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NHS County Durham & Darlington
Ambulance evaluation research:Key insights (March 2013)
June 2013Presented by Joanne Loughlin-Ridley
Introduction
Explain was commissioned by NHS County Durham & Darlington in 2012 to deliver a comprehensive research programme that would independently evaluate the evidence based model of ambulance provision that was operating in the Durham Dales at that time.
Public
• On-street survey with 366 local residents
Patients
• In-depth telephone interviews with 13 patients
Professionals
• In-depth telephone interviews with 21 relevant professionals
216 Teesdale, 150 Weardale
Random selection
Mix of demographic
profiles
8 Teesdale, 5 Weardale
Opt-in sample
12 emergency care / 3
primary care
14 Teesdale, 12 Weardale
Nominated sample
Included operational
and strategic roles
Fieldwork was completed between mid-January and mid-March 2013, with insight delivered at the end of March 2013.
Model
Below is an outline of the model of provision in the Dales which was central to the research:
WeardaleThere is one 24 hour ambulance crewed by two Paramedics based at St John’s Chapel. There is one rapid response car crewed by one Paramedic seven days a week 07.00-19.00 working from St John’s Chapel. The crews work closely with GPs in both St John’s Chapel and Stanhope, and are able to carry out a number of tasks.
TeesdaleThere is one 24 hour ambulance crewed by two Paramedics based in Barnard Castle.There is one ambulance crewed by two Paramedics seven days a week 08.00-20.00 working from Middleton-in-Teesdale.The Paramedics are available to work with the GP practice in Middleton, and are able to carry out a number of tasks.
In both areas, the tasks that the ambulance service crew can assist GPs with is the same: Completing discharge reviews Administering flu vaccinations Taking urgent bloods Reviewing COPD patients Completing a ‘well person review’ for patients over 80 who have not had contact with their GP for some time to review
their blood pressure, pulse, oxygen levels and general healthThey also respond to GP home visits so that the GPs can stay in the surgery and see patients with appointments uninterrupted.
In both areas, the ambulance service crew can also provide support to local community hospitals by taking patient bloods for example, and setting up IVs (drips).
Key insight: satisfaction
High levels of satisfaction found from patients of the ambulance service, particularly in relation to the crew being caring and compassionate, helpful and reassuring
Quick and efficient
Professional and helpful
Familiar faces
Calming and chatty
Reassuranceand
comfort
Overall (146-147)
Weardale (62-63)
Teesdale (83-84)
How long it took to be seen 86% 82% 89%How long it took to travel to hospital 80% 78% 82%How clean the response vehicle was 85% 84% 86%How compassionate and caring the crew were 93% 92% 94%How helpful the crew were 94% 94% 94%How well they kept you/your family or friends informed 91% 89% 92%How well the care matched your needs 90% 89% 91%The overall quality of care they delivered to you 89% 87% 91%
Patients that discussed positive experiences identified key contributors:
Key insight: reputation
Identification that the ambulance service is very valued by the wider local community also, a strong and positive reputation found
Patients discussed how valued the local ambulance crew are in the Dales:
“Everybody is positive about them...round here there’s only praise as far as I know for the ambulance service here. Oh God, I couldn’t do without them. Honestly, we could
not do without them. This would be disastrous, where we are in Romaldkirk. You need a fast response to here. And there’s some quite elderly people in the village, so you
would rely on them” (Teesdale – stomach pains)
Yes No
15%
86%
20%
80%
11%
89%
Have you heard anything negative about the local ambulance service in the last 12 months?
Overall (366) Weardale (150) Teesdale (216)
The model of provision was detailed to patients and the public and was very well received, particularly for the benefits of local GPs, with no consistent themes for improvement found
Key insight: reviewing the model
Good use of the crews
time
GPs are busy and will find this helpful
Crew are / become
familiar faces
Could prevent
admissions
Support is great, especially for older people
Patients that discussed positive experiences identified key contributors:
Positive Indifferent Negative
78%
15%10%
85%
8% 8%
73%
19%
8%
How do you view the Paramedics supporting the local GPs?
