Transforming Welsh Ambulance Service: scrapping times, supporting patients! Dr Brendan Lloyd Medical Director Welsh Ambulance Services Trust Founding Senior Fellow FMLM
Dr John Kotter: Leading Change 8-stage process to creating major change
Our Burning Platform - 2013 Operating Context Increasing demand and acuity Financial constraint / resourcing gap Deteriorating performance Flawed operating / performance model Frequent senior management turnover Weaknesses in corporate governance Challenging industrial relations climate Talented but disengaged workforce Intense political and media scrutiny Repeated review and re-organisation Doubt about the organisation s future
The Problem: Contacts 2013/14 999 420,000 calls 40% or 166,000 RED 1&2 86,000 HCP 25,000 RED RED: multiple dispatches CALL TYPE CATEGORY A CATEGORY & CODE (MPDS) RED 1 (~3%) 8 min (Echo and high end Delta codes) RED 2 (~35%) 8 min (Delta and high end Charlie codes) 317,000 NHS Direct 3m website hits 1m PCS Journeys CATEGORY C GREEN 1 & 2*(~40%) Face to Face 20 min (Charlie & Bravo codes) GREEN 3 (~22%) Call Back CTA 10 min or Face to Face 30 min (Alpha & Omega codes)
Designing ambulance into unscheduled care
Conditions for Change Health Policy
Clinical Response Model CATEGORY RESPONSE MODE DEPLOYMENT MEASURES RED ( 60-70 calls per day out of 1300) Blue lights 8 minutes Ideal/Suitable Multiple Resources 65% within 8 minutes AMBER (65%) Blue lights Ideal/Suitable Right clinician/resource in a timely manner, based on clinical need. Clinical Interventions Patient Outcomes GREEN (30%) Hear and Treat Normal Road Speed Planned non-emergency transport (ambulance/taxi): Telephone advice / clinical assessment Clinical Outcomes Patient Satisfaction SIMPLE CLINICALLY FOCUSED... PRUDENT SAFE
Process to achieve change in Wales Clinical Modelling Workshops Oct. 2014 16/1/15: Jeremy Hunt announces English pilot sites following letter from Keith Willett 26/1/15: letter to Vaughan Gething from Welsh MDs 29/1/15: response from Vaughan Gething asking WG officials to work with NHS Wales clinical leads Extensive communication with staff & public, videos, FAQs and staff surgeries across Wales
Process 24/4/15: CMO requests Case for Change revised with focus on patient experience & outcomes June: presentations at Clinical Stakeholders including CMO/CNO, GPC Wales & Welsh CEM 10/7/15: Letter from WAST MD to Vaughan Gething on behalf of MDs
29 July 15 changes announced in Senedd it can be done! Go Live 1 October 2015 18 month pilot
Key Enabler: Digital Pen Technology for completing Patient Clinical Records
So what do we measure now? This striking result shows we must focus more on the care, compassion and continuity provided by our highly-skilled ambulance clinicians than simply measuring the worth of the service by the time it took an ambulance to respond to a 999 call. http://gov.wales/statistics-and-research/ambulance-services/?lang=en http://www.wales.nhs.uk/easc/ambulance-quality-indicators
WAST Clinical Indicators 16
STROKE Old System Time from 999 call to ambulance or RRV arriving at address Multiple dispatches perverse behaviours New System Ideal or Suitable response Clinical Indicator Time to intervention? Future System Measures across USC system?
RED Performance
Lets look at December 15 v December 16. Dec 15 Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sep 16 Oct 16 Nov 16 Dec 16 Total Total Verified Incidents 38,777 39,659 37,561 40,611 35,448 38,623 37,046 39,584 38,601 37,550 39,437 37,897 41,668 502,462 Conveyances to Hospital 18,900 18,911 17,498 18,765 17,266 18,405 17,278 18,308 17,813 17,282 18,496 17,421 18,442 234,785 December 2016-41,668 incidents. 2,891 more incidents than December 2015 458 less conveyances! Resource shift of 3,349 cases.
