Mr Russell B Hamilton, Chief Executive of the Hereford and Worcester NHS Ambulance Trust had been invited to advise the Committee on options being considered to manage the Trust’s financial situation.  He was accompanied by Mrs Frances Martin, Director of Service Delivery and Operations.

The invitation had been prompted in part by reports in the press that the Trust was proposing to close/relocate the four existing ambulance stations at Bromyard, Kington, Ledbury and Ross-on-Wye.  However, having previously received presentations from the Hereford NHS Hospitals Trust and Herefordshire Primary Care Trust it was also considered opportune for the Committee to receive its first formal report from the Ambulance Trust.

The presentation to the Committee covered the following broad areas: operational performance, finance, national NHS changes and local issues.

Operational Performance

The role of the Ambulance Service in transporting patients was outlined and the Committee reminded of the National Standard which required the Service to reach 75% of people within 8 Minutes of receipt of a call, a potentially difficult challenge in rural areas.

Mrs Martin explained that by using historical data of calls it was possible to deploy ambulances to where they were most likely to be needed throughout the day.  There was a 13 month rolling programme for deployment.  This was something that was kept under constant review. 

She reported on the plans to expand the Community First Responder scheme, with a scheme already having been launched in Ledbury and with the launch of schemes in Hereford and Ross-on-Wye imminent with others to follow in the new year.  This involved providing training to volunteers to a defined accredited standard so providing an additional resource in the event of an emergency.  This was particularly valuable in such a rural area.

The Committee was advised that whilst the Ambulance Service faced many challenges it was pleased to report that it was delivering services to the required standard.

Finance

Mr Hamilton reported that the Ambulance Trust, unlike many across the Country had historically always achieved financial balance.  Whilst at the end of October the accounts showed an overspend of £36,000 he believed that the Trust would again break even for the 2005/06 financial year.

In addition the Trust was also on track to deliver the requirements of the national cost improvement programme which required the Trust to make efficiency savings of £258,000 (1.7% of the total budget).

The Trust had received a generous increase in income for 2005/06 of some £2.989 million, of which some £2 million had been allocated to meet pay awards in this year along with another £814,000 relating to back pay for last year.  The Trust’s total budget was £17.9 million of which approximately 75% was spent on staff costs.  Mr Hamilton reported that this meant that the Trust had more better trained, better paid staff than at any time in its history.

In addition the Trust had to negotiate with the Primary Care Trusts as Commissioners of Services over what they would invest in the Trust for its services.  The Redditch and Bromsgrove Primary Care Trust was the lead Commissioner on behalf of the Primary Care Trusts within Herefordshire and Worcestershire.  Whilst these negotiations were rarely concluded before the start of the financial year as they should be, the negotiations for 2005/06 had taken longer than expected and agreement had not been reached until September 2005.

At the time of the Trust’s September Board meeting the Trust had had to agree additional cost improvement measures to be able to ensure a break even at the year end.  He reiterated, however, that the Trust had never had a deficit, did not have one and did not face one.

National NHS Changes

Mr Hamilton informed the Committee that, following an initial exercise in September, a formal consultation exercise on the reconfiguration of health services was to be conducted by the West Midlands Strategic Health Authority (SHA) was likely to be launched on 14th December.  The SHA’s preferred option was for an Ambulance Trust covering Coventry, Warwickshire, Herefordshire and Worcestershire, Shropshire and the West Midlands.  This would doubtless be the subject of further discussions with the Committee and other interested parties. 

Local issues

Mr Hamilton emphasised that patient safety was of the highest importance.  He believed the service locally had made a lot of progress and was at the forefront of developments in a number of areas, such as the use of mobile technology and the use of the electronic patient record.  A new national radio system was also being rolled out. 

Training and deploying Emergency Care Practitioners would have important benefits allowing far more people to be treated on the spot rather than being transported to hospital.  Making better use of local minor injury units would also bring improvement. 

As had already been mentioned the Community First Responder Scheme was also an important element of service development.

He had always stressed that the Ambulance Service was a part of the NHS and not a stand alone service.  He wanted the service to be integrated with other parts of the NHS.  Joint training was a key part of this and the Trust’s own training centre at Hartlebury had transferred to Worcester University in April 2005, an important development in advance of the commencement of foundation degree level training for paramedics from April 2006.  He believed that Hereford and Worcester Ambulance Service was at the leading edge in this regard.  Ambulance Trust staff would then be trained alongside other health professionals.  It was thought this would assist in improving skills and increasing the range of care ambulance staff could provide, leading to services being delivered in partnership with others.

Co-location with other health providers was a logical part of this process and this was one of the reasons for seeking to co-locate Ambulance Stations with Minor Injury Units.

