AMBULANCE SERVICE. Integrated Business Plan Summary. Summary Operating Plan 2014/ / / /16

Y UR AMBULANCE SERVICE Integrated Business Plan Summary Summary Operating Plan 2014/15 2018/19 2014/15 2015/16 Saving lives, lives, caring for for you you 0

Contents Introduction 2 Trust Overview 4 Strategic Context 4 Strategic Vision 5 Range of Services 6 Contractual Relationships 8 Service Capacity and Developments 9 Quality and Safety 10 Workforce 11 Foundation Trust Rationale 12 Market Assessment Overview 13 Operational and Quality Performance 16 Risk 18 Financial Strategy 20 Summary 22 1

Introduction Welcome to the summary of the Yorkshire Ambulance Service (YAS) Integrated Business Plan (IBP). This document outlines our ambitions, aspirations and plans for the next five years to provide an ambulance service for Yorkshire and the Humber which is continually improving patient care, setting high standards of performance, always learning and spending public money wisely. The rising demand for healthcare services from a population that is getting older and has more complex healthcare needs is placing considerable pressure on the current emergency and urgent care system. In January 2013 NHS Medical Director Professor Sir Bruce Keogh announced a comprehensive review of the NHS urgent and emergency care system in England. This Keogh Review 1 and NHS England planning guidance 2 both highlight the need to improve the urgent and emergency care system so patients get safe and effective care whenever they need it. The key priorities to achieve this are to: provide better support for self-care help people with urgent care needs get the right advice in the right place, first time provide highly responsive urgent care services outside of hospital, so people no longer choose to queue in A&E ensure that those people with serious or life-threatening emergency care needs receive treatment in centres with the right facilities and expertise in order to maximise chances of survival and a good recovery connect all urgent and emergency care services together so the overall system becomes more than just the sum of its parts. We have a significant role to play in supporting these plans and have the skills to deliver the changes required. These are laid out in this IBP. The development of our Clinical Quality Strategy will ensure that the quality of our services will continue to be of the highest importance to us as a Trust. Over the next five years we will seek to firmly establish our position in the top quartile of ambulance services for delivery of Ambulance Quality Indicators (AQIs), reflecting excellence in the delivery of emergency care for patients with life-threatening conditions. YAS is transforming from a service that has traditionally transported patients to hospital for treatment, to a service that is clinically-led and treating more patients at scene, in their own homes or over the telephone. Development of our A&E workforce is essential to improving productivity, reducing costs and delivering better outcomes for patients. Our strategy aims to ensure our staff have the skills, technology and information to support the delivery of our aims for the delivery of excellent and innovative emergency and urgent care. Alongside these plans our enabling strategies for workforce, fleet, ICT and a hub and spoke estate model will enable us to become more flexible, efficient and qualified to ensure patient care is provided in the right setting at the right time. Our emerging developments in urgent care build upon our successful implementation of NHS 111 to emphasise working in new ways to deliver a better quality service. We are taking this forward with individual Clinical Commissioning Groups (CCGs) to ensure these services are tailored to meet local priorities and needs. The expansion of our community-based Urgent Care Practitioners (UCPs) and services such as tele-health and Patient Transport Service (PTS) are key to local solutions to support seven-day services. We will provide an improved patient-centred service across emergency and urgent care which will contribute to increasing the proportion of older people living independently at home following discharge from hospital. The development of Urgent Care Transport and inter-facility transport solutions to ensure timely and appropriate transport is available for patients including those referred from GP Urgent, discharge and falls services. 1 The Keogh Review: Transforming urgent and emergency care services in England, Urgent and Emergency Care Review, End of Phase 1 Report was published by NHS England in November 2013 2 Everyone Counts: Planning for Patients 2014/15-2018/19 published by NHS England in December 2013 2

