1. Ambulance Response Programme (ARP)
Yvonne Ormston, Chief Executive, NEAS
The Association of Ambulance Chief Executives (AACE)
13th November 2017
Association of Air Ambulances Conference

2. National picture 2016/17 10 English NHS Ambulance Services
999 calls increased by 21% since 13/14
11.2 million 999 calls
Includes 1.46 million transfers 111 > 999
Led to 6.9 million face-to-face attendances
52% conveyed to ED
38% treated at home & discharged or referred
10% telephone advice and/or referral
700,000 hours lost waiting to transfer care in ED

3. The Emergency / Urgent Picture: complex remit for ambulance services
10% Life threatening
Advances in cardiac care, stroke, major trauma, cardiac arrest
Alternative destinations – Trauma Centres, PPCIs, Stroke Units
Acute service reconfigurations - maternity, paediatrics, surgery
Clinical vs Response time performance measures (AQIs)
90% Urgent care
Mix of acute/chronic, LTCs, complex and multiple health issues
Increasing care closer to home
Alternative destinations - UCCs
Ambulance clinicians working alongside community, primary care, social care, mental health in MDTs
Advanced and specialist paramedic roles (MSc) - expanded clinical decision making, advanced clinical assessment, diagnostic & treatment skills
Public health promotion/prevention role - MECC
Plus, maintain Resilience for major incidents & mass casualties - working with other emergency services and specialist response agencies (JESIP)

4. Challenges growing demand and tightening finances
complex commissioning arrangements
ageing population, with rising numbers of frail people living independently at home
increasing numbers of people living with one or more long term conditions
extended job-cycle times
social care services under severe pressure
increasing delays in transfer of care into ED and out of hospital
too few paramedics across country – attractive to other sectors
gaps in technology to support care remotely, at scene, at home or whilst travelling
new arrangements for health and care, with the emergence of Accountable Care Systems
ensuring the ambulance service has ‘a seat at the table’

5. Demand vs Performance

6. Handover delays at ED Hours ‘lost at ED’
directly increase pressure on resourcing and responding
In 2016/17, 700,000 hours were lost, the equivalent of 80 years of ambulance time, or 560,000 patients*
* Based on average job cycle time of 75mins

7. Introduction
NHS England announced its recommendations for changes to the ambulance service operating model and associated standards, developed through the Ambulance Response Programme (ARP).
The redesigned system for ambulance services in England will focus on ensuring patients get rapid life-saving, life-changing treatment for conditions such as cardiac arrest, stroke and heart attack, rather than simply sending ambulances to “stop the clock”.
Currently, as many as one in four patients who needs hospital treatment, more than a million people each year, undergo a “hidden wait” beyond the current 8 minute target because the vehicle dispatched cannot transport them there.

8. Evaluation
An evaluation has been undertaken by the Sheffield School of Health and Related Research (ScHARR).
The results highlighted have been impressive and once ARP is adopted nationally, it should:
Improve early recognition of life-threatening conditions, particularly cardiac arrest. Based on figures from London Ambulance Service, they predict up to 250 additional lives could be saved in England every year.
Improve waiting times; as many as 750,000 patients every year will receive an immediate ambulance response, rather than joining a queue.
Reduce the differences in response time between patients living in rural areas, and those living in towns and cities.
ARP evaluation has been the largest of its kind in the world, and has included 14 million 999 calls with no patient safety or adverse incidents attributed to the programme.

9. New System
Under the new system ambulance call handlers will change the way they assess cases and have slightly more time to decide the most appropriate clinical response. At the same time, changes to the early call handling process mean that cardiac arrest patients will be identified quicker than ever before – with evidence in London showing this will save more lives each year.
Ending the out-dated 8 minute target will free up more vehicles and staff to respond to emergencies. Under the existing standards three or even four vehicles may be sent to the same 999 call in attempt to meet the target, meaning that across the country one in four ambulances are stood down before reaching their destination. These changes mean that more than half a million calls annually that would currently go into a queue will get an immediate response.

10. New System
For patients with a serious condition such as heart attack or stroke, Dispatchers will send the most appropriate response to deliver treatment to the patient at scene and then transport them rapidly to the right specialist centre.
A new set of clinical indicators will be introduced that will put improving outcomes central to demonstrating the impact that ambulances can have when the right resource is sent to patients in a timely manner, ensuring that patients are taken to the hospital offering the most appropriate emergency treatment that they need. We expect to see steady gains in patient outcome, including mortality, as a result.
The changes also introduce a mandatory response standard for all patients who dial 999. Currently, half of all ambulance calls (around five million a year) are classed as “green” and not covered by a national response time standard. Response times for these patients, who are often frail and elderly, have risen by up to 100% in some ambulance services during the past two years, with some patients waiting over 8 hours.

11. New System
The ARP changes have been strongly endorsed by expert organisations such as the Royal College of Emergency Medicine, the Stroke Association, and the College of Paramedics.

