Integrated Business Plan - swast.nhs.uk · Integrated Business Plan 2014/15 to 2018/19 Version: Final - 31 July 2014 Approved by: Trust Board of Directors Date approved: 31 July 2014

Integrated Business Plan

2014/15 to 2018/19

Version: Final - 31 July 2014

Approved by: Trust Board of Directors

Date approved: 31 July 2014

Name of originator/author: Karina Janas, Planning Manager

Date issued: 23 September 2014

Integrated Business Plan 2014/15 to 2018/19

Page 2 of 77 Final Version

Contents

1. Executive Summary..................................................................................................... 3 2. Profile .......................................................................................................................... 4 2.1. Overview ................................................................................................................................................4 2.2. The Trust Profile.....................................................................................................................................4 2.3. Core Services.........................................................................................................................................5 2.4. Non-Core Services.................................................................................................................................7 2.5. Patient Pathways ...................................................................................................................................8 2.6. Main Commissioners............................................................................................................................10 2.7. Performance Summary ........................................................................................................................10 2.8. Overview of Other Service Line Procurement Arrangements ..............................................................11 2.9. Joint Ventures and Partnership Arrangements ....................................................................................12

3. Strategy ..................................................................................................................... 13 3.1. Trust Mission Statement ......................................................................................................................13 3.2. Trust Vision ..........................................................................................................................................13 3.3. Trust Values .........................................................................................................................................14 3.4. Key Strategic Drivers ...........................................................................................................................14 3.5. Strategic Goals.....................................................................................................................................16 3.6. Summary of Strategy Development Activity and Communications Plans ............................................24

4. Market Assessment ................................................................................................... 26 4.1. Trust Markets .......................................................................................................................................26 4.2. Market Drivers......................................................................................................................................28 4.3. Objectives of the Local Health Economy .............................................................................................30 4.4. Summary of the PESTLE Analysis.......................................................................................................33 4.5. Conclusions..........................................................................................................................................34

5. Service Development Plans ...................................................................................... 35 5.1. Strategic Principles ..............................................................................................................................35 5.2. Planning Assumptions..........................................................................................................................36 5.3. A&E Service Line Strategy...................................................................................................................36 5.4. Urgent Care Service Line Strategy ......................................................................................................53

6. Leadership and Workforce Implications .................................................................... 58 6.1. Overall Summary .................................................................................................................................58 6.2. Management Arrangements.................................................................................................................58 6.3. Workforce Key Performance Indicators ...............................................................................................59 6.4. Maintaining Workforce Establishment..................................................................................................62 6.5. Designing and Developing the Future Workforce ................................................................................64 6.6. HR and Organisational Development Strategy – Aligning People, Strategy and Process...................64

7. Governance Arrangements ....................................................................................... 66 7.1. Governance Context ............................................................................................................................66 7.2. Assurance Mechanisms .......................................................................................................................69 7.3. Quality Governance Framework ..........................................................................................................70 7.4. Changing Governance Landscape.......................................................................................................71 7.5. Risk Management ................................................................................................................................71 7.6. Risk Assessment Framework and the NHS Provider Licence .............................................................72

Appendices: Appendix 1: Glossary of Terms Appendix 2: Full List of Trust Estate



Chapter 1: Executive Summary

1. Executive Summary The Trust developed a five year Integrated Business Plan (IBP) as part of its application to become an NHS Foundation Trust. Published in 2010/11 the Strategy described what the Trust would look like in five years’ time (2015/16) setting out the Trust’s plans for the life of the IBP and how the Trust intended to deliver them. Since that Strategy was published the Trust has been through a number of significant changes including achieving NHS Foundation Trust status, implementing NHS Pathways, securing a number of NHS 111 contracts, responding to significant changes to national targets for 999 A&E services and acquiring Great Western Ambulance Service NHS Trust in early 2013. In addition the Trust is operating in the context of wide scale NHS reforms that are, and will continue to have a significant impact on the future structure and business of the organisation. In response, the Trust brought forward a programme of work in 2013/14 to establish a new over-arching Strategy for the next five years. This has been informed by a series of activities to seek views from key stakeholders in re-setting the Trust’s strategic priorities. These stakeholders include the Trust’s Council of Governors who have been engaged throughout the year in reviewing and developing elements of this forward plan. The Governors provide a valued mechanism through which the Trust can communicate with its members and the public, and in turn provide feedback on behalf of the population the Trust serves. Feedback received throughout the year has been reviewed and incorporated into the various stages of planning and development, helping to shape the future plans of the Trust. Overall the feedback has indicated that there is strong support for the objectives and strategic goals identified by the Trust and that these are consistent with the priorities of the members they represent. The quality initiatives detailed within the Plan confirm that the Trust will continue to focus on ensuring that the safety of patients and the delivery of high quality services remains a top priority. Throughout the life of this Plan the Trust will develop and further enhance a number of schemes aimed at improving the experience of care and clinical outcomes for patients, making this a key element of every decision made. The Board of Directors recognises that improving quality will ensure that the services provided are clinically effective and timely; more patient focused and ultimately safer. The Trust will continue to work closely with all staff, volunteers, governors, members and the public to identify the best ways to improve services and deliver high quality care to all. The period covered by this Plan will be no less eventful and challenging than previous years. The short term challenges identified range from whole system reform for urgent and emergency care services to ensuring localism and responsiveness in the services the Trust delivers. In response the Trust will continue to embed consistent ways of working across the enlarged organisation with large scale change programmes planned to align systems and processes, in developing system wide productivity offerings such as Right Care2 and the implementation of major new systems such as the Electronic Patient Care Record to support the further integration of care. The pressure to manage and use Trust finances ever-more prudently will grow, and there is no reason to suggest that the trend of annual increases in the number of 999 calls the Trust receives each year will not continue. Finding better and more appropriate ways to respond to patient need, without necessarily sending an ambulance resource, will be essential in ensuring that the Trust can continue to provide high-quality care to all our patients wherever and whenever they require our services. This is reflected within the service developments set out within this Plan and remains a primary focus of the integration and standardisation plans for the Trust going forward.



Chapter 2: Profile

2. Profile 2.1. Overview South Western Ambulance Service NHS Foundation Trust (the Trust) has a longstanding reputation for quality and innovation and is one of the best known ambulance services in the UK. It was the first ambulance service to be authorised as an NHS Foundation Trust on 1 March 2011 and, on 1 February 2013, the Trust acquired its neighbour Great Western Ambulance Service (GWAS). This created a single ambulance service that covers the entire south west region and provides emergency care to around 2,500 people every day. The enlarged Trust serves a resident population of over 5.3 million people plus an estimated annual influx of more than 17.5 million tourists. The Trust covers almost 10,000 square miles, which is approximately 20% of the English mainland. The Trust provides services across the counties of Cornwall and the Isles of Scilly, Devon, Dorset, Somerset, Wiltshire, Gloucestershire and the former Avon area (Bristol, Bath, North and North East Somerset and South Gloucestershire). The operational area is predominantly rural but also includes the City of Bristol and a number of other urban centres. 2.2. The Trust Profile The business of the Trust is centred predominantly around a range of core services that are delivered across three operational divisions: • North Division covering Bath and North-East Somerset,

Bristol, Gloucestershire, North Somerset, South Gloucestershire and Wiltshire;

• West Division covering Devon, Cornwall and the Isles of Scilly;

• East Division covering Dorset and Somerset. Trust Headquarters are based in Exeter, Devon (marked A on the map), co-located with one of the Trust’s clinical hubs (emergency control rooms). The Trust has a further four clinical hubs, 95 ambulance stations (leasehold and freehold), two Hazardous Area Response Team bases and 15 vehicle workshops (four of which are non-ambulance stations). In addition the Trust utilises a range of facilitated and non-facilitated dispatch points and Trust clinicians also work in the heart of communities in Local Treatment Centres (LTC), Minor Injury Units (MIU) and Urgent Care Centres.The full estate list can be found at Appendix 2. The Trust has a total of 1,002 vehicles comprised of the following: • 316 A&E frontline vehicles; • 24 HART vehicles; • 255 Rapid Response Vehicles (including OOHs, responder cars and patient support vehicles); • 53 Patient Transport Service vehicles; • 254 other vehicles including mules, resilience, pool, logistics vehicles, events and training; • There are also 100 employee leased vehicles, five paramedic cycle response units and a medical launch

for the Isles of Scilly.

SOUTH GLOUCESTERSHIRE

BRISTOL

BATH & NORTH EAST SOMERSET

NORTH SOMERSET



Chapter 2: Profile

As at 31 May 2014 the Trust employs a workforce of 3,709 whole time equivalents (WTE). 2,310 of these are frontline A&E staff that includes the following roles: • Paramedics, Critical Care Paramedics and Air Support Unit Paramedics; • Emergency care Assistants; • Technician, Advanced Technicians and Ambulance Practitioners; • Emergency Care Practitioners (ECPs); • Clinical Support Officers; • Clinical Support Officers ECPs; • HART Teams; • Lead Paramedics; • Clinical Operational Tutors. The Trust also has access to 147 (143 WTE) student paramedics, 498 bank staff, 339 sessional and 8 employed GPs who support delivery of the Out of Hours Service, and 3,580 responders who support delivery of the A&E service. Responders are individual volunteers or partner agencies that respond to emergencies within their local communities and include: • Community First Responders: Volunteers who support their local community by attending emergency

calls ahead of an ambulance; • St John Ambulance Community First Responders: Volunteers working for St John Ambulance who

respond within their local community ahead of an ambulance; • Fire Co-Responders: Retained fire fighters who attend emergency calls on behalf of the Trust, as part of

their day to day role with the fire and rescue service; • RNLI Co-Responders: Life guards who patrol beaches and respond to local incidents; • Establishment Based Responders: Staff who respond to an incident that may occur during their normal

working day, for example in a railway station or shopping centre; • Staff Responders: Ambulance clinicians who volunteer to attend emergencies in their local communities

on their day off. The organisation is configured under six Directorates led overall by the Chief Executive, with delegated budgets based upon functions and responsibilities: • Delivery; • Finance and Performance; • Human Resources (HR) and Organisational Development; • Information Management and Technology; • Medical; and • Nursing and Governance. In addition the Trust has a Public Relations (PR) and Communications Department that reports to the Chief Executive. More details on the leadership arrangements of the Trust are set out in Chapter 6. 2.3. Core Services The Trust provides a range of ‘core services’ that require a clinical hub including call handling facilities, initial triage (clinical assessment), advice, filtering, signposting and call allocation or dispatch capabilities. These core services are set out in the following sections. 2.3.1. Emergency/Ambulance Services For the Trust, this involves three main types of service; 999 A&E services, Hazardous Area Response Teams (HART) and Patient Transport Services. 999 A&E Services



Chapter 2: Profile

The Trust provides emergency and urgent responses to ‘Red’ or ‘Green’ categorised injuries and illnesses, which are likely to require treatment and possible transport to a hospital or other facility. Provision covers and is commissioned by all 12 Clinical Commissioning Groups (CCGs) in the south west region and activities included within this core service are: • Call handling and triage of 999 calls from the general public; • Call handling and response management to requests from healthcare professionals (HPC Calls) and

other emergency services; • Prioritisation of calls, utilising an approved IT system, into either Red (Category A8 Red 1, Red 2 or A19)

or Green (Green 1 to 4 dependent upon contract) calls; • Identification and onward referral to alternative care pathways; • The provision of front line and rapid response vehicles with suitably qualified staff, including Community

First and Co-Responders, Paramedics, Student Paramedics and Emergency Care Practitioners to meet the needs of patients;

• Support and referral services for healthcare professionals; • Inter hospital emergency and urgent transport of patients; • Transport for formal and informal psychiatric patients and patients sectioned under the Mental Health Act; • Street safe buses in urban areas to act as clinical mobile support units; • The provision of clinical teams for five air ambulance charities (the helicopters are funded and owned by

independent charities with the bases managed by the charities or another organisation); • Emergency preparedness in line with the duties of the Civil Contingencies Act (2004), including Search

and Rescue. HART Hazardous Area Response Teams (HART) are specially recruited and trained personnel who provide the ambulance response to major incidents. HART, as an initiative, forms part of the health response in support of the national capabilities programme being led by the Home Office, which aims to ensure that fewer lives would be risked or lost in the event of a terrorist or accidental chemical, biological, radiological or nuclear occurrence (CBRN) incident. The Trust has two HARTs, one based in Exeter and one in Bristol, available for deployment on a 24/7 basis. They are trained and equipped to provide: • Incident Response Unit (IRU) capability: this forms the basis for improved response in the event of

potential or actual CBRN contamination or presence of other hazardous substances or environments; • Urban Search and Rescue (USAR) capability: this extends the areas or environments in which

paramedics can operate safely providing clinical intervention to include those areas where access and egress is difficult and requires specialist equipment and training;

• Mutual aid to other Trusts as and when appropriate and requested, in accordance with the most recently published UK Mutual Aid strategy.

Patient Transport Services The Trust provides ambulance non-emergency medical Patient Transport Services (PTS), such as to and from out-patient appointments, for the Isles of Scilly, Bristol, North Somerset and South Gloucestershire (BNSSG). Commissioned by four CCGs this service includes the following activities: • Handling calls from treatment centres including calls from healthcare professionals; • Prioritisation of calls, utilising an approved IT system, into mobility categories; • Provision of specialist patient transport vehicles with suitably qualified staff (eligibility criteria apply in

relation to access to the service as determined by commissioners); • Inter hospital transport of non-emergency patients; • Out of area transfers. 2.3.2. Urgent Care Services



Chapter 2: Profile

For the Trust, urgent care involves three main types of service: Out of Hours services, NHS 111 and the provision of a Single Point of Access in Dorset. Out of Hours Services (OOHs) The Trust provides a range of non-emergency responses to people who require, or perceive the need for, urgent (but not emergency) advice, care, diagnosis or treatment. The core element of this service is commissioned by three CCGs and is delivered across Dorset, Gloucestershire and Somerset. The OOH service includes the following activities: • Treatment by General Practitioners (GPs), Emergency Care Practitioners and Nurse Practitioners; • Single point of access for dental emergencies; • Treatment services at Minor Injury/Treatment Units (in Dorset and Somerset) and delivered within the

Trust’s new Urgent Care Centre in Tiverton, Devon; • GP and Emergency Care Practitioner home visiting. In addition there are a range of ad-hoc Out of Hours services procured by a variety of bodies including NHS Commissioners, HM Prisons, universities and military organisations. NHS 111 Services The Trust is the provider of NHS 111 services in Cornwall and the Isles and Scilly, Devon, Dorset and Somerset. Commissioned by four CCGs, NHS 111 provides 24/7 call handling, triage and signposting of services to respond to people’s healthcare needs in non-life threatening situations. The service includes: • Call handling, clinical assessment and triage to determine the appropriate course of action; • Referral of calls to other providers following triage; • Transfer of clinical assessment data to other providers and the booking of appointments where

appropriate; • Dispatch of ambulances without delay or re-triage in life threatening situations. Single Point of Access Initiated in November 2010 the Single Point of Access (SPoA) operates 24/7, 365 days a year, across the county of Dorset. It is used by health care professionals including GPs, ambulance crews, community and hospital based health and social care professionals that need access to community services including: • 24/7 nursing services, community matrons and specialised nurses including acute outreach teams; • Therapy teams including physiotherapy, occupational therapy, speech and language, falls teams etc; • Palliative care; • Intermediate Care Teams for admission avoidance and supported discharge support; • Community hospital beds; • Urgent social care; • Urgent Transient Ischaemic Attack (TIA) clinics; and • Emergency Dental Services. The SPoA team use the Capacity Management System (CMS)/Directory of Services (DoS) to maximise utilisation of both capacity and capabilities across locally commissioned services. 2.4. Non-Core Services In addition to the core services detailed above the Trust provides a range of other services: • Provision of Chemical, Biological, Radiological, Nuclear and Explosive (CBRNE) Training; • Transport of medical samples and clinical records (Medical Transport Service); • Provision of treatment/staff at Newquay Minor Injury Unit; • Provision of commercial and Higher Education training to meet the requirements of both the private and

public sectors; • Provision and management of medical services at events; • Provision of driving tuition, statutory compliance advice and incident investigation through the Trust’s

Driving Faculty;



Chapter 2: Profile

• Hosting the Ambulance Radio Project (ARP) personnel on behalf of the Department of Health. 2.5. Patient Pathways The following sections set out information on the various pathways through which a call from a member of the public or a healthcare professional, may progress dependent upon the service being accessed. 2.5.1. The Emergency and Urgent Care Pathway The diagram below sets out the patient pathway for 999 (Public) and healthcare professional calls (HCP) received in the East and West Division clinical hubs (based in Exeter and St Leonard’s). The pathway is based upon the key stages within the NHS Pathways triage system. Within the North Division the Trust uses the AMPDS triage system and although there are differences in the detail of each stage, the principles of how a call is managed are broadly similar. As part of the post-acquisition integration activity the Trust is aligning the Computer Aided Dispatch (CAD) and triage systems, standardising the approach across the whole Trust. More detail on this is set out in A&E Theme 2, Chapter 5. 999 (Public) and HCP Call Pathway

The diagram above highlights a number of key points in the pathway: • Clock start for Red 1 Incidents: For Category A (Red 1) calls (the most time critical patients), the “clock

starts” when the call is presented to the control room telephone switch. This will be the case for all calls received on control room telephone lines, from dedicated emergency lines or otherwise. For calls that are electronically transferred to the computer aided dispatch (CAD) system from another CAD the clock starts immediately when the call record is first received by an ambulance trust system.

• Clock start for Red 2 Incidents: For Category A (Red 2) calls (serious but less time-critical patients), the “clock starts” the earliest of: • Chief complaint information (or Pathways initial code) is obtained; • First vehicle assigned (as highlighted above); • 60 seconds after the call connect to the hub;

• Clock stops: The "clock stops" when the first ambulance service-dispatched emergency responder arrives at the scene of the incident.

• Hear and Treat: In contractual terms these are defined as incidents closed without a Trust resource arriving at the scene, meaning that clinical care was completed over the telephone;



Chapter 2: Profile

• See and Treat: In contractual terms these are incidents that are closed with a Trust resource arriving at the scene of the patient but not subsequently transferring a patient to a destination or hospital. Clinical care was therefore completed at the scene;

• See and Convey: In contractual terms these are incidents that are closed with a Trust resource conveying a patient to a destination/hospital, meaning that clinical care was transferred to the staff of the chosen destination.

Variances in outcome arise where, in addition to telephone triage, a patient may be advised to attend A&E, be referred to a local treatment centre or receive a home visit from a medical practitioner. For PTS the pathway is substantially different with patient journeys secured through a formal booking system and responses subsequently planned and pre booked. For HART activity, the responsibility for the identification of appropriate incidents rests with the Trust’s clinical hub both in terms of initial deployment and in response to requests for assistance from operational staff. The subsequent identification, mobilisation and selection of vehicles and personnel to send to an incident rests the HART Team. There are some incidents types which the HART team would always be informed of, examples include: • Major incidents; • Complex entrapments; • Remote patient extrications; • Incidents involving patients from heights; • Collapsed or unstable structures. 2.5.2. The NHS 111 Pathway The patient pathway for all NHS 111 calls is set out below and operates in line with a set of core principles: • That clinical assessment and information gathering can be completed on the first call without the need for

a call back; • That the service can refer callers to other providers without the caller being re-triaged; • That the service can transfer clinical assessment data to other providers and book appointments where

appropriate; and • That an ambulance can be dispatched without delay where required.

As indicated in the pathway above, where the clinical assessment of a 111 caller indicates that the dispatch of an ambulance is appropriate, the NHS 111 adviser is able to dispatch an ambulance without any delay or re-triage of the call. The only exceptions are where the caller’s location is unknown. In these instances the



Chapter 2: Profile

111 advisor instructs the caller to hang up and redial 999 themselves, thereby ensuring that the call reaches the correct ambulance service with immediate access to location information. 2.6. Main Commissioners Within the south west region there are 12 Clinical Commissioning Group (CCGs) each responsible for the commissioning of healthcare services for their local population. • A&E services are provided across all 12 CCGs with a coordinated commissioning arrangement currently

led by NHS South Devon and Torbay CCG. The South West Commissioning Support Unit (CSU) acts as the contract manager for the contract with Performance and Contracting and Quality Monitoring Meetings held monthly;

• Patient Transport Services are commissioned by four CCGs, namely NHS Bristol, North Somerset and South Gloucestershire CCGs, otherwise referred to as the ‘BNSSG’ commissioners, and NHS Kernow CCG for provision on the Isles of Scilly. Performance management arrangements are yet to be confirmed for the Isles of Scilly. For the BNSSG contract monthly joint Performance and Operational meetings are held;

• OOHs services are delivered across three CCG areas (namely NHS Dorset, Gloucestershire and Somerset CCGs) with contracts managed at an individual CCG level. Performance and Contracting meetings are held monthly with quality monitoring meetings held quarterly;

• NHS 111 services are commissioned by four CCGs with contracts managed at an individual CCG level. This includes NHS NEW Devon, Dorset, Somerset and Kernow CCGs. Combined Performance and Contracting and Quality Monitoring Meetings are held monthly for each contract.

2.7. Performance Summary The quality of services provided by NHS providers and commissioners is measured against a set of minimum standards for operational, financial and clinical quality. For ambulance trusts service quality is measured through the Ambulance Systems Indicators and Ambulance Clinical Outcomes, known collectively as Ambulance Quality Indicators (AQIs). Category A8 and A19 form national key performance indicators with predetermined targets. Performance against these and other regulatory requirements is set out in Table 1. The amber-green Governance Ratings in Quarter 4 of 2012/13 and Quarter 2 of 2013/14 are a result of performance against the Red 1 and Red 2 targets. Nationally these targets are measured on an annual basis; however Monitor measure these on a quarterly basis to provide an assessment of future service delivery risks. Table 1 – National and Regulatory Targets Performance Summary 2011/12 to 2014/15 YTD 2011/12 2012/13 2013/14 2014/15 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Monitor Governance Risk Rating Monitor Financial / Continuity of Services Risk Rating 4 4 4 4 4 4 4 4 3 3 4 4 4

Key Performance Indicator Target Performance

2011/12 Performance

2012/13 Performance

2013/14 Performance 2014/15 YTD1

Category A82 75% 76.1% 75.85% Category A8 Red 13 75% 73.01% 73.15% 75.50% Category A8 Red 2 75% 75.93% 77.23% 75.95% Category A19 95% 95.8% 95.36% 95.76% 95.21% NHS Litigation Authority Rating Level 1 Level 1 Level 1 Not applicable4

Information Governance Toolkit Level 2 Level 2 Level 2 Level 2 Level 2 Thresholds for the remainder of the AQIs are negotiated locally with commissioners. Performance against the thresholds is set out within Table 2.

1 Performance up to the period 30 June 2014 2 Performance for 2012/13 covers the months of April and May 2012 only prior to the introduction of the technical amendment 3 From 1 June 2012 the Department of Health issued a technical amendment to the Category A8 ambulance response time target. This split the target into two parts – A8 Red and Red 2 4 The NHS Litigation Authority have advised trusts that they will no longer be conducting their assessments, however, to ensure best practice, the Trust has continued to ensure that all policies and process meet the existing standards.