Effectively collecting, interpreting and sharing information is a key component in improving care and integration and we are investing in technology to enable us to further share information with acute and primary care services, to ensure the most up-to-date patient information is available at all stages in the care pathway. The roll-out of the electronic patient report form (eprf) across the region is a significant step in this process. Through focused investment in ICT we can also radically improve our delivery of healthcare services and reach greater numbers of patients in community and home settings which can assist decision making at scene by providing front-line clinicians with the technology and information to access patient and pathway information and, through provision of tele-health and tele-care services, to support patients living independently in their own homes. Utilising our skills in telephone triage, call centre resilience and our mobile clinical workforce, working in partnership with the commercial sector and other public sector and voluntary organisations we will be at the forefront of the delivery of telehealth services. Given the diverse communities and geography we serve across Yorkshire and the Humber, we realise the importance of engaging with staff, volunteers, patients, the public and other stakeholders to inform and improve our services and to ensure that we deliver services which meet the needs of our population both now and in the future. To assist us in achieving this aim, in spring 2014 we introduced an elected membership body known as the YAS Forum. Membership of the Forum is comprised of elected representatives of our membership, our staff and key stakeholders. Their responsibilities include informing and providing insight into the development of Trust strategies and plans through engagement with our Members, the public, staff and partner organisations including local Healthwatch and special interest groups. The YAS Forum will operate until we are in a position to call an election for a (shadow) Council of Governors who will build on the work of the Forum. Della Cannings QPM Chairman David Whiting Chief Executive We will achieve this by: Our Mission Yorkshire Ambulance Service Your Ambulance Service, Saving lives, caring for you Our Vision Providing world-class care for the local communities we serve continually improving patient care setting high standards of performance always learning spending public money wisely Our values are fundamental to our strategy and future direction, given that it is the actions, behaviours and the day-today culture that we adopt that 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 3

Trust Overview Yorkshire Ambulance Service NHS Trust (YAS) was formed on 1 July 2006 from the merger of South Yorkshire, West Yorkshire Metropolitan and Tees, East and North Yorkshire (East and North Yorkshire areas) ambulance services. We are one of 10 ambulance trusts in England. In the years since 2006 we have demonstrated a strong track record of improving patient care through the adoption and implementation of innovative clinical practices, equipment and technology. We are now an integrated provider of emergency and urgent care services, employing over 4,600 staff who, together with over 1,055 volunteers, provide 24- hour healthcare services to a population of more than five million people. Our organisation provides services including: Operating from 76 sites (including 62 ambulance stations) as well as an additional 36 facilitated stand-by points and 19 PTS reception centres in hospitals; 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 1.3m calls each year across Yorkshire and the Humber, Bassetlaw, North Lincolnshire and North East Lincolnshire. In West Yorkshire we provide an urgent care service in partnership with Local Care Direct (LCD). 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. Strategic Context The rising demand for healthcare services from a population that is getting older and has more complex healthcare needs is placing considerable pressure on the current emergency and urgent care system. The Keogh Review 3 has established a clear vision for the changes needed to deliver improvements in urgent and emergency care and delivering better outcomes for patients by moving care closer to home. The Review also underlines the significant and unique role ambulance services can play in managing patients closer to home through enhanced paramedic skills and integrated delivery of NHS 111. Everyone Counts: Planning for Patients 2014/15-2018/19 calls on Commissioners and providers to adopt a wholesystem planning approach in order to ensure plans address the healthcare needs of their local community. The guidance also underlines the importance of a shared digital patient record with the NHS number as the primary patient identifier for all providers. Effectively collecting, interpreting and sharing information is a key component in improving care integration and outcomes and it is essential that the ambulance service and NHS 111 are able to access GP and hospital patient data to improve clinical decision making and patient outcomes. One of the greatest challenges is the task of integrating urgent care across primary, secondary and community care and providing the right care to people with long-term conditions. 4 The ambulance service is already demonstrating that it has the potential to be a significant lever for positive change both as the provider of 999 emergency and urgent care and NHS 111. 999 ambulance services and NHS 111 are frequently the first point in the NHS to see demand building up in the system. 3 The Keogh Review: Transforming urgent and emergency care services in England, Urgent and Emergency Care Review, End of Phase 1 Report was published by NHS England in November 2013 4 Getting to grips with integrated 24/7 emergency and urgent care: a practical way forward for clinical commissioners - NHS Alliance October 2012 4

