoing mortality review. Effective - clinical effectiveness including ambitious targets for improvement of ACQIs and CPIs (Clinical Performance Indicators); priorities within this include improvement of survival from cardiac arrest, treatment of MI and stroke). Other priorities for development include effective pain management, and developments in the areas of major trauma management, mental health and public health. A key area for development will be the deployment of Paramedic Pathfinder and eprf, with close alignment to wider urgent care pathways, implementation of NICE (National Institute for Health and Care Excellence) and Joint Royal Colleges Service Liaison Committee (JRCALC) guidance, effective management of sepsis and clinical audit. Caring - Patient experience, including improved responsiveness to patient complaints and concerns, patient surveys (including use and analysis of Friends and Family Test in line with national policy), use of patient stories in the Trust Board management meetings, training programmes and staff campaigns. Work will also focus on triangulation of performance reporting 33
and patient feedback, greater engagement of patients in focus groups and developmental initiatives and increased use of patient feedback to inform service improvements. Responsive - A&E and PTS service transformation and further development of the NHS 111 clinical service as part of the wider service development strategy. Within the Clinical Quality Strategy there will also be a focus on patients with specific needs, including mental health, dementia and learning disabilities. Well-led - Clinical leadership and supervision, increased communication and engagement on quality, embedding quality and safety across service lines, enhancement of the reporting of key quality indicators aligned to the refreshed Clinical Quality Strategy. Workforce Introduction Our workforce strategy is focused on the delivery of our mission, vision and values and has been refreshed as a combined approach to people management and development. Our strategy has taken into consideration a number of themes which emerged from a consultation and diagnostic process undertaken with a range of stakeholders. It places at its heart the development of the right culture and engagement with staff to deliver clinical quality and better outcomes for patients. This drew upon externally commissioned reviews and relevant internal audit reporting into areas such as personal development reviews (PDRs). Key parts of our workforce strategy include: Patient-centred Professionalism - this centres on personal accountability for the provision of high quality compassionate care, promoting, encouraging and developing professional behaviour in our clinicians and a clear clinical supervision structure. Management and Leadership Development - with a focus on capability, capacity, management structure, engagement and training. Assessing the Quality Impact of Changes in Workforce Models - our service developments and implementation of service transformation will impact on our current workforce models, which will require engagement, consultation and assessment of any quality impact. Staff Health and Wellbeing - we recognise that an important aspect of achieving our aim to be an employer of choice within the region is the promotion and maintenance of the physical and psychological wellbeing of our workforce. An Employee Wellbeing Strategy has been created as part of a wider commitment to provide the best possible opportunities for employees to maintain or improve their wellbeing. Staff Engagement - responding to staff feedback and engaging with staff and trade unions to identify concerns and areas for improvement will be the means through which such fundamental change can be achieved. In order to promote this the Trust Board has recently agreed to recognise GMB, Unite the Union and Royal College of Nursing in addition to Unison. Addressing the Challenge Posed by a National Shortage of Paramedics development of internal training courses to enable an appropriate skill mix to be maintained in line within the A&E workforce model. This will include the retention and development of the technician role. In addition, particular attention will be given to both diversity and staff appraisal. 34
Diversity of Workforce The Trust has prepared for the introduction of the first NHS workforce race equality standard in April 2015 which requires NHS organisations to demonstrate progress against a number of indicators of workforce equality, including a specific indicator to address the low levels of Black and Minority Ethnic (BME) Board and senior leadership representation. As part of the Trust s preparation for the standard, in addition to the ongoing monitoring of the Trust s equalities data, an action plan is being developed against the draft workforce metrics, together with a review of the latest annual staff survey results for the Trust. We will continue to work to ensure that our workforce truly reflects the communities that we serve. PDR Process and Nurse Revalidation The Trust is preparing for the introduction of nurse revalidation which commences in December 2015. We have established a proactive revalidation steering group whose key role is to ensure that all registered nurses across the Trust are informed of the revalidation requirements and are supported in their own preparations for this process. As the national guidelines become available, the Trust is reviewing its internal processes in support of revalidation, including that of the staff appraisal process, to ensure that this incorporates the necessary sign-off by nurse line managers. Completion of PDRs across the whole organisation remains a priority and we aim to ensure that all staff receive a high-quality appraisal annually. Our Workforce Plans At its simplest, effective workforce planning will ensure the Trust has a workforce of the right size, with the right skills, organised in the right way, within a budget we can afford, delivering services to provide the best possible patient care. As part of the strategic workforce planning process, a template has been used which provides the practical framework steps to help develop service workforce plans. 35