Chapter 2: Profile

Table 2 - Ambulance Quality Indicator Performance 2012/13 to 2014/15

Ambulance Quality Indicators 2012/13

% 2013/14

% 2014/155

% Call Abandonment Rate (% of calls abandoned before answering) 1.17 0.63 0.59

Of discharge of care by clinical telephone advice 15.60 12.26 13.32 Re-Contact Rate Following

Discharge of Care - unplanned re-contact with the ambulance service within 24 hours:

Of discharge of care following treatment at scene 6.60 5.46 5.49

Calls closed with telephone advice 6.40 6.78 6.62 Ambulance calls closed with telephone advice or managed without transport to Emergency Departments (where clinically appropriate)

Incidents managed without the need for transport to A&E 51.20 51.52 50.64

Ambulance Clinical Quality Indicators

Overall 24.63 24.54 Outcome from Cardiac Arrest -Return of Spontaneous Circulation at time of arrival at hospital Utstein Comparator Group 41.60 44.90

Not available

at the time of writing

% of patients suffering a STEMI receiving thrombolysis within 60 minutes of call 40.74 Not

applicable Not

applicable % of patients suffering a STEMI and who, following a direct transfer to a PPCI centre, primary angioplasty commences within 150 minutes of call

81.59 81.81 Outcome from Acute ST-Elevation Myocardial Infarction (STEMI)

% of patients suffering a STEMI and who receive an appropriate care bundle 84.15 89.56

% of Face Arm Speech Test (FAST) positive stroke patients (assessed face to face) potentially eligible for stroke thrombolysis, who arrive at a hyperacute stroke centre within 60 minutes of call

52.64 55.60 Outcome from Stroke for Ambulance Patients

% of suspected stroke patients (assessed face to face) who receive an appropriate care bundle

95.77 97.29

Overall survival rate 8.40 10.03 Outcome from Cardiac Arrest - Survival to Discharge Utstein Comparator Group survival rate 22.92 25.95

Not available at the time of

writing

2.8. Overview of Other Service Line Procurement Arrangements NHS Supply Chain The Trust has made a strategic decision to procure the majority of its medical consumables and equipment through NHS Supply Chain. The cost benefit in this approach will be through the full utilisation of NHS Supply Chains distribution network. The supply chain distribution centre is centrally located within the Trust’s patch. Crown Commercial Services (CCS) It is the Trust’s Procurement Policy to call off from existing framework agreements where it represents best value to do so. The Trust calls off from a number of CCS agreements (formally, Government Procurement Services ) and the Procurement Department has built strategic relationships with a number of CCS category teams to ensure the Trust’s requirements are considered and included in specifications when CCS go out to tender. CCS framework agreements provide the Trust with a compliant route to market and ensures robust contractual terms and conditions. Examples of current requirements that are fulfilled via the CCS framework route include car hire, fuel, vehicle purchase, vehicle conversions, temporary staffing, utilities, telephony, printer cartridges and multifunctional devices. NHS Shared Business Services

5 Covers the period 1 April to 30 April 2014



Chapter 2: Profile

In addition the Trust calls off from a number of free to access, NHS Shared Business Services framework agreements where it represents best value to do so. Current requirements fulfilled via this route include telephone translations, PC’s, laptops, monitors, servers, storage and membership and election services. East of England Collaborative Procurement Hub The Trust is part of the NHS Ambulance Procurement Hub. The agreement is in place until September 2015. This forum represents all 10 English Ambulance Trusts and, the recent new members, the Welsh and Scottish Ambulance Services. The terms of this Hub are to work in the interest of synergies for common goods and services that result in multi-million pound spend across the ambulance service network. This is with a view to conducting joint tendering exercises and projects such as for national uniforms and medical devices, whilst inputting local requirements into the specifications. The Hub feeds back to the Department of Health and CCS from a national perspective and is also represented at the NHS Supply Chain Customer Board and Department of Health pilot studies on standards of procurement. 2.9. Joint Ventures and Partnership Arrangements The Trust defines a partnership as one with a pooled budget; as such the Trust has no partnership arrangements. However, the Trust does have a range of formal agreements with other organisations to achieve combined ambitions with both statutory and non-statutory agencies.



Chapter 3: Strategy

3. Strategy 3.1. Trust Mission Statement The Trusts mission statement is ‘To respond to patients’ emergency and urgent care needs quickly and safely to save lives, reduce anxiety, pain and suffering.’ Underpinning this mission statement is the Trust’s ability to: • Provide truly integrated Out of Hours, NHS 111, 999 and other urgent care services giving individuals the

care and support they require, in the most efficient and appropriate care settings and within a safe timescale;

• Simplify, coordinate and manage access to healthcare locally through a support and referral desk for Health Care Professionals;

• Maximise capacity and capabilities across locally commissioned services through the Capacity Management System and Directory of Services;

• Establish system resilience as health and social care arrangements become increasing complex and fragmented;

• Ensure patients always receive an appropriate and proportionate response when dialling 111 and 999 which includes avoiding unnecessary admissions to hospital;

• Embrace and use assistive technology going forward in order to support innovation and service delivery; • Deploy highly skilled, flexible clinicians across the entire south west region; • Support the health and social care community in its ambition to deliver more community based care

including care delivered closer to home and helping patient’s access health and social care services 24 hours a day, seven days a week.

3.2. Trust Vision The Trust has formulated a new vision, which takes account of the acquisition of GWAS in 2013/14, but is also forward looking and influenced by the new national direction refocusing health policy on prevention, on reshaping urgent and emergency care and on increasing care delivered within the community and in people’s homes. The Trust’s vision statement is ‘To be an organisation that is committed to delivering high quality services to patients and continues to develop ways of working to ensure patients receive the right care, in the right place at the right time.’ Both the mission and vision statements reflect the vision for emergency and urgent care set out by Sir Bruce Keogh: ‘for those people with urgent but non-life threatening needs we (the NHS) must provide highly responsive, effective and personalised services outside of hospital.’ The vision statement is underpinned by a long term vision for the Trust that: • Creates a high performing ambulance Trust which continues to improve, innovate and deliver high quality

services to patients based on experience and best practice; • Stabilises the enlarged Trust through strong leadership and clear decision making; • Manages the safe transition of staff into the enlarged Trust ensuring their on-going wellbeing and

professional development; • Develops a positive, dynamic culture for all staff to work within creating an enlarged Trust that staff are

proud to work for and would recommend to others; • Establish and develop close working partnerships with key stakeholders within the south west including

the emerging Clinical Commissioning Groups, local NHS Trusts and NHS Foundation Trusts; • Uses the opportunity presented by the acquisition to improve relationships with patients and the local

population in order to ensure that they feel that they are receiving a personalised and local service from a dedicated and experienced ambulance Trust.



Chapter 3: Strategy

In order to help the Trust communicate and promote its renewed vision for the future, four phrases have been adopted: • “From Prevention to Intervention”: this phrase summarises the Trusts ambition to support a safer,

more efficient and sustainable urgent and emergency care system for the future. It recognises the integral part ambulance services can play in working alongside health partners to prevent disease and identify effective ways of influencing people’s behaviours and lifestyles and in playing an increasingly significant role in urgent and emergency care provision;

• “Right Care, Right Place, Right Time”: this phrase captures one of the Trust’s key initiatives that focuses on ensuring patients receive the best possible care, in the most appropriate place and at the right time. This is alongside a drive to safely reduce the number of inappropriate A&E attendances at acute hospitals and deliver a wide range of developments to improve the appropriateness of the care delivered to patients;

• “1 Number, 1 Referral, 1 Outcome”: this phrase captures the value added by the Trust as a provider of NHS 111 services that are integrated with out of hours and 999 services;

• “Local Service, Regional Resilience”: this phrase recognises the dual role of the ambulance service in delivering a local service providing individual and personalised care to patients balanced with system wide coverage and capacity for resilience.

3.3. Trust Values The Trusts core values are based upon the NHS Constitution6. Respect and dignity We value each person as an individual, respect their aspirations and commitments in life, and seek to understand their priorities, needs, abilities and limits. Commitment to quality of care We earn the trust placed in us by insisting on quality and striving to get the basics of quality of care – safety, effectiveness and patient experience – right every time. Compassion We ensure that compassion is central to the care we provide and we respond with humanity and kindness to each person’s pain, distress, anxiety or need. Improving lives We strive to improve health and well-being and people’s experiences of the NHS. Working together for patients We put patients first in everything we do, by reaching out to staff, patients, carers, families, communities, and professionals inside and outside the NHS. Everyone counts We maximise our resources for the benefit of the whole community, and make sure nobody is excluded, discriminated against or left behind. 3.4. Key Strategic Drivers In order to ensure that the Trust’s strategy is both relevant and consistent with our health and social care partners a number of key strategic drivers have been taken into account in its development. These are summarised below and are explored further in Chapter 4 ‘Market Assessment’. 3.4.1. A Requirement for Transformative Change in the NHS The NHS has reached a tipping point. It is recognised nationally in NHS England’s document ‘A Call to Action7’ that without bold and transformative change to how services are delivered, a quality yet free at the point of use health service will not be available for future generations.

6 NHS Constitution for England, Department of Health (26 March 2013) 7 The NHS Belongs to the People. A Call to Action – NHS England (11 July 2013)



Chapter 3: Strategy

‘A Call to Action’ calls for a reshaping of services to put patients at the centre by: • Refocusing on prevention; • Putting patients in charge of their own health and healthcare; • Matching services more closely to individuals risks and specific characteristics; • Using technology and exploiting the potential of transparent data. 3.4.2. A Renewed National Focus on Urgent and Emergency Care In recognition of the challenges facing the urgent and emergency care system, there have been a number of recently commissioned national and local reviews that examine the current pressure points and explore the development of sustainable models for the future. The most significant of these is the Urgent and Emergency Care Review being led by Sir Bruce Keogh. The ambulance service is cited in the review as one of the most important gateways into the health and social care system and an integral part of urgent and emergency care provision. There is explicit recognition that the ambulance service has a vital role to play in addressing the challenges and ensuring all patients get the right care, in the right place, at the right time. Increasingly it is becoming recognised that ‘in order to enhance the overall system of emergency care in England, ambulance services should be regarded as a care provider and not a service that simply readies patients for journeys to hospital’8. Recent studies have also identified a number of roles and specific opportunities that have as yet remained largely unexploited by the ambulance sector. These studies have recognised that ambulance services have a relatively unique set of characteristics that make this possible: • Providing increased levels of ‘hear and treat’ and ‘see and treat’ in order to help alleviate current system

pressures; • Acting in a coordinating capacity for the urgent and emergency care system and as capacity managers

with regional oversight particularly for system wide issues such as winter pressures and handover delays; • Establishing the ambulance service as the gateway for accessing health and social care and assisting

the health community in managing referrals; • Recognising the contribution the ambulance service can make in providing an overview of healthcare

systems by analysing and benchmarking activity levels, sharing data to make the system more transparent and in monitoring system pressure points;

• Acknowledging and acting on the fact that ambulance services have access to a wealth of information on patients whose needs are not currently being met. Examples quoted in the reviews include assisting the health and social care community in identifying patients who have frequent falls or repeated heart or mental health problems, and whose lives could be transformed through early intervention and better support from primary and community services and social care.

3.4.3. Factors leading to an Increasing Demand on NHS Resources Demand on NHS hospital resources has increased dramatically over the last ten years. The failure of emergency departments to meet national waiting time targets in the early months of 2013 is one reflection of the demands that are being placed on the emergency care system. A survey by the Foundation Trust Network9 cited a number of principal reasons for the increasing pressures: • Increasing demand arising from a combination of factors such as an ageing population, out-dated

management of long term conditions, rising expectations and disjointed care between adult social care, community services and hospitals;

• The resource intensity of managing patients with a long term condition and multiple co-morbidities; • Failures in parts of the system to manage demand, particularly GP surgeries and doctors out of hours

services whilst recognising that these services are also under extreme pressure themselves; • Slow progress in investing in community facilities for out of hospital care closer to home; • A ‘broken’ hospital emergency care funding system; • The inability of many Trusts to recruit and retain the right staff; • The uneven introduction of the new NHS 111 system; • Issues discharging patients in a timely and effective way due to problems in social care; 8 Urgent and Emergency Services. Second report of Session 2013/14. House of Commons Health Committee. Vol 1 24 July 2013 9 ‘Emergency care and emergency services 2013.View from the frontline’. Foundation Trust Network, 2013



Chapter 3: Strategy

• Poor patient signposting; • Failures by some acute hospitals to manage their patient flow as effectively and efficiently as they could. In addition the NHS is facing a significant funding gap from 2015/16 and as a result there will be a dramatic slow-down in spending growth. In order to remain financially viable the focus for the Trust is therefore on increasing internal productivity gains, securing new business and achieving additional income from commissioners through the provision of ‘value added services’. This approach requires the Trust to be increasingly innovative and commercially oriented. The volume of calls and incidents resulting in a 999 emergency response has increased in the last ten years with over 8.5 million patients calling 999 in England in 2012/13. Demand is primarily being driven by patients requiring urgent care rather than patients calling with a life threatening condition. Patients suffering significant trauma or an acute medical emergency constitute approximately one third of the average ambulance workload. Challenges that arise from this sustained growth in activity include increased: • Costs for providing care to the growing population; • Demands for preventative care, particularly self-care or care that can be provided closer to people’s

homes; • Demand driven by the number and proportion of older people likely to require hospital based care and

treatment as the population lives longer with more complex conditions; • Palliative care requirements; and • Numbers of patients with complex health needs and long term conditions. 3.4.4. A Review of Local CCGs Strategic Documents The Trust has reviewed the strategic intentions of NHS England and the 12 CCGs within its geographical footprint. The outcome of this review is considered in more detail in Chapter 4 ‘Market Assessment’ including a number of consistent emerging themes. 3.4.5. The Acquisition of GWAS The decision to acquire GWAS was seen by the Trust as a significant strategic endeavour. The Trust acquired GWAS on 1 February 2013 and developed an Integration Plan in order to secure a smooth transition from two standalone organisations to a single, enlarged Trust. 3.5. Strategic Goals In order to underpin delivery of the Integrated Business Plan, the Trust has formulated four new strategic goals covering the period 2014/15 to 2018/19. Strategic Goal 1: Safe, Clinically Appropriate Responses Delivering high quality, compassionate care to patients in the most clinically appropriate, safe and effective way. Strategic Goal 2: Right People, Right Skills, Right Values Supporting and enabling greater local responsibility and accountability for decision making; building a workforce of competent, capable staff who are flexible and responsive to change and innovation. Strategic Goal 3: 24/7 Emergency and Urgent Care Influencing local health and social care systems in managing demand pressures and developing new care models. Leading emergency and urgent care systems, providing high quality services 24 hours a day, seven days a week. Strategic Goal 4: Creating Organisational Strength Continue to ensure the Trust is sustainable, maintaining and enhancing financial stability. In this way the Trust will be capable of continuous development and transformational change by strengthening resilience, capacity and capability. Further detail on the rationale, drivers and a headline of the key initiatives for each strategic goal is set out in the following sections. Strategic Goal 1: Safe, Clinically Appropriate Responses



Chapter 3: Strategy

Delivering high quality, compassionate care to patients in the most clinically appropriate, safe and effective way. “The NHS is there for all of us and should offer appropriate, effective and rapid care whenever and wherever it is needed…we need to review the increasingly complex and fragmented system of urgent and emergency care, so that sick, anxious and often frightened people can get what they need when they need it.” Sir Bruce Keogh10 Rationale Challenging national targets for call categories are set by the Department of Health and apply to every ambulance service in England. Emergency 999 calls to the ambulance service are prioritised into categories to ensure life-threatening cases receive the quickest response; Category A8 Red 1 and Red 2 and Category A19. The requirement for ambulance services to deliver a fast responsive service is underpinned by these national targets and has recently been reaffirmed through the application of an A8 Red 1 Quality Premium payment for NHS commissioners. In line with these requirements the Trust needs to continue to respond as quickly and as safely as possible to patients with life threatening conditions (Category A patients) whilst balancing the need to ensure that sufficient capacity exists within the service to respond appropriately to patients with non-life threatening conditions. Strategic Goal 1 therefore focuses on ensuring patients receive the most appropriate response from the ambulance service. To support its delivery, this goal continues to build upon the Trust’s Right Care, Right Time, Right Place initiative to enable the delivery of more care, where appropriate, closer to home and reducing unnecessary attendances and admissions at hospital. Drivers underpinning the development of Strategic Goal 1 • The ambulance service is recognised nationally as an important gateway into the NHS for many patients

and as a key player within a local health system in determining where patients receive their onward care;

• Better outcomes for patients are achieved by providing a safe, fast response for those patients with immediately life-threatening conditions and by ensuring they receive a response at the scene which is able to transport them to the most appropriate facility which is often a specialist centre. This includes patients with life threatening conditions such as stroke and cardiac arrest and those suffering from major trauma;

• For those patients with non-life threatening conditions such as older people who have had a fall, patients with exacerbated problems from long-term conditions, and those with minor injuries or illnesses providing care in the local community or at home, so that patients do not have to go into hospital unnecessarily, often delivers the best outcomes and experiences for patients;

• 40% of patients attending A&E are discharged requiring no treatment at all; there were over 1 million avoidable admissions last year; and up to 50% of 999 calls requiring an ambulance to be dispatched could be managed at scene11;

• There is a renewed onus on all partners within the health and social care system to review how urgent and emergency care is delivered. For example the introduction of major trauma centres has seen a 20% increase in survival rates, despite increased travel time, for patients suffering from a heart attack;

• Skilled paramedics are trained to make clinical judgments and administer care – ambulance paramedics increasingly require the skills and knowledge to judge whether patients should be treated at local emergency departments or regional specialist centres;

• The Urgent and Emergency Care Review states that patients should flow smoothly between the different components of the system through the development of emergency care networks and the introduction of an efficient critical care transfer and retrieval system. In order to achieve this each network will be performance managed with integration essential to deliver improved outcomes;

• During 2013/14 the Trust faced many challenges in delivering the Category A8 Red 1 target. Variance to

10 Sir Bruce Keogh - http://www.england.nhs.uk/2013/01/18/service-review/ 11 Transforming urgent and emergency care service in England. Urgent and Emergency Care Review (end of Phase 1 Report) – NHS England (13 November 2013)



Chapter 3: Strategy

plan is attributed to several factors including, but not limited to, increased activity against contract, the launch of the new NHS 111 service across the south west region, peaks in hospital handover delays creating pressure points in the system and a national shortage in paramedics in order to support service delivery;

• In addition the delivery of Red performance across the Trust’s geographical area is particularly challenging given the rurality of the Trusts catchment area compared with other English ambulance trusts with the Trust being the most rural service in England. The scale of rurality has direct consequences for performance as the Trust has to consistently perform at the achievable target levels in both urban and semi-urban areas in order to achieve Trust-wide performance, the basis upon which the Trust is contracted to provide services.

Objectives • Ensuring clinically appropriate responses to patients the first time every time; • Delivering rapid, safe and effective assessment of patients clinical needs; • Responding quickly to patients with immediately life threatening conditions; • Avoiding preventable admissions to hospital and reducing pressure on emergency departments at peak

times; • Meeting key national and contractual targets; • Establishing partnerships, NHS, commercial or other, to support business development ensuring a

sustainable service model going forward that supports the development of existing and new care pathways across health systems and providers;

• Improving clinical and other forms of engagement with commissioners and providers of healthcare within the south west;

• Building strong relationships with key clinical partners.

Initiatives • Delivery of the Right Care2 initiative establishing Health Care Professional Support and Referral Desks

– Right Care for Health Care Professionals; • Delivery of the Trusts Performance Sustainability Plan for A&E Services; • Extending paramedic skills and training to better assess, prescribe for and manage patients; • Working more closely with GPs and community team to establish mobile urgent treatment centres; • Increasing the capacity of 999 ambulance resources to respond to emergency calls; • Reviewing trauma pathways and the use of major trauma centres across the region; • Working with commissioners at a local level to support the development and use of high acuity

pathways; • Providing increased emergency preparedness and recovery planning and support across the region; • Supporting health system winter planning and delivering targeted schemes in local areas to establish

sustainable operational resilience. Measures of Success • Performance against the ambulance category A response time targets; • Measures relating to the appropriate management of patients including auditing of incidents managed

through each patient pathway, conveyance rates etc; • Admission avoidance: numbers of patients who would have been taken to an emergency department

and admitted to an acute hospital bed (represents a financial saving to the local healthcare system); • An overall increase in the proportion of patients treated over the phone - ‘hear and treat’; • An overall increase in the proportion of patients treated on scene – ‘see and treat’.



Chapter 3: Strategy

Strategic Goal 2: Right People, Right Skills, Right Values Supporting and enabling greater local responsibility and accountability for decision making; building a workforce of competent, capable staff who are flexible and responsive to change and innovation. “What a skilled paramedic can do in an ambulance now is most of what we spent the first 15 minutes doing in A&E ten or 15 years ago, so the options are very different. One of the things for remote and rural communities is to supply at the scene in an emergency, the skill set that is most likely to be able to maintain the patient there or to temporise until the local general practitioner arrives” Professor Willett, House of Commons Health Committee: Urgent and Emergency Services 12 Rationale

This strategic goal confirms the Trusts commitment to its workforce and recognises that significant improvements in patient care are achieved through the dedication and professionalism of staff, and through the discretional energy discharged by them in order to provide high quality services and care for patients and their families. Drivers underpinning the development of Strategic Goal 2 • The Trust needs to ensure that it has the right staff available in the right numbers with the right skills,

values and competencies in order to deliver excellent clinical outcomes and patient-centred care; • The Trust is committed to developing ways of working to ensure patients receive the right care in the

right place, at the right time; • The Trust is firmly committed to attracting high quality talented staff by encouraging the development of

specialist expertise and innovation and working in partnership with key stakeholders to ensure that ambulance services continue to make a valuable contribution within the local health economy;

• The health and social care system will place greater emphasis on integrated health services in the future if the ambition of transformative change is to be achieved. The Trusts workforce will need to support this change including developing skills that are increasingly transferable between different care settings;

• The first stage Emergency and Urgent Care Review sets out the need to harness the skills, experience and accessibility of a range of healthcare professionals, including paramedics. By extending paramedic training and skills, and supporting them with GPs and specialists, there is an opportunity to develop 999 ambulances into mobile urgent treatment services capable of dealing with more people at scene, and avoiding unnecessary journeys to hospital;

• The mandate for NHS England states “in focusing the NHS on preventing illness, staff should be using every contact they have with people as an opportunity to help people stay in good health. As the country’s largest employer, the NHS should also make an important contribution by “promoting the mental and physical health and wellbeing of its own workforce”;

• The healthcare market is becoming increasingly competitive through the introduction of ‘Any Qualified Provider’, provider licensing and increased tendering activity. NHS and private employers are having to adopt a more flexible approach to managing their workforce not only as a temporary retention strategy, but as a permanent and sustainable solution to increase competitiveness;

• The Trust has a critical role in commissioning education and training to support the strategic objectives of its commissioners and partners, as well as embedding further public health capacity across the health system in the south west;

• In line with the acquisition benefit ‘Improving Quality to Patients’ the Trust needs to continue to standardise clinical practice across all Divisions, levelling up clinical skills and adopting best practice.

Objectives • Promoting and maintaining staff health and wellbeing; • Creating flexibility and capacity within the workforce to enable the Trust to meet new challenges,

respond to change and remain competitive; • Continuing to focus on clinical excellence and skills; • Securing an engaged, capable and effective workforce; • Developing local, empowered leaders; • Integrating workforce planning and training;

12 House of Commons Health Committee: Urgent and Emergency Services - Professor Willett (July 2013)



Chapter 3: Strategy

• Delivering consistently high quality care to patients and improve outcomes; • Improving patient experiences of the service; • Delivering improvements in productivity, motivation and engagement of staff; • Maximising the Trusts ability to remain competitive in the market place in order to secure a sustainable

future. Initiatives • Implementing new systems and processes to support changes in resource management; • Developing new roles and ways of working; • Creating multidisciplinary teams; • Expanding commercial training; • Developing a cultural strategy and refreshing the Staff Engagement Strategy. Measures of Success • Sickness and absence rates across the organisation; • Other staffing measures e.g. retention and turnover rates, health and wellbeing etc; • Range and number of clinical qualifications held by Trust clinicians; • Growth within the Trust’s commercial training arm; • Maintenance or improvement in staff engagement and satisfaction measures within the annual staff

survey; • Plaudits and patient experience measures demonstrating improvements in patient experience.