The ambulance service has the skills and capability to triage and signpost patients appropriately across the whole health economy whilst also gathering information to identify gaps in the system to support improved commissioning decisions to best meet local patient needs. Services such as NHS 111, tele-health, community-based enhanced paramedic skills and PTS are key to local solutions to support seven-day services providing an improved patientcentred service across emergency and urgent care and increasing the proportion of older people living independently at home following discharge from hospital. If these opportunities are to be fully realised a number of challenges must be overcome including; improving engagement with Commissioners and partners within urgent care in relation to the role the ambulance service can play. Increased collaboration between providers of emergency, urgent and social care services is essential to ensure a responsive, effective and personalised service outside of hospital for those people with urgent but non-lifethreatening conditions, long-term conditions management, further development of information systems that will support continuous improvement and integrated urgent care delivery, addressing incentives in the existing system that support and reward hospital admission and continuing to develop the Directory of Services as a joint enterprise across the urgent care system with Commissioners so that patients receive the right care in the right place. Strategic Vision When developing our strategy we have taken into account the key themes within local and national strategies that are relevant to our services and the communities we serve. This includes NHS England planning guidance Everyone Counts, the Health and Social Care Act 2012, the Report of the Mid Staffordshire NHS Foundation Trust Public Enquiry (the Francis Report), the Sir Bruce Keogh Review and the new Care Quality Commission (CQC) inspection regime. Locally we have focused on the priorities and plans of Clinical Commissioning Groups (CCGs), Healthwatch, Health and Wellbeing Boards and Urgent Care Boards. Our plans and mission Your Ambulance Service, Saving lives, caring for you focus on our commitment to quality and ensuring 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 improving frontline clinical skills, giving staff access to advice, technology and information to aid decision-making and ensuring that our estate, fleet and other support services enable staff to provide patients with the highest standards of care. Our services, clinical capability and technology have 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 key role to deliver the transformation, integration and alignment of healthcare services across the region to best meet the needs of local communities and deliver more care closer to home. At the core of our strategic priorities are: an expansion in the number of urgent care clinicians such as community-based Urgent Care Practitioners (UCPs) and Advanced Paramedics, to bridge the gap between the need for an initial urgent response and community based planned care services expanding the role of the existing NHS 111 service in care co-ordination and provision of local community Single Points of Access (SPA) for health and social care services developing care pathways for specialist groups such as frequent callers, mental health patients and palliative care development of urgent and inter-facility transport solutions to ensure timely and appropriate transport is available to convey patients including GP Urgent, discharge and falls services. 5

Range of Services Figure 1: Range of Services Provided Table 1: Our Core Patient Services Service Budget 2014/15 m A&E Operations 161,123 PTS 26,379 Resilience and Special Services 4,618 NHS 111 (including West Yorkshire Urgent Care (WYUC)) 28,792 A&E, Community Paramedics, 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 urgent conditions or an emergency. This includes resolving calls by telephone advice from clinicians in the Clinical Hub or using transport activated by our Emergency Operations Centre (EOC). Where clinically-trained staff attend at scene, they assess and treat patients and, where necessary, transport them to an emergency department or another NHS facility for further assessment and treatment. In a number of areas across Yorkshire we are implementing community paramedic schemes, whereby paramedics with enhanced clinical skills work alongside GPs and other primary care providers to support and manage patient care within their local communities thus avoiding 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 emergencies. The two YAA helicopters are based at Nostell Priory near Wakefield and Topcliffe in North Yorkshire. Patient Transport Service (PTS) and On-Day Discharge Transport The current Patient Transport Service (PTS) represents a significant part of our operations. This involves the transport of eligible patients who have been referred for treatment to hospital outpatient departments or other treatment centres. It also provides non-urgent patient transfers between hospitals and other healthcare providers. Our PTS is operated by staff trained in first aid, moving and handling techniques and specialist driving skills. 6