Overall (364) Weardale (143) Teesdale (221)
Key insight: strengths of the model
Many strengths of the service model were identified by stakeholders, particularly the primary care role of paramedics in local communities and the prevention of (re)admissions
Social care for those
vulnerable
Builds familiarity with
local people
Good use of time and resource
Being based in area to respond
more quickly
Improved patient
outcomes with two
paramedics per vehicle
High caliber paramedics
Local knowledge
allows a quicker
response
Prevents admissions and re-admissions to hospital
A model that is being held up nationally as 'good practice'
Key insight: weaknesses of the model
The majority of stakeholders discussed weaknesses of the current model, it not working in practice due to ongoing challenges such as the impact of the 111 system, delayed handovers of patients at hospitals, and ‘critical escalation’ leaving the Dales without cover
Reduction of wider resource in North East
Critical escalation becoming more frequent
Delays in handover of patients at hospitals
Once out of area, must respond if closest to a call
Impact of the 111 system not working as planned
Leaves the Dales
with no cover
Reduces opportunities for community work
Causes breaches /
increases in response
times in the Dales
Perception is that the service model is not working in
practice
Key insight: paralleled perspectives
Feedback from the ambulance control staff stood out as distinctive from other stakeholder roles, perceiving of the service model as ‘above and beyond requirements’
Control staff did not echo the concerns of other professionals about the model not delivering sufficient coverage in the Dales, holding a paralleled perspective that the model exceeded requirements and could be reduced in the future:
“People’s lives will be put in danger, and I know that's quite a strong thing to say, in fact I’ll say it
even stronger, people will die if we don't have a 24-hour proper crewing system here in the Dale. We are
so remote, we have an aged population, and definitive care for a number of different things, for
example, heart attacks, and trauma, are a long way away...if we don't have 24-hour cover, and someone
has to come into the Dale to do that, then that's a long way to go” (Paramedic)
Protect the provisionReduce the provision
“I don't think it requires any more than any other ambulance, one paramedic and one other...
they've got four vehicles operating, during the day, and two vehicles operating through the
night, and for the demand they've been treated very generously,… you could probably take one vehicle out of that equation… I don’t have this much cover in Durham city centre… they are
getting above and beyond… It’ll be more efficient by not having the Middleton vehicle at all without
hurting the service, I could use that vehicle somewhere else, much more efficiently”
(Ambulance control staff)
Key insight: improvements
The majority of stakeholders discussed improvement mainly in terms of ensuring the service model was being delivered to provide ‘true’ 24 hour cover in the Dales
In order to provide ‘true’ 24 hour cover in the Dales a number of improvements were noted..
Investigate causes of critical escalation across NEAS patch which takes / keeps ambulances out of the Dales
Improve 111 system
Improve handover on admissions to
A&E
Allow admissions to community
hospitals nearby
Cover across NEAS to improve
Consideration of ring fencing
Be transparent about performance so areas for improvement are evidenced
and clear for all involved
A number of other areas were discussed also:- Importance of 2 paramedics per vehicle due to the distance from hospitals
- Training required to deliver valuable primary care to the Dales communities to tackle (re)admissions
- 4x4 vehicle being needed all year long in Weardale
- Ambulance station at St John’s Chapel being in need of attention / review
- Retention of paramedics in the Dales and wider NEAS patch
Strained relationships and communication were found between stakeholder groups, and a call for increased transparency as to performance rates was evidenced as a way forward
Key insight: communication
Paramedics
Information is not disseminated on
performance
No opportunities available at operational
level to feed back
Community representatives
Unresponsive to queries / concerns highlighted
Actions not followed through as agreed
Seen as 'opposition' not as partners
GP
Crew seem disengaged and morale can appear
low in light of this
Lack of information / justification for
performance levels
Evidence of ongoing frustrations were found in regards to some of the professionals relationship and communication with the NHS and with NEAS specifically:
By its nature of exploration research can often unearth many questions alongside answers and so a number of areas for further exploration have been recommended
Key insight: challenge
Based on the current feedback, consider and explore the feasibility of ‘smarter working’ across services, to minimise the ‘strain’ on the ambulance service that impacts on provision and
performance in the Dales
Tackle the causes of delay in hospitals when admitting
patients
Alternative care pathways for patients in need of social
care
Ensuring 111 calls are handled correctly with appropriate responses
delivered
Clear guidance for the public on ‘out of hours
services’ to reduce misuse
Comprehensive and independent analysis of performance data of the ambulance service in the Dales and across the NEAS patch is advised, including an assessment of the paramedics role in supporting
GPs and community hospitals
Need to verify the strong concerns of professionals
Due to strained relationships and mistrust amongst professionals this is
advised to be independent
Transparency with the outcomes is key to building trust and relationships