To consider the outcome of the efficiency review of the West Midlands Ambulance Service NHS Trust.

The Committee considered the outcome of the efficiency review of the West Midlands Ambulance Service NHS Trust (WMAS).

The report noted that the Regional Specialised Commissioning Team, responsible for commissioning the ambulance service on behalf of the 17 Primary Care Trusts (PCTs) in the West Midlands Strategic Health Authority area, had commissioned an independent review looking at the operational and financial effectiveness of the ambulance service across the region. 

The findings of the efficiency review undertaken by Lightfoot Solutions (the Lightfoot Review) had been  published on 30 September 2009.  A summary and analysis by NHS Herefordshire was appended to the report.  The Lightfoot Review had been circulated separately to Members of the Committee.

Representatives of WMAS attended the meeting to present the findings of the Lightfoot Review.

The presentation provided some background statistical information on the service and some of its recent achievements, including being Ambulance Service of the Year 2007, 2008 and 2009.

It was reported that the main issues to be addressed by the Independent Review had included demand, performance, the implications of the urban/rural mix of services, ambulance resources, the Paramedic skill mix, the status of urgent care provision

and the cost of the service.

Demand on WMAS was consistently above both the contract level and previous year

April ’08 to March ’09: +3.5% above previous year and 1.9% above contract, April - October ’09: +7.2% above previous year and 4.5% above contract.  There were

not enough ambulances across the region

In terms of performance, despite achieving national targets for the last three years WMAS performance was not sustainable due to high demand and was not consistent across the region.

Performance varied between urban and rural areas.  In Herefordshire performance against the national target of responding to Category A calls within 8 minutes of 75% was 72% and the Lightfoot review recommended a target of 68%.  This compared with performance across the Region as a whole of 75% with the Lightfoot Review recommending a target of 80%.  It was stated that WMAS was still seeking to hit the 75% target in Herefordshire and had not adopted the Lightfoot recommendation of a target of 68%.

The fact that demand was above the level provided for in WMAS contract with the commissioning bodies meant there were not enough front line ambulance staff and WMAS was unable to complete mandatory training updates.

The Paramedic skill mix of 52% meant WMAS could not put a paramedic on every ambulance.  This meant too many patients were taken to hospital and there was insufficient use of alternative care pathways

Urgent care provision varied across the region.  Emergency ambulance demand increased when patients could not access urgent care

WMAS costs were amongst the lowest in England.  Rural costs would always be higher than urban costs but there was a wide variation in payments made by PCTs with some paying proportionately more than others.

The main recommendations of the review were summarised.  Immediate action taken in response to the review included the establishment of PCT/WMAS Task & Finish Groups to implement recommendations; investment by PCTs of c£11m to recover performance by deploying additional ambulances; a Regional Clinical Support Desk in Emergency Operations Centres to manage non-life threatening category C calls; increased use of alternative pathways; a healthcare Referral Tier for Urgent Referrals introduced; 25 additional ambulances and 100 staff trained

By March 2013 it was planned to increase the number of paramedics by 300,

improving the paramedic skill mix to 69% from 52%.  This would be achieved by a major increase in training and development of the existing workforce, direct entry from university and direct recruitment of qualified people.

Ongoing action included agreeing commissioning PCT intentions and the WMAS response, agreeing ongoing funding arrangements; the proposed replacement of the “block” contract with tariffs; agreeing a response model and performance management arrangements.

In discussion the following principal points were made:

·         It was noted that a move from a block contract to a tariff based system would be the first such arrangement in the Country and would require the agreement of all 17 PCTs in the region.  The ambulance service had been seeking such a change for a number of years.  It believed that a tariff system encouraged efficiency as well as a good quality service.

·         A question was asked seeking clarification of the costs of the proposed increase in the number of paramedics.  Assurance was sought that the plan would deliver value for money and better care for patients.  WMAS acknowledged that there would be increased costs but the review had highlighted the need for increased funding of WMAS, recognised already by the additional investment made by the PCTs in the current financial year in response to the review.  Increasing the number of paramedics had a number of service and cost benefits, for example, permitting care to be provided locally in a community setting such as a primary care centre, Minor Injuries Unit or GP surgery, which was what most patients preferred, reducing the number of patients taken to hospital.  The PCTs had a key role in performance managing the service and ensuring patient care was appropriate.  Because facilities varied across the region it was important that the operation control centres had a directory that detailed the facilities available.  It was requested that in reporting on progress in response to the review WMAS should include comment on the outcomes for patients and the costs.

·         One of the findings of the Committee’s own scrutiny review of the ambulance service in Herefordshire had been that there was a need to improve ambulance clearance procedures at hospitals.  Disappointment was expressed that this finding, and others of the Committee’s review, did not appear to have been acted upon.  In reply it was acknowledged that waiting to book patients into hospitals was an issue and WMAS did pursue this with the PCTs.  Other actions taken had included putting more ambulances on the road and developing a workforce plan.

·         The importance of Community First Responders was acknowledged.

·         The proposition in the Lightfoot Review that the target for responding to Category A calls within 8 minutes should be set at 68% for rural areas was discussed.  WMAS assured the Committee that, whilst it was a struggle to hit the 75% target in rural areas WMAS would continue to seek to meet the 75% target.

·         There was criticism of the dip in WMAS performance.  WMAS replied that demand for the service had increased so dramatically that the service had not been able to cope as it would wish.

·         In response to concern that good performance in urban areas could provide good performance statistics on a regional basis, masking poor performance in Herefordshire, WMAS replied that each PCT was provided with an assessment of performance in its area.

·         In response to a question about service integration the Director of Public Health said that this was at the forefront of service planning in Herefordshire.

·         WMAS acknowledged that targets were not outcome based and there was an aim to move towards this position.

·         In response to a suggestion that that not all ambulances available to WMAS were in service, WMAS said that it could take time to commission vehicles and resource needed to be managed to ensure cover.  All vehicles available to WMAS were being deployed.

RESOLVED:

That    (a)        a report be made to the next meeting setting out progress in response to the findings of the Lightfoot Review, performance against targets in Herefordshire the cost implications for the NHS as a whole of the improvements proposed in the Lightfoot review and the projected outcomes;

            (b)       the report should also include commentary on action in response to the findings of the Committee’s review of the ambulance service in the light of the Lightfoot Review; and

            (c)        the Committee’s disappointment at the time taken to address the recommendations in its scrutiny review be recorded.