Agenda item

Purpose: To present an overview of current performance including response times and hospital transfers, and winter service plans for 2022/23.

Mark Ainsworth, Director of Operations, South Central Ambulance Service (SCAS), presented the report on the Service (Agenda Item 5).

Mark Ainsworth gave an overview of the number of calls to the SCAS by category and the associated response times. He noted the increase in demand in category 2 calls (emergencies requiring an 18 minute response). Patients who normally presented as category 3, which required a two hour response, were presenting as category 2 which indicated a higher acuity of patients in communities than was the case. They were failing to achieve all of their performance standards, however SCAS benchmarked very well against other Trusts nationally. Their current focus was on improving category 1 calls where their average response times should be seven minutes.

Mark Ainsworth moved on to Berkshire West Performance. It was noted category 1 response times had increased by about 40 seconds more than the SCAS average. There were challenges in the Berkshire West region and particularly response times in rural areas. Mark Ainsworth moved on to give an overview of SCAS service outcomes. Some patients were responded to by clinicians in control rooms (hear and treat) and an ambulance or rapid response car went to the remaining calls. Some patients were dealt with on site (see and treat) and the remaining patients were see, treat and convey. He explained convey was not always to an emergency department. It could be a minor injuries unit or other speciality. Mark Ainsworth noted that year on year there had been a growth in hear and treat response rates. Last year’s slight drop in hear and treat was due to high rates of hear and treat during the pandemic the previous year. NHS England set a target of a maximum of 49% of patients being conveyed to an emergency department and Mr Ainsworth highlighted that SCAS was above that. They had an active campaign to introduce additional care pathways to avoid patients going to Emergency Departments. Mr Ainsworth advised that Berkshire West see and treat performance was higher than the SCAS average and that was because of the pathways they had in the community rather than conveying patients to hospitals.

Mr Ainsworth presented data on hospital delays. He advised that patients should be handed over within 15 minutes of arrival at hospital. This had been a challenge during Covid with hospitals having high bed occupancy. There had been a slight increase in average handover time in July 2022 of 40 - 43 minutes. The impact was that it took ambulances out of the system and therefore unable to respond to further calls. SCAS were working with all their acute trusts to reduce handover delays. For Berkshire West, Mr Ainsworth advised the majority of patients went to the Royal Berkshire Hospital (RBH). They had a very good working relationship with the RBH and they resolved issues when they arose. There were some challenging weeks, where bed occupancy was very high, but they had good processes to resolve things quickly.

Mr Ainsworth explained that the Community Engagement Team were volunteer community first responders who attended a range of calls from category 1 to falls, as well as responding to alarms for concern for welfare. In some areas these were military co-responders and in Hampshire there were fire service co-responders. These were all volunteers who attended on behalf of SCAS. The Berkshire West calls were slightly lower than the rest of SCAS, however the impact the Community Engagement Team had on overall response times was significant especially in rural areas where they were able to respond more quickly. 

Councillor Andy Moore noted the statistics on hospital delays and asked if there was anything the Ambulance Service could do about those. Mr Ainsworth advised that they were working to reduce the number of patients taken to emergency departments. He advised that the Care Quality Commission (CQC) inspectors highlighted that SCAS could do more to bypass busy hospitals. SCAS were working with NHS England and the Acute Trusts to see what they could do differently. They were commissioned to go to the nearest hospital and they had to request to divert through the hospital system to convey a patient to an alternative hospital. The challenge with the RBH was that the nearest hospital was some distance away. The CQC had stated that SCAS could do more to influence those diverts of patients and Mr Ainsworth advised it was an action in the CQC Recovery Plan. The key was to avoid emergency departments where possible.

Councillor Moore asked for clarification regarding the statistics for alternative care pathways in Berkshire West and whether there were fewer alternatives in Berkshire West. Mr Ainsworth advised there was 0.1% difference between Berkshire West and the rest of the SCAS area. He confirmed Berkshire West had a good number of options. They accessed urgent care response teams for category 3 and 4 calls, district nurses and GPs. They also accessed paramedics employed by GP practices. They were not concerned about the number of community pathways in Berkshire West compared to the rest of their region.