We have responded to recent requests from Commissioners and acute providers by increasing our provision of weekend and evening urgent transport cover and over the life of this plan 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 Co-ordination Since March 2013 we have provided 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. This includes telephone advice and signposting to other NHS services. We also deliver an in-hours and out-of-hours urgent care call handling service for West Yorkshire in conjunction with West Yorkshire Urgent Care (WYUC) and provide call-taking support to other services. Over the life of this plan we will seek to make the most of our skills and infrastructure by offering other local health communities our expertise to assist them in operating their own local care co-ordination programmes. Resilience, Training and Volunteers Our Resilience and Special Services team plans the Trust s response to major incidents and large scale public events. Examples include the Tour de France Grand Départ, flooding, public transport incidents, pandemic flu and chemical, biological, radiological or 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. We benefit from the support of many community-based volunteers known as Community First Responders (CFRs) who have been trained by us to assist in our response to appropriate medical emergencies. Volunteers are always backed-up by ambulance professionals and their early intervention has saved many lives. We also have over 100 volunteer car drivers who support the delivery of our PTS. We work in partnership with local British Association for Immediate Care (BASICS) doctors who voluntarily provide support to ambulance crews at serious road accidents and other trauma incidents across the region. As part of our commitment to saving lives and raising the profile of health issues affecting the people of Yorkshire we undertake numerous school and community educational visits, 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. Our own Charitable Fund supports local initiatives such as the provision of mobile Community Medical Units (CMUs) and public access defibrillators. Events and Commercial Services, Sporting and Events Cover Another important part of our service is the provision of clinical cover to sporting events and festivals. Yorkshire Ambulance Service is the market leader in provision of 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 other groups and actively promote community 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, IT systems and communications platforms. It is leading the way in developing new integrated systems such as ResWeb which is a multi-agency hosted site for sharing real-time emergency incident planning information. With our online and systems development teams, IT Help Desk and on-call arrangements, we also provide services to a number of external healthcare organisations including GP Out-of-Hours (GP OOH) ICT services and e-learning and web facilities. The Trust s data analysis and reporting is undertaken by the Business Intelligence team who are working with ICT to develop a data warehouse self-service approach to reporting to meet the many information requirements of staff across the organisation. 7

Contractual Relationships Table 2: Core Contracts Contract A&E Lead Commissioner Yorkshire Ambulance Commissioning Collaborative Group (YACCG) Activity (000s) Contract Value ( 000s) 695 165,741 Length of Contract (Years) 2 nd year of 2 NHS 111 & WYUC Greater Huddersfield CCG 1,292 28,792 3 (plus 2) PTS South Yorkshire Consortium 294 5,593 2 North Yorkshire Consortium 141 4,373 1 West Yorkshire Consortium 573 12,522 1 East Yorkshire Consortium 109 3,497 3 We provide A&E and PTS services for all 20 CCGs in Yorkshire and East Riding. East Riding CCG is the Lead Commissioner for our A&E service, and as such chairs the YACCG meeting with representatives of the three areas; North Yorkshire, Hull and East Riding; South Yorkshire and West Yorkshire. Our NHS 111 service covers the 20 CCGs in Yorkshire and the Humber as well as Bassetlaw, North Lincolnshire and North East Lincolnshire CCGs. The Lead Commissioner for this service is Greater Huddersfield CCG. In addition we provide urgent care services to the 10 West Yorkshire CCGs via the WYUC contract in partnership with LCD. For PTS, the CCGs have formed four commissioning consortia covering East Yorkshire, West Yorkshire, South Yorkshire and North Yorkshire for the 2014/15 contracts. Figure 2: Map of Clinical Commissioning Groups (CCGs) for Yorkshire and the Humber including the NHS 111 areas south of the River Humber. 8