Strategic Goal 3: 24/7 Emergency and Urgent Care Influencing local health and social care systems in managing demand pressures and developing new care models. Leading emergency and urgent care systems, providing high quality services 24 hours a day, seven days a week. ‘Millions of people in England have non-life threatening short-term illnesses or health problems for which they need prompt and convenient treatment or advice. Others have pre-existing health problems which fluctuate or deteriorate. To meet these needs an improvement in information and advice and access to timely and appropriate urgent and emergency care, across the 24-hour period within the NHS, is required.” High Quality Care for all - NHS England (June 2013)13 Rationale Working in partnership with primary and secondary care, the Trust is well placed to act as a single point of access and coordinator of the urgent and emergency care system, having the capability and incentives to develop a ‘map’ of the local health and social care system. Strategic Goal 3 recognises the developing role the ambulance service has in providing urgent care. In addition there is a huge opportunity to shift treatment and advice from acute hospital based services to home or close to home alongside a need to provide faster and consistent same day, every day access to primary care and community services for people with urgent care needs. This is likely to mean GP, OOHs services, community health, NHS 111 and the ambulance sector working together, and differently, to ensure that patients with urgent care needs can receive prompt advice and care 24 hours a day, seven days a week. Drivers underpinning the development of Strategic Goal 3 • Part of the vision for emergency and urgent care services in the future is ‘for those people with urgent

but non-life threatening needs we must provide highly responsive, effective and personalised services outside of hospital’14 - the reality is that millions of patients every year seek or receive help for their urgent care needs in hospital who could have been helped much closer to home;

• Once urgent care services outside of hospital have been enhanced, there is a proposal to introduce two levels of hospital emergency department – Emergency Centres and Major Emergency Centres with senior clinicians and consistent staffing seven days a week;

• The national mandate is that much more needs to be done to support urgent and primary care in

13 High Quality Care for all, now and for future generations: transforming urgent and emergency care services in England - NHS England (June 2013) 14 Transforming urgent and emergency care service in England. Urgent and Emergency Care Review (end of Phase 1 Report) – NHS England (13 November 2013)



Chapter 3: Strategy

managing demand, developing more anticipatory approaches, creating improved continuity for high risk patients and providing joined up out of hours services. The Urgent and Emergency Care Review Evidence Base highlights a number of issues within each part of the current urgent and emergency care system:

• The NHS should operate as an integrated system of organisations and services bound together by the principles and values reflected in the Constitution and should works across organisational boundaries, and in partnership with other organisations, in the interest of patients, local communities and the wider population;

• Existing urgent care services are highly fragmented and difficult to navigate causing many patients to experience difficulty choosing the service most appropriate to their needs;

• Variations in opening hours, clinical expertise, access to diagnostics and nomenclature can lead to confusion and referrals to a number of urgent care services within the same episode of care;

• Primary care can struggle to manage some patients with long-term conditions effectively, including those with mental health problems. This may lead to avoidable A&E attendances and emergency admissions to hospital;

• A 2010 Department of Health study found that most GP out-of hours services in England were good but standards varied unacceptably. Primary Care Foundation data supports this, showing large differences between geographic areas in how quickly patients can access face-to-face care through out-of-hours services;

• Currently, urgent care walk-in services across England range from large integrated care services that encompass a 24/7 urgent care centre, GP services in and out-of-hours, a dentist, a rapid response team and radiology services to a minor injuries unit that has variable access to essential healthcare professionals and diagnostics, and may not be available out-of-hours;

• There have been attempts to develop pre-hospital services in England to enable patients to be treated at the scene or at home, and to therefore avoid unnecessary attendance at Emergency Departments. Despite these measures, however, a high proportion of emergency 999 calls still result in an attendance at hospital with patients who could receive treatment elsewhere;

• Self-care for minor ailments and self-management of long-term conditions play a crucial role in influencing the level of demand for urgent and emergency care. Improving access and encouraging the use of support for self-care of minor ailments could help to free capacity in primary care and prevent unnecessary use of urgent and emergency care services;

• The differential level of impact that the NHS 111 service has had on the Trust’s A&E 999 service in different geographic locations, partially linked to the way in which services have been launched and partially due to the NHS 111 provider. This has resulted in increased activity for the ambulance service in some areas and a change in the profile of when the activity is received. The peak volumes transferred from the new service are weekend mornings and early evening periods, with the Trust receiving approximately 40% of its activity from the NHS 111 service at peak times;

• The Phase 1 Report of the Urgent and Emergency Care Review proposes a significant expansion and enhancement of NHS 111 services positioning them as the ‘front door’ of urgent and emergency care services in England. This is designed to deliver a 24 hour, personalised priority contact service, with direct contact to a nurse, doctor of other healthcare professional where appropriate, and direct booking or call backs from a GP or whichever urgent or emergency care facility can best deal with the problem. The final specification for this enhanced service is expected to be published during 2015/16 and will present both challenges and opportunities for the Trust.

Objectives • Coordinating the delivery of care and simplifying access including oversight of the alternatives to

accident and emergency services within a local health and social care system; • Assisting the local health and social care system in understanding the reasons for increases in demand

for urgent and emergency care including improving data capture and patient tracking; • Leading the integration of services including NHS 111 and Out of Hours; • Preventing injury and illness and promoting good health; • Assisting in providing early diagnosis and appropriate treatment; • Delivering safe and effective mobile healthcare for patients who need urgent and primary care; • Assisting long term condition management particularly in helping patients receive care closer to home; • Providing greater choice for primary care when planning unscheduled admissions for patients; • Smoothing demand to support the provision of an efficient and cost effective service.



Chapter 3: Strategy

Initiatives • Integrating NHS 111, Health Care Professional Desks and Out of Hours services; • Developing an enhanced NHS 111 service in line with national specifications - Without a single, clear

point of advice it has been shown that people ‘bounce around’ the system, being sent from one place to the next and are given conflicting advice and information;

• Working collaboratively with primary care to increase the range of mobile health and social care services provided;

• Providing support to primary care for in-hours home visits; • Health screening and referral pathways including atrial fibrillation screening and referral; • The provision of a mobile response service to assist patients whose fall results in non-injury but they are

unable to mobilise without assistance; • Enabling care to be delivered closer to people’s homes through the use of assistive technology; • Increased seven day working across service lines; • Reviewing the management and response to healthcare professional calls including same day and next

day admissions; • Assisting the health and social care system in reducing gaps and duplication in service delivery. Measures of Success • Delivering cost efficiency for the system in a form agreed with commissioners and key healthcare

partners; • Improving clinical and wider quality outcomes; • Improving the patient’s experience; • Reshaping services to put patients at the centre: matching services more closely to individuals risks and

specific characteristics; • Simplifying access to health and social care – through the provision of integrated care, simplifying the

way in which a patient or their representative or carer can navigate the NHS and social care systems in order to meet their needs;

• Improving quality and safety through the provision of full week services; • Reduction in unwarranted variation in care across a health and social care system. Strategic Goal 4: Creating Organisational Strength Continue to ensure the Trust is sustainable, maintaining and enhancing financial stability. In this way the Trust will be capable of continuous development and transformational change by strengthening resilience, capacity and capability. “Healthcare mergers and acquisitions are highly challenging and integration is unlikely to happen quickly. They are not a ‘quick fix’ and new ways of working have to be embedded, and that takes time. Loyalties to old ways of working are sometimes very hard to shift and achieving a long-term vision takes time and lots of patience, not just for senior management, but also for the stakeholders impacted by the change.” Taking the Pulse – KPMG International Rationale 2013/14 was a year of significant change for the Trust both internally and externally including changes to the commissioner landscape and the emergence of CCGs, the loss of Patient Transport contracts, the introduction of NHS 111 and the acquisition of GWAS. Three key benefit drivers underpinned the acquisition of GWAS: ‘To Improve the Quality of Care provided to our Patients’, ‘to Secure Value for Money for the taxpayer’ and to ‘Create Organisational Strength’. This Strategic Goal focuses the Trust on the continued delivery of these benefits and in meeting a number of integration challenges across operational Divisions and with the wider health community. The Trust recognises that there needs to be a sufficient period of consolidation, strong visible leadership and stability in order to establish a sustainable infrastructure for the future. Drivers underpinning the development of Strategic Goal 4 • The NHS is facing a significant funding gap from 2015/16 and as a result there will be a dramatic slow-

down in spending growth. In order to remain financially viable and balance the onus on increasing internal productivity gains, the Trust needs to secure additional income through the provision of value



Chapter 3: Strategy

added services for commissioners – this will require the Trust to be increasingly innovative and commercially oriented;

• The NHS is becoming increasingly competitive and previously defined ’core’ services will be at risk. The increasingly fragmented healthcare market will drive cooperation between health and social care partners and promote alliances strengthening competitive advantage whilst at the same time encouraging competition and therefore an increased level of ‘threat’ to the contracts when tendered;

• Over the life of this Plan the Trust is expecting all three of its current core service contracts for OOHs to be retendered;

• In order to remain fit for purpose, relevant and competitive the Trust needs to ensure that there is a sustainable and affordable infrastructure for the enlarged Trust going forward;

• Underpinning this goal is the necessity for the Trust to establish a solid foundation and provide headroom for the Trust to maintain its reputation for leadership in delivering a wide range of innovative and cutting-edge treatments which has previously secured the Trusts national reputation for implementing the latest evidence based care pathways and interventions;

• Maximising the opportunities for growth that will exist within an increasingly financially constrained environment. This recognises that only the most flexible and responsive providers will attract funding;

• “The new approach [to delivering care] cannot be developed by any organisation standing alone and we are committed to working collectively to improve services” A Call to Action – NHS England15;

• The health and social care system will place greater emphasis on integrated health services in the future if the ambition of transformative change is to be achieved. The Trusts workforce will need to support this change including developing skills that are increasingly transferable between different care settings;

• The first stage Emergency and Urgent Care Review sets out the need to harness the skills, experience and accessibility of a range of healthcare professionals including paramedics. By extending paramedic training and skills, and supporting them with GPs and specialists, there is an opportunity to develop 999 ambulances into mobile urgent treatment services capable of dealing with more people at scene, and avoiding unnecessary journeys to hospital;

• The acquisition of GWAS created a regional ambulance service with geographical coverage extending from the Isles of Scilly to Gloucestershire encompassing 12 Clinical Commissioning Groups. This strategic goal recognises the complexity and amount of work and legacy issues associated with the integration of two previously standalone organisations, some of which will take a number of years to materialise and work through;

• Ensuring that the benefits of integration arising as a result of the acquisition are realised as planned is critical to successful integration;

• In line with the acquisition benefit ‘Improving Quality to Patients’ the Trust needs to continue to standardise clinical practice across all Divisions, levelling up clinical skills and adopting best practice;

• The Trust will need to ensure all of its systems and practices, including major IT systems, are aligned to support the delivery of care and enable the achievement of greater efficiencies e.g. the implementation of the Electronic Patient Record across the southern England ambulance services as set out in more detail within the Quality Plans table;

• Over the next five years, the Trust has a significant programme of activities related to the Trust estate and IT support systems, including the Clinical Hubs, in order to realise greater synergies and support the introduction of a single operating model across the Trust;

• ‘Local Service, Regional Resilience”: the ambulance service has a dual role in delivering a local service that provides individual and personalised care to patients balanced with the benefits of whole system coverage and capacity for resilience. This presents challenges to the Trust in ensuring it is integrated with the health care providers in each area and responding to local commissioner needs, whilst managing an organisation and services that cover the whole south west region.

Objectives • Ensuring that the Trust is on a firm financial footing going forward; • Broadening the scope of services provided – geographical, skills, markets; • Developing a shared organisational culture with consistent values and ambitions;

15 The NHS Belongs to the People. A Call to Action – NHS England (11 July 2013)



Chapter 3: Strategy

• Ensuring that the Trust delivers the benefits and pledges associated with the acquisition of GWAS including embedding consistency and standardisation where possible in order to deliver efficiencies and establish best practice;

• Attracting and retaining a high quality workforce; • Optimising the advantages of being an enlarged NHS Foundation Trust; • Enhancing the reputation credibility and attractiveness of the Trust as a business partner. Initiatives • Delivering the Cost Improvement Strategy; • Delivering the Integrated Estates Strategy; • Delivering the Acquisition Integration plan; • Pursuing opportunistic acquisitions; • Developing tactical, strategic and operational alliances to enhance the service offering and add value to

commissioned services; • Tendering for new business that fits strategically; • Developing a Cultural Strategy; • Implementing a Financial Strategy that is both sustainable and affordable; • Retaining existing services, developing new service models in response to enhanced service

specifications particularly for out of hours care reviews and responding to the desire to integrate models of care across contracts such as NHS 111 and Out of Hours services.

Measures of Success • Delivering the Integration Plan, Benefits and Pledges associated with the acquisition of GWAS; • On-going financial sustainability measured through for example the Trust’s Continuity of Services Risk

Rating; • Continually achieving a Green Governance Risk Rating; • Achieving clean opinions in independent governance reviews; • Maintaining a stable senior leadership team from senior management to Board level; • Successfully implementing changes to service models, rotas, skills mix etc to support service delivery. 3.6. Summary of Strategy Development Activity and Communications Plans The Trust has undertaken a series of activities to engage key stakeholders in re-setting the Trust’s strategic priorities. In the context of establishing a new over-arching strategy the key stakeholders are defined by the Trust Board of Directors as patients and the general public, Trust staff, NHS Commissioners and local health system managers. Commencing in early in 2013 the Trust Board of Directors and Executive Directors Group undertook numerous activities focused on: • Identifying initiatives that build upon the clinical strengths of the Trust; • Considering new markets and opportunities; • Identifying where the Trust could add value to existing care models and service provision in the wider

health community; • Assessing the implications of current NHS and emergency service reviews on the future structure and

service model of the Trust; • Exploring the potential benefits of pursuing ‘partnerships’ of various forms including integrated working,

shared services, contractual outsourcing and joint ventures; and • Considering the potential for future acquisitions or mergers on an opportunistic basis. Using the outputs of these discussions the Trust developed a draft set of Strategic Goals for delivery through to 2018/19. These were developed further through discussions with the Trust’s Deputy Director’s Group before being presented for consideration to NHS Commissioners, members of the Council of Governors, Trust senior managers and Union representatives at a strategic away day organised by the Trust in July 2013. Further Board discussions throughout September to December 2013 finalised and approved the goals as represented within this chapter.



Chapter 3: Strategy

To test the principles of the proposed future strategy, and secure wider stakeholder support, the Trust engaged the south west CCGs and South West Commissioning Support Unit (CSU) during the planning stages. In addition the Planning Sub Group of the Council of Governors used the structure of the goals; mission etc to form the basis of their Annual Plan engagement questionnaire. This was distributed to all ‘Level 2’ members electronically early in 2014 as well as being published on the Trust’s website. The Council of Governors presented a paper summarising the findings to the Trust Board of Directors during May 2014. To secure wider stakeholder support, the Trust has developed a Communications and Engagement Strategy to ensure ongoing discussion and feedback throughout the life of the Plan. This will include a series of planned testing and feedback mechanisms for a range of audiences, including staff, members, Governors, local Councillors and MPs, as well as existing networks of patients and the public (HealthWatch, PPI and patient groups). More robust mechanisms are now in place to ensure structured engagement with commissioners and key stakeholders, including Health Overview and Scrutiny Committees, Health and Wellbeing Boards, HealthWatch groups and Urgent Care Groups. This is being led by the Trust Board and has enabled routine and regular updates and exchanges that will continue to influence the development of the Trust’s strategy and direction of travel. In addition to the more traditional presentations and feedback from commissioners and key stakeholders, a more creative approach to engagement is being employed to enable a range of responses from a variety of audiences on a number of key service developments. This includes online surveys, voting and social media activity, as well as opportunities to engage and debate face-to-face at meetings and events. A programme of events has already created opportunities to engage with GPs and MPs across the south west. Key themes from the Trust’s Communications and Engagement Strategy include: • Patient Experience: Learning from what people say about the Trust;

o The outcome will be: The Trust will learn from and respond to feedback, improving services, the Trust’s reputation and its relationships with key audiences;

• Internal Communications: Promoting the vision, values and goals of the Trust; o The outcome will be: Staff feel informed and act as ambassadors for the Trust;

• Stakeholder Engagement: Changing the way the Trust talks to people; o The outcome will be: The Trust has strong relationships with all of its stakeholders;

• External Communications: Promoting the work of the Trust; o The outcome will be: The Trust has an excellent reputation.

The Strategy includes the key messages to be relayed under each theme, the channels to be used and a commitment around how the Trust will share any learning and respond to feedback. This Strategy forms part of an on-going proactive approach by the Trust to clearly communicate change to ensure everyone understands what is happening, what it will mean for them and how they can participate in two way communication and involvement activities. The Board will be proactive in communicating and creating involvement opportunities with all staff and the communities the Trust serves. The Board will not be passive participants in the change programmes. The Trust’s Board recognise the benefits that patients, carers, the public, staff and stakeholders offer by sharing their feedback and the powerful impact that all staff; especially frontline clinicians as advocates can have on patients, carers and the public during communication and involvement activities.



Chapter 4: Market Assessment

Gloucestershire

Wiltshire

Dorset

Somerset

Devon

Cornwall

BNSSG

BaNES

Swindon

SWASFT

E-Zec

NSL

Arriva

SWASFT

SRCL Ltd Plymouth

4. Market Assessment 4.1. Trust Markets 4.1.1. Market Overview An overview of the market for each serviceline is set out in the table below.

999 A&E

• Covers the entire south west region serving a resident population of 5.3 million with high seasonal variations

• The Trust has maintained a 100% monopoly in the emergency 999 market following the acquisition of GWAS

A&E

PTS

• Nationally PTS are delivered by a range of NHS and independent sector providers with service provision tendered typically every three to five years. Contracts are negotiated annually either direct with an acute or community hospital or at an individual CCG level

• At the start of 2013/14 Trust provision covered Cornwall and the Isles of Scilly, Devon (excluding Torbay), Dorset, Somerset, the former Avon area, Gloucestershire and Wiltshire and, on occasion, to those on the borders within neighbouring counties.

• Following numerous tendering activities it was confirmed to the Trust in Quarter 1 of 2013/14 that all of its PTS contracts, with the exception of the BNSSG area and the Isles of Scilly, had been awarded to private providers

NHS 111

• 111 was a new market established during 2012/13 following a national procurement programme • As with PTS and OOH, NHS 111 services are competitively tendered and there are a number of private

and NHS providers delivering this service across England • In 2014/15 the Trust is contracted to deliver NHS 111 services in Dorset, Devon, Cornwall and the Isles

of Scilly and Somerset UCS

OOHs • OOH services are delivered by a range of NHS and independent sector providers. Service provision is

tendered typically every three to five years with contracts negotiated annually at individual CCG level • The Trust currently provides OOH services in Dorset, Gloucestershire and Somerset

4.1.2. The Market for PTS in the South West Following numerous competitive tendering processes the Trust was informed in Quarter 1 of 2013/14 that the majority of its PTS contracts had been awarded to private providers. From 1 October 2013 the provision of the North and East Devon and Somerset PTS contracts transferred to their new providers, with PTS in the Non BNSSG areas transferring from 1 December 2013.




4.1.3. The Market for OOHs Services in the South West The market profile for OOH services is complex and fragmented with multiple providers delivering contracts across the region. The Trust’s Somerset and Gloucestershire contracts were in the process of being tendered at the time this Plan was drafted. During 2013/14 the Trust received an extension to the Dorset contract through to the 31 March 2017. 4.1.4. The Market for NHS 111 Services As part of the initial tender process the Trust secured the contract to deliver NHS 111 in Dorset. Subsequently during 2013/14 the Trust secured three additional NHS 111 contracts, in Devon, Cornwall and Somerset. Formerly provided by NHS Direct the Trust agreed an 18 month ‘holding’ contract with NHS Somerset CCG in order for the commissioner to run a new tender process. A new contract will be awarded from 1 July 2015.

Serco

Devon Doctors

SWASFT

The Vocare Group

Brisdoc

SWASFT

WMS

SEQOL Gloucestershire

Wiltshire

Dorset

Somerset

Devon

Cornwall and Isles of

Scilly

BaNES

Swindon BNSSG

Gloucestershire

Wiltshire

Dorset

Somerset

Devon

Cornwall and Isles of

Scilly

BaNES

Swindon BNSSG

SWASFT

Harmoni




1 CSU

6 Partnership

Trusts

18 Acute Trusts 12 CCGs

4 Local Area

Teams

NHS ‘Partners’ The Trust relates to and works with the following NHS organisations within its operational area: 4.1.5. Partner Segmentation The graph below sets out commissioner segmentation for each of the Trust’s service lines. This is based upon contracted income for 2014/15 by service line, and overall contribution to Trust income by commissioner.

4.2. Market Drivers There is a wealth of information in the public domain that sets out the factors driving change and demand in the NHS. The following sections attempt to highlight the more significant drivers that are increasingly influencing the shape of the local health systems in the south west and are driving key elements of the Trust’s Strategy moving forward. The position is a complex one. Not all of the factors driving change point in the same direction however there is a clear set of principles. Namely that: • Change is inevitable – transformational change is required in certain areas; • Given the complexity of the drivers, planning for change is essential; • “More of the same” is not the solution – to meet the challenge of the drivers will require new ways of

working, involving the whole health care system in the change process.

Avon and Wiltshire Mental Health Partnership NHS Trust Cornwall Partnership NHS FT Devon Partnership NHS Trust

Dorset Healthcare NHS FT 2gether NHS FT

Somerset Partnership NHS FT

Bath and North East Somerset (BaNES) Bristol Dorset

Gloucestershire Kernow

NEW Devon North Somerset

Somerset South Devon and Torbay

South Gloucestershire Swindon Wiltshire

Dorset County Hospital NHS FT Gloucestershire Hospitals NHS FT Great Western Hospitals NHS FT

North Bristol NHS Trust Northern Devon Healthcare NHS Trust

Plymouth Hospitals NHS Trust Poole Hospital NHS FT

Royal Bournemouth and Christchurch Hospitals NHS FT Royal Cornwall Hospitals NHS Trust

Royal Devon and Exeter NHS FT Royal National Hospital for Rheumatic Diseases NHS FT

Royal United Hospital Bath NHS Trust Salisbury NHS Foundation Trust South Devon Healthcare NHS FT Taunton and Somerset NHS FT

University Hospitals Bristol NHS FT Weston Area Health NHS Trust Yeovil District Hospital NHS FT

South West Commissioning Support Unit

Bath, Gloucestershire, Swindon and Wiltshire Bristol, North Somerset, Somerset and South Gloucestershire

Devon, Cornwall and the Isles of Scilly Wessex

SWASFT




4.2.1. Demographic Drivers The table below summarises key demographic drivers for growth in the medium to long term.

Domain Drivers for Growth

Population

• Population growth in the region has been faster year on year than UK as a whole (6.7% vs 5.3%) • South west population is forecast to grow from 5.3 million to 5.8 million by 2021 with an average increase

of 0.8% year on year • Highest percentage change in the south west as a result of migration and lowest due to natural change • More females in the south west region than males

Age

• The median age of the region was 42, 3 years higher than the England and Wales average • More people above 65 years of age with the over 65 population expected to increase by 25% by 2021 • Increase in females over 70 years of age • Life expectancy in England has increased by 4.2 years between 1990 and 2010 (79.5 years for males and

83.5 years for females compared with 78.2 and 82.3 years respectively for the UK) • Hospital treatment for over 75s has increased by 65% over the past ten years and someone over 85 is

now 25 times more likely to spend a day in hospital than those under 65 • The number of older people likely to require care is predicted to rise by over 60% by 2030

Ethnicity

• 91.88% of population classed as ‘white British’ • In 2011 there were 405,000 foreign-born residents in the south west, 8% of the usual resident population • Bournemouth, Bristol and Swindon had the highest proportions of foreign-born usual residents, with 15%,

15% and 13% respectively

Tourism • Increase in the number of local holidays as a result of the deteriorating economic conditions • Third highest region for overseas visitors

Weather • Weather extremes – recent hard winters, snow, floods • Carbon footprint reduction • Seasonal variations

Socio Economic

• Difference in life expectancy between the richest and poorest parts of England is now 17 years • Nature of rural communities • Inequalities in access to healthcare • Jointly with the south east, the south west had the smallest proportion of ‘socially rented local authority’

households (6%)

4.2.2. Change Drivers The table below summarises key change drivers for growth in the medium to long term.

Domain Drivers for Change

Economic

• Since it was formed in 1948 the NHS has received around 4% of national income • Modelling shows that continuing with the current model of care will lead to a funding gap of £30 billion

between 2013/14 and 2020/21 • Deep recession resulting in funding pressures and dramatic slow-down in spending growth forecast for the

NHS from 2015/16 – Commissioners reinforcing through contracts • National call for Transformational Change to ensure NHS services can remain free at the point of delivery • Limited further internal productivity gains • Investment associated with the delivery of Category A8 Red 1 and Red 2 performance • Quality Premium Payment introduced for NHS Commissioners from 2013/14

Regulatory

• National drive for increasing range of healthcare services to be available 24/7 • Civil Contingencies Act requirements • Care Quality Commission changes to regulation and inspection • Monitor Risk Assessment Framework introduced October 2013 • Changes to Commissioning of NHS services including move towards CSUs • Establishment of GP Consortia’s • Commissioning for Quality and Innovation (CQUIN)

Industry

• Increasing number of private providers delivering and winning NHS provided business in the region • New entrants to UK marketplace including competition from oversees

Technology and

Medicine

• The NHS must change to meet demand and make the most of new medicines and technology without reducing or charging for core services




Domain Drivers for Change • Use of assistive technology as an enabler • Single point of access • NHS 111 • Electronic Patient Record • General advances in IT software, hardware and solutions • IT supported care pathways

Health & Wellbeing

and Lifestyle Choices

• NHS facing demand increases, rises in emergency and urgent admissions and increasing readmission rates

• Approximately 80% of deaths from major diseases, such as cancer, are attributable to lifestyle risk factors such as smoking, excess alcohol and poor diet

• One quarter of the population has a long term condition such as diabetes, depression, dementia and high blood pressure – and they account for 50% of all GP appointments, 70% of days in a hospital bed and 70% of total healthcare expenditure

• There are around 800,000 people with dementia in the UK, and the disease costs the economy £23 billion a year. By 2040, the number of people affected is expected to double - and the costs are likely to treble

• The south west has 18% of people whose day to day activities were limited by a long term health problem or disability. The south west had 11% of its people providing unpaid care for someone with an illness or disability

4.2.3. Strategic Landscape Chapter 3 explored some of the national policy drivers that have influenced the development of the Trust’s Strategy. This included short to medium term policy drivers that have influenced the development of the Trust’s Strategy. The tables set out in the following pages provide more detail and highlights further statutory reviews and consultation exercises that will impact on the Trust Strategy over the life of this Plan. Urgent and Emergency Care • It is suggested that the current system of urgent and emergency care is unaffordable and unsustainable and

consuming NHS resources at a greater rate every year. There needs to be a review in the way the NHS responds to and receives emergency patients16;

• The number of emergency admissions to hospitals continues to rise at a time when NHS budgets are under significant pressure. In 2012/13 there were 5.3million emergency admissions, costing approximately £12.5billion. This is a 47% increase in emergency admissions in the last 15 years. In addition it is estimated that approximately 1/5 of admissions are for known conditions which could have been managed effectively by primary, community and social care and could be avoided;

• The NAO review into emergency admissions17 outlines that all parts of the health system have a role to play in managing emergency admissions and ensuring patients are treated in the most appropriate setting. This includes ambulance services reducing conveyance rates to Emergency Departments by conveying patients to a wider range of care destinations;

• A wealth of evidence points to the need to re-design the entire system of urgent and emergency care pathways. Led through Sir Bruce Keogh’s Review10 the emerging principles and evidence base outline a system that should: o Provide consistently high quality and safe care, across all seven days of the week; o Be simple and guides good choices by patients and clinicians; o Provide the right care in the right place, by those with the right skills, the first time; o Be efficient in the delivery of care and services;

• There is a clear need to adopt a whole system approach to commissioning more accessible, integrated and consistent urgent and emergency care services, with greater investment required in out of hours primary care and community services. The new system need to be intuitive and should people make the right decision;

• The first stage Urgent and Emergency Care Review sets five key proposals: o Providing better support for people to self-care; o Helping people with urgent care needs to get the right advice in the right place, first time; o Providing highly responsive urgent care services outside of hospital so people no longer queue at A&E; o Ensuring that those people with more serious or life-threatening emergency care needs receive treatment in centres

with the right facilities and expertise in order to maximize chances of survival and a good recovery; o Connecting all urgent and emergency care services together so the overall system becomes more than just the

16 http://www.england.nhs.uk/ourwork/pe/uec-england/ 17 Emergency admissions to hospital: managing the demand – National Audit Office (31 October 2013)




sum of its parts; • The Kings Fund report18 suggests some areas need to do more to provide clear strategic oversight and drive to tackle

the main challenges to emergency care systems. Accurate analysis of care processes as well as a clear understanding of demand, activity and capacity is essential to managing emergency care;

• The report further highlights that ambulance services are often well placed to act as the coordinator of the system and capacity managers, with the capability and incentives to develop a partial map of the system. Opportunities to extend their scope include supporting primary care and nursing homes more actively; for example, by providing in hours home visits;

• This view is supported by the Health Committee suggesting ambulance services should be developed through changing the staff mix, reforming tariffs and ensuring access to patient information to establish ambulance Trusts as care providers in their own right12.

