Meeting documents

            Meeting: Health Scrutiny Sub-Committee (County Hall, Durham - - 11/09/2008 12:30:00 PM)

                  Item: A2 County Durham Primary Care Trust Proposals for Modernising Rural Ambulance Services: (a) Report of Head of Overview and Scrutiny (b) Report of Cameron Ward, Director of System Management, County Durham Primary Care Trust

         

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1. Introduction

In September 2006, the former Durham Dales PCT, following public consultation agreed to modernisation of the rural ambulance service provided by North East Ambulance Service (NEAS) in the Teesdale and Weardale areas.

The modernisation approved comprised:
· Removal of standby* working practice
· Recurring investment of £254k to introduce a 24/7 community paramedic service *out of hours oncall by inhours crew The closure of the two rural ambulance stations at Middleton and St Johns Chapel was deferred until it could be considered that relocation would not have a detrimental effect on service provision.

A year long monitoring exercise ran from December 2006 to December 2007. The key headlines from this and further discussion and concerns from the local communities can be seen at Appendix 1

An interim report was submitted to Commissioning Directors in February 2008, and County Durham Overview and Scrutiny Committee in March 2008

Subsequent discussions with community stakeholders identified continuing inequities and poor performance within the service. From public and stakeholder meetings and feedback received, options for each Dale were constructed with the help and support from both GP Practices in the two Dales, NEAS, and the paramedic crew.

Implications and risks

A number of initial options were considered, including remaining as ‘status quo’. Attached at Appendix 2 there are three options that have been considered more fully. Option 3 is fully supported by the clinical leaders in the Dales, and shared with the rural communities. The feedback from Teesdale from the meetings is more supportive of their service model, However Weardale continue to have concerns about the ambulance base and the lack of a full 2x 24/7 service model.

It is anticipated that it will take up to two years from a decision to fully implement both options due to recruitment and training programme requirements, and so anticipate part year costs up to 2011/12.

The new proposed service model also provides a platform from which further service integration, particularly for local access to urgent and out of hours care can be enhanced. However this is dependent upon recruitment of trained paramedics, or suitable trainees referred to above.

3. Recommendations

The Board is asked to consider the service improvement potential of the two proposals for Teesdale and Weardale, and approve:

· The preferred option 3, with a phased investment profile anticipated to have a full year effect in 2011/12.
· Further work be undertaken to confirm the phased costs up to 2011/12
· a new stakeholder group, including local clinical and political leaders and community representatives who will receive information and feedback on the implementation of the new service models.

4. Author and sponsor director

Author: Sharon Smith
Title: Assistant Director for Acute Care Pathways

Director: Cameron Ward
Title : Director of Systems Management
Date: August 2008

Document management

Purpose of the Paper: 1. Info sharing: Yes 2. Development/discussion: Yes 3. Decision/action Yes

Does this paper provide evidence against any of the areas the PCT is required to demonstrate assurance in eg WCC, ALE key lines of enquiry or NHS national standards? If so which ones?

WCC, Access targets for Cat A/CAT B, Healthcare in rural communities

VersionDateSummary Owner’s NameApproved

Key Area	Teesdale	Weardale	Total	Comment
No Cat A responses (patients who are/or maybe life threatened and who would benefit from a timely clinical intervention)	Highest monthly demand (50) Lowest monthly demand (21)	Highest monthly demand(12 ) Lowest monthly demand (1)	448	NEAS advise of low levels of demand relative to population size
No Cat B responses ( require urgent face to face contact/clinical attention but not immediately life threatened)			852	NEAS advise of low levels of demand relative to population size
No Cat C responses( not require an immediate or urgent response by blue light and may be suitable for alternative care)			87	NEAS advise of low levels of demand relative to population size
Call Connect (Cat A performance)	DL12 0 = 5.7% (40.9%) DL12 8 = 68.9% (47.4%) DL12 9 = 50% (9.5%) DL13 5 = 2.1% (4.9%) DL2 3 = 35.7% (20.5%) (2005/06 in brackets)	DL13 1 = 60% (41.75) DL12 2 = 38.3% (16.7%) (2005/06 in brackets)	N/App	National Target 75% Cat A response time Weardale 43.8% (21.7%) Teesdale 46.9% (31.8%) 06/07 (05/06) Majority responses in rural areas well in excess of service average although significant improvements seen overall
Response Times (Cat A) Night Times	Max c12 mins Min c8 mins Av c13 mins	Max c35 minutes Min c7 minutes Av c13 mins		Service average <7 minutes Majority responses in rural areas well in excess of service average although significant improvements seen overall
Response Times (Cat A) Day Time	Max c10mins Min c7mins Av c11mins	Max c 23 minutes Min <2 minutes Av c 11minutes		Service average c7minutes Majority responses in rural areas well in excess of service average, although significant improvements seen overall
Use of Dales vehicle within Dale	73% (27%)	43% (57%)		()This reflects the extent of pull on the vehicle out of the Dale for Cat A calls
Conveyance Rate	62%	68%		Reflects positive increased rate of management of patient presentations out of hospital eg community paramedics

Conclusions

Activity is advised as very low for both Dales which presents challenges, not only in the potential for statistical skew, but also in configuring and rationalising some of the stepped changes and investments that need to be considered to achieve relatively small further improvements, without considering other benefits to be achieved from utilising any additional investments in skilled resources.