Service Capacity and Developments To support us in achieving our strategic vision we are developing a number of service initiatives. The most significant service developments are outlined below. Electronic Patient Report Form (eprf) and Paramedic Pathfinder The deployment of the Paramedic Pathfinder triage systems and eprf supporting infrastructure will be a key enabler of integrated digital health and social care records within the Trust s area of influence and is a key component of our current strategy to ensure patients are treated in the most appropriate care setting. The eprf system allows our clinical staff to record and receive key information regarding the patient s clinical condition and background medical history and to record the treatment we have provided in an electronic format that can be shared with other healthcare professionals involved in their care. Paramedic Pathfinder provides frontline clinicians with a systematic triage process to assist in determining the most appropriate treatment and care. Emerging Developments The nature of how we operate has greatly changed in recent years. Ambulances carry significantly more technology and equipment and tend to be positioned at strategic deployment sites to best meet demand, meaning out-dated ambulance stations are empty for much of the time. We are therefore looking to introduce a Hub and Spoke resource centre model including Make Ready teams and facilities to fuel, repair and re-stock vehicles, maximising the time clinicians have available to deliver patient care. Other service initiatives in development include: an enhanced NHS 111 & WYUC clinical service model, care coordination services, community- based UCPs, advanced paramedics, tele-health, tele-care, PTS transformation, urgent tier and unscheduled transport and enhanced ICT capability including development of a data warehouse to aid real-time reporting across service areas and enhancing staff and patient access to web and smart phone technologies. Another area we are exploring is supporting CCGs and primary care clinicians in the provision of a Single Point of Access (SPA) for local urgent and community care services. The purpose of the SPA is to provide patients with a seamless and safe gateway to appropriate NHS and social care services and support delivery of coordinated care closer to home. 9

Quality and Safety Yorkshire Ambulance Service In November 2013, the Department of Health published the Government response to the Francis public enquiry. This report outlined the Government response to the recommendations made by the Health Select Committee and described how the Government intends to build on progress already made. Other inquiries and reviews including the national review of patient safety: The Berwick Report -A Promise to Learn- a commitment to act (National Advisory Group on the Safety of Patients in England 2013) and national review of NHS complaints management: The Clwyd- Hart Report - A Review of the NHS Hospitals Complaints System Putting Patients Back in the Picture were also published in 2013. These publications have built on key themes in the Francis report relating to fundamental standards of quality and safety, patient dignity, openness and transparency and provided additional guidance for NHS trusts and Commissioners. The key themes from these reviews - patient safety, patient experience and compassion in practice - are also at the heart of NHS England and Trust Development Authority planning guidance for 2014/2019. The Care Quality Commission and Monitor are also in the process of reviewing and developing their approaches to the assessment of quality and quality governance. It is anticipated that these will come into operation for ambulance trusts by the end of 2014. In light of these national developments we have reviewed and updated our clinical quality strategy. We have revisited our plans for staff engagement and our developing strategy for embedding patient-centred professionalism in our workforce. We will continue to draw on both internal learning and development and emerging national guidance and good practice to build on these key initiatives. Our 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. 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 from the public inquiry. 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 has been implemented across the Trust and further work is progressing to ensure that the new model is fully embedded and that we achieve the intended benefits of improved consistency and quality of clinical practice. Our approach to improving quality and safety covers the five key CQC domains of quality: safe caring effective responsive well-led Quality is a central element of all Trust Board meetings. Our 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 Trust Board meetings alongside the quantitative data to ensure a clear patient focus and a monthly patient experience survey has been introduced to add a regular real time view of quality from a patient s perspective. 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 an engagement programme involving the Chairman and other Non-Executive Directors Our Quality Committee is chaired by a Non-Executive Director and supports the Trust Board by providing an objective and independent review of quality to support the delivery of safety and excellence in patient care. The Committee works in liaison with our Audit Committee to provide effective scrutiny of the management of all aspects of clinical governance and quality and has a key role in reviewing the quality impact assessments of the Cost Improvement Programme (CIP) schemes and early warning indicators, based on reports from the Executive Medical Director and Executive Director of Standards and Compliance (Nurse Director). 10