Transformation in the NHS • The wider NHS System is not working effectively with research indicating that at least 25% of patients currently

attending Emergency Departments could and should be treated by other parts of the NHS19; • There are a series of national consultations underway on the NHS payment systems and tariff. This includes proposals

for national tariffs, the operation of the 30% marginal tariff for emergency admissions, a review of the operation of the national contract and its associated regime of incentives and rewards. This is alongside the 2015/16 Government Spending Review. Each will be critical in determining the level of financial risk on providers and securing a financial settlement in the future that supports the sustainability of the Trust and its services;

• At a strategic level there is growing recognition that radical workforce reform is needed to align the NHS workforce and its pay, terms and conditions with health demands and the more financially constrained environment within the NHS;

• The Francis Reports have paved the way for wide ranging changes to the regulatory system in the NHS. It is expected that further change will be required following Royal Assent of the Care Bill;

• Competition and choice issues were more widely introduced in the NHS by the Health and Social Care Act 2012 alongside a new regime to manage organisational mergers. Both have implications for how the Trust chooses to partner in respect of future contracts, where the Trust can expect competition to increase in relation to its existing contracts and how the Trust may deliver some if its proposed service developments;

• Quality of services reviews are ongoing and cover many aspects of the Trust governance arrangements including complaints20 and safety21. Each review makes a number of recommendations for setting common standards that Trusts will be held to account against. The Trust needs to ensure it considers each review in turn and implements changes at a local level to further improve the quality of patient care;

• During 2013 Monitor and the NHS TDA announced a tripartite approach to urgent and emergency care planning for next winter. The detrimental impact on quality of care and the failure to achieve key operational standards requires a multi-faceted, inter-organisational approach. Throughout the life of this Business Plan the Trust will be heavily involved in developing and implementing initiatives that support the local health economy to manage performance pressures.19

Blue Light’ Services

Two key reviews22 are driving questions about the future of ‘blue light’ services in England and the potentially significant financial and operational efficiencies to be gained from streamlining, increasing interoperability and strengthening ministerial leadership: • It is recognised that collaboration and co-responding with other blue-light services to support the delivery of efficiencies

already occurs in some areas. These reviews go further in making a number of recommendations to capitalize on opportunities for structural, organisational and operational collaboration with other ‘blue light’ services23;

• Relatively new, these recommendations are yet to be considered in greater detail at a national level, however the Trust is mindful of their potential impact. A tri-service conference held in late 2013/14 suggested that at present there is little appetite to legislate collaboration or integration. Instead there is an expectation that this will be driven independently by services where benefits can be identified and through national programmes such as the Fire and Rescue Authority Transformation Scheme that encourages greater collaboration with other emergency services.

4.3. Objectives of the Local Health Economy The objectives of the local health economy are set out in a number of key strategic documents. These include Everyone Counts, the Strategic Intent of NHS England and individual CCGs, Acute and Mental Health Trust’s strategic plans. The following sections highlight national and local strategy that directly influences the future plans of the Trust.

18 Urgent and Emergency Care – A Review for NHS South of England’ – King’s Fund (March 2013) 19 Emergency Care and Emergency Services 2013. View from the Frontline – FTN (2013) 20 https://www.gov.uk/government/news/review-of-nhs-complaints-system 21 https://www.gov.uk/government/speeches/the-government-s-response-to-the-francis-report 22 Facing the Future. Findings from the Review of Efficiencies and Operations in Fire and Rescue Authorities in England’ – Sir Ken

Knight (May 2013) and Improving Efficiency, Interoperability and Resilience of our Blue Light Services – Tobias Ellwood MP and Mark Phillips (June 2013)

23 ‘Facing the Future. Findings from the Review of Efficiencies and Operations in Fire and Rescue Authorities in England’ – Sir Ken Knight (May 2013)




4.3.1. The NHS Mandate The Mandate to the NHS Commissioning Board sets out the objectives for the NHS and highlights the areas of health and care where the Government expects to see improvements. Focused on areas that matter most to people, five key areas for improvement have been identified: • Preventing ill health and helping people to live longer; • Managing ongoing physical and mental health conditions; • Helping people recover from episodes of ill health or following injury; • Making sure people experience better care; • Providing safe care. Aligned to these five domains the NHS Commissioning Board subsequently developed a Commissioning Outcomes Framework measuring health outcomes and the quality of care to be achieved by CCGs. This identifies the contribution of CCGs in achieving the requirements of the NHS Outcomes Framework and confirms those that the Secretary of State for Health will use to assess national progress in improving patient outcomes. 4.3.2. CCG Strategic Plans Individual CCGs have published a range of plans setting out the priorities and outcomes to be commissioned at a local level. In developing the refreshed five year Strategy the Trust has reviewed these plans and identified both the recurring themes that will impact the Trust at a holistic level given its regional nature, and the local priorities of CCGs that the Trust can contribute towards through delivery of existing services or new developments. A summary of the overarching objectives and principles that have emerged include: • Delivering service change in all organisations to support whole-system transformation; • Delivering systems of care that are safe and responsive to patients’ needs and ensure the right level of

care from the most appropriate person; • Delivering added value and value for money in all current and prospective services within existing

resource constraints, supporting sustainability of services; • Designing and implementing an integrated, 24/7 urgent care system with simplified access for patients; • Providing urgent care services closer to home in support of self-care, preventing escalation of long term

conditions, offering alternatives to hospital attendance or admission, ambulatory care, accelerated discharge, and continuity of care to prevent unnecessary readmission;

• Supporting increased self-care and self-management through the promotion and use of assistive technology;

• Ensuring system-wide care pathway integration and collaboration so that patients experience seamless care throughout their treatment

• Implementing a single point of access for more effective utilisation of urgent and emergency services; • Increasing early detection/ diagnosis and intervention; • Strengthening emergency preparedness and resilience planning; • Ensuring effective medicines management to optimise the use of medicines and new technologies and

reduce variations in prescribing; • Reducing emergency admissions for ambulatory care sensitive conditions associated with long term

conditions and the frail elderly; • Improving palliative care and end of life pathways and reduce the conveyance of patients at end of life to

hospital; • Expanding use of virtual clinics/telephone follow up across specialties; • Supporting commissioners to deliver national clinical strategy including elements of the Dementia

Challenge and National Dementia Strategy. 4.3.3. The Quality Premium The key theme from the NHS Commissioning Board’s Everyone Counts is a focus on delivering high quality services through improving outcomes. In order to support this, a ‘quality premium payment’ will be made to CCGs that demonstrate an improvement or achieve high standards of quality in four national measures from the NHS Outcomes Framework, including reducing avoidable emergency admissions (25% of the quality




premium payment), and for achieving or improving measures in medication-related safety incidents and one other locally agreed priority area. Although the design of the quality premium will evolve from year to year the regulations are likely to remain the same. The NHS Commissioning Board will reserve the right not to make any payment where there is a serious quality failure in-year. For 2014/15 this includes the total payment for a CCG (based on its performance against four national measures and two local measures) being reduced if its providers do not meet the NHS Constitution rights or pledges for patients in relation to (a) maximum 18-week waits from referral to treatment, (b) maximum four-hour waits in Emergency Departments, (c) maximum 14-day wait from an urgent GP referral for suspected cancer, and (d) maximum 8-minute responses for Category A red 1 ambulance calls (75%). 4.3.4. Commissioning for Quality and Innovation (CQUIN) CQUIN will continue to have a significant impact on the local health economy in relation to future priorities and potential provider income. The CQUIN payment framework enables commissioners to reward excellence, by linking a proportion of English healthcare providers' income to the achievement of local quality improvement goals. The aim of the 2014/15 CQUIN framework is to support improvements in the quality of services and the creation of new, improved patterns of care. Guidance states that CQUIN schemes should be used to incentivise providers to deliver quality and innovation improvements over and above the baseline requirements set out in the NHS Standard Contract, with no innovation pre-qualification criteria in 2014/15. CQUIN income is set at a level of 2.5% for all healthcare services commissioned through the NHS Standard Contract with 0.5% linked to national goals where they apply. For Ambulance Trusts the Friends and Family Test (FFT) is the only potentially applicable national CQUIN, equating to 0.125% of total CQUIN. The remainder of the 2.5% is to be locally agreed through contract negotiations. CQUIN continues to represent significant opportunities for the Trust in supporting future service redesign and development. 4.4. Summary of the PESTLE Analysis The Trust has undertaken an extensive PESTLE, from Board level to front line staff, to identify the key risks and opportunities within its operating environment. The table below sets provides a summary of the key outputs and considers the implications for the Trust as a result. Risk/Opportunity Political • Opportunity to rebrand the Trust to raise its profile and re-position the Trust as a provider in its own right in the wider

urgent care market • Partnerships are becoming an increasingly integral part of health and social care delivery encouraging more effective

working across care interfaces, disciplines and specialisms • Health and social care policy is increasingly structured around a commissioning led approach encouraging health and

social care partnerships and leading to the joint commissioning of health and social care • Barriers to the integration of services are beginning to be broken down including differences in how to treat patients

between different institutions, operating procedures across health and social care providers and governance including ownership of risk

• Risks associated with further ambitious and widespread reform programmes following the 2015 general election Economic • Opportunities to grow the level of private patient income or develop ‘for-profit’ provider arms/partnerships –

increasingly acceptable for Trusts to diversify and generate a profit/surplus • Opportunities to secure private sector income and ‘transformational’ funding to support new initiatives and growth in

key markets • Implications for health and social care budgets of the further spending review following the 2015 elections • Increased efficiency requirements, accounting for rising demand and inflation pressures, to maintain the current level

of NHS services Social




Risk/Opportunity • Cultural differences between organisations or staff groups i.e. management and frontline clinicians, affecting

willingness to share information, resources, support system changes etc • The region has one of the highest proportions of graduates in the UK, however one of the lowest proportion of

graduates in the workforce. More young people leave the region each year than come to it • The region has the oldest median age in terms of population and among the highest rate of life expectancy in England

– creates challenges in tackling the healthcare needs of an ageing population, including the increased prevalence of conditions such as dementia and other long term conditions

• As the demography of the population changes – in particular, a growing proportion of older people – not only will the need for social or long-term care become increasingly important, but the boundaries between what constitutes social care and what is considered health care to be are likely to become increasingly blurred

• GP ‘workforce crisis’ with the number of applicants into general practice falling and the number of GPs approaching retirement rising – the current growth in general practice is not strong enough to meet the predicted demand

Technological • Innovative technology solutions including telehealthcare and telemedicine can be introduced into patient care

pathways to improve patient experience, reduce the costs of care and alleviate pressures in parts of the system • Through existing and new technologies provide community based monitoring enabling increased self-care and

management of health within the community • Introduction of the electronic care patient record system across the south west • Continued developments to enable IT supported care pathways creating opportunities for service development Legal (and Regulatory) • Ability for the Trust to develop and exploit its commercial flexibilities • Potential for acquisition of non NHS Trust that are unable to achieve Foundation Trust status independently • Conflict of interests between CCGs, GP practices and other providers in the commissioning of healthcare services

e.g. financial links to private providers and for-profit firms Environmental • Regionalism vs localism: the paradox between a drive for the localism approach to promote economic development

and shape and deliver services and regionalism to ensure there remains a level of coordination and integration • Lack of clarity for providers and health care professionals in areas of urgent care as to the appropriate referral

pathways for patients and how these are best accessed • The impact of housing and other developments on the provision of healthcare in an area e.g. increased demand for

services, inadequate infrastructure – roads, healthcare facilities etc • Significant relationship between rurality, response times, ambulance costs per journey, increased fixed costs etc

resulting in variations in the level of service that can be provided across the region The outputs of the PESTLE have been used to inform strategic discussions and have influenced the development of the forward plans by highlighting the external pressures and opportunities facing the Trust. Key themes presented in the table above form part of the planned service initiatives and strategic options for each service lines that are set out later within this Plan. 4.5. Conclusions Moving forward there are a number of key challenges facing the Trust, and the NHS as a whole including how competition will evolve and how it can be used to deliver improvements in the services offered for patients. In respect of competition for the market, where there is a need for a single or limited number of providers, competition is managed through competitive tendering processes so as to select the most economically advantageous provider. The Trust needs to focus on developing services that deliver commercially without compromising the Trusts position on delivering high quality, safe services. This will require a determined focus on preparing for tenders including a detailed understanding of the commissioner needs and local market, a focus on engagement and communication activity to ensure the Trust is positioned appropriately, a rigorous assessment of the competition, consideration of future partnerships and alliances going forward to strengthen the Trusts position and an ability to articulate the benefits of integrating urgent care with other Trust services. The following chapter sets out a summary of the Trust’s proposed service development plans in response to this market assessment and the overview of the strategy as presented in Chapter 3.




5. Service Development Plans 5.1. Strategic Principles This section summarises the strategic principles that underpin the service development plans and provides an introduction to the Trusts approach to the development of its new strategy. 5.1.1. Principles The following six strategic principles underpin all of the service development plans presented in this Plan: • Ensuring that the Trust maintains and enhances its reputation as a leading ambulance service trust by

continually improving the quality of services delivered to patients and as a trusted health partner delivering emergency and urgent care services within the south west of England;

• Recognising that although the Trust is commissioned to provide a number of services, including accident and emergency services on a Trust wide basis, there is also a need for the Trust to focus on working in partnership with other local health system organisations to ‘co-create’ future services in order to maximise the gains for patients;

• Integrating services within the Trust where there are clear benefits for doing so and integrating services within local health systems to improve access and quality of care for patients;

• Developing and enhancing the operational model of the Trust to ensure that it is seen as a care provider in its own right;

• Protecting the Trusts existing market shares for key services to ensure future sustainability, positioning the Trust to ensure that it has the capacity and capability to compete against existing and new entrants to the emergency and urgent care market;

• Forming strategic alliances and partnerships with other organisations where they contribute positively towards the objectives and ambitions of the Trust.

5.1.2. Approach Each service development plan has been considered in the context of whether it is a ‘sound’ development, an ambition or an aspirational development for the Trust: • Sound Service Developments: The Integrated Business Plan and Long Term Financial Model assumes

that sound initiatives are funded, occur within the lifetime of this Integrated Business Plan; • Ambitions: These are future ambitions of the Trust within the lifetime of this Integrated Business Plan

but are subject to internal and external factors such as national policy, support for the Investment Strategy, commissioner intentions etc. These ambitions are briefly outlined;

• Aspirations: These are developments that the Trust is considering but are outside the timeframe of the Integrated Business Plan or there is currently not enough information to describe their impact on the five year plan.

In addition, each service development has also been considered in terms of its placement both within the Trust and within the local health system. This approach is key to assisting the Trust in understanding the relative importance and priority of each of the individual developments. This approach ensures that each development: • Compliments the internal management structure of the organisation; • Reflects the existing and likely future contractual arrangements for commissioning emergency and urgent

care services. The service development plans are therefore presented under two service lines namely, an accident and emergency service line which includes patient transport services and an urgent care service line which includes out of hours and NHS 111;

• Aligns as far as possible with the stated strategic and commissioning intentions set out by the 12 Clinical Commissioning Groups within the south west. Section 4.3.2 sets out a number of consistent themes across all CCGs. These will be used to inform CCG level plans that identify those service developments that are applicable to all CCGs and those that need to be developed and co-created locally to ensure a ‘fit’ within the local health system. This approach will ensure that the Trust takes account of significant strategic factors within the local health system that will have a direct and future bearing on the development of the Trust plans including:



Chapter 5: Service Developments

o The existing presence of the Trust within the local health system; o The opportunity, scale and scope for the Trust to improve services; o The degree of competition within the local urgent and emergency care market; o The strength of existing relationships within the local health community including the Trusts

relationship with primary care, clinical networks, local acute and community providers and at a more strategic level with urgent care boards and clinical commissioning groups;

o Specific local challenges faced by commissioners which will include challenges around geography, provision of services etc.

5.2. Planning Assumptions The Trust has established a base case for both its financial and activity modelling as part of its five year plans. Both are based on a number of assumptions, underpinned by the following principles: • The Trust previously negotiated a five year framework for A&E services, under commissioner

convergence principles, for all former Trust commissioners. Following the acquisition of GWAS, during 2013/14, the Trust operated two separate A&E contracts. However moving forward the Trust has negotiated a single contract and secured a two year financial framework through to 2015/16. The planning assumption is that the Trust will be in a position to negotiate and secure a further three year financial framework for the outer years of this plan through to 2018/19;

• Right Care2 presents an invest to save scheme for the wider health community; • Growth will continue within 999 A&E services; • The Trust has historically developed its forward plans on a prudent basis; • Although a proportion of the Trust’s contracts contain provisions that allow commissioners to apply a

local deflator, under the national tariff guidance, it is expected that commissioners enter into ‘reasonable discussion about the level of any payment variation’. The Trust would therefore expect further negotiations before the application of any such tariff and would be in a position to challenge any deflator should the contract become uneconomic.

5.3. A&E Service Line Strategy The ambulance service is one of the most vital gateways to the NHS. Through its day to day activities the Trust accesses and optimises the use of alternative care pathways ensuring patients are routed in the most appropriate way through the wider NHS system. The Trust already delivers significant added value to the wider health economy through specific activities. This includes, through its Right Care initiatives, a focused reduction on the number of patient conveyances and therefore subsequent admissions to A&E departments. These activities in turn contribute to improved productivity within the Trust and enable the Trust to manage and mitigate the risks associated with unfunded activity growth. In order to strengthen the Trust’s current service, its competitive position and provide a more seamless service to patient’s, integration will be the primary focus for A&E in the outer years. This will include integration across service lines internally such as integrating the A&E clinical hubs with 111 but also focus on external integration with local healthcare providers, community services such as Minor Injury Units and urgent and emergency care networks. More detail on these initiatives is set out within the following sections. The A&E service operating model, over the two years 2014/15 and 2015/16, is based upon six key principles: • Investing to deliver the Trusts Productivity Framework; • Consolidating resources invested by the Trust in Quarter 4 2013/14 in order to deliver consistent

performance with additional resources identified to respond to a change in the demand and activity profile linked to the introduction of NHS 111 within the south west;

• Supporting and enhancing the work of the Community Engagement Team in rolling out community based defibrillators, expanding the Community Responder Teams and enhancing the communication systems to support the operation of these resources;

• Investing in the Trusts Clinical Hubs: • Investing in clinicians based within the Clinical Hubs to assist in the management and delivery of

performance, support the implementation of the Trusts Right Care2 initiative and establish the Health Care Professional Support and Referral Service;




• Investing in additional staff in order to support the implementation of a single CAD, triage and telephony systems;

• Launching the Trusts Right Care2 initiative including investing in a project team to provide leadership and support to the project and to enable the Trust to engage with commissioners locally;

• Investing in paramedic training and targeted training for frontline crews to ensure the successful implementation of the Electronic Patient Care Record Form during 2014/15.

The outer year strategic plans then build upon these themes. Key to ensuring the future sustainability of services will be a focus on managing future activity growth alongside the continued delivery of any national or contractual targets. Alongside the delivery of the Trust’s Cost Improvement Plans, as set out earlier within this Plan, a primary focus for the Trust’s A&E Service line is the continued delivery of its Right Care2 initiative.

Theme 1: Right Care, Right Place, Right Time2

Strategic Drivers

The previous chapters set out the pressures currently facing the NHS, and in particular the emergency and urgent care system. These include: • the current system of urgent and emergency care is unaffordable and unsustainable there needs to be

whole scale change in the way the NHS responds to and receives emergency patients; • Acute beds have reduced by a third over the last 25 years24 whilst emergency admissions continue to

rise. However it is estimated that approximately one fifth of admissions are for known conditions which could have been managed effectively through alternative routes meaning admissions could have been avoided;

• CCGS are looking to commission activities that support service change, deliver added value, support the move towards seven day services and create an integrated 24/7urgent care system for patients, with simplified access;

• The profile of the ambulance service has been raised, with an explicit recognition of the vital role the ambulance service has to play in addressing the challenges and ensuring all patients get the right care, in the right place, at the right time;

• Studies have identified a number of roles and specific opportunities that have as yet remained largely unexploited by the ambulance sector that can deliver solutions to manage increasing demand across the system and establish ambulance trusts as care providers in their own right.

This theme focuses on the role of the Trust in reducing attendances at Emergency Departments and is being driven by a need to deliver value added services, more localised care, in more appropriate settings, and reduce pressure across the emergency and urgent care system. Reduced attendance, and therefore admissions, will generate significant savings for commissioners and the wider health economy and contributes to the successful delivery of acute provider targets.

Proposed Development

Right Care, Right Place, Right Time1 (Sound Development) Historically the Trust has had consistently one of the lowest conveyance rates to Emergency Departments in the country. However in response to a need to further reduce the rate of conveyances to A&E, the Trust established an initiative in 2009 called 'Right Care, Right Place, Right Time1’ as part of its previous five year Strategy. The initiative aimed at ensuring patients received the best possible care, in the most appropriate place and at the right time and focused on a wide range of developments to improve the appropriateness of the care delivered to patients. The initiative was based upon an outcome of “Reduction in A&E attendances” based upon a trajectory of a 10% reduction over five years from 2010/11 to 2014/15. The original financial case for commissioners set out a trajectory that would save c£30 million worth of A&E attendances and associated admissions in return for c£10 million worth of income over the life of the initiative.

24 Imison C, Poteliakhoff E, Thompson J. The King’s Fund, August 2012; www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/older-people-and-emergency-bed-use-aug-2012.pdf




The patients targeted through Right Care1 were those who could be classified as ‘managed patients’. These being patients who have presented to the Trust through the 999 system and are then subject to telephone clinical triage and an ambulance response, either under emergency or normal road speed conditions depending on severity and clinical need. Delivering substantial benefits and savings for the local health community Right Care1

: • Exceeded the trajectory agreed with NHS Commissioners (East and West Divisions) by 2% resulting in

an increase in the ‘managed’ non conveyance rate from 50.84% in 2010/11 to 57.45% in 2013/14; • Enabled the Trust to convey annually 83,517 fewer patients to Emergency Departments across the south

west compared to the national average (based upon the October 2013 Ambulance Clinical Quality Indicator performance data). If the Trust conveyed patients at the lowest performing Trust level within England, this would have resulted in an additional 140,864 more patients attending south west Emergency Departments;

• Delivered a cumulative benefit of £72m since 2010/11 from an investment of £10.5m. (East and West Division Commissioners only)25;

• Provided operational productivity benefits for the Trust through the saving in job cycle times between conveyed (86 minutes) and non-conveyed (60 minutes) patients, or the saving in responses due to the increase in calls managed via the Hear and Treat pathway.