He believed that it was in the local interest to have joined up care delivered by professional staff and, that being the case, the Trust’s proposals were sound.  He believed that this was important as patients wanted seamless care and the Trust supported this as by doing so it was likely to reduce the opportunity for things to go wrong.  However, it was important to establish that there was local understanding of and support for this approach.

He concluded by explaining that the approach was consistent with the recommendations of the Department of Health's Report: “Taking Healthcare to the Patient - Transforming NHS Ambulance Services”.  Whilst the response time to 999 calls would remain the same the plan was that the response would be tailored to the patient need.  If an ambulance were required one would be sent but there were a range of other options becoming available such as the use of Emergency Care Practitioners which might be more effective.

In the course of discussion the following general principal points were made:

·         Although the Ambulance Trust was clearly an integral part of the NHS and most of its work related directly to other NHS providers it was noted that the Fire and Rescue Service was facing many of the same issues as the Ambulance Service.  It was suggested that opportunities for co-operation between the two Services should be constantly borne in mind.  It was also important in the face of the move to regionalise both services that a local presence was retained.

·         That it was important that the Ambulance Trust’s Patient and Public Involvement Forum (PPIF) was fully involved by the Trust in developing its proposals.  It was asked what steps had been taken to date in this regard.

Mr Hamilton replied that the consultation on the future configuration of Services by the SHA would be seeking views from a range of sources including the Forums.  He said that he would also be willing to return to discuss the issues with the Committee.  He believed generally that there was a good relationship with the Forum and that this was developing.  Members of the Forum had sat on the Steering Group which had conducted the Operational Review of the Service and had been involved in vehicle design. 

Mrs Martin outlined other work being undertaken with the PPIF including service planning.

·         Support was offered for the way in which it was proposed to develop the service to tailor the response to meet patient need.  It was noted that ambulances were a costly resource which could not and should not be deployed in response to every incident and the resources should be better matched to the type of call. 

·         It was suggested that it might be useful to develop some way of measuring the success of the new approaches being proposed to set alongside the existing national targets for response times.

·         It was noted that Mr Hamilton had initiated discussions with the Mayors of the Market Towns about the Trust’s proposals.  It was suggested to him that in planning future meetings to explain proposals he needed to be mindful of the role of the Councillors elected to Herefordshire Council and Parish Councillors, noting that people living in the hinterland of the Market Towns might in fact have even greater concerns about access to services than those in the Market Towns themselves. It was noted that Herefordshire Association of Local Councils would be one point of contact.  Mr Hamilton noted and welcomed the constructive comments and feedback.

·         Assurance was sought about the competence of Community First Responders.  It was explained that there was a rigorous recruitment process and a formal qualification had to be obtained.  Mr Hamilton agreed to circulate details of future launches of the scheme across the County.

·         A number of concerns were expressed about matters which were outside the remit of the Ambulance Trust including the availability of pharmacists out of hours and a suggestion that information on a leaflet giving details of clinics for Parkinson’s disease was incorrect. 

Mr Hairsnape, Deputy Chief Executive of the Herefordshire Primary Care Trust advised that out of hours pharmacy provision in Herefordshire, outside Hereford itself, was limited.  However, the out of hours Doctors carried a nationally prescribed selection of medicines. Additional supplies were held at Gaol Street.  There was also a rota of pharmacists on call 24 hours a day 7 days a week who could be called on in urgent cases of need.  There was no reason why a patient could not be provided with the necessary medication to meet needs until the local GP surgery re-opened.  He undertook to establish whether information on the clinics for Parkinson’s disease needed to be corrected.

The following principal points were made in relation to the future of the ambulance stations in the Market Towns:

·         In relation to the ambulance station in Ross-on-Wye reference was made to the funds which had been raised by the local community to support the station.  It was asserted that the station was in the best location at the moment and that the Trust’s plan to relocate to share the Community Hospital site was not practical, given the pressure on space at that site. It was suggested that it was also hard to see what cost savings, if any, would be achieved by such a move.  The identification of a completely new site appeared problematic given the pressure on development land.

In response Mr Hamilton acknowledged the past support of the community.  He emphasised that he was not pursuing change for change’s sake.  His objective was to explore the options and to find solutions which would lead to an improvement in patient care.  He added that it was important to recognise the limited importance of the stations themselves in service delivery terms.

·         A Ward Member expressed further concern about moving the ambulance station at Ross-on-Wye and doubt about the role of the voluntary Community First Responders. 

Mr Hamilton clarified that there were currently 2 Ambulances in Ross-on-Wye and a Patient Transport Service vehicle.  He informed the Committee that there were on average 146 emergency calls per day across Herefordshire and Worcestershire. There were on average 4.1 emergency calls in Ross-on-Wye, 2.4 in Ledbury, 1.6 in Bromyard and 0.6 in Kington. 