Councillor Alan Macro noted that not only did ambulance queues impact on response times but it also meant patients were lying in the back of ambulances and that some patients would have had much worse outcomes. He highlighted that there was a choice of hospitals from Newbury as some hospitals were the same distance as the RBH and perhaps quicker to get to. Councillor Macro asked for clarification about what was being done to get the turnaround time down. Mr Ainsworth said that RBH turnaround time was better than Basingstoke Hospital and so for most patients the RBH was quicker for them. They monitored the numbers daily and if they saw any delays building they spoke to the site manager to see what actions they could take to reduce their delays. If a number of crews reported queueing, crews were messaged to consider other hospitals. This was not a formal divert but if a patient was on the border, crews could consider other hospitals. Crews made the decisions dynamically. They also considered where patients had ongoing treatment in deciding which hospital to attend.

The Chairman asked if there was any difference in performance since Covid or if Covid cases were still causing delays. Mr Ainsworth explained that Covid was not the issue. Bed occupancy was much lower than the previous two years, but Acute Trusts were catching up with patients with long term conditions and elective surgery, and that was impacting on bed occupancy. There was a direct correlation between total bed occupancy level and ambulance handover delays. He noted that handover delays at RBH meant that 317 hours were lost in August but that was very low compared to other hospitals.

Mr Ainsworth then moved on to discuss the CQC report and their response to it. He explained that the CQC found a number of issues within SCAS which were highlighted in the report. They had listened, fed back to the CQC and had taken rapid actions in response in order to turnaround the rating as soon as possible. They had split their work streams into four main areas to improve their CQC rating. The first was patient safety and experience. In particular issues were highlighted with safeguarding reporting and processing the referrals, challenges to patient safety incident management, concerns regarding processes around medical devices and the storage and maintenance of medical devices, and they highlighted some infection prevention and control issues. Mr Ainsworth explained that they had made immediate changes to respond to these issues.

The next work stream was culture and wellbeing. The CQC carried out a staff survey which highlighted that staff felt direct line managers were supportive but issues raised higher up were not listened to nor actioned. In response they had looked at leadership, training of leaders, looked at issues around sexual harassment in the workplace and listening to staff. It would be a long term campaign to build trust with staff to show they could speak up, would be listened to and they would receive a response.

The third work stream was governance and leadership. The CQC found that the executive team were not fully sighted on operational issues and that they were not visible to staff. They had stopped going to sites due to Covid but the executive team was now going to operational stations and were being more visible.

The next area was performance recovery. They were not meeting performance standards but were benchmarking very well. They had a number of actions to improve their response to patients, effective use of resources and reviewing recruitment and retention actions to increase clinical staffing levels and to reduce staff turnover of 999 call handlers. They were looking at where they could recruit staff from and improving training opportunities.

The CQC and NHS England were monitoring their progress. They had ten weeks to finalise the plan and to deliver the key aspects. The CQC were due back in November 2022 to see progress and SCAS would be re-inspected in January 2023.

Councillor Tony Linden noted that the CQC was a damning report and was glad that it was being taken seriously.

Councillor Alan Macro highlighted two areas which stood out in the CQC report. The first was safeguarding and noted that it was raised by the CQC in November 2021. Secondly, Councillor Macro expressed concern with leaders dismissing staff when raising issues and being treated badly. Councillor Macro noted that it was a theme with various Trusts across the country and asked what SCAS were doing about it. Mr Ainsworth firstly responded to the question regarding safeguarding. He advised that it was the 111 Service that was inspected in 2021 and that the problems were rectified. More recently it was the patient transport service and 999 Service that was included in the CQC report. Mr Ainsworth explained that staff were reporting effectively but it was the inward referrals that were not being managed effectively and they were taking too long. They had taken robust steps in response to this which included increasing staff numbers in the safeguarding team and recruiting a head of safeguarding. They also had a specialist in safeguarding supporting the process.