Right Care2 (Sound Development) Right Care2

is a continuation and enhancement of the original Right Care1 initiative. The productivity

offering should be seen in the context of the overall investment schedule presented by the Trust for 2014/15. The investment associated with Right Care2

is therefore offset against other lines in the Accident and Emergency contract to ensure that the contract going forward maintains a ‘value added’ element for the local health community. This is a key principle of commissioner convergence. It is proposed that Right Care2

is delivered across two Phases and will continue to focus on delivering a reduction in attendances at Emergency Departments through a range of enablers and initiatives. Phase 1 covers the period 2014/15 to 2015/16, with benefits continuing into the outer years. Phase 2 covers the period from 2016/17 to 2018/19.

In Phase 1 the Trust is proposing a further reduction of 1% in the number of conveyed patients to Emergency Departments, reducing the overall rate to 44.89% against a backdrop of 5% growth per annum. In Phase 2 the Trust is proposing to work with local health partners and NHS Commissioners to co-create services that directly benefit the patient and continue to make a positive impact on the local health system. Development work will commence during 2014/15 with agreed schemes being implemented from 2016/17 at a local level. Initiatives can be grouped under three key headings: clinical advice and skills, mobile care and pathways management. Table 3, overleaf, sets out a high level summary of each scheme and its proposed area of implementation. 25 Based on a revised tariff of £2,103 – see the Trust document ‘A health system productivity offering in the form of Right Care2




Table 3: Summary of Right Care2 Initiatives

Theme No. Initiative Area of Implementation Health Care Professional Support and Referral Service

Phase 1: Clinical Support Desk Whole Trust Phase 2:’Unmanaged’ HCP Calls Whole Trust

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Phase 3: Whole System HCP Support Individual CCG models 2 Increasing paramedic assessment skills Whole Trust

Clinical Advice and Skills

3 GPs Co-located in the Clinical Hub Whole Trust 4 Emergency Care Practitioners Whole Trust 5 GP frontline trials Individual CCG models Mobile Care 6 Management of resources in the community Individual CCG models 7 Tailor made local referral pathways Individual CCG models 8 Embed Right Care1 Trust wide Whole Trust Pathways

Management 9 Telehealthcare Individual CCG models Clinical Advice and Skills – Health Care Professional Support and Referral Service (HCP SRS) The HCP SRS will act as a single point of access in determining and implementing the most appropriate care package for patients with non-life threatening urgent care needs. It will be delivered in three phases, each phase focusing on different types of call. Each of these phases is described in more detail in the following paragraphs. Phase 1 – Clinical Support Desk (2014/15 onwards) Phase 1 will focus on supporting existing 999 A&E activities, both within the clinical hubs and by supporting frontline staff. This phase will focus on establishing a clinical support desk to provide additional hear and treat capabilities in the east and west clinical hubs, and expanding and enhancing the existing clinical desk in the north division clinical hub. In both cases this will bring together existing and new activities under one function. Once fully operational across the Trust the desk will provide three core services: • Crew Support Referral Desk: This service provides support to the Trusts frontline clinicians who are

with patients in the community and require assistance in finding the most appropriate care pathway for their patient. Enabling them to discuss a patient’s assessment the desk will review the available alternative pathways to support clinical signposting to other services. Where it is agreed that the patient does not require immediate admission to an Emergency Department the clinician will be able to hand over the clinical responsibility for the patient to the desk and become available to respond to calls. This will ensure patients are not inappropriately conveyed to Emergency Departments enabling a greater proportion of patient’s to remain in their own homes, or ensure that the patient is conveyed to a more suitable alternative care provider such as a treatment centre;

• Using the Capacity Management System Directory of Services (CMS DOS) clinicians will be able to discuss the suitability and availability of community care services. The desk will also rely on the establishment of clinical networks and pathways across local health systems to support onward referral. The aim is to provide more appropriate care for the patient, reduce inappropriate conveyance and potential admission and improve the patient experience through the care episode;

• Normal low acuity re-triage: This service provides re-triage for those calls categorised as Green 4 (Public) Calls. These are lower acuity calls requiring a clinical response within 90 minutes or a clinician call back within 60 minutes;

• Enhanced pre-arrival care: Where the Trust is delayed in responding to a patient and is likely to miss the defined response time target, particularly those incidents that are triaged as potentially life threatening, a clinician in the Clinical Hub will make contact with the patient/caller to review the triage and offer further advice and support. Depending on the clinicians assessment the incident may then be up or down graded in priority (in accordance with performance guidance and clinical knowledge).

In addition the desk manages frequent callers and fallers. Frequent caller leads with local providers and commissioners to mitigate the Trust’s response to frequent callers agreeing response plans for known callers. For fallers, where a 999 non-injury fall is recorded the Clinical desk manages the referral of the patient to the local Rapid Response Teams. These teams can then manage the acute pick up and carry out a holistic falls assessment for the patient.

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The majority of patients that can be signposted in this way will be the elderly and patients with long term conditions including: • Patients experiencing falls that do not require hospitalisation but require further observation or support; • Patients with long term conditions such as COPD; • Psychiatric patients, providing there is access to support from Partnership Trusts; • Patients with diabetic conditions that can be referred to a specialist nurse; • Patients that have an agreed care plan; • Patients at nursing homes, where it would be more appropriate for them to be treated in the home. Benefits include: • More immediate treatment for the patient; • Reduced ambulance dispatches; • Patients conveyed to alternative lower cost settings of care; • Reduced admissions at Emergency Departments Through expansion of the clinical support desk it is expected that the Trust can manage additional calls through the see and treat pathway. Phase 2 – ‘Unmanaged HCP Calls’ (2014/15 onwards) ‘Unmanaged patients’ are those who have been seen, or have received a telephone assessment, by a healthcare professional, do not have an immediately life threatening condition, and are being booked to attend an Emergency Department or acute trust facility for further diagnostics or treatment. For the Trust this includes direct requests from HCPs for patients to be admitted to Emergency Departments within 4 hours. This element of the HCP SRS will operate on a 12/7 basis between 08:00-20:00 daily in each of the Trust’s Clinical Hubs (Bristol, Exeter and St Leonards) and will be staffed by Call Advisors and Clinical Staff, on a 2:1 ratio. The Service will review all HCP requests received by the Trust for admission to Emergency Departments within 4 hours and, through searching the Directory of Services, will determine whether a more appropriate care pathway can be implemented. Using specific referral templates, developed with providers and commissioners and tailored to local need through the Directory of Services, liaison will then take place between the clinician on the HCP SRS and the clinician requesting transport in order to agree the appropriate care pathway. A proportion of patients will receive a ‘hear and treat’ service; i.e. they will be advised to refer themselves down an appropriate care pathway and an ambulance will not be required to attend. These ‘hear and treat’ patients are not counted towards the Right Care2 initiative. Phase 3 – Whole System HCP Support (2016/17 onwards) This phase would develop in the outer years of the Strategy (year 3 onwards – 2016/17) and expand the HCP SRS to receive calls from other HCPs including GPs, District Nurses, Community Teams, NHS 111, Out of Hours Services and tele-health services. The expectation is that the Service would provide access to a range of local services to be determined with commissioners. These could include: • 24/7 nursing service, community matrons and specialised nurses including acute outreach teams; • District Nursing; • Mental health crisis teams; • Therapy teams including physiotherapy, occupational therapy, speech and language, Falls teams etc; • Palliative care; • Intermediate Care Teams for admission avoidance and supported discharge support; • Community hospital beds; • Urgent social care; • Urgent TIA clinics; • Emergency dental services. Key benefits include:




• The patient will receive the right care, at the right time and in the right place. • It is recognised that the health care system is complex and difficult to navigate. For patients this is

alleviated by the NHS 111 service. For healthcare professionals the HCP SRS will be key. Under this model the healthcare professional is able to access support through a single telephone number and handover responsibility to the Service and move on to their next patient;

• The health economy will have the opportunity to become increasingly integrated and deliver care which is proportionate and tailored to the needs of the individual patient. The HCP SRS will provide a service that is central to achieving integrated working and delivering the most holistic and appropriate care to patients;

• The Service will support a reduction in the percentage of patients currently self-presenting or arriving by ambulance, at Emergency Departments;

• The Service can be co-created and tailored to a local health communities specific needs; • There is a further benefit to commissioners which cannot be underestimated. That is the inherent ability

of such a system to provide system wide intelligence and identify current gaps in service provision within the community to assess the impact this has on admissions to acute care. This service will be the focal point for the development of services and care pathways at a local level;

This phase is dependent upon commissioner support and sign up and would likely be developed on an individual CCG basis, although there would be scope for creating greater efficiencies and innovation if CCGs grouped together. As a result the impact of this scheme will be modelled over the first two years of the plan based upon those areas that have expressed an interest in using the HCP SRS in this way. As this would provide the Trust with access to a larger range of HCPs it is likely that the outcome measures used to assess its impact could be expanded outside of a reduction in attendances at Emergency Departments. Clinical Advice and Skills – Increasing Paramedic Assessment Skills This scheme capitalises on the additional patient assessment skills that newly qualified paramedics hold as part of their degree. In the past, paramedic education focused on patient stabilisation and transport rather than assessment, treatment and onward management. Current university programmes for paramedic students teach the medical model of patient assessment and test student skills by means of OSCE (Objective Structured Clinical Examination) and in practice placement. The result is that contemporary paramedics have the necessary physical assessment skills to underpin clinical decisions about their patients. This group of Paramedics possess the enhanced patient assessment skills that enable them to make more informed decisions regarding whether a patient needs to attend an emergency department or whether they would be better served by referral to another local healthcare professional or alternative location. The Trust will implement learning and development for existing Paramedics and other clinicians in order to ensure that they have high quality patient assessment skills. In future years the Trust would expect to see a gain translate through to the on scene care provided by these paramedics as the additional training will assist Paramedics to recognise patients who do not require transport to an Emergency Department, but do require referral to another healthcare professional for follow up treatment. In addition, the Trust will take opportunities to signpost existing Paramedics to appropriate courses in order to enhance their patient assessment skills. Clinical Advice and Skills – GPs Co-located within the Trust’s Clinical Hubs This scheme builds upon the trial undertaken during the winter period of 2013/14 where GPs were utilised in the Clinical Hubs at peak times. It supports the creation of a multidisciplinary team in the Clinical Hubs. The scheme sees a GP/Doctor working within the Hubs focused on key activities to provide independent clinical decision making and management of those areas that present more risk to patients. A GP is able to assess and manage clinical risk to a greater degree than other less qualified healthcare professionals and this means that patients will be able to receive appropriate clinical advice in order to negate a need to attend an emergency department. The Trust intends to develop this model in order to provide senior medical support to the Healthcare Professional Support and Referral Service. Activities that the GPs would focus on include: • At the request of Clinical Supervisors, the GP/Doctor would listen in on calls and intervene as

appropriate, or identify jobs from the stack to call back and carry out an assessment similar to the enhanced pre-arrival care;

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• Reviewing those incidents categorised as A8 Red 1 Reviewing those calls categorised as Green Reviewing NHS 111 calls that are transferred to the service, especially those that have been categorised as A8 Red 1/2 and Green 2 ;

• Providing support to, and identify educational opportunities for, clinical teams within the Clinical Hubs; and

• Developing a system of crew support that compliments the HCP SRS. Each GP would be indemnified by the Trust, have their own indemnity cover and would be registered on the national performers list. They will be issued with OOHs Services Sessional Contracts so would not be employees of the Trust. Mobile Care – Emergency Care Practitioners The Emergency Care Practitioner (ECP) role was developed by ambulance trusts in order to contribute a more appropriate response to patient needs in emergency and urgent care settings. ECPs can deliver a wide range of advanced interventions to patients experiencing minor injuries and ailments. Utilising their additional skills to work across traditional boundaries they can work with local healthcare professionals to design and deliver more appropriate care pathways. In addition they can administer and supply medication in line with Patient Group Directions (PGD). In cases where further investigation or treatment is required, ECPs have the relevant skills and pathways open to them to refer patients to other health and social care professionals, where appropriate. ECPs play a significant role in the reduction of A&E attendances, generating cost-savings for commissioners by releasing resources across the healthcare community. As such, they also contribute to an improved patient experience by delivering safe and appropriate healthcare in the community. Studies, report that between 50% and 66% of patients are not being taken to A&E by ECPs, compared with only 25-30% of patients seen by paramedics26. Further studies have demonstrated a 25% reduction in A&E attendance, when ECPs saw and treated elderly people with acute minor conditions. The Trust has an existing ECP Strategy in place setting out how in what capacity the Trust aims to employ ECPs in service delivery however, as part of the Right Care2 initiative this will be reviewed to transform the ECP role and utilise this resource more effectively, providing an improved patient experience and a more cost-effective method of service delivery. Key elements of the Strategy include: • Currently all front-line resources, including ECPs, function within the Trust status plan. It is proposed to

remove A&E ECPs from the system status plan to enable ECPs to be deployed to treat patients within the community;

• As a result of trialling a new ECP role, determine the way in which ECPs will work within the Trust to achieve the Trust targets around increased ECP utilisation and non-conveyance;

• Establish the way in which ECPs will work in different geographical areas within the Trust, due to differences in service provision and differing CCG requirements;

• Focusing ECPs on the development and management of local care plans for patients in the community; • Identifying a set of dispositions/types of incident which form the primary caseload for ECPs. This would

include: • Provision of care at nursing homes/rest homes; • Management of fallers; and • Case management of frequent callers. ECPs will be targeted with managing frequent callers to the ambulance service. In addition there is a significant opportunity for ECPs to assist Nursing and Residential Homes in developing care plans to reduce admissions and the readmission of patients to hospital. By directing ECPs to patients that they will be able to treat in the community, their utilisation rates will increase, with a subsequent increase in non-conveyance rates to Emergency Departments. Mobile Care – GP Frontline Trials This scheme looks at establishing a number of trials across the Trust operational area that utilise GPs to support A&E delivery. Experienced GPs will be available for the Trust’s Clinical Hubs and crews to directly

26 Cited in Taking Healthcare to the Patient - Mason et al and Cooper et al, Minney and Halter

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request an attendance to patients with certain presenting conditions, and to assist clinical decision making - especially those who might safely be cared for at home, referred into community pathways or directly treated by the doctor. During 2014/15 the Trust is trialling the concept of mobile GPs who support operational ambulance clinicians in patient assessment and delivering treatment at home in order to avoid unnecessary conveyance to Emergency Departments. This entails experienced GPs, who will be available for the Trust Clinical Hubs and crews to directly request to attend patients, to assist clinical decision making, to provide advice on the patient’s presentation and provide a senior decision maker at scene where appropriate. The GPs would be available from across the high demand days of Friday, Saturday, Sunday and Monday. The service supplied by the GPs would be seen as an “urgent” rather than an “emergency” service primarily directed towards medical rather than trauma patients. Doctors will be driving at normal road speed and will have the range of equipment and medication usually carried by GPs. Mobile Care – Management of Resources within the Community Pathways Management – Tailor Made Local Referral Pathways These two initiatives form part of the outer years offering for Right Care2. Detailed proposals will be established from 2014/15 onwards for implementation from 2016/17. The Trust will work with NHS Commissioners and healthcare providers at a local level to identify groups of patients within each CCG area with the explicit objective of improving their care through the development and co-creation of care pathways and embedding optimum local referral pathways. Potential opportunities include respiratory pathways, falls work, mental health and providing local healthcare professionals with a mechanism for identifying and accessing the most appropriate care pathways for older people living independently with one or more long term conditions. Local examples could include the: • Development of a local pathway for Trust frontline staff to call in and advise the Single Point of Access of

any patients that they had attended that had fallen across Dorset and Somerset. The Single Point of Access organises the appropriate response from General Practitioner’s and community teams, collects a defined set and organises follow up deep dive audits of these patients to help evaluate responses and further develop effective and efficient patient pathways;

• Development of the current triage arrangements for this group of patients with the objective of managing bespoke patient care plans in order to ensure effective continuous care 24/7, seven days a week. Auditing patients and the care pathway to ensure that the care pathway is as efficient and effective as possible;

• Management and booking of community resources by the Single Point of Access or HCP SRS where for example the Community Rehabilitation Team is unable to manage a patient at home due to manual handling issues and capacity. The Single Point of Access could organise: o A front line crew to respond and move the patient upstairs to their bed; o An extra package of care to support the patient and the Community Rehabilitation Team; o A night response team to support the patient overnight and an overnight District Nurse to manage

intravenous antibiotics; o Information to the patients GP practice.

Pathways Management – Trust Wide Rollout of Right Care1

Right Care1 focused on three key aspects to ensure that the most appropriate care is being sourced for the patient’s needs: • Culture: Achieving the Right Care agenda across the whole Trust area will require a shift in culture. Trust

staff, alternative healthcare providers and the public alike will therefore witness the new ways in which patients are managed;

• Clinical Support: Additional training and feedback will ensure that our clinicians feel confident in the decisions they are making, when establishing the most appropriate care for the patient;

• Communication: A high level of communication is already being undertaken and this is only set to rise as the initiative goes forward, this will involve communications with staff, external stakeholders as well as public engagement.

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This element sees the continuation of the Right Care1 initiatives in the east and west to maintain the current conveyance rates against a back drop of year on year growth in excess of 5%. Within the north division the Trust will rollout the governance arrangements previously adopted in the south including Right Care Champions, a dedicated implementation team etc, and embed those initiatives in line with the three ‘Cs’ above that can deliver the most change. Pathways Management - Telehealthcare Telehealthcare covers a wide range of technology that can be introduced into patient care pathways to deliver specific benefits, both reducing costs of care and improving patient experience. An outline business case produced in early 2014/15 sets out proposals for a two phase introduction of a telehealthcare service (‘Monitor and Treat’). Phase 1 ‘intervention’ (Treat) addresses the needs of the highest dependency patients living with Long Term Conditions through intervention with home or care home-based equipment, and monitoring and clinical triage through the existing Trust clinical hub infrastructure (perhaps integrated with the existing SPoA service). This intervention should reduce both hospital admissions and other community-based care costs and Trust call response costs. Patients in this cohort are not expected to remain on the intervention for more than 6 months, after which they can be ‘stepped-down’ to Phase 2.. This proposal is strengthened by including care homes in the composition of the virtual ward. There is good evidence of initiatives from other parts of the NHS where an ambulance service has worked with care homes successfully to reduce hospital admissions27. As shown in the diagram opposite patients will be enrolled in the Virtual Ward (in the community) through clinician, paramedic and/or social care referral. Within the Virtual Ward patients will fall into one of two categories – self-testing (patients living in their own homes provided with appropriate equipment by the Trust); near-testing (patients in care homes being tested by care home staff using appropriate equipment provided by the Trust). Data will be sent to the appropriate clinical hub, where it will be monitored and triaged by clinical staff if any of the data trigger a problem or potential problem. The triaging process will determine the best kind of support for the patient. In addition patients and care homes will be encouraged to contact the hub by phone in the first instance (rather than 999) if they are concerned, but their data has not triggered an alert. Phase 2 ‘prevention’ (Monitor) addresses reduced numbers of the highest dependency patients as the majority of patients from Phase 1 will be supported with lighter touch intervention such as telecoaching, compliance and education. Some new patients may be added to this Phase 1 cohort as their risk increases, and existing Phase 1 patients may experience an exacerbation (such as seasonal COPD) which requires a temporary step-up back to the more interventional service. The over-riding theme of both Phases of the telehealthcare service is to continuously promote ‘self-care’ and ‘self-management’. There are real benefits for both the patient and the clinician. A summary of these is set out in the diagram overleaf. At a high level the individual patient has more control and understanding of their long term health condition, and the clinicians utilising telehealth as part of a care pathway can ensure that they are proactively involved in the ongoing wellbeing of their patient, managing timely interventions and helping to improve their patient's quality of life. As well as the direct benefits to the individual, in the many telehealth pilots that have taken place across the UK telehealth has been shown to reduce hospital admissions, enable clinical resources to be managed more effectively and to save lives. Evidence suggests that when used correctly, telehealth can benefit a patient’s health and quality of life with trial findings indicating a: 27 Burns C, Hurman C (2013) Reducing hospital admissions from care homes. Nursing Times; 109: 1/2, 23-25

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• 15% reduction in visits to A&E; • 20% reduction in emergency admissions; • 45% reduction in mortality rates.

Telehealth will form part of the outer year’s strategy for Right Care2 and will be dependent on an individual CCGs needs and priorities, and subsequent commissioning to support any investment in technology. The outer year’s plans will be discussed in more detail with commissioners over 2014/15 and 2015/16 with modelling based upon agreed developments. Changes to Patient Pathways In addition through Right Care2 the Trust will deliver elements of its planned productivity savings and changes to patient pathways. Key initiatives and their subsequent impact on each patient pathway are set out below in more detail. Hear and Treat Hear and treat covers those patient calls that are managed through telephone clinical triage and advice in the hub (self-treatment) or referral to more appropriate local treatment pathway such as local GPs and NHS Walk-In Centres. Future initiatives that will affect the numbers treated through this pathway include those activities that increase telephone triage within the clinical hub, deliver more effective clinical assessments (including the utilisation of GPs within the clinical hub) or increase the utilisation of the local Directory of Services to direct patients to more appropriate pathways of care. For example, the introduction of GPs into the clinical hub to work alongside the current NHS Pathways triage system will be a significant driver in changing the number of patients the Trust treats with clinical assessment tools on the first patient contact, thus reducing the number of resources that arrive on scene and subsequently convey to A&E and other treatment centres. See and Treat See and treat constitutes those calls where treatment is carried out on scene and patients are not conveyed to an alternative location. The number of patients treated through this pathway will change as the Trust increases the skills available to clinicians to manage appropriate conditions with additional training. The use of the See and treat pathway will further benefit from the targeted use of Emergency Care Practitioners for key patient groups and the introduction of the electronic patient care record that will increase clinicians access at scene to decision support tools and referral pathways. See and Convey The see and convey pathway includes those patients conveyed to A&E departments or alternative treatment centres to receive care. The Trust is implementing a number of initiatives to reduce the total number of patients conveyed to A&E where more appropriate treatments or patient pathways are available. This will support the health community in managing growth and demand in future years and improve the patient




experience ensuring they receive the right care at the right place at the right time. A key example of this is the introduction of the electronic patient care record during 2014/15 which will provide clinicians on scene with ‘live’ access to the local Directory of Services to access information on the local services available to provide the right care for the patient.

Theme 2: A&E Modernisation

Strategic Drivers

An overall priority for the Trust will be to develop its core service delivery models to become further integrated and capitalise on available synergies. The Trust is in a unique position to move towards becoming a truly integrated provider organisation, delivering 999, out of hours and 111 services, increasing clinical productivity and improving service resilience and sustainability. Furthermore by exploiting the synergies across the core services the Trust can design services that make it easier for patients to enter and navigate the health system, reduce bottlenecks and duplication, support the management of demand across the health community and help create shared plans that respond to patient needs as they progress through a range of patient pathways. Specific plans are set out in the following sections however this will include as a minimum the integration of clinical hub functions between the Trusts A&E 999 and NHS 111 services. In addition the Trust has an opportunity to further exploit synergies, consolidate and create productivity gains following the acquisition. This theme therefore includes reference to the delivery of schemes within the Trust’s productivity framework and opportunities arising from the integration of the Trust estate. Finally the Trust needs to ensure that moving forward it is in a position to sustainably deliver the national emergency response time targets. From 2014/15 onwards the Trust will need to balance its focus to both deliver Red 1 across the region as it is contracted to do, whilst at the same time ensure that its community engagement plans are focused and targeted to achieve improvements in rural performance.

