15 July - Non-executive directors - Ambulance service pinch points and pressures, with David Astley OBE

This week’s session opened in conversation with David Astley OBE, chair of South East Coast Ambulance Service (SECAM).

David said: “The 111 service is increasingly becoming the front line between the NHS and the public. As other bits of the NHS get into trouble and access gets harder to primary services, 111 becomes the gateway.

“In SECAM we offer a service with a partner organisation, IC24, which we call a clinical assessment service. And that’s not just listening and trying to point the caller in the right direction to get help. We have a battery of advice ranging from medical staff, mental health nurses, midwives, dental nurses. The 999 service is the one we like people to use in a real emergency but increasingly what is happening is that it’s becoming a default number for people who can’t get access to the system.

“One of the most significant recent changes in the NHS and one I’m very proud of was developing a network of stroke and trauma centres where the evidence was very clear: timely access to these services, speedy diagnosis, treatment within the golden hour, could normally lead to recovery from a brain haemorrhage or from a heart attack – certainly a better life thereafter. We had a lot of these gold standard pathways developed in the early 2000s which are now at risk because we cannot meet those standards. Not just due to the delay in answering the initial call, which should be in seconds but is now sometimes minutes. Then there are delays in getting eyes on the patient in distress, which is causing real harm. What should happen in minutes can stretch to 45 minutes or an hour. And that’s really scary.

“We do all we can to keep patients at home. Once you take them to hospital they’ll probably be in a queue for many hours. But once you’re in the pathway, in theory once the ambulance crosses the hospital drive the patient becomes their responsibility. In practice it’s shared. I would ask colleagues – do you really understand who’s waiting on your hospital drive? It’s got to be more joined up than it currently is.

“Demand for 111 has significantly increased – by about 30% in the last two years. And 999 calls have gone up by about 18% in the same period. Because the system is now running so hot, there are many diseconomies in that system. Up to 20% of calls are repeat calls as callers get anxious despite being told an ambulance is on the way.

“Generally, the hospitals that are successful are those that are united from boardroom to frontline clinicians. But we also had contact with A&E clinicians so they had hope that things would be sorted out because they were working together with the boss. So it’s about top rate clinical leadership, great A&E consultants, and the nursing teams and others in A&E being absolutely switched on about flow. They’ve got to be supported by the rest of the hospital – so is the rest of the hospital prepared to pull patients out of A&E and are they pushing the patients through social care? In the ambulance service we have to make sure we can deliver the patients in a timely fashion and in the best condition we can because that’s going to speed up the process of them going through A&E.

“The majority of calls that come through our call centres are not life or death emergencies, they’re probably the result of a breakdown somewhere in the care chain. Most calls were from a patient in distress – or more often a partner in distress because of the patient’s condition – because somebody had not phoned them back with a promised call or a call had not arrived from another part of the health service, the weekend was coming, and people were panicking because that person had not got the care they needed. The population of the chronically ill elderly frail who are being the most damaged and ended up in the current hospital queues where possibly there could be some community initiative to keep them safely in their own home.

Also overheard during the session

“I am wondering if we need to focus on building primary and community capacity and responding to the Fuller stocktake report? The lack of capacity in the acute sector is a real problem – so although I agree leadership and on-call arrangements are important, the solutions I think need to be outside of hospital so that flow is managed better and acute hospitals can focus on patients with emergency needs.”

“I listen in to the bed meeting every morning, not to interfere but to understand operations and to get to know the people. I also pop into the ED with biscuits and fruit once a week. It takes very little time but makes the board real to them and vice versa.”

“One of the biggest challenges faced currently in urgent and emergency care is the mental health needs of patients. To my knowledge, mental health risk and needs assessment is only done once the patient reaches the hospital bay. What’s the clinical practice and who is accountable? And does the ICS working allow paramedic access to patient GP record where their mental health needs may have been recorded?”

“There are great palliative care models that are working – the IMPaCT model in Merseyside is a good example – so it is a collaborative between hospital, community services and hospices through a single point of access and they have reduced length of stay in hospital and reduced admissions to hospital considerably.”

These meetings are by invitation and are open to all NHS non-executives directors, chairs and associate non-executive directors of NHS providers. Others may attend by special invitation.

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