From the date of the original investment there has been significant levels of improvement with two of the postcode areas in Teesdale (DL12 0 and DL13 5) showing deterioration. Weardale has been a significant gainer on Cat A performance. However performance is poor in comparison with performance achieved in urban areas overall.

Response times at night are poorer with greater inconsistencies, whilst the service overall remains consistent.

The rural communities are made more vulnerable and poorer response times are worsened reflecting workload outside the Dale without adequate back up and support services.

Reduced conveyance rates cannot be interpreted as solely the result of a community paramedic service, however it should be seen that the availability of a local (limited) urgent care service has contributed to this improvement.

During the period from December 2006 to date a number of outcomes could be observed/derived from the changes as follows:

· Potentially more staff available to work on rotation
· Potentially more opportunity for integrated working with other healthcare services in the rural communities, particularly urgent and out of hours care.
· Improved training and support will continue to reduce the % of patients conveyed to hospital, although further improvements may be less marked.
· Activity remains very low, providing greater potential for integrated working whilst recognising that the emergency response is the key priority for the ambulance service
· The local communities value the presence of the paramedic service

However it could also be seen that the local community has a number of concerns as follows:

Concern	Response
Vulnerability of communities with inadequate back up support. The vehicles for the rural areas are regularly pulled out to provide services to populations outside the two Dales and leaving the rural populations with no cover	Both Option 2 and 3 provides resilience both in terms of additional vehicle and paramedic cover within the Dale - a greater resilience is offered with Option 3 as the vehicles will operate fully within each Dale.
Weardale/Teesdale support 24/7. Significant community concern over the heightened sense of isolation resulting form road configuration and the impact of bad weather	The ‘second’ vehicle operates 12/7. The PCT will work with NEAS to ensure the cover is over the 12 hour period shown to reflect greatest demand across the seasons. Levels of demand historically do not warrant the recommendation of two 24/7 vehicles.
Closure of rural ambulance stations	This is NEAS estate. The stations are not planned to close. There is potential to increase usage of the stations as part of a next stage piece of work on outreach urgent care subject to further evaluation and costing.
Operational base for paramedic crews	The PCT has concentrated on a service model that provides care across the wider Dales areas with services and cover up the Dales as part of this model. Vehicles will begin and end shifts at Barnard Castle and Stanhope but a vehicle will work across both Upper Teesdale and Upper Weardale as part of the service model.
Post code areas particularly around Upper Weardale and the Middleton area, receive a very low Category A performance response.	Option 3 particularly supports a community based integrated service model which will allow vehicles to work across both Dales in hours and will be operational from Stanhope/Barnard Castle out of hours
Ambulances supporting conveyance out of the Dales	Negotiations with NEAS confirm that vehicles conveying out of the Dales will be returned promptly unless they are the closest unit to respond to another Cat A call whilst on route back.
Speed of implementation	This will be as fast as recruitment/training programme allows which may be up to 2 years. However there is a positive recruitment campaign in progress which indicates we will be in a position to deliver a phased implementation from 2008/9
Local knowledge	Paramedic training does not begin until 21years. NEAS have confirmed a commitment to work with local schools to raise the profile for future job opportunities for youngsters and local practices have agreed to advertise paramedic training opportunities. Skilled and knowledge existing staff will work on rotation with new recruits to increase local knowledge.
Equity of Service/Performance Issues remain over the distance the rural population needs to travel to receive urgent care (other than the care available from the two GP Practices in the areas), particularly out of hours.	The PCT acknowledges the performance in Cat A is poorer - but is and will continue to work with NEAS to continue the improvements made. The introduction of a community paramedic service offers the rural communities an urgent care service that is not available in urban areas.