Proposed Developments

The key developments set out within this theme include: • Enhanced A&E Clinical Hub Rationalisation including the procurement and implementation of single Trust

wide CAD, telephony and triage systems and the re-provision of the north clinical hub; • Productivity Framework; • Red Performance Sustainability Plan; • Estates including the rationalisation of office accommodation, operational estate and the new HART

development. Enhanced A&E Clinical Hub Rationalisation (Sound Development) The review and provision of clinical hubs across the Trust was initially proposed as part of the original Trust Cost Improvement Strategy and as a benefit of Integration Planning during the acquisition of GWAS. A scheme for ‘Enhanced A&E Clinical Hub Rationalisation’ was developed and advocated moving to a model of two clinical hubs. This model is strategically dependent on the provision and creation of a standardised technology platform between Exeter (West) and Bristol (North) and requires the Trust to be operating on a single CAD (Computer Aided Dispatch), a single triage system and telephony system. The clinical hub programme has four key projects: • CAD; • Telephony; • Triage algorithm; • Estates. These four projects are enablers to support a revised staffing and supervisory structure. These infrastructure and technology developments will provide the platform and basis to enable the A&E service line to work ‘virtually’ across a wider range of clinical hub locations. The proposed change in staffing structure and

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operating model will create further efficiencies and support the realisation of the cost improvement programme. In addition a revised staffing and supervisory structure will support flex in the operating models at times of increased demand and improve overall system resilience. It will further support the development of Right Care2 initiative and help fulfil aspirations set out within this Plan. When all enabler projects in the clinical hub programme are delivered, it is envisaged that the final optimum operating model will contribute significantly to support the delivery of the original cost improvement plan (CIP) set out for the Clinical Hub Programme. The cost improvements of the combined clinical hub programme can only be fully realised when all four projects are completed and implemented across all clinical hubs, generating efficiency savings through standardisation. CAD and Trust Wide Telephony The Trust is currently operating on two separate Computer Aided Dispatch (CAD) systems, one in the North Division and a separate system for the East and West Divisions. As part of the overall plan to integrate activities across the Trust, and to further generate efficiencies in systems and processes, the Trust is under-taking procuring the provision of single service-wide CAD and telephony system. This will enable Trust response vehicles anywhere in the region, to be dispatched from any of the Clinical Hubs. The solution will provide significant benefits in respect to: • Increased operational capabilities and efficiencies, for example, a single regional view; • Increased resilience; • Increased reliability; • Increased functionality; • Improved performance and speed; and All of the above will in turn directly contribute to improving Category A8 Red 1 and Red 2 A&E performance. Implementation of the new Trust wide CAD will be supported with a comprehensive training programme and, depending on the approved supplier, will be in operation prior to the start of 2015/16. Alongside a new CAD platform, the Trust is also seeking to standardise the telephony systems to ensure that the Clinical Hubs are able to communicate, using both voice and data platforms, with all vehicles across the Trust’s operational area. Triage Triage tools are used in the clinical hubs to help call takers identify the type of call and the nature of the medical emergency. This enables call takers to identify the most appropriate clinical pathway and ensure the patient receives the right care, in the right time and in the most appropriate clinical setting. Following the acquisition of GWAS in 2013 the Trust uses two different triage systems to deliver 999 A&E services: Advanced Medical Priority Dispatch System (AMPDS) in the North and NHS Pathways in East/West Hubs. In addition the Trust utilises NHS Pathways for clinical triage in the delivery of 111 services. A decision in principle has been made by the Trust to move to NHS Pathways as the single unified triage system for the Clinical Hubs. It was agreed to postpone implementation until the wider aspects and implementation of the clinical hub programme were completed and full consideration of the training requirement for all A&E hubs had been conducted pending the outcome of the CAD tender. This is to support delivery of the optimum profile for all training (CAD or triage), on a service wide basis and to mitigate performance delivery risk. In this respect it is anticipated that a new Trust wide CAD and telephony system will be implemented prior to the implementation of a single triage system. Implementing the most appropriate single telephone triage system across the whole Trust is necessary to ensure that: • Patients receive an equitable service.




• Call taking resilience is improved. • Patients receive the right care which meets their clinical needs and the urgency of those needs. • The Trust’s resources are used efficiently, to ensure value for money. • That maximum opportunity is explored to deliver service integration across the spectrum of urgent and

emergency care. The change will enable the Trust to maximise efficiencies in supporting a single triage. It will support the Trust in the provision of triage systems which are fit-for-purpose and deliver effective, efficient and optimum performance in the 999 call handling service. Consolidation of a service wide triage platform also enables efficiencies to be drawn in reducing the quantity of differing IT packages to be supported and generates efficiencies in training resources required to support implementation. It would further create improved response capacity and hence flexibility to manage business systems as NHS Pathways is used across the NHS 111 environment. Estates Prior to the acquisition, GWAS had begun scoping potential alternate accommodation for its north clinical hub as the lease on the existing premises, Acuma House, expires in December 2015. The need to secure future accommodation for the north clinical hub was further highlighted in the Trust’s Integrated Estate Strategy 2014/2015 to 2018/2019, which in turn is an enabler to support the delivery of the initiatives set out within this Plan. GWAS moved into Acuma House, Almondsbury, South Gloucestershire in 2001, some 13 years ago to house the clinical hub. This north hub now houses key business critical functions for the A& E service line including call handling, dispatch, audit training and other administrative support functions such as estates, human resources, quality and strategy. Since January 2014 developments such as the expansion in the Resource Operations Centre (ROC), the decision to create a centralised sick line and the business benefits derived from co-location the ROC with the hub function has resulted in an uplift of accommodation need. As a result there is a need to identify and provide additional accommodation to meet both current pressure on accommodation in the Bristol area and anticipated growth in line with the five year plan. The Trust has identified an alternative site from the north division clinical hub functions can be re-provided and consolidated – St James A (St James Court, Great Park Road, Almondsbury Park, Bristol). The delivery timeline for re-location is essentially independent of other parts of the clinical hub programme. The current tender for the CAD has been designed to enable, if necessary, the CAD to be installed and then subsequently moved. The project to deliver a unified telephony platform and single triage algorithm need to follow the implementation and have synergies and dependencies on the implementation of CAD. During 2014/15 the Trust will secure appropriate tenders and contracts for specialist support work including hub design, specialist surveyors, property consultants and for internal works/fit-out as required. The Trust would then intend to re-locate the hub and other functions during 2015/16. Productivity Framework (Sound Development) The Trust’s Productivity Framework is designed to ensure that it delivers services safely, efficiently and effectively whilst providing best value for money for taxpayers. The Trust continually strives to modernise and create productivity savings in order to ensure that the expected increase in activity on an annual basis can be met. The principles of the Productivity Framework apply to all of the Trusts core services and will further enable modernisation and integration across service lines. The Framework is based upon three fundamental and interdependent elements represented as a ‘Productivity Triangle’: • Available Operational Hours; • Deployment of Operational Hours; • Call Cycle Management. Red Performance Sustainability Plan (Sound Development) The Trust is contracted to deliver the national response times targets Trust wide and not on a Divisional or individual CCG basis. As previously stated, during 2013/14 the Trust faced many challenges in delivering the Category A8 Red 1 target. Variance to plan is attributed to many factors including, but not limited to,

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increased activity against contract, the launch of the new NHS 111 service across the south west region, peaks in hospital handover delays creating pressure points in the system and a national shortage in paramedics in order to support service delivery. In addition the delivery of Red performance across the Trust’s geographical area is particularly challenging given the rurality of the Trusts catchment area compared with other English ambulance trusts with the Trust being the most rural service in England. The scale of rurality has direct consequences for performance as the Trust has to consistently perform at the achievable target levels in both urban and semi-urban areas in order to achieve Trust-wide performance, the basis upon which the Trust is contracted to provide services. The Trust established an action plan to deliver the Red 1 target in quarter 4 of 2013/14 with actions carried through to 2014/15 in the form of a Red Performance Sustainability Plan. The Trust has agreed an investment package for 2014/15 and a framework for 2015/16 with NHS Commissioners for the delivery of the A&E contract. Whilst the investment package will deliver forecast activity growth, there is an acknowledged residual risk for the Trust in guaranteeing delivery of Red 1 performance. Underpinning operational delivery of the national targets is the Red Performance Sustainability Plan focused on building sustainable performance improvement plans from 2014/15 onwards. This plan has a number of ‘building blocks’ including actions relating to: • The Clinical Hub including enhancements in the way calls are triaged; • Staffing, rotas, skill mix and establishment including additional frontline operational resources in order to

deliver improved performance and to manage the impact of additional activity forecast for 2014/15 and 2015/16;

• Community engagement including improved communications with Community Responders, a programme of working with Care and Residential Homes and continuing to roll out static and public access defibrillators;

• Improving call management cycle productivity; • Improvements in performance linked to changes in the Trust estate including the introduction of new

dispatch points and the development of the Bristol Ambulance Station; • Increased availability and tracking of Officers/Pool vehicles; • On-going engagement with NHS 111 providers to ensure calls transferred to the ambulance service are

appropriate and that peaks in demand such as on weekends and out of hours are mitigated as far as possible. During the life of this Plan the Trust will need to undertake a re-profiling exercise to ensure its resources are aligned to the changing activity profiles.

The contract contains penalties linked to the achievement of the national response time targets although their impact on the financial plan has been mitigated to manage the Trusts maximum financial in-year risk exposure. In addition to the contractual requirement is a link to the national Quality Premium payment for CCGs for delivering Category A8 Red 1. This is conditional on delivery of Red 1 over the whole financial year. Against this backdrop the Trust recognises that in order to improve performance in its most rural areas there needs to be a different approach and is absolutely committed to working locally with other health and social care partners to this end. The Trust will need to balance its focus for 2014/15 – the Trust must deliver Red 1 across the Trust as it is contracted to do, whilst at the same time ensure that its community engagement plans are focused and targeted to achieve improvements in rural performance. Discussions have already been held with commissioners in regard to what support other local community healthcare professionals can provide in helping the Trust meet local response time targets and there is strong support to progress these initiatives in 2014/15. The Trust’s Community Engagement Team continues to work with volunteer groups and others to improve local responses through a number of schemes including Community First Responders and Fire Co-Responders. Estates (Sound Development) The Trust has in place an Estates and Facilities Strategy that covers the period 2014/15 to 2018/19. The Strategy aims to create a cost effective and fit for purpose estate that, as part of a suite of enabling strategies, assists in the delivery of the Trust mission, vision and strategic plans. This includes conducting a

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wholesale review and, where necessary, reconfiguration of the estate and providing an estate infrastructure capable of supporting current and future models of service delivery. The Strategy identifies three key Estates and Facilities service development themes that will be implemented over a five year period. Theme One focuses on the review and rationalisation of office accommodation and Theme Two addresses a number of operational stations. Further opportunities for operational estate rationalisation may be identified following more detailed reviews from March 2015 following the implementation of a single CAD. Theme Three sets out plans for the provision of a new HART site and utilisation of the existing site. Theme One – Rationalisation of Offices The Trust Board confirmed in June 2012 that following the acquisition of GWAS the Headquarters for the enlarged Trust would be located in Exeter. This decision created a direct acquisition synergy and an opportunity to centralise services and rationalise HQ and administrative sites across the enlarged Trust. Further, the acquisition provides the Trust with opportunities to centralise and rationalise the number of clinical hubs within the enlarged footprint. The proposed rationalisation will result in a cost reduction in 999 call handling and dispatch costs as a result of fewer dispatch queues, reductions in management costs and a reduction in estate costs. • HQ and Office Rationalisation: This element focuses on those opportunities for rationalisation agreed

by the GWAS Board pre acquisition and those synergies that arise as direct result of integrating the two Trusts. A number of schemes have already been delivered, including the closure of Jenner House (former GWAS HQ) and the expansion of the Trust Headquarters at Abbey Court. Additional schemes include: o Dorman House, Malmesbury Road, Chippenham – Relocation followed by Closure 2014/15; o Marybush Lane, Central Bristol – Closure and relocation January 2015;

Theme Two – Operational Estate Rationalisation and Re-Provision Over the period of the Strategy the Trust estate will be reviewed to ensure that it fully supports service delivery, contributes towards operational performance, delivers best value for money and remains fit for purpose as an enlarged Trust. The review will be carried out in two key phases: Phase 1 will cover the short to medium term from 2014/15 to 2015/16, and Phase 2 the longer term from 2016/17 onwards. Phase 1 - Known developments include: • Malmesbury Road Site, Chippenham – Relocation; • Bristol Operational Services Review as part of the closure and re-provision of Marybush Cebtral

Ambulance Station; • Greater Bristol Station Consolidation: This scheme will focus on the consolidation of stations initially in

the greater Bristol area and identifies three stations where the combination of land sale receipts, and savings on current and future revenue costs, result in a strong financial case for disposal in the short term (2014/15);

• Whole Trust Estate Review 2015/16: Following the implementation of a single integrated Computer Aided Dispatch system in 2014/15, it is proposed to carry out a full review of the Trust’s operational estate including facilitated standby points.

Phase 2 – 2016/17 onwards From 2016/17 onwards the Trust will develop a programme of activity to implement any agreed changes from the estates review. This is likely to include a number of changes across the estate including stations in Gloucester, Cheltenham, the Forest of Dean, Bath and West Wiltshire and Taunton. Currently there is one known area/station that will require review in this Phase – Poole. A full review will be conducted as part of the business case development for Bournemouth (due in 2014/15) and will consider the future requirement for an ambulance station in Poole or an alternative development Theme Three – HART Exeter The Trust has access, directly from the Department of Health, to Public Dividend Capital funding to support the establishment of a permanent accommodation solution for HART. A full business case was developed and approved by the Trust Board during 2012/13 which identified a suitable location for the new HART Base namely SkyPark / St. Modwen, Clyst Honiton, Exeter. Following confirmation of funding and planning




permission in early 2013/14, development works commenced in August 2013 with a target completion date of May 2014. The existing HART facility was relocated during July 2014. In addition the Trust has a number of options for the current HART site (Kestrel Way, Exeter) that are currently being considered. The current planning assumption is that the site will be retained and developed to establish a Trust Fleet and Logistics facility. Theme 3: Supporting the Local Health Care System

Strategic Drivers

This theme focuses on those developments and activities outside of the core 999 A&E service that will contribute directly to patients and other healthcare providers across the region. In addition this theme considers a number of initiatives that are largely enhancements to current business activities. They would require discussions at CCG level and commissioning as additional elements to an existing contract, or a new service, in most cases.


Key initiatives within this theme include: • The retention and delivery of service improvements within the Trust’s existing Patient Transport Service

contract; • The implementation of the Electronic Patient Care Record Form; • Delivery of Safer Wards, Safer Hospitals schemes; • The development of a number of 999 A&E ambitions and aspirations. Patient Transport Services - PTS (Sound Development) The Trust continues to operate PTS in the Bristol, North Somerset and South Gloucestershire (BNSSG) area and on the Isles of Scilly. However, PTS contracts in all other areas are now operated by external private providers as set out within the market profile at section 4.1.2. Activity within the BNSSG contract is profiled for the year however in 2013/14 the Trust operated at circa 4% over contract. The Trust is yet to agree the activity profile for 2014/15 with commissioners however there is an expectation that services will be contracted on the same basis as previous years - primarily on a block basis with an element of marginal variance for activity above and below contract. Moving forward the Trust will look to retain the current contract and deliver a number of changes to bring about service improvement. As a result of patient surveys carried out in 2013/14 the Trust formed an action plan that included actions to improve the information provided to the public on how to contact the PTS service directly and how to provide feedback in relation to patient experience. In addition the Trust is improving the popular existing call-to-confirm service by enhancing this with SMS text messaging features. 2014/15 will see further service improvements with the development of an in-house bariatric capability. This will be achieved through the procurement of specialist bariatric equipment and the adaptation of an existing Trust vehicle from within our fleet. Furthermore specialist training will be provided to staff that will provide the service. In addition the Trust will focus on improving performance against the locally agreed key performance indicators in relation to the timeliness of the service delivered to patients. This will be underpinned by creating a more flexible and responsive workforce. The Trust will invest in new ways of working to drive efficiencies and better utilisation of available resources. This approach, together with a rigorous focus on value for money, will ensure that the Trust uses resources wisely to deliver high quality PTS solutions to patients and commissioners. On an ambition/aspirational basis the Trust will consider tendering for additional contracts on an opportunistic basis for two main reasons: • It is beneficial for the Trust to be able to manage patient flow in and out of acute trusts; • PTS provides resilience for times of high demand, adverse weather and major incident.

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Further, PTS is likely to provide opportunities in the future for integrated working with A&E. For example, PTS resources could form part of an intermediate tier of resources which could deliver services to Green category patients. Implementation of the Electronic Patient Care Record - ePCR (Sound Development) Central to the NHS Programme for IT Strategy is the delivery of a patient and clinically focused Care Record Service within and between NHS communities. The Trust is part of the Southern Ambulance cluster looking to implement an Electronic Patient Care Record for use in the pre-hospital phase, which will also have the technical ability to integrate with Acute and other health community systems. The Southern Ambulance Programme will be funded for four years from contract signature by central government, and the procurement will be supported by Health and Social Care Information Centre. The solution will provide systems which will allow ambulance Clinicians to capture information while attending patients on a mobile device to support frontline care delivery. It will enable the receipt, generation, storage and onward transmission of ePCR data in an ambulance and wider pre-hospital setting. In addition it will enable improvements to the routing of patients, increase the number of patients who can be treated at the scene, reduce the number of people conveyed to hospital and provide improvements in the quality of care delivered in the ambulance and in receiving locations. The ePCR is a key enabler within the wider solution set that enables transformation of urgent and emergency care pathways. Delivered through a detailed programme of activities the Trust is aiming to have the system fully live by August 2015. Safer Hospitals, Safer Wards (Sound Development) The Safer Wards, Safer Hospitals publication sets out a vision for fully integrated digital patient records across all care settings by 2018. During 2013/14 the Trust submitted a bid for Safer Hospitals, Safer Wards Technology Funds in support of an electronic medicines management system and paramedic notebooks and applications. An electronic medicines management system will greatly enhance the functionality of the current Trust systems and will allow interoperability by interfacing with other systems including an interface with the ePCR system, the C3 system (monitoring and audit), the Out of Hours Adastra system (stock control and controlled drug monitoring), and Datix a system for monitoring issues with medicines. The functionality of the electronic system will also allow controlled drug spot checks by managers, the regulator and NHS Security Management. The objective of the paramedic notebook is to provide a single mobile electronic system allowing a paramedic to access and update a range of information real-time thereby supporting them in their clinical and operational duties throughout the day. Access to applications and information will reduce clinical risk and support high quality, joined up care. In addition the tablet will allow two way dialogue enabling front-line staff to communicate their status, vehicle condition and medicines status with the Trust support functions and allow face to face communication with clinicians improving triaging. A&E Ambitions and Aspirations In addition to the developments set out previously the Trust has a number of ambitions and aspirations related to the 999 A&E service that it will continue to engage commissioners and key partners on. Any activity or financial implications for these have not been included within the financial or activity modelling as they would be subject to negotiation. A high level summary includes: • The on-going development of local CCG plans and trajectories to ensure localism alongside regional

delivery; • Increasing the range of health promotion activities delivered by the Trust. This includes activities aligned

to national campaigns e.g. stroke and Know Your Blood Pressure, delivery of health checks to Trust staff, external organisations and members of the public, working with local Fire and Rescue Services to raise awareness and deliver health promotion activities through their pre-existing educational activities etc. These activities would look to reduce activity within the wider health and social care system by focusing on preventative action;

• Implementing a system co-ordination/management role as an NHS body with regional oversight. This could include providing activity analysis and benchmarking information, supplying evidence to demonstrate the effectiveness of local healthcare systems, the provision of early warning alerts for pressure points across the region, winter planning preparedness and facilitating discharge from acute hospitals. These activities would link into the establishment of the Health Care Professional Support Desk

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being established as part of Right Care2 and look to reduce pressure on acute beds and ensure patients are discharged safely;

• Establishing a planning and intervention team that would see the deployment of staff to A&E when escalation occurs to support the management of handover pressures;

• Providing a same day and next day GP/Health Care Professional urgent call response service. Focused on high acuity patients (same day) and those patients requiring diagnostics/admission but where it is clinically appropriate to wait for next morning submission (next day) this service would ensure a more appropriate response for the patient, smooth peaks in demand within the system and alleviate an element of the pressure on acute beds;

• Providing opportunistic screening for Atrial Fibrillation (AF) during routine patient contacts in line with NICE guidelines including supplying GPs with a copy of ECGs where AF is identified. This initiative would help to reduce the workload and demands on GP practices and support the integration of key care pathways;

• Implementing closer working between HART and USAR teams in responding to major incidents. This would explore efficiencies and increase interoperability between emergency services and support a more integrated response to incidents;

• Pursuing opportunistic acquisitions and mergers in line with the Trust’s strategic objectives to support growth in key areas of the business, underpin the sustainability of key elements of a service, improve the quality of services and create further operational efficiencies.

5.4. Urgent Care Service Line Strategy The service line plans for urgent care will be driven largely by national policy, including the outcomes of the Urgent and Emergency Care Review, the service specifications issued by commissioners through any tendering activity and local drivers such as stakeholder and patient involvement. Key objectives over the life of this Plan include ensuring the provision of sustainable and effective services that fully meet all elements of any contract or service specification, whilst delivering a number of additional and innovative benefits. For example, unlike a private NHS 111 or OOH provider the Trust does not seek to make a profit through its services, but aims to reinvest value earned through synergy and contract efficiency back into the system for the benefit of the patient and wider health economy. The Trust firmly believes that the future of urgent care lies in developing effective relationships with other urgent, emergency, primary and community care providers. This could include NHS acute and partnership trusts, local interested parties including GP practices, community pharmacies, dentists, social care and neighbouring OOH and 111 providers. In developing these relationships the Trust can create a more integrated service delivery model and ensure a sustainable and successful future for services across the south west. In addition, this collaborative focus establishes a ‘whole system approach’ meaning the Trust is better positioned to manage pathways for patients. This way accessing urgent care services becomes one episode of patient care with improved clinical outcomes. In turn, working with its ‘partners’ the Trust will be able to reduce duplication of cost and effort, allowing this value back to be reinvested back into the system. In addition, as part of the Trust’s overall strategy for the development of Urgent Care, the Trust will look to expand its role in urgent care provision outside of its existing core contracts. During 2014/15 the Trust was awarded the contract to deliver minor injury and minor illness services in Tiverton including local assessment and treatment and the coordination of a patient’s onward care. The contract was awarded to the Trust on an interim 20 month basis and therefore there is an expectation that this will be retendered during 2015/16. It will be the Trust’s ambition to retain this contract when tendered.




Theme 1: Out of Hours Services

Strategic Drivers

During 2013/14 the Trust saw a reduction in certain types of activity within its Out of Hours Services linked to the introduction of the NHS 111 service. This impact will continue into 2014/15 as NHS 111 becomes more established across the south west. Moving forward the Trust expects to see growth in other key areas such as home visits, however this will be subject to future tender specifications and the structure of any new service model as determined by NHS Commissioners / Urgent and Emergency Care Review(s).


Over the five year period the Trust will have the following areas of focus in relation to OOH: • Performance management of the existing contracts to ensure that current service delivery meets the

expectations of commissioners. This includes implementing the initiatives and activities set out below. In addition the Trust will look to build upon the existing service model to incorporate, where possible, key elements of the new localised service specifications as they are released; and

• The retention of existing contracts when tendered. In addition the Trust holds a number of ambitions related to the OOH service including: • Developing innovative business partnerships to strengthen service delivery and resilience; provide

economies of scale; contribute to profit margins and strengthen further the probability of success in securing contracts when tendered;

• To grow the existing market share in out of hours provision by bidding for additional out of hours and urgent care contracts as they arise over the lifetime of this Plan.

Existing Contracts Each of the Trust’s current OOH services will be tendered over the life of this Plan with the Trust expecting a significant level of competition for each contract: • Somerset OOH: At the time of writing the Somerset contract was out to tender with a contract

commencement date of 1 July 2015; • Gloucestershire OOH: As per the Somerset contract at the time of writing the Gloucestershire contract

with a contract commencement date of 1 April 2015; • Dorset OOH: During 2013/14 the Trust received notification that its existing Dorset OOH contract had

been extended by three years until the 31 March 2017, therefore the Trust would expect this service to be tendered during 2016/17 with a service commencement date of 1 April 2017.

To assist in strengthening its competitive position, for its existing contracts, the Trust is aiming to deliver a number of initiatives over the life of this Plan including: • Developing local partnerships and responding to local health community developments. This includes the

remodelling of the existing Out of Hours Services plus developing more services via the Single Point of Access such as dental call handling and advice, prison call handling, daytime ECPs to support A&E 999 ‘green’ calls, Transient Ischaemic Attack services, district nurse call handling, and Nurse Practitioner Pilots in local areas;

• Continuing to deliver the service with, and working alongside, local GPs to provide a more resilient and responsive service. This includes strategic dispatch, separate advice queues for each locality to enable GPs to triage their own local areas, running a 999 GP pilot to support a reduction in emergency department admissions, and reconfiguring shift patterns to encourage a greater take up of shifts resulting in better patient care;

• Continuing to enhance the Directory of Services to facilitate patient pathways; • Developing the enriched Summary Care Record in support of End of Life Care Pathways, improving

special messages and joined-up communications with emergency departments;




• Providing training for clinicians including End of Life care, safeguarding, dementia, learning difficulties, verification of death training for health care professionals in other organisations and joint skill mix training with GPs, nurses and ECPs;

• Reviewing the Trust’s prescribing practice including antibiotics and emergency supplies used in urgent care;

• Supporting the introduction of the electronic medicines management system as part of the ‘Safer Hospitals, Safer Wards’ initiative.