Number of Incidents Resulting in an Emergency Response 20,399 22,139 20,971 22,362 21,931 21,546 22,802 21,878 23,970 23,548 20,431 22,381 21,868 Red 8 % What have we learned? 40,000 35,000 71.0% 75.5% 77.1% 75.3% 78.1% 79.5% 77.1% 78.9% 75.8% 75.4% 74.6% 77.9% 80.5% 90.0% 80.0% 30,000 70.0% 25,000 4,096 4,442 4,139 4,066 4,021 3,793 3,944 3,832 3,640 3,386 3,332 3,690 3,577 60.0% 50.0% 20,000 40.0% 15,000 30.0% 10,000 20.0% 5,000 10.0% 0 1,591 1,670 1,504 1,702 1,579 1,472 1,673 1,666 1,986 1,958 1,652 1,833 1,758 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 0.0% RED Incidents* AMBER Incidents* GREEN Incidents* AW All Wales Red % in 8 mins
Amber Response (includes Amber 1)
Resolving the Ambulance Problem - Collaboration Local Health Boards Police and Fire AACE Board Workforce Trade Unions Ministers NHS Wales Our Regulators Our Commissioners
Indirect Benefits
Frequent Callers Health Board Jun Jul Aug Sep Total Abertawe Bro Morgannwg 82 15 13 9 119 Aneurin Bevan 51 16 18 20 105 Betsi Cadwaladr 112 52 37 30 231 Cardiff and Vale 76 25 12 11 124 Cwm Taf 59 12 5 13 89 Powys 4 16 3 1 24 All Wales 384 136 88 84 692 Health Board Sep Oct Nov Dec Total Abertawe Bro Morgannwg 57 3 2 6 68 Aneurin Bevan 92 87 30 20 229 Betsi Cadwaladr 58 13 14 18 103 Cardiff and Vale 77 21 8 10 116 Cwm Taf 21 11 9 7 48 All Wales 305 135 63 61 564
Associated benefits Staff Survey 2016 - best improvement (10% increase in engagement score) across NHS Wales Decreasing sickness absence - lowest absence rates for years Achievement of full establishment in Paramedic and EMT numbers (now over-recruiting) Achieved routine monitoring in 2016 - only NHS Wales organisation to be de-escalated Partnership working with Trade Union colleagues Reduction in vehicle allocations per incident. It is estimated that over 5,500 unnecessary allocations have been avoided since October 2015 Sustainable savings delivered each year Improvements in Frequent Callers, Clinical Desk, See & Treat New ways of working: Specialist Paramedics in Community
NHS Confederation Wales: The key enablers to outcomes based performance targets. When developing a performance management framework, the Welsh Government and other stakeholders should consider the key enablers that led to the implementation of the new Clinical Response Model (CRM) for the Welsh Ambulance Services NHS Trust (WAST). The CRM pilot has moved the focus from a specific time target, other than where clinical evidence supports such a target, to improving outcomes and experience for patients through introducing a clinically appropriate response.
NHS Confederation Wales Review: The key enablers: The 10 enablers below have been identified from the CRM pilot as important factors to consider when developing new performance frameworks for the NHS. The enablers must be taken in their entirety because of the synergies between them. 1. Clinical evidence & leadership 2. Patient outcomes and pathways 3. Independent review 4. Staff support 5. Political Support 6. Policy direction 7. External stakeholder support 8. The operating environment 9. External messages 10. Audit and benchmarking
Clinical evidence and leadership: Gaining support and advice from clinicians when developing a new performance management framework is critical. Working with Medical Directors across the NHS and gaining support from senior clinicians within Government to develop new targets is essential to ensure that patient pathways and clinical outcomes are considered.
External messages: It is key that NHS leaders engage with the media and provide consistent messages around why the changes are required and evidence the benefits to patients. As well as the media, it is important to keep Assembly Members informed about the process and highlight the evidence of how it will improve patient outcomes.
Audit and benchmarking: Once the pilot has been developed, it is critical that a clear audit of the process is developed and information released publicly. As part of the audit, it is important to consider all LHBs performance so that we can benchmark to drive up consistency and improvements across Wales.
Conclusion One of the key barriers to shifting from specific time targets to a clinical indicator patient outcome-focused model, considering the NICE guidance, is that the different stages of the patient pathway are presently not recorded. We will, therefore, have to introduce, collate and record the new clinical indicators and measures on the NHS data system. The evidence available demonstrates outcome-based targets are able to be introduced into the NHS and that these targets can drive up performance and enhance patient safety and experience.
PACEC & Medical Care Research Unit, University of Sheffield, Review Evaluation Objectives: Clinical Indicators/Outcomes to demonstrate the effect of the removal of time-based response standards on clinical performance Value for Money establish the cost effectiveness of ambulance services Patient Experience impact of new model on patient satisfaction and welfare Staff perceptions WAST and Health Board
PACEC & Medical Care Research Unit, University of Sheffield, Review Findings: Clear and universal acknowledgement from WAST and external stakeholders that new CRM appropriate and right thing to do No new risks to patient safety introduced by CRM Without CRM likely that there would have been significant risk for patients, particularly over winter No serious safety concerns Positive impact on performance response time reliability increased substantially Fewer resources used per incident, regardless of categorisation Direct costs reduced Stroke consistent and STEMI improving Much more clinically focussed service WAST much more visible to wider health system and a central player rather than passive recipient
Culture & External Recognition
if we were doing it again The things we would do differently are. Re-profile our resourcing prior to model change Undertake a Demand & Capacity review first Continuously check that all stakeholders, internally and externally, and partners remain on the journey with us, updated and involved at every stage and review Think long and hard about our approach to rural areas and areas with low population bases Ensure all conversations are clinically led especially in relation to Red to Amber E-PCR
Transforming Ambulance Services in Wales System Change WAST Organisational Transformation Improved Outcomes Clear Accountability Establishment of EASC Collaborative Commissioning CAREMORE/Five Step Model New Clinical Response Model Ambulance Quality Indicators Creation of CASC Role
Transforming Ambulance Services in Wales System Change WAST Organisational Transformation Improved Outcomes New Board New Leadership Improved Governance Community/Stakeholder Focus Clinical Modernisation Workforce Modernisation Staff Re-engagement NEPTS
Transforming Ambulance Services in Wales System Change WAST Organisational Transformation Improved Outcomes Improving Quality Improving Performance Financial Balance Improving Media Profile Renewed Credibility De-escalation BUT Still Early Days Much More To Do Need Consistency
Welsh Ambulance Service Transformation Journey Transport Organisation ( Scoop and Drop ) 1998 Formation of WAST 2004-2008 Medical Assessment Model 2011 Working Together for Success 2013 McLelland Review 2014-2017 Clinical Transformation Clinically Focused Emergency Service Embedded in the Unscheduled Care System
The first responsibility of a leader is to define reality. The last is to say thank you. In between, the leader is a servant. (Max De Pree)