	Option1	Option 2	Option 3
Outline	Status Quo ie ‘control option’	Fully integrated community paramedic service with shared back up conveyance	Fully integrated community paramedic service with dedicated back up conveyance
Detail	24x7 traditional paramedic crew (1 paramedic and one driver/emergency support worker) 1 vehicle per Dale starting and finishing from rural ambulance station but operating from Barnard Castle/Stanhope. Vehicles and paramedics leave locality to respond appropriately to call priorities and transport to hospital Rural communities receive back up from wider NEAS service out of area	Single community paramedic service based in rural communities 12/7 plus 24/7 service traditional crew(see Option 1) based at Barnard Castle and Stanhope. Single paramedic back up transport as a retained resource 24/7	Teesdale 24/7 and 12/7 vehicle staffed by double paramedic crew Weardale 24/7 staffed by double paramedic crew and 12/7 4WD by single paramedic crew Vehicles start finish at Barnard Castle/Stanhope. The 12/7 provide service to Middleton/Upper Weardale communities Dedicated 12/7 provides back up resource in area
Pros	Maintains current performance status (where improved) Continues valued support for service in local communities Some potential to work more fully as integrated service Platform to explore opportunities for implementing successful service models elsewhere	Fuller development of community paramedic role. Service visible and valued in community Improves performance across all postcodes Enhances urgent care in rural area and reduces transport out of area for urgent care Retains more resource in area and reduces vulnerability and exposure for local community Increased resilience and enhanced integration Reduced recruitment and retention issues	Fullest development of community paramedic role Service visible and valued in community Improves performance across all postcodes Greatest enhancement of urgent care in rural area and reduces transport out of area for urgent care Retains greatest resource in area and reduces vulnerability and exposure for local community Most increased resilience and enhanced integration Model of service receiving support from both local clinicians and paramedic crews No anticipated recruitment and retention problems
Cons	Continue to see poorer performance across some postcodes Contributes to underachieving PCT performance Service and community exposed in event of emergence/urgent care requirement Service model not supported. Difficulties in recruitment and retention of paramedic staff	Requires significant investment Requires additional staff - increase 10 paramedic staff Requires back up agreement Disruption to urgent care work due to emergency response priorities and limited numbers of community paramedics on rota Vulnerability and confidence of response time for shared vehicle	Requires most level of significant investment Requires additional staff - increase 13 paramedic staff Requires back up agreement Lesser disruption to urgent care work due to emergency response priorities givenumbers of community paramedics on rota Discreet vehicles reduces vulnerability for cover
Estimated Response Times	As now	Improve performance to 50-50.9%	Improve performance to 50-50.9%
Recommended			Option 3

County Durham Primary Care Trust proposals for modernising Rural Ambulance Services
Report of the Head of Overview and Scrutiny

Purpose of Report

1. To consider proposals from County Durham Primary Care Trust for the modernisation of Rural Ambulance Services provided in the Teesdale and Weardale areas - agenda item 2 (b).

Background

2. Proposals for modernising rural ambulance services were agreed by the former Durham Dales Primary Care Trust in September 2006 for:

§ A 24/7 ambulance service to be established in the Weardale and Teesdale areas staffed by Community Paramedics and a Technician. § For the current ambulance stations to remain in place until the changes have been evaluated and proved to be more effective. This option was being put forward to address public concern that the proposal is a significant change in service that may have a detrimental effect on the most rural and isolated areas.

3. The JHOSC has continued to consider and comment on the proposals as they have developed and the dialogue with communities has continued. Members are referred to the papers of the JHOSC meeting on 11th March 2008 at which there was consideration of the service evaluation undertaken by the Durham Dales PCT and the North East Ambulance Service. Conclusions to this evaluation are detailed in Appendix 1 of report 2 (b).

Information

4. The County Durham Primary Care Trust Board is to make a final decision on these proposals at its Board meeting on 9th October.

5. Members are asked to note the conclusions from the monitoring exercise set out on pages 4 and 5 in Appendix 1 to the paper 2 (b), in particular in relation to areas of performance and outcomes observed and derived from the changes made.

6. Members are asked to note the summary of local community concerns to the proposals, and the response to them, set out on page 5 and 6 in Appendix 1 to the paper 2 (b).

7. Members are asked to note the implications and risks from the options set out on pages 7 and 8 in Appendix 2 to the paper 2 (b).

The JHOSC notes:

8. That the proposals represent enhanced investment to provide improved integrated working between primary care teams and ambulance staff to meet the needs of communities in Teesdale and Weardale.

9. That the Ambulance Stations in St Johns Chapel and Middleton-in-Teesdale are not planned to close and that potential exists to increase their usage for outreach urgent care.

10. That there is to be a next stage piece of work to look at the potential to increase usage of the stations.

11. That aspects of poor performance within the Ambulance Service need to be addressed as a matter of urgency and progress reported to JHOSC.

12. The active consultation that has taken place over recent years in the development of these proposals and the positive way in which County Durham Primary Care Trust and the North East Ambulance Service has responded to public and stakeholder concerns.

13. The proposal to establish a new stakeholder group, including local clinical and political leaders and community representatives who will receive information and feedback on the implementation of new service models.

14. That activity levels in both Dales remain low, providing greater potential for integrated working, recognising that the emergency response is the key priority for the ambulance service. Recommendations

(i) The JHOSC acknowledges the work that County Durham Primary Care Trust and the North East Ambulance Service has done with respect to the views and concerns of local residents affected by proposals to modernise rural ambulance services.

(ii) The JHOSC welcomes further investment in rural ambulance services and suggestions to increase the usage of existing ambulance stations to best effect to respond to the needs of local communities.


(iii) The JHOSC welcomes the proposal to establish a stakeholder group and looks forward to receiving the Terms of Reference of this group. The JHOSC suggests that this group should:

§ Help to evaluate the implementation of service models and to shape the development of these services models where appropriate, ensuring poor performance is addressed.
§ Has a specific role in relation to the further evaluation and costing of outreach urgent care and the potential for increased usage of the ambulance stations.
§