Theme 2: NHS 111 Services

Strategic Drivers

The following core principles reflect the ambition for NHS 111 including those within the Urgent and Emergency Care Review. As the service evolves these core principles are likely to develop further. People contacting NHS 111 for urgent care needs expect the service to: • Be always available, 24 hours a day, 365 days a year; • Be accessible, personalised and based on their individual needs; • Have knowledge of when they have previously contacted NHS 111 so they do not need to repeat their

story; • Be able to connect them to a clinician with access to important health records and notes; • Be safe and give the right advice based on the best and most up to date clinical and medical knowledge

available; • Definitively resolve health concerns without the need to go anywhere else; • Book appointments with the urgent care provider they need; • To dispatch an ambulance without delay; • Be able to access the service through digital or online channels both to give better access to information

and to meet specific needs people have; • Make sure that specific health needs, such as palliative care, mental health and long term conditions are

properly catered for. In future years an enhanced NHS 111 service is a key enabler for the system of urgent and emergency care envisaged in Sir Bruce Keogh’s Urgent and Emergency Care Strategy. This vision states that: • For people with urgent but non-life threatening needs: We must provide highly responsive, effective and

personalised services outside of hospital, and deliver care in or as close to people’s homes as possible, minimising disruption and inconvenience for patients and their families;

• For people with more serious or life threatening emergency needs: We should ensure they are treated in centres with the very best expertise and facilities in order to maximise their chances of survival and a good recovery;

• Specifically, an enhanced NHS 111 service will deliver one of the key changes needed to ensure the vision of improvements to patient care can be achieved. The NHS 111 service is critical to help people with urgent care needs to get the right advice in the right place, first time.

To make this happen NHS 111 needs to develop service protocols and underpinning technical functionality that will enable greater integration with all other elements of the urgent and emergency care system. This includes ambulance services, primary care (in hours and out of hours), urgent care centres, emergency departments and both community and hospital based services. These principles will drive the development of NHS 111 in future years and influence the initiatives implemented by the Trust.





Over the five year period the Trust will have the following areas of focus in relation to NHS 111: • Performance management of existing contracts to ensure that services are delivered in line with

commissioner expectations and the terms of the contract; • Reducing the impact of NHS 111 services on the 999 service and manage the impact on the wider health

system including the impact on local Emergency Departments; • Minimising the penalties that can be applied to the Trust as a result of a failure to deliver contractual

KPIs; • Retaining existing contracts when tendered; • Creating a service that is responsive and adaptable to change in light of the emerging themes from the

Urgent and Emergency Care Review. Existing Contracts All four NHS 111 contracts currently provided by the Trust will be tendered during the life of this Plan: • NHS Somerset 111: At the time of writing this Plan the Somerset NHS 111 contract was out to tender

with a contract commencement date of 1 July 2015. Secured by the Trust following the dissolution of NHS Direct the contract was awarded on an 18 month holding basis in order for it to be tendered in line with the Somerset OOH contract. ;

• The remaining NHS 111 contracts in Dorset, Devon and Cornwall were awarded on a five year basis and will all be tendered within the final year of this Plan with service commencement dates of 1 April 2018, 1 June 2018 and 4 February 2019 respectively.

As mentioned within the short term challenges section, 2014/15 and 2015/16 will be critical for the Trust’s NHS 111 services with a particular focus on developing and stabilising the services, embedding the service in each county, consistently delivering upon the contractual key performance indicators and ensuring staffing models and management structures are fit for purpose to meet the needs of each service as public engagement and use increases. The Trust is forecasting that over 1 million calls will be received by the Trusts NHS 111 services in 2014/15. The Trust operating model is a combination of call takers and Clinical Nurses based within the Clinical Hubs. Whilst the Trust will continually review this service model to ensure it is fit for purpose and delivers the contractual KPIs, there are no plans to implement significant changes to the model over the life of this Plan. The Trust continues to review the profiling of these resources as the activity profile beds in. 2014/15 will be a year of consolidation for these services as it will be the first full year of operation for the Trusts NHS 111 services and therefore actual activity levels and their impact on other services particularly 999 A&E will be carefully monitored throughout the year. The Trust has recently appointed two NHS 111 Liaison Officers whose role it is to work with other NHS 111 providers within the south west in order to assist with the implementation and ‘bedding in’ of the new service and to manage the impact of the introduction of NHS 111 on the ambulance service.




Chapter 6: Leadership and Workforce Implications Integrated Business Plan 2014/15 to 2018/19


6. Leadership and Workforce Implications 6.1. Overall Summary At the very heart of the organisation and key to the sustainable delivery of quality patient care are the many people the Trust employs. In order to provide safe, responsive, compassionate and effective services the workforce requires strong leadership and clear direction, delivered within a culture that fosters learning and developing, openness and striving for continual improvement, so that the Trust always puts the patient first. The changes in the commissioning landscape combined with the pressures facing the NHS community as a whole, resulting from changing demography, the increase in long term conditions combined with the economic pressures, will continue to have a significant impact on the way in which care is delivered and a continued requirement to provide more care closer to home. This presents an organisational challenge for delivering transformational change to the way some of our services are delivered with impact on the skills required and the deployment of our workforce. Central to the delivery of transformation change is effective workforce planning and redesign, delivered through strong leadership and with clear engagement from our staff and stakeholders. The following areas are core workforce objectives, underpinning the Trusts strategic objectives whilst taking into account the learning from the Francis and Keogh reports: • Developing existing clinical and managerial leaders whilst creating clear career and developmental

pathways to ensure sustainability through talent management and succession planning; • Developing a culture of openness, participation and empowerment through staff and stakeholder

engagement; • Delivering education, learning and development in line with the workforce plan and clinical workforce

strategy to ensure staff are appropriately skilled to respond to the changing profile of healthcare needs and demand;

• Ensuring the assessment of values and behaviors are key to the recruitment processes, reinforced and promoted through induction, and that performance is evaluated and reviewed through appraisals, clinical supervision and line management;

• Ensuring Trust services and employment practices are responsive to the needs of the public, future candidates and existing staff and recognise and respond to the diversity of these;

• Building responsive capacity through a flexible workforce and ensuring the deployment of the Trust’s workforce and underpinning terms and conditions support the delivery of efficient services, whilst rewarding Trust staff in support of service modernisation and new ways of working;

• Developing effective and enhanced partnerships and teamwork with other NHS organisations, social care providers and the independent sector is crucial to delivering radical improvements for patients.

This chapter outlines the management and leadership of the Trust and the response to the workforce challenges presented above are explored in more detail. 6.2. Management Arrangements 6.2.1. Role of Non-Executive Directors The Board structure is comprised of six Executive and seven Non-Executive Directors and is Chaired by Mrs Heather Strawbridge. Key points include: • The Chief Executive is Mr Ken Wenman, who has been in post since 1 July 2006; • The Executive Director of Finance and Deputy Chief Executive is Mrs Jennie Kingston who has been in

post since 1 January 2008; • The Executive Director of Nursing is Jennifer Winslade who has been in post since December 2013; • The Executive Medical Director is a GP. Dr Andy Smith who has been in post since 1 February 2010,

prior to which he was the Associate Director of Primary Care Services for the Trust since April 2008; • The Executive Director of Human Resources and Workforce Development is Ms Emma Zeeman who has

been in post since May 2014; • The Executive Director of IM&T is Francis Gillen who has been in post since 1 March 2013. Prior to that

he was a Director of IM&T with the Trust since December 2005;



• The Non-Executive Directors are Mr Tony Fox, Professor Mary Watkins, Mr Hugh Hood, Mr Robert Davies, Mr Chris Kinsella and Mrs Venessa James;

• Deputy Directors may attend Board meetings in the absence of their Executive Director and also by invitation of the Board.

6.2.2. Role of Non-Executive Directors Legally there is no distinction between the Board duties of Executive and Non-Executive Directors; both sharing responsibility for the direction and control of the Trust. Non-Executive Directors have a particular responsibility for encouraging the cultural change required to secure full engagement of patients, staff and local communities. Non-Executive Directors share responsibility with other Directors for the success of the Trust but they have a particular role to play in a number of areas: • Leadership and strategy: active leadership, constructive challenge and leading on strategic planning and

development; • Performance: scrutiny of data quality and performance; • Risk: ensuring robust and defensible risk, financial and clinical control systems are in place; • Compliance: ensuring compliance with Trust Provider Licence, the Trust constitution, mandatory

guidance and relevant statutory requirements and contractual obligations; • People: remuneration of Executive Directors, make recommendations on senior management; including

succession planning, secondment and talent management; • Quality and safety: ensuring highest standards of healthcare services, education, training, research and

innovation applying the principles of clinical governance and best value for money; • Accountability: upholds the highest standards of integrity and probity and are fully accountable to

patients, the public, communities, the membership and governors; • Experience: balance of skills, knowledge and experience. 6.2.3. Board Development The Trust Board has been assisted with specific developments designed to support the Trust’s integration with GWAS following the acquisition in February 2013. This included: • A range of NHS South West conferences and workshops including the Urgent and Emergency Care

Forum; • NHS Confederation conferences and network meetings; • Trust Integration Board Development Days; • Key conferences hosted by NHS Innovations, Monitor, National Ambulance Leadership Forum, HFMA,

Health Service Journal, the Essential Role and Responsibilities of Governors. • National Ambulance Directors meetings that include Department of Health and Monitor membership; • KPMG session on Media and Reputation Management; • PwC workshop on Approach to Winning Bids; • Board Investment in expert legal team support and advice by Bevan Brittan Solicitors; • Investment in membership of Foundation Trust Network for access to internet support materials and

guidance; • Audit Commission workshops and training sessions; • Westminster Briefing on the Care Bill 2013, understanding and implementing the new framework. 6.3. Workforce Key Performance Indicators The Trust has a multi-disciplinary workforce and employees are from a wide range of professional backgrounds, both clinical and non-clinical, together with support staff. A workforce plan has been developed demonstrating workforce projections for the next five years and this is aligned to the Long Term Financial Model and Cost Improvement Strategy. The Trust supports workforce planning through innovation and the management of change. The workforce staffing projections for the next five years demonstrate changes to the workforce profile as the Trust realigns



its skill mix and deployment models to provide patient centred care within the community setting and through working with the wider healthcare team. The service developments that support non conveyance and service improvements have shifted an emphasis on the development of career pathways through from Emergency Care Assistants and Technicians to fully qualified Paramedics. The emphasis on caring for patients closer to home and the significance of the urgent care agenda also lead to the requirement for enhanced skills. This is in both direct patient facing roles such as Emergency Care Practitioners and within the Clinical Hubs, where enhanced clinical assessment and triage ensures immediate patient care, whilst ensuring the most appropriate response from within the service or the wider health community. 6.3.1. Agenda for Change Pay Band Distribution The graph below indicates the distribution of staffing numbers across the Trust. The occupational grouping indicates that the majority of staff are employed in direct operational roles including Emergency Care Practitioners, Paramedics, Technician and Student Paramedics (including Emergency Care Assistants and ACA PSVs) which accounts for 2,443.06 (66%) of the occupational groups employed in the Trust. Management and support services account for 14% of the total WTE, ensuring 86% of our workforce are involved in the delivery of direct patient care.

Actual Staff Establishment by Staff Group - Whole Time Equivalent (31 May 2014)

This high density distribution is expected given the nature of the organisational service delivery and the prevalence of front line clinicians within the workforce. Workforce planning is concentrated on the deployment of the clinical workforce and on enhancing the skills available to respond and assess complex healthcare needs in support of treating patients within their community. In support of a resilient workforce will be the enhancement of our flexible workforce, providing capacity as and when the Trust requires it with roles designed to support both enhanced skills and, where applicable, generically skilled roles to enable the workforce to be deployed across integrated service lines. 6.3.2. Diversity Data This section provides an overview of the staff ethnicity, age, disability and gender. Ethnicity Table 4 sets out the ethnicity breakdown in the south west and in England as a total. The data shows that the overall representation of Black and Minority Ethnic individuals in the south west is on average 4.6% of the total population. The percentage of Black and Minority Ethnic employees in the Trust is 1.43% which reflects an under proportionate representation of the community. Table 4: Ethnicity Information

Ethnic Group South West England and Wales28 Trust Total (at 31/05/14) White 95.4% 86% 97.97% Black and Minority Ethnic 4.6% 14% 1.43% Not stated 0% 0% 0.60%

Age

28 Office of National Statistics Census data 2011



Table 5 outlines an analysis of the age profile of staff within the Trust as at 31 May 2014. This data is used to inform workforce planning in service delivery and can indicate where loss of key skills can be anticipated through normal retirement. It also enables strategies to be developed to introduce succession planning and career development routes. Table 5: Trust Workforce Age Profile

Age Profile Number of staff (Headcount)

Percentage of workforce

18-25 293 7.09 26-35 986 23.86 36-45 1349 32.65 46-55 1097 26.55

56+ 407 9.85 The table illustrates that the concentration of staffing is aged between 26-55 (83%) which is expected. It also highlights that there are significantly less staff in age group 18-25 at only 7.09% of the total workforce. Future projections of age profile for the Trust are shown in Table 6. This outlines the anticipated staff retirement figures over the next six years. As well as normal staff turnover, age related retirement enables the Trust to predict both the capacity to manage change and inform succession planning for a range of job roles. Table 6: Forecast Trust Workforce Retirement Forecast

Job Roles 2014/15 2015/16 2016/17 2017/18 2018/19 Emergency Care Practitioners 2 Paramedics/ Clinical Support Officers/Clinical Team Leaders 3 2 3 3 12 Technicians 1 4 2 2 Student Paramedics/Emergency Care Assistants/ACA PSVs 3 2 2 2 6 Clinical Hub 1 3 3 Urgent Care Service 6 6 10 4 8 Patient Transport Service 4 3 1 2 Managers, Administrators and Support Staff 1 4 4 8 2 Totals 18 17 25 22 37

Improvements for the employment of younger people will include greater emphasis on recruitment drives through schools and colleges, and further development of apprenticeship opportunities. Disability Table 7 indicates the number of staff employed who are declared as disabled under the category of the Disability Discrimination Act 1995; ‘a physical or mental impairment which has a substantial and long-term adverse effect on a person's ability to carry out day-to-day activities’. Table 7: Trust Workforce Disability Profile

Disability Number % All Ambulance Trusts Yes 100 2.42 2.99% No 3,202 77.49 56.96% Undisclosed 830 20.09 40.05%

There are a number of employees who are not disclosed under the disability definition which could significantly affect the true representation. Further work will be done to encourage disclosure and assure staff that information is used to inform good practice and access opportunities. Gender



Table 8 indicates the gender breakdown of employees in the Trust by headcount and occupational group. The breakdown shows that 56% of employees are male and 44% are female. The total for all ambulance trusts shows a breakdown of 57% of all employees are male and 43% are female that is broadly comparable. Table 8: Trust Workforce Gender Profile by Staffing Group

Job Role Male Female Emergency Care Practitioners 121 29 Paramedics/ Clinical Support Officers/Clinical Team Leaders 945 550 Technicians 155 117 Student Paramedics/Emergency Care Assistants/ACA PSVs 405 293 Clinical Hub 115 260 Urgent Care Service 150 301 Patient Transport Service 69 52 Managers, Administrators and Support Staff 319 251 Total 2,279 1,853

6.3.3. Sickness Absence Sickness absence is a key workforce quality indicator. It provides valuable information relating to the health and wellbeing of the workforce and can be used as indication of engagement. The management of sickness absence is an on-going and constant priority for the organisation in recognition that high levels of sickness can impact both on the delivery of services and can place a burden on budgets if allowed to rise. From information taken from the Electronic Staff Record system for the NHS the following key facts were identified: • The average sickness absence rate for the NHS in England was 4.02%; • Amongst types of organisation, ambulance trusts have the highest average sickness absence rate with

an average of 5.52%; • Clinical Commissioning Groups had the lowest average with a rate of 2.18%. Sickness absence for the Trust in 2012/13 was 5.29%, which decreased marginally to 5.28% for 2013/14. The Boorman Report highlights health and wellbeing as a significant issue and highlights three main areas of recommendations these are: • Recommendations aimed at improving organisational behaviours and quality; • Recommendations aimed at achieving an exemplar service; • Recommendations for embedding staff health and well-being in NHS systems and infrastructure. The Trust has a continual focus on managing sickness absence and supporting improvements to the long term health and wellbeing of its workforce. A dedicated Health and Wellbeing Strategy has been developed and a Health and Wellbeing Action Plan ensures proactive management of all absence and appropriate monitoring of all cases as well as health and wellbeing interventions and system improvements which are being implemented for the benefit of longer term and sustained improvements. 6.4. Maintaining Workforce Establishment 6.4.1. Recruitment and Selection The Trust has a recruitment plan for each key service line which is aligned to the Trusts training plan, identifying the resource requirements to support both the assessment processes and also the induction or training courses required for new entrants upon joining the Trust. The Trusts recruitment plan utilises turnover data from the previous two years to predict turnover and also considers the age profile of the organisation to anticipate any increase in retirements. Recruitment to most roles continues to be successful with particular successes noted with non-qualified front line, call handling, administrative and management roles. The current national shortage of paramedics impacted considerably on the recruitment efforts within 2013/14 and the decline in applications and candidates accepted offered posts presents a challenge to the Trust in



terms of its future recruitment strategy. As a result a revised candidate attraction strategy was developed and launched in February 2014. This was founded on underpinning research from recent new starters to take account of their experience in joining the Trust and to understand the choices they made within the competitive labour market. Additionally the whole approach to attracting and engaging with graduate / qualifying paramedics has altered, ensuring early interaction, engagement and rapid offers of employment. Developments in recruitment have led to the introduction of values based recruitment. This is currently being trialled for ECA recruitment with telephone interviews introduced to assist an early streamlining and quality sift of candidates prior to progressing them through assessments. Values based questioning and scenarios are being developed and tested for a wider range of recruitment and this work will be progressed throughout 2014 to form part of the standard assessment processes for all roles going forward. The work on candidate attraction, whilst commencing with paramedics, will be rolled out to all recruitment activity ensuring active targeting of people with the skills and talent required in the organisation. The newly developed recruitment website promotes not only current roles but also careers within the ambulance service and will be shared with educational providers and local communities to promote a wide range of careers within the ambulance service. 6.4.2. The Flexible Workforce The use of a flexible workforce, to provide resilience to service provision through seasonal peaks in demand or major incidents as well as to provide support to day to day abstractions from the employed and substantive workforce, is critical to the Trust’s sustainability and performance. Bank workers are utilised across the Trust area within front line clinical and non-clinical roles and recently these contracts have been incentivised to encourage work at the most unsocial times of evening and weekends. Staff who leave the organisation are routinely offered to convert to a bank worker, enabling continued engagement on a more flexible basis for many of the staff who leave Trust to pursue other opportunities. Additionally bank work is encouraged and promoted to university students throughout their degree. This enables growth in the bank provision over the summer months when parts of the region experience a surge in activity due to the increase in population associated with the summer months. OOH and 111 services also employ a high number of staff on bank arrangements, enabling these individuals to work flexibly with some picking up very minimal hours at the most unsocial times. The OOH/111 service employs a greater proportion of female workers than the A&E service line and it is apparent that bank working enables the flexibility and working arrangements, which often suit the home and family commitments. Developments in bank workers will include consideration for centralisation and management, and a greater opportunity for this part of the workforce to access CPD opportunities facilitated by the Trust Education Team. Systems need to be developed to enable the sharing of Statutory and Mandatory Education training records between providers where bank workers are employed elsewhere within the NHS. This would increase assurances regarding skills assessment whilst reducing duplication of training delivery by the Trust and within the Trust’s neighbouring organisations. 6.4.3. The Volunteer Workforce Community Responder schemes are initiatives in areas where it is difficult for an emergency ambulance to reach within effective targets. The schemes are made up of volunteers who, within the community in which they live or work, have been trained to attend designated emergency calls providing first aid until the ambulance or clinician arrives. This voluntary unpaid scheme supplements the workforce profile and enables the Trust to improve its ability to respond to life threatening calls in a timely and safe way. Community Responders increase the quality of patient care and contribute to quality patient outcomes. Each group is likely to consist of about 6 to 12 members with one member identified as the Team Leader, with the main role being to support members of the group and assist with arranging availability and cover. The scheme is managed by the Responder Manager and is continually growing and improving the services they provide to the core A&E contract. The responder scheme also extends to staff responders and work is on-going to increase the provision of staff available and equipped to respond to Category A Red 1 calls. Fire Co-responders are also a key area of



service growth and opportunities to extend this to other emergency services and medical providers is being considered in light of recent approaches by new potential partners. 6.5. Designing and Developing the Future Workforce The Trust supports workforce planning through innovation and the management of change. The workforce staffing projections for the next five years demonstrate changes to the workforce profile as the Trust realigns its skill mix and deployment models to provide patient centred care within the community setting and through working with the wider healthcare team. The service developments that support non conveyance and service improvements have shifted an emphasis on the development of career pathways through from Emergency Care Assistants and Technicians to fully qualified Paramedics. The emphasis on caring for patients closer to home and the significance of the urgent care agenda also lead to the requirement for enhanced skills in both direct patient facing roles such as Emergency Care Practitioners and within the Clinical Hubs, where enhanced clinical assessment and triage ensures immediate patient care, whilst ensuring the most appropriate response from within the service or the wider health community. A primary focus of the Trust over the life of this Plan will be to create a more flexible workforce to service a number of different operational models. This will include creating multi-disciplinary teams and reviewing and expanding the clinical skill mix that can be used to support service delivery. These activities will be linked into talent management programmes to support succession planning and the recruitment and retention of a multi-skilled workforce. The main factors impacting on the workforce will be the Cost Improvement Strategy and the investment in frontline resources and the Clinical Hubs through the Master Added Value Investment Strategy (MAVIS). This investment has a particular focus on the delivery of the Right Care2 trajectories and the delivery of targets against a back drop of increased activity.. 6.6. HR and Organisational Development Strategy – Aligning People, Strategy

and Process The Trust is committed to recruiting and developing a workforce that is focused on high quality services to patients, that is constantly striving to develop itself, that communicates internally and externally and that maximises the talent of its diverse workforce. There is evidence that shows a substantial link between the ways people are managed, employee attitude and service improvement. A good indicator of a high performing organisation is the model employment practices. These include recruitment and retention strategies where employers of choice will attract, recruit and retain the best staff with the best skills. A number of areas where these practices will influence the skills of the workforce include: • Effective recruitment and induction processes; • Support for professional training and continuing professional development; • Clear and accessible career structures and opportunities for people to develop and reach their full

potential; • Effective retention and succession plans; • Competitive, business focused and attractive contracting arrangements and with clear reward packages; • Effective appraisal systems, personal development planning supporting career development and

progression. Organisational Development activities will support the Trust in creating a high performing culture, becoming a learning organisation, shifting the focus from service delivery to service transformation and, boosting capacity, maximising the cross fertilisation of ideas, pooling resources and sharing knowledge and skills. The Department of Health Mandate ‘Delivering High Quality, Effective, Compassionate Care; developing the right people with the right skills and values’ (May 2013) emphasises the importance of leadership, culture change and organisational development in terms of delivering step change and performance improvement. Managers and leaders are required to address new challenges and provide inspirational and engaging leadership that motivates people to go the extra mile. Visible leadership and management are critical to the success of the Trust; performance results are delivered through people. The mission of the Trust is about making life better for its patients and this vision must be re-enforced through every stage of organisational improvements. The Workforce and Organisational Development plan



outlines the Trusts approach to connecting Learning and Skills Development and Organisational Development with a view of maximising the high quality services to patients. It will support the development of a culture, mind-set and activities of a high performing organisation over the five years which significantly contributes toward the capacity to become leaner and more effective. This means: • Contribution of each member of staff to the Trust mission; • Right people with the right skills and the right behaviours to deliver the strategic goals; • Patient centred leadership and management development; • Effective partnerships with partners and key stakeholders; • Performance and reward to attract and retain. The underpinning HR and OD Strategy will: • Assure the Board that its investment in workforce is managed and governed appropriately; • Identify the actions required to improve productivity and demonstrate effective usage of the staff resource

to maximise resources for patient services and care; • Identify actions required to enhance staff flexibility, resource productivity and engagement; • Promote partnership working with key stakeholders and continued engagement with staffside colleagues

and professional bodies • Set out plans to improve the health of the workforce, reducing the costs of sickness and improving the

wellbeing of staff; • Identify actions required, including recruitment, training and development, to deliver the Trusts Service

Development Strategy and improve the quality of care to the population of the South West; • Deliver its responsibilities and maintaining its image as a good employer, through meeting its statutory

obligations and adopting good employment practices; • Enhance the Trust’s community image and reputation as an employer of choice.