Workforce Our workforce strategy supports 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 and 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 reports into areas such as Personal Development Reviews (PDRs) and staff development. Key elements of our workforce strategy are listed below. 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 having 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. Board Development - ensuring the right blend of strategic leadership ability and experience exists, along with the necessary range of skills and expertise to create a wholly effective unitary board is essential to our future success. 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. We have developed a revised operational workforce model for A&E and PTS operations in order to provide a flexible, safe, responsive and effective service to meet the changing needs and expectations of patients. Our workforce plans place a greater reliance on a streamlined and simpler front-end model, where qualified paramedics provide frontline clinical care assisted by Emergency Care Assistants (ECAs) and supported by our Clinical Hub. The hub provides members of the public who have called 999 but do not require an ambulance with treatment over the telephone or signposting to appropriate NHS services. In addition, they provide clinical advice to frontline staff at the scene of incidents where this is required. During 2014/15 we will continue to implement our new operational workforce model for PTS to ensure that our vehicle and staff availability reflect the changing nature of services, with more patients being transported to alternative care settings and increasing demand from Commissioners and hospitals for seven-day services. We also see our awardwinning PTS apprentice scheme as an important part of our commitment to developing the skills and future prospects of younger people within our community. The NHS 111 & WYUC services have been fully operational for one year and we are working with Commissioners to review the numbers of clinical and call-taking staff to ensure that patients have appropriate and timely access to high quality clinical advice. This pre-empts work being undertaken nationally to review service specifications for NHS 111. 11

Foundation Trust 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 apprentice 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 target public membership and now have over 6,000 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 1,055 volunteers and local communities in raising local public health issues. We have introduced an elected Membership body known as the YAS Forum in 2014. 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 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. We continue to progress our FT application under the stewardship of the NHS Trust Development Authority (TDA). A key stage of the application process will be a review of our services by the CQC (expected early in 2015). Subject to satisfactory approval following this inspection we are looking to enter the final phase of the assessment process with Monitor, the authorising body of FTs, in the second half of 2015 with authorisation by the end of that year. 12

Market Assessment Overview Yorkshire Ambulance Service In order to drive forward our strategy we must move beyond reacting to central policy and service changes, to better anticipate the needs of our patients and communities and pioneer new and better services. In short, we need to recognise that the healthcare environment is more challenging and competitive and become more business like and patient and market-focused in our approach. We must recognise and leverage the potential offered by technical and clinical innovations and partnership working to better meet the intentions of our Commissioners and the needs of the local communities we serve. This will enable us to fulfil our future potential and deliver the highest quality care by shaping our services around the needs of local communities. Demographic Profile of Yorkshire and the Humber Yorkshire and the Humber health economy s population is 5.3 million (10% of England total). Population density is lower than the national average, but has significant variation with intensively populated inner city areas of South and West Yorkshire and relatively sparsely populated areas of North and East Yorkshire. Projected population growth is 4.4% by 2018 (England average of 6.8%). Main growth expected to be in the 0-4 and 5-9-year-old age groups and those over 65 years (the highest incidence of ambulance calls is within the age range of 75 to 84 years). Yorkshire and the Humber region has a greater proportion of semi/low-skilled workers and people living on state benefits than the England average (37% vs. 31%). The local variation is significant, with Hull for example having 47.1% of the population in this category against a North Yorkshire profile of 29.8%. Demand on the ambulance service is higher where there is a prevalence of lower family income and social housing, which correlates with poor diet and higher levels of alcohol consumption and smoking. Although Black and Minority Ethnic (BME) groups represent 8.3% of our population compared with 13% for England as a whole, there is significant local variation and we need to ensure we are actively engaged with and meeting the needs of these patients. Commissioner Profiles Core 999 ambulance services are now commissioned through a Lead Commissioner arrangement, with three cluster leads representing North Yorkshire, Hull and East Riding; West Yorkshire and South Yorkshire CCGs. PTS continues to be commissioned on a sub-regional/local basis with CCGs formed into four clusters; North, East, West and South. In general, commissioning organisations within Yorkshire and the Humber are in a robust financial position. North Yorkshire continues to work through a transformation and reconfiguration programme which may lead to significant opportunities for us in supporting urgent care initiatives to manage demand as well as creating challenges for our traditional A&E and PTS services. Markets We know that we perform well in relation to public experience, are highly regarded by the public and need to use our growing Membership and Council of Governors to promote the positive impact of YAS across the region. We have assessed our markets as relating to three main areas of business. Accident and Emergency incorporating all elements of the 999 pathway. Non-emergency PTS and Urgent Transport. NHS 111 and Urgent Care. We have assessed emergency care demand as growing on average 3% in 2013/14, 2.5% in 2014/15 and then 2% for the remainder of the plan. The national trend is a 3% per year increase over the last four years and within Yorkshire and the Humber this trend has been matched with an average 2.95% increase over the last four years. PTS demand is expected to reduce over time by 10% over the life of this plan, in line with more strictly applied eligibility criteria and Commissioner affordability. We also expect to see increases in higher acuity patients and decreases in lower acuity patients as a result of the application of these criteria and we know that there will be demographic links to higher demand and higher acuity patients requiring PTS resources. 13