The suggestion that the ambulance station in Ross-on-Wye was well located because of access to the motorway and dual carriageway was not supported by statistical information on the number of calls.  The Service had carried out a fundamental review of where it would locate stations if starting afresh and the analysis had shown that central Ross-on-Wye would be a better location.

He defended the importance of the Community First Responder Scheme explaining that the scheme was a national scheme and was in the process of being rolled out across Herefordshire and Worcestershire.  He said that it was important that the principle of voluntary service was recognised and seen as an additional resource.   He also noted the outstanding voluntary commitment of their time by 10 Basics Doctors within the two Counties.

·         A Member expressed a lack of confidence in the effectiveness of the mobile technology to which Mr Hamilton had referred and suggested that there were a number of communication difficulties.

·         In relation to the ambulance station in Hereford Mr Hamilton said that discussions had for a number of years taken place about the possibility of basing the ambulance station at Hereford Hospital. However, there was not space on the site and in any case analysis showed that the station’s present site was the best when complemented by the strategic location of two ambulances at the Hospital.  There were therefore currently no proposals in relation to the Hereford Ambulance Station.

·         A question was asked about the timescale for any change and how Members could represent the views of their constituents to the Trust. In reply Mr Hamilton began by drawing a distinction between the stations at Kington and the stations at Bromyard, Ledbury and Ross-on-Wye.

He said that there was one ambulance at Kington and one full time Member of staff lived there.  In the morning the other two crew members drove to Kington.  The ambulance was then driven away, parked at strategic locations throughout the day and returned to the station at night.  In short the station was only a garage.  He was shortly attending a full Town Council meeting at Kington to explain the position and intended to seek to progress the station’s closure at the beginning of the new year.

In the case of the other three stations he wanted to identify what the options were, decide whether it was feasible to improve the service and discuss any proposals with local communities.  He emphasised that what was being considered was a relocation of service not a removal of it.  He wanted to reach a conclusion on the way forward by the start of the new financial year but if proposals to relocate were agreed there would then be a further implementation period.

It was noted that the Trust had set up a Working Group to conduct the review and that the Membership included members of the Patients Forum and Staff representatives.

·         In response to questions about the amount of calls attended out of area Mr Hamilton said that the Service was funded by the Primary Care Trusts to provide a service to the residents of Herefordshire and Worcestershire.  Whilst there was a national agreement for neighbouring areas to provide mutual assistance there were very few out of area calls.  The performance report covering the period September 04 to October 05 showed an average of 16 out of area calls per month.

·         That there were particular sensitivities given the rural nature of the County about response times.  It would be important for the Trust to demonstrate that these would definitely not be affected by any changes.

·         It was acknowledged that the Community Hospital site in Bromyard might well be able to accommodate the ambulance station.  It was requested, however, that it was vital to ensure the long term security of any arrangements entered into.

·         In response to a question about how the proceeds of the sale of any of the existing stations would be used Mr Hamilton said that no decisions had been made because it was not yet known what those proceeds, if any, might be.  His intention, subject to Board discussion and agreement, would be to reallocate any surplus to improve services in Herefordshire, with improvements to the main ambulance station in Hereford being the first priority.

·         The way in which the consideration being given to the future of the four ambulance stations had been handled in public relations terms was heavily criticised. 

It was also suggested that the role of stations as garage and secure storage areas was important.

Mr Hamilton acknowledged that the way in which the Trust’s plans had been publicised could have been handled better.  However, the initial press report had not been issued by the Trust.  The Board discussion had been prompted by the lack of Service Level Agreement with the Trust’s commissioners at the time of the September Board meeting and that had prompted the need for this action at this time.  He emphasised that the proposals did not involve the loss of any ambulances or any staff and nothing would be done to the detriment of performance.  He had himself insisted that all operational vehicles were garaged and careful account was taken of security.

He added that there had been considerable investment in the vehicle fleet and in training.  Indeed the Trust had made the biggest investment in vehicles and equipment in the Trust’s history in the last 2 years. In total this amounted to over £2 million.

·         It was asked whether a similar approach was being adopted regarding ambulance stations in Worcestershire.   Mr Hamilton answered that, given the findings of the operational review, to which he had previously referred, there were a number of areas where similar action was under consideration.  In part the Trust’s approach was dependent on decisions being considered by partner organisations.

·         Asked about communication with staff Mr Hamilton reported that extensive efforts had been made to explain the position but it was difficult to ensure that every member of staff received or read information which was distributed. 

·         The Chairman thanked Mr Hamilton and Mrs Martin and advised that some observations by the Committee on the evidence which had been provided to the Committee would be forwarded to the Trust.