Chapter 7: Governance Arrangements Integrated Business Plan 2014/15 to 2018/19


7. Governance Arrangements 7.1. Governance Context In order to maintain the highest standards of service and care, the Trust will continually review and enhance its quality governance arrangements as appropriate for the requirements of the organisation and its service users. The Board of Directors will regularly test itself against Monitor’s Quality Governance Framework, reporting compliance dynamically within the Board Memorandum on Quality Governance, and in quarterly submissions to Monitor against the provider licence conditions. This will help to: • Ensure required standards are achieved; • Investigate and take action on substandard performance; • Plan and drive continuous improvement; • Identify, share and ensure the delivery of best practice; • Identify and manage risks to quality of care. The Trust’s change in focus on governance began in 2009, with its decision to seek authorisation as an NHS Foundation Trust, subjecting the organisation’s governance arrangements to a considerable level of scrutiny. The application process involved: • Three historical due diligence governance reviews by an independent body (KPMG LLP); • A quality review by the South West Strategic Health Authority; • Interviews on key areas such as Board assurance, risk management and quality governance; • The development of a Board Memorandum on Quality Governance supported by documentary evidence,

which was accepted as fit for purpose by Monitor. The Trust passed through the application process without delay, achieving a Governance Risk Rating of Green at authorisation in March 2011. The Trust’s approach to governance going forward is to maintain the high standard it achieved, through a process of continual review to ensure that it remains robust, compliant and ready to respond to an ever changing landscape. The Trust’s Governance Strategy will be reviewed on an annual basis to ensure that it continues to meet the needs of the business. The Governance structure of an NHS Foundation Trust comprises of a Board of Directors and Council of Governors governed by a Trust constitution. This chapter covers the approach to be taken by both parties in ensuring the strongest governance arrangements are in place. Going forward the Trust will play an active role in understanding and contributing to future change, supported by a focus on compliance with: • Monitor and the license conditions; • Monitor’s code of governance and three yearly governance reviews; • CQC Inspection regimes; • Legislative and sector changes. 7.1.1. Governance Definitions Corporate Governance includes the systems, processes and behaviours by which the Board of Directors leads, directs and controls so that organisational objectives, including safety and quality of service, are achieved. The primary duty of an NHS Foundation Trust Board is to ensure the organisation is well governed. Quality Governance refers to the combination of structures and processes at and below Board level which support Trust-wide quality performance including ensuring required standards are achieved, investigating and taking action on sub-standard performance and planning and driving continuous improvement. 7.1.2. The Board of Directors The Board is made up of a Non-Executive Chairman, a Chief Executive, five Executive Directors and six Non-Executive Directors (NED). Recent Board recruitment has taken place to achieve these levels that the Trust aims to maintain.



A future consideration for the Board is the role of an Associate Non-Executive Director. The introduction of this role would support the phased retirement of existing roles where appropriate, as well as providing specific NED skills for a set period of time for the business. The composition of the Trust Board is strong and healthy. It achieves a good gender balance, brings together a wide range of skills and experiences, has a good clinical and commercial balance and works effectively together. The Trust aims to continue with this approach, ensuring a healthy rotation of Board Members and Committee roles. The Trust will continue to seek applications from a wide range of candidates, particularly in areas where the Board is currently under-represented. To ensure that the Board continues to thrive, a Board Development programme will be created. This will ensure that individual Board Members, Committees and the whole Board receive the development that is right for them and will be achieved through a wide range of experiences and training. The Board is committed to its own development and the need to constantly challenge itself on its thinking and assumptions. Over the life of this plan, there will be changes made to the NED role. The Code of Governance suggests a six year cap on NED appointments, and whilst appointments can be made beyond this term, Governors and Directors would need to be closely involved in discussion about proposed exceptions. When the Trust became an NHS Foundation Trust, the terms of office for each NED was reset. The Chairman and three Non-Executives were part of the Board when the Trust was authorised, therefore, in line with the guidance the Trust will be looking to recruit four new Non-Executives before February 2017. The Trust will want to ensure that the succession planning is suitably phased in order to support each new NED, as well as enabling the Trust to retain the right knowledge and skills throughout the process. The Board operates a buddying system between Executive and Non-Executive Directors. The NED is then able to learn more about an area of the business whilst offering a sounding board for the Executive Director. Through this partnership ideas can be developed, coaching and guidance offered, plans developed and knowledge shared. The buddies will be rotated on regularly to ensure that they remain effective and dynamic partnerships. An important step in maintaining effective governance controls is to ensure that the performance of the Board and its sub committees is appraised. Appraisals will take place on an individual and collective level. Each Director will be appraised and each committee will review its effectiveness and report it to the Board. The Board will also undertake this process. Any skills gaps identified will be supported to ensure continuous improvement. The Council of Governors will continue to be involved in the appraisal of the NEDs. Their feedback will be collated and shared with each NED by the Chairman who will lead on the NED appraisals. The Senior Independent Director will lead on the appraisal of the Chairman with the Chief Executive leading on the Executive Director appraisals. A Trust Secretary was appointed in 2013 to lead on the continual review and development of mechanisms for business planning by the Board and its committees. The role going forward will support the Board of Directors and Council of Governors to ensure that the Trust procedures are followed, that applicable rules and regulations are complied with, that meetings of both committees are held in accordance with the Trust’s constitution and that Directors and Governors receive appropriate support and guidance. 7.1.3. Committees of the Board There are five formal committees of the Board as illustrated in the diagram below:



The Board has a number of committees to ensure that the organisation is well governed. The committees are: • Quality and Governance Committee: Meets bi monthly to develop and implement effective quality and

governance assurance systems and processes (including: governance, compliance, patient safety and experience, risk management, clinical effectiveness and development, research and audit, medicines management, safeguarding, health and safety, training, and HR);

• Audit Committee: Meets bi monthly to review and seek assurance on the effectiveness of processes in place for the management of arrangements for governance, risk, clinical assurance, internal control, and financial reporting; and to ensure the Trust and its auditor remain compliant with Monitor's Audit Code for NHS Foundation Trusts;

• Finance and Investment Committee: Meets bi monthly to conduct an independent and objective review of activities relating to financial planning, cost improvements, investments, disinvestments, and financial performance;

• Charitable Funds Committee: Meets as required to oversee the proper collection, accounting and distribution of the Trust's charitable funds;

• Remuneration Committee: Meets as required to approve the nomination, remuneration and terms and conditions for Executive Directors. A separate group (the Remuneration and Recommendations Panel) reports to the Council of Governors and is responsible for Non-Executive Director appointment and terms and conditions.

Each committee will continue to complete an annual effectiveness review. This will include considering whether they have met the responsibilities of the committee and its key functions. In addition it will review the Committee’s Terms of Reference to ensure they are reflective of best practice, up to date and remain fit for purpose. The Board will be considering an overarching piece of work on its effectiveness of its processes. This will involve looking at best practice and making amendments that add value and improve the way in which the Trust conducts its business. Through its annual self-assessment, each committee will be given the opportunity to undertake a skills analysis and identify any committee specific training that they believe to be relevant to them as individual members. 7.1.4. Constitution and Standing Orders The decision making processes for the Trust Board of Directors and Council of Governors (CoG) are set out within the Trust’s Standing Orders that form part of a legally binding Constitution. The Constitution was amended to account for changes made by the Health and Social Care Act 2012 to the role of governors. The process for amending the Constitution to account for future local or national change has been tested and is robust and governors will be supported in managing any future change by the Trust Secretary. There are no plans to change the Constitution, however, as part of its approach to continuous improvements the next version of the constitution is always being considered. If when using the Constitution, scope for improvement is identified, it is noted and will be incorporated into the next review. 7.1.5. Code of Governance Monitor first issued a Code of Governance in 2006, which was last updated in December 2013. Based upon the Cadbury Code, with which all FTSE companies are expected to comply, the Code is set on the principle of “comply or explain”. The Code is therefore best practice advice and not mandatory guidance. However, NHS Foundation Trusts are strongly encouraged to take full account of the best practice provisions described in this code. The Trust’s Board of Directors has consistently reviewed and considered its practice against the requirements of this Code with an action plan for compliance against the requirements developed annually. Implementation of this Plan is led by the Head of Governance and monitored by exception through the Quality and Governance Committee. Compliance will also be reported as a disclosure statement within the Trust’s Annual Report.



7.1.6. Membership Recognising the benefits of a membership base the previous Trust Membership Strategy focused on increasing the size of the overall membership. Consequently the Trust now has a substantial membership base of over 18,000 people that is reflective of the population it serves. Moving forward the Trust will focus on maintaining this level with the focus of the revised Membership Strategy being engagement as opposed to recruitment. Initiatives will focus on increasing engagement with its members, working with the governors to review the priorities for membership, working with the Trust’s Community Engagement team to consider how the Trust can increase its membership of under-represented groups and ensuring that the views of the public are brought forward for consideration in the development of key Trust strategic documents. 7.1.7. Council of Governors Changes had also previously been agreed to the make-up of the Council of Governors to allow a larger membership during and following integration between the Trust and GWAS. The second phase of the Council of Governors took effect from 1 March 2014. This saw the Council constituted at 34 members, made up of nine appointed, six staff and 19 public governors. The Trust has worked with the Governors to ensure that the Council of Governors are meeting their constitutional and statutory duties; in particular holding the Non-Executive Directors individually and collectively to account for the performance of the Board of Directors and to represent the interests of NHS foundation trust members and the public, and reporting back to the membership. The Chairman and Trust Secretary will continue to work with the Council of Governors to ensure that they receive the right information and support to enable them to fulfil their duties to the highest standard. The Council have undertaken a significant effectiveness review that considered the format and structure of meetings, future work programmes and the structure of its sub groups. Further work will now be undertaken to effectively implement the outcomes from this review. Each Governor’s term of office is three years. In parallel to the Board review, the Council of Governors will be looking at the most effective way to manage its succession planning; balancing the need for new ideas and new people to join whilst retaining the knowledge, skills and experience that the Council has. 7.2. Assurance Mechanisms The Board of Directors’ proactively seek assurance that the business of the organisation is being conducted appropriately, that patients are receiving high quality care in a safe environment by appropriately trained staff, that all statutory and regulatory requirements are met and that the Trust is able to meet its strategic objectives. The Quality Assurance mechanisms used to support this are set out in Table 9.

Table 9: Trust Quality Assurance Mechanisms

Assurance Mechanism Purpose Future Developments

Annual Cycles of Business

Support the Board and each of its committees in ensuring all appropriate business is planned for the year ahead

A Trust Secretary was appointed in 2013 to lead on the continual review and development of mechanisms for business planning by the Board and its committees. This will continue on an annual basis

Board Assurance Framework

Reflects assurance received by the Board from key forums against performance indicators and objectives, documents external assurance and allocates a quality score to the level of assurance provided

A new Board Assurance Framework will be developed by the Head of Governance at the end of each year to take account of: NHS outcome frameworks, national guidance and critical review (e.g. Francis), changes in Trust strategic approach and new service developments and identified risks

Critical Assurance Roles

Critical assurance roles undertaken by Board members include: • Caldicott Guardian • Senior Information Risk Owner • Nominated Individual (CQC) • Board Champions

The Trust has consistently ensured that essential statutory/regulatory roles are allocated to appropriate Board members and will maintain this as good practice, incorporating any new roles as they arise

Governance Checklists

Designed to provide a quick assessment of the governance requirements for any new function or initiative

A risk based programme of governance checklists will be developed annually by the Governance and Compliance team to take account of the outcome of Internal Audit reviews, new service developments and any other new risks identified in year

Governance Quality reviews of Trust arrangements The Trust will continue to consider national critical



Assurance Mechanism Purpose Future Developments

Assurance Reviews

against critical assurance reports about other trusts: e.g. Mid Staffs. Action plans developed and monitored

reports in terms of any potential impact upon the Trust and the safety of our service users and other stakeholders

Integrated Corporate Performance Report

Provides the Board with a set of contractual and statutory metrics, focusing on performance exceptions and providing early warning of risk to performance

The Board will continue to monitor this to ensure that it is fit for purpose

Regulatory Framework

Contains details of all statutory and regulatory targets with details of the forum to which they should be presented

A regulatory framework will be developed annually to ensure that annual committee cycles are aligned to take account of statutory deadlines

Risk Registers

The Corporate Risk Register is reviewed at each Board meeting and all risk registers, including directorate, are reviewed annually and cross referenced against the Board Assurance Framework

The risk registers will be continually reviewed against best practice and the Audit Committee will undertake a twice yearly review of the risk management process

7.3. Quality Governance Framework Monitor’s Risk Assessment Framework requires NHS Foundation Trusts to demonstrate conformity with the Quality Governance Framework. This is reflected in a comprehensive Board Memorandum on Quality Governance. A new Memorandum will be required each year to support the Trust Forward Planning process. The Board Memorandum addresses the 10 questions posed by Monitor’s Quality Governance Framework, as set out in Table 10, and a summary is presented to the Board on a regular basis to support preparation for the three yearly governance reviews. The first of these is planned for 2015/16. Table 10: Quality Governance Framework

Strategy Capabilities and culture Process and Structure Measurement 1. Does quality

drive the trust’s strategy?

2. Is the Board sufficiently aware of potential risks to quality?

3. Does the Board have the necessary leadership, skills and knowledge to ensure delivery of the quality agenda?

4. Does the Board promote a quality focused culture throughout the trust?

5. Are there clear roles and accountabilities in relation to quality governance?

6. Are there clearly defined processes for escalating and resolving issues and managing quality performance?

7. Does the Board actively engage patients, staff and other key stakeholders on quality?

8. Is appropriate quality information being analysed and challenged?

9. Is the Board assured of the robustness of the quality information?

10. Is quality information used effectively?



7.4. Changing Governance Landscape The Trust continually scans the changing healthcare landscape and in 2013 reviewed the key reports set out in Table 11, with the resultant impact report or action plan considered at the Board of Directors or the Quality and Governance Committee Table 11: Key Governance Reviews and the Trust Response Report Trust Response Code of Governance consultation (December 2013)

Consultation response submitted to Monitor and briefing paper provided to Board of Directors

Duty of Candour consultation (April 2014) Consultation response submitted to Department of Health and briefing paper provided to Board of Directors

Fit and Proper Persons consultation (April 2014)

Consultation response submitted to Department of Health and briefing paper provided to Board of Directors

Francis Report (January 2013) Plan implemented to address 79 relevant recommendations, and cultural surveys undertaken with Board, Council of Governors, Senior Managers, and Staff

Health and Social Act, 2012 Comprehensive changes made to the Trust Constitution, signed off by Council of Governors in September 2013

Saville Letter from Sir David Nicholson (January 2013)

Received at Quality and Governance Committee in January 2013 and reviewed by the Board of Directors

Keogh Report - Hospital Mortality Rates (July 2013) Reviewed by the Board of Directors

Keogh Report – NHS Services, Seven Days a Week (December 2013) Reviewed by the Board of Directors

Winterbourne View – A Compendium of Key Findings, Recommendations and Actions

Report presented to Quality and Governance Committee in January 2013 for onward communication to staff

7.5. Risk Management 7.5.1. Risk Management Strategy The Trust has a Risk Management Strategy is approved by the Board, with systems and processes for managing risk based on the AS/NZS 4360:1999 Risk Management Standard. The Strategy is reviewed annually to ensure that it remains fit for purpose and incorporates any change to national guidance or the healthcare environment. Intelligence is triangulated to provide a robust process for risk management which is in line with the Trust’s risk appetite and for operation as an NHS Foundation Trust. 7.5.2. Board of Directors The Board of Directors has overall responsibility for risk management, part of which is to ensure that appropriate structures are in place to implement effective risk management: • The Senior Information Risk Owner is the Executive Director of IM&T; • The Caldicott Guardian is the Executive Medical Director; • The Deputy Chief Executive/Executive Director of Finance is the responsible officer for reporting any

concerns to the NHS Local Counter Fraud Specialist and is the Security Management lead; • The Board of Directors receives the Corporate Risk Register (containing significant risks) at each

meeting alongside the Board Assurance Framework; • The Board of Directors receives Directors Risk Register and individual Directorate Risk Registers

annually to provide assurance that all functions of the organisation are managing their risks effectively; • The Audit Committee reviews the Trust risk management process twice each year; • The Quality and Governance is the committee with responsibility for risk management and receives the

Corporate and Directors Risk Registers at each meeting, alongside copies of action plans and associated exception reports that have been developed to further manage the Trust’s risks. It also introduced a programme of deep dives into key functions in 2013.



7.5.3. Board Assurance Framework (BAF) The BAF is based upon best practice and guidance and has been rated as low risk by Internal Audit review since March 2010. It is closely aligned with and referenced to the Trust’s risk registers. It also includes a Quality Assurance Score (QAS) to indicate the robustness of the assurance mechanisms used. This highlights those areas where additional assurance may be required. 7.5.4. Annual Governance Statement Each year The Trust develops an Annual Governance Statement that is approved by the Audit Committee and provides assurance that the Trust has a sound system of internal controls. These statements have consistently received an endorsement of ‘significant assurance’ from the Head of Internal Audit Opinion. 7.5.5. Internal Audit The Head of Internal Audit provides the Trust with an opinion on the overall arrangements for gaining assurance through the Board Assurance Framework and on the controls reviewed as part of the internal audit work. At the end of each fiscal year the Audit Plan is agreed for the following year and, along with mandatory financial and governance related audits, it includes audits of specific functions or work areas. These are identified by the Executive Management team and take into consideration the Trust’s Risk Registers, Board Assurance Framework and the outcome of previous audits. A mid-year review is then undertaken to account for any risks identified in year and adjustments are made accordingly. The Trust risk management arrangements are reviewed annually as part of the Internal Audit plan monitored by the Audit Committee, to provide assurance that the systems for managing risk were fit for managing risk were fit for purpose and compliant with statutory and regulatory obligations. Any actions that arise from an Internal Audit report are monitored by the Audit Committee. 7.5.6. Risk Watch Group The Risk Watch Group meets regularly to quality assure, sense check, validate and manage all Trust risks, forming the basis of a robust identification and escalation system for risks which are proactively managed. The Group is Chaired by the Executive Director of Nursing and Governance and attended by other senior managers. Managers are invited to attend relevant meetings for training sessions or to discuss and clarify the magnitude of their team risks. 7.5.7. Risk Registers Directors have responsibility for the management of risks within their directorates and the Directors Group receives and debates the Corporate and Directors Risk Registers on a regular basis, conducting period deep dives on behalf of the Board. Individual directorate risk registers are reviewed and updated at directorate team meetings and are forwarded to the Head of Patient Safety and Risk on a quarterly basis who quality assures the content and will highlight any key risks to the Risk Watch Group. 7.6. Risk Assessment Framework and the NHS Provider Licence Monitor assesses the Trust against four broad categories: in-year quarterly submissions; annual submissions; exception reports; and other information from NHS Foundation Trusts: In-year Submissions and Exception Reports Each quarter the Trust is required to declare compliance with elements of Monitor’s Risk Assessment Framework and a quarterly assurance paper is presented to the Board report against the requirements of that Framework. This includes any indicators of governance concern including: CQC information; Access and Outcome Targets; Third Party information and compliance with the Quality Governance Framework. The cumulative year end forecast is presented to and reviewed by the Finance and Investment on a monthly basis as part of the Finance Report to support submission of compliance with the Continuity of Service Risk Rating. Annual Submissions The Trust is required to prepare and submit detailed two year operating plans each April, followed by a full five year plan in June. These are based on the full planning guidance issued by Monitor, the detail set out within Everyone Counts, other key strategic documents including CCG and health partner strategic plans, and are aligned to the outcome of any contract negotiations. The two year plan covers, as a minimum, the short term challenges facing the Trust, quality plans, operational requirements and capacity, productivity,



efficiency and CIPs and the financial plan. The five year plan covers, as a minimum, a declaration of sustainability, market analysis and context, risks to sustainability and strategic options and strategic plans. In addition the Trust is required to provide Monitor with a Corporate Governance Statement setting out any risks to compliance with the governance condition; and actions taken or being taken to maintain future compliance. This Statement will be supported by the Trust’s Annual Governance Statement which provides assurance of the efficacy of the organisation’s internal controls and risk management systems. The Corporate Governance Statement is required three months prior to the year end and is published in the Annual Report. An auditor statement may be requested to provide additional assurance. Finally the Trust submits to Monitor its Annual Report, Audited Annual Accounts and FTCs, an annual commentary on governor development activity and membership data. Exception Reporting The Trust will continue to liaise proactively with Monitor and the CQC and other stakeholders where exceptions may be detected e.g. a Serious Incident or Complaint which may attract media interest, or a new patient safety trend identified. Other Information from NHS Foundation Trusts (Governance Reviews) Monitor recommends that all NHS Foundation Trusts commission external reviews of their governance arrangements at least once every three years. These reviews should include at least one of the following areas: • Board governance and leadership; • Effectiveness of organisational oversight; • Quality governance; • Board’s capability. The Board of Directors has already considered how it would implement such a review and proposes to prepare for and undertake its first review in 2015/16.


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Appendix 1: Glossary of Terms A & E Accident and Emergency

ARP

Ambulance Radio Programme – a managed service for the provision of a digital radio communications system including: voice and data communications via the Airwave radio network; fixed, vehicle mounted and hand held radio terminals; Integrated Communication and Control System (ICCS); integration of existing mobile data solutions onto the Airwave network; provision of new mobile data solutions and the integration of all of the elements above into an end-to-end managed service.

Board of Directors The Board of Directors is the executive body responsible for the operational management and conduct of an NHS Foundation Trust/NHS Trust.

Capacity Management System (CMS)

Category A19 Calls Calls that may be life-threatening (Red 1 and Red 2 calls) receive a response at scene which is able to transport the patient in a clinically safe manner. The target is for 95% of life-threatening calls to receive an ambulance able to transport the patient within 19 minutes.

Category A8 Red 1 Calls

Calls that are identified as the most time critical response and cover cardiac arrest patients who are not breathing and do not have a pulse and other severe conditions such as airway obstruction. The target is for 75% of all Red 1 calls to receive an emergency response at scene within 8 minutes.

Category A8 Red 2 Calls

Calls that may be life-threatening but less time critical then Red 1 calls. The target is for 75% of all Red 2 calls to receive an emergency response at scene within 8 minutes.

CIP Cost Improvement Programmes

Commissioning

A continuous cycle of activities that underpins and delivers on the overall strategic plan for healthcare provision and health improvement of the population. These activities include stakeholders agreeing and specifying services to be delivered over the long term through partnership working, as well as contract negotiation, target setting, incentives and monitoring.

DH Department of Health Directory of Services (DoS)

Executive Directors

The Executive Directors are senior employees of the NHS Foundation Trust who sit on the Board of Directors and will include the Chief Executive and Finance Director. Executive Directors have decision-making powers and a defined set of responsibilities thus playing a key role in the day to day running of the organisation.

Facilitated Dispatch Point

This is where a crew or lone responder may park their vehicle in a designated facilitated standby point. It is acceptable to share a facility with other Health professional or emergency services. There are no time limitations that a crew or lone responders can standby at a facilitated/fully facilitated location. A facilitated standby point must be equipped to the following standard: comfortable seating, television, where practicable, provision of tea and coffee, toilet access, a place where employees can be away from the general public gaze and ability to make cold drinks.

Governance

Governance arrangements are the ‘rules’ that govern the internal conduct of an organisation by defining the roles and responsibilities of key offices/groups and the relationship between them, as well as the process for due decision making and the internal accountability arrangements.

Green 1 These are calls where presenting conditions are serious but not life threatening, and there is a less serious clinical need. These calls should receive an emergency response within 20 minutes.

Green 2 These are calls where presenting conditions are serious but not life threatening, and there is a less serious clinical need. These calls should receive an emergency response within 30 minutes

Green 3 These are calls which are assessed as lower acuity calls requiring a response at normal road speeds within 60 minutes or a phone assessment within 30 minutes (a clinician calling back for a secondary telephone triage to establish the most


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appropriate care pathway for the patient).

Green 4 These are calls where presenting conditions are not serious and therefore not life threatening and do not require an emergency response. These calls should receive a clinical response within 90 minutes or a clinician call back within 60 minutes.

Green 4 (999) These are calls where presenting conditions are not serious and therefore not life threatening and do not require an emergency response. These calls should receive a clinical response within 60 minutes

Green 4 (HPC) The Green 4 category includes all responses made by the Trust to requests from Healthcare Professionals to undertake urgent transfers of patients within a 1, 2 or 4 hour time window

KPI Key Performance Indicator

NHS National Health Service

NHS FT NHS Foundation Trust

Un-Facilitated Dispatch Point (06.00-00.00)

An area where a crew or lone responder will park the vehicle in a nominated standby area, ensuring that the safety of the crew and vehicle is not compromised. The Trust Standby Policy sets out the allowed standby times and other criteria to ensure employee safety.

OOH Out of Hours GP Medical Services

PTS Patient Transport Services

RRV Rapid Response Vehicles

SWASFT South Western Ambulance Service NHS Foundation Trust

UCS Urgent Care Services including NHS 111, Out of Hours and other urgent care services


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