1. BRAVE NEW WORLD – WHERE DOES THE AMBULANCE SERVICE FIT IN? KGMM Alberti National Director for Emergency Access “Trolley Dolly”

2. THE PAST THE PRESENT THE FUTURE

3. EMERGENCY CARE The Past 1 »Major focus on A&E »Demand exceeding capacity »Long waits »Trolleys »Sickest patients seen by most junior doctors »Poor relation

4. EMERGENCY CARE The Past 2 Ambulance service »“Scoop and run” »Focus on blue light »Separate from NHS General practice »Patchy »A&E focused Fragmented services

5. THE SIZE OF THE PROBLEM 7 million OOH GP calls 5+ million 999 (60% to A&E) 6 million NHSD calls 2 million WiC/MIU 14+ million A&E 2.5 million Admissions

6. WHY HAS IT CHANGED? Unsustainable Patients and clinical need NHS Plan 2000 REC 2001 Ambulance targets New GMS TARGETS

7. THE TARGETS 90% in and out of A&E within 4h (31/3/03) 100% (now 98%) by 31/12/04 75% Cat A < 8 mins

8. WHERE ARE WE NOW? 96.2% A & E 76.4% Cat A

9. But … there are still problems

10. CURRENT PROBLEMS Rising demand Too much focus on EDs Beds – use, place, number Staff – too few Buildings, gear Silos, fragmentation

11. A & E ATTENDANCES All types (millions) 1962 5.0 1992 13.1 2002/03 14.4 2003/04 16.5 2004/05 8.9 (6 months only) NB Interpret with caution

12. AMBULANCE SERVICE 999 CALLS No Incidents of calls attended(millions) 2001/024.73.78 2002/034.963.99 2003/045.344.27 (1993/942.422.41)

13. STAFF Too few Paramedics Too few ECPs Too few ENPs Too few AHPs Too few Radiographers Too few Consultants

14. SO WHAT NEXT? Have we got the right targets?

15. THE STARTING POINT THE PATIENT

16. WHAT CARE DO PATIENTS WANT - AND NEED? Convenient High quality Rapid Simple access Friendly Choice

17. KEY FACTORS ECN SHA-wide ECN ECN tasks

18. EMERGENCY CARE NETWORKS Partners Mental health Acute OOH Social Services Children’s services Ambulance PCT Pharmacies Public/patients Etc.

19. EMERGENCY CARE NETWORKS What will make them work? »Commitment by all partners »TEETH

20. KEY ROLE FOR AMBULANCE SERVICE?

21. KEY FACTOR The Pathway

22. THE EMERGENCY CARE AND URGENT CARE PATHWAY - FUTURE PATIENT A&EGP SIMPLE LOCAL ACCESS Acute Alcohol Team Voluntary Sector Mental Health Services Emergency Social Services NHSD OOH UCC PharmacyGP Appt RRTs Acute Trusts Paramedic 999

23. WHO SHOULD PROVIDE THE SIMPLE LOCAL ACCESS? THE NAVIGATOR ROLE NHSD? OOH Services? Ambulance Service? AN AMALGAM OF ALL 3?

24. THE WHOLE SYSTEM Components »Home »Community »Urgent Care Centres »Emergency Department »Rest of hospital »Intermediate Care

25. HOME CARE CDM Teams Care of the elderly teams ECPs Social services, etc.

26. COMMUNITY Care teams Paramedics/ECPs based in Primary Care Centres (? wider role) Voluntary Sector, etc.

27. URGENT CARE CENTRES (1) WiCs and MIUs “Minor” injury and illness ENP/ECP led GPSI supported Diagnostics available 24/7

28. URGENT CARE CENTRES (2) Location? Co-location with OOH/social services Primary care AND Secondary care skills Children?? Mental health?? Co-location CDM

29. URGENT CARE CENTRES Problems »Ownership »Numbers »Staffing »Location ALL SOLUBLE

30. COMMUNITY ROLE FOR THE AMBULANCE SERVICE First contact practitioners (ECPs)

31. THE ROLE OF THE FIRST CONTACT PRACTITIONER Rapid assessment, initial treatment, education Decision re disposition »Leave at home »Contact other agencies »Take to UCC/GP/hospital

32. OTHER ROLES FOR ECPs UCCs Primary care A & E

33. NUMBERS OF ECPs Now 600 + Needed 11,000 !

34. TOMORROW’S AMBULANCE SERVICE Co-ordinating role in network Close working with GPs, social services, mental health services, rapid response teams for CDM, A&E Rapid transport of patients to acute hospital - but only for those who need it! Other transport services

35. PROBLEMS Attitudes Habit Other parts of the service Training / education Resources

36. THE FUTURE Exciting Get on with it!