Competitor analysis Yorkshire Ambulance Service Our competitor analysis has shown that, although we have a dominant position in relation to A&E services, patient choice is limited. We need to be aware of the potential threats of market segmentation, particularly in relation to call receipt, non-clinical triage and urgent transport, acknowledging that these are some of our key strengths. We have been successful in reducing our reference costs for A&E services, but further work is needed to bring these in line with the national average position. This will be achieved through improving productivity and enhancing clinical triage skills to ensure patients are managed in the most appropriate setting. We are aware that PTS may be significantly affected by greater plurality of providers, market accessibility and the promotion of competition at a national level. The risks to this service area have been identified and are reflected in our risk register and scenario planning. As the provider of the NHS 111 service, we have a unique opportunity to manage the interface between NHS 111 and 999 to ensure that demand is managed by the most appropriate service. We want to build on our call receipt and triage skills and support the healthcare economy to optimise delivery of urgent and emergency care. We can maintain a regional overview of healthcare providers and signpost patients more efficiently and effectively to the most appropriate care setting and treatment option first time. We recognise that the Government wishes to see plurality of provision for NHS 111 services between NHS providers and the independent sector, providing a competitive risk in the medium to longer term. SWOT (Strengths, Weaknesses, Opportunities, Threats) Analysis Our Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis has also been used to help shape our strategy, service developments and future workforce plans. Our priorities and objectives for the next five years will be kept under review and will be influenced by the new Clinical Commissioning Groups (CCGs), with the aim of providing more integrated and modern services. 14

Table 3: SWOT Analysis Strengths High public confidence in our services evidenced through patient feedback and external review Very strong market share in A&E, PTS and NHS 111 Region-wide infrastructure and footprint, economies of scale and supporting interdependencies High level of expert knowledge in clinical delivery and clinical call centre management that is not readily available outside ambulance service Commitment of staff and volunteers as demonstrated by 1,055+ CFRs and PTS volunteer car drivers Opportunities Financial stability Good clinical outcomes as evidenced in nationally reported clinical Ambulance Quality Indicators (AQIs) Utilise new technologies to improve clinical decision making and to provide new services - eg eprf, Paramedic Pathfinder and tele-care Development of estates and fleet infrastructure including development of Hub and Spoke and Make Ready business model More cross-selling of services (eg private and events and commercial training) FT Membership influencing the future direction of services through greater staff, patient and public engagement Partnering strategies within our supply chain Expanding service provision to provide more care closer to home e.g. care coordination model, urgent care transport and inter-facility transport solutions Improve consultation and engagement in designing local services Health education and public health influence Expansion of Urgent/Unscheduled Care aligned to managing care closer to home Use existing call centre, ICT and fleet infrastructure to provide services to other providers Expansion of apprentice and staff bank models Weaknesses Threats Yorkshire Ambulance Service Inconsistent delivery of A&E and PTS performance indicators set by Commissioners Lack of internal commercial general management skills - most managers have limited experience outside of the ambulance service Delivery of Service Improvement and Cost Improvement Programmes against plans Inconsistent external relationship management and organisational engagement in partnership working and service re-design High costs when benchmarked against other non-nhs services Historically high turnover in senior management team particularly at executive level Management and staff engagement Variable responsiveness to new opportunities NHS and social care funding position resulting in funding not keeping pace with activity demand Increased competition from NHS and independent sector in PTS and urgent transport Fragmentation in Commissioners intentions under Clinical Commissioning Group (CCG) arrangements Cost and complexity of achievement and maintenance of quality standards Acute sector specialisation and re-configuration Employee relations from a national economic standpoint Re-tendering of NHS 111 & WYUC services in 2015/16 or 2017/18 Implementation of Payment by Results currencies and tariffs 15