With regards to staff speaking up, Mr Ainsworth advised that there were 2000 staff across 4000 miles and so it was hard for staff to be heard by the Chief Executive. Staff would raise concerns to the local management team who would try to resolve the issue locally rather than escalating it for support. There would then be no response back to staff. In terms of immediate actions, they had a freedom to speak up lead and a non-executive director who was a freedom to speak up champion. They had also added two new members of staff and had local freedom to speak up champions in all areas. They would ensure staff got a response back. Mr Ainsworth also noted the reports of sexual harassment at work claims and said that they were working with the safeguarding team and freedom to speak up team to respond. This would take time to resolve as they built trust with staff. Councillor Macro asked for more information about how they were responding to the issue raised that staff were treated badly when they spoke up. Mr Ainsworth advised that SCAS were continuing their retraining programme for managers to a Just and Learning Culture and were moving away from adhering to policies rigidly. This was to refocus thoughts on how to treat staff, being supportive and understanding.

Councillor Andy Moore asked for further information around support from NHS England and an update on the Governance Review by NHS England. Mr Ainsworth advised they would be allocated a turnaround director and a performance director that would come in to SCAS to help them. In addition their commissioners would be holding them to account on delivering CQC actions and improving their performance. There were regular meetings with NHS England. They had also brought in their own internal turnaround director who had experience in turning around services post CQC inspections. They have had some quick wins and there had been change already. They had a programme for the next ten weeks which would bring significant change and then they needed to embed those changes so that staff and patients noticed the difference.

Councillor Linden noted that external organisations shared many of the challenges facing SCAS such as staff retention and risk, and that they could be consulted in order to learn good practice. Councillor Linden asked what West Berkshire Council, and other organisations, could do to help SCAS in trying to improve practice in the short, medium and long term. Secondly, Councillor Linden asked for their key staffing concerns in the coming months and years. He asked what were their main barriers to recruitment and retention, and how were they addressing these challenges. Mr Ainsworth pointed out that the CQC highlighted staff dedication in providing the best care possible. He was not sure what West Berkshire Council could do to support them but it could prove useful to discuss challenges with recruitment and retention. There was a national pay scale and once staff were trained they would relocate to areas with lower housing costs. As their recovery programme developed, they would like to come back to show the progress they had made and use Councillors to help be a conduit between the ambulance service and the public to show the efforts they had made. Mr Ainsworth confirmed he would make contact with the Fire Service. The Chairman would welcome Mr Ainsworth returning to the Health Scrutiny Committee to show their progress and also to work with SCAS in communicating with the public.

Councillor Linden recognised the challenges with staffing and the cost of living. Mr Ainsworth confirmed the national pay scale made it difficult and they had some staff living near to areas where they received a cost of living allowance on their wages and so would choose to work there. They offered relocation packages to staff. There were limited numbers of paramedics coming out of University because it was no longer funded. They had implemented an apprenticeship programme which was working really well. This went up to paramedic level and would take three to five years. Whilst they had a number of vacancies they also had private providers to fill the gap. They were looking at the reasons why staff were leaving. Some reasons were cost of living, others were development opportunities. They had schemes across the Trust where staff worked partly on ambulances and partly with GPs in the community to develop their skills. The national salary review was ongoing.  The CQC rating would make it harder and that was another reason to turn it around quickly. Councillor Moore noted the cost of living challenge and affordable housing, and wondered whether affordable housing was accessible for SCAS staff in West Berkshire.

Councillor Macro noted that staff appraisals were not being completed and asked what was being done to address that. Mr Ainsworth advised that during Covid all staff were working at REAP 4 (major incident standby). This meant they stopped training, appraisals, meetings etc to ensure all staff were on the road dealing with patient care. They were at REAP 4 for nine months last year and that was why appraisals and training dropped. They were reviewing what needed to be continued when at REAP 4. Appraisals were going to become essential meetings. They had a target to get all 85% of appraisals completed by the end of October and 95% complete by the end of December.

The Chairman asked if it would help if Berkshire West Health Scrutiny Committees came together as a group to help SCAS and requested Mr Ainsworth make contact if there was more West Berkshire Council could do to help. It was agreed that SCAS be considered on the Work Programme in the future.

RESOLVED that the report be noted and the South Central Ambulance Service NHS Trust be invited to attend and present an update at the appropriate time.