12. Ambulance Response Programme Principles
What does the patient need?
The right vehicle
The right skills
The right place for care
(Home, Trauma, A&E, stroke centre, UCC….)
The right time
What does AS need?
Less on scene time for RRVs
Fewer stand-downs and diverts
Less multi-vehicle deployments on CAT 2,3&4

13. New categories CATEGORY 1 - LIFE-THREATENING
Time critical life-threatening event needing immediate intervention and/or resuscitation e.g. cardiac or respiratory arrest; airway obstruction; ineffective breathing; unconscious with abnormal or noisy breathing; hanging.
CATEGORY 2 - EMERGENCY
Potentially serious conditions (ABCD problem) that may require rapid assessment, urgent on-scene intervention and/or urgent transport.
CATEGORY 3 – URGENT
Urgent problem (not immediately life-threatening) that needs treatment to relieve suffering (e.g. pain control) and transport or assessment and management at scene with referral where needed within a clinically appropriate timeframe.
CATEGORY 4 – NON-URGENT
Problems that are not urgent but need assessment (face to face or telephone) and possibly transport within a clinically appropriate timeframe.
TYPE S – SPECIALIST RESPONSE (HART)
Incidents requiring specialist response i.e. CBRNe, hazardous materials; specialist rescue; mass casualty

14. Categories
National Standard
How long does the ambulance service have to make a decision?
What stops the clock?
Category 1
(8% of demand)
7 minutes mean response time
               
15 minutes 90th centile response time
The earliest of:
•The problem is identified
•An ambulance response is dispatched
•30 seconds from the call being connected
The first ambulance service-dispatched emergency responder arrives at the scene of the incident
(There is an additional Category 1 transport standard to ensure that these patients also receive early ambulance transportation)
Category 2
(48% of demand)
18 minutes mean response time
40 minutes 90th centile response time
•240 seconds from the call being connected
If a patient is transported by an emergency vehicle, only the arrival of the transporting vehicle stops the clock. If the patient does not need transport the first ambulance service-dispatched emergency responder arrives at the scene of the incident
Category 3
(34% of demand)
120 minutes 90th centile response time
Category 4
(10% of demand)
180 minutes 90th centile response time
Category 4T:
If a patient is transported by an emergency vehicle, only the arrival of the transporting vehicle stops the clock.

15. Range of benefits from new model:
Allows resources to be focussed on improving response for Cat1
Cat 1 patients identified quicker due to
Creates potential to improve cardiac survival
Greater efficiency in deployment of vehicles, releasing resources
Effective targeting of right resource, first time
Improvements in getting patients to definitive care in specialist units, eg stroke and STEMI
More patients managed appropriately through H&T or S&T without need for conveyance to hospital
Reduces stress on resources and better able to absorb peaks in demand
Greater transparency about whole system / ambulance performance

16. ARP Roll Out

17. Points To Note
ARP provides a focused approach to ensuring that the right response is delivered to patients the first time. As such the targets and reporting cannot be compared with historical performance.
The classification of incidents (the ‘code-sets’) may be subject to further change as ARP is embedded.
A period of grace has been granted to make the necessary changes to its reporting systems, which includes reporting to NHS England.
High level reporting to Lead Commissioners is expected from October onwards.
Lead Commissioners are having weekly discussions with NHS England on the implementation of ARP.

18. See & Treat
Mobile Healthcare

19. Workforce priorities Lack of paramedics in some areas of the country
Develop and retain more Specialist & Advanced level paramedics – increase provision of S&T / H&T
Greater integration across sectors – multi-professional workforce / rotational models
Diversity – especially Board level and to reflect the communities we serve
Health & Wellbeing – MECC principles also apply to staff
Mental health support & suicide prevention
System leadership

20. Technology & Innovation in Healthcare Delivery
Connectivity on the move
ePRF
Dynamic access to and integration with Summary Care Records, Care Plans, End of Life plans
Clinical decision support – e.g. Pathfinder
Telecare – monitoring pendant alarms etc
Telehealth – virtual consultations
Remote clinical support
Online 111 advice
Medicines management
Connecting staff to back office functions – briefings, HR services etc
eLearning
Video conferencing

21. Transforming the Ambulance Service – what is needed?
Joint Ambulance Improvement Programme – NHSI & NHSE
Collaborative commissioning framework
Developing & retaining the right skill mix & capacity across ambulance workforce, moving to multi-professional workforce
Enhance & develop new models of care / response
Less focus on targets – more on patient / system outcomes
More direct referral pathways within the community and smoother integration across providers
Changing NHS culture – building trust across professions and sharing responsibility for change
Interoperable technology and timely data sharing
Improved patient safety, outcomes & experience
and happier, healthier workforce
and more sustainable systems & services

22. THANK YOU - ANY QUESTIONS ?