Operational and Quality Performance During 2013/14 we made significant progress and improvements against many of our objectives. These include: improving both overall performance and national benchmarking for Ambulance Quality Indicators (AQIs) achieving delivery against the Red 1 and Red 2 mandatory targets our PTS service has improved delivery against key performance indicators (KPIs) and the continuing service transformation will build upon these achievements throughout 2014/15 NHS 111 is now fully embedded across Yorkshire and the Humber, Bassetlaw, North Lincolnshire and North East Lincolnshire and is consistently providing one of the best performing, safe services across England achievement of 97.6% achievement of the 2013/14 CIP Plan. The CIP target for 2014/15 is 10.35m and schemes have been identified to this amount progress has been made in relation to reducing staff sickness levels and we continue to work with our occupational health services provider to deliver further improvement. Emergency Response Performance We have seen improvements in emergency response times and increases in activity that have varied across our service lines and we recognise the need for sustainable performance going forward. In 2012/13 and 2013/14 we delivered the 75% standard for Red calls for the Yorkshire and the Humber region and we will build on this in future years. Table 4: Emergency Response Performance Actual Forecast Category Standard 2012/13 2013/14 2014/15 2015/16 2016/17-18/19 Red 1 8-Minute Response 75.0% 72.5% 77.4% 75.5% 75.5% 75.5% Red 2 8-Minute Response 75.0% 75.5% 75.1% 75.5% 75.5% 75.5% Red 19-Minute Response 95.0% 97.0% 97.3% 97.0% 97.0% 97.0% Ambulance Quality Indicators 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 to 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. Table 5 highlights where we are performing above or below the national benchmarked average of all other ambulance trusts in England. Table 5: Ambulance Quality Indicators Upper Quartile Achievement YAS Ranking YAS National /Average Time to treatment - 95th percentile* 1 13m 54s n/a Cardiac - STD Utstein** 2 31.6% 25.6% Stroke - Care** 5 96.5% 96.3% Lower Quartile Achievement YAS Ranking YAS National Average Return of Spontaneous Circulation (ROSC) ** 7 23.6% 25.7% Resolved by telephone* 8 4.4% 5.9% Non-conveyance to A&E* 9 29.7% 36.0% *Figures up to March 2014 **Figures up to January 2014 16

Patient Transport Service Performance In PTS we closely measure service performance and delivery through a number of KPIs. One of these is patient feedback which allows us to listen closely to our users/patients views. Work commenced in 2012 to look at those KPIs where we were not fully meeting targets for the timely arrival and collection of patients to and from their hospital appointments. The launch of our PTS Transformation Programme has seen the development of new staff rosters to better match vehicle and staff availability to times of peak patient demand. The first new rosters were developed for South Yorkshire and implemented in September 2013. Following the success of this similar changes are being introduced in the West, East and North Yorkshire localities. Figure 3: Patients arriving on time for their appointment South Consortia NHS 111 Performance Our NHS 111 service has one of the best response rates nationally. The service received over 1.1m calls by the end of 2013/14. We expect this to increase to over 1.3m calls in 2014/15, rising to 1.6m in future years. Table 6: NHS 111 KPIs YAS National Average Key KPIs % % Abandoned calls (after 30 seconds waiting time) 1.3 1.2 Total answered calls within 60 seconds 94.9 94.8 Warm transfers (from call handler direct to clinician) 38 64.1 Figures to end of March 2014 The warm transfer target remains challenging and is subject to review as part of the national development of the NHS 111 service. The NHS 111 & WYUC 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. Future Performance Our future challenges include sustaining improvements in performance against the emergency response targets, continuing to develop the NHS 111 service and sustaining improvements in PTS KPIs. In addition, we aspire to achieve upper quartile performance across all of the AQIs and to excel in indicators relating to cardiac arrest and major trauma. Progress against all these deliverables will be monitored monthly through our Integrated Performance Report and bimonthly by the Trust Board. Delivery of plans is regularly reviewed as part of our annual planning cycle and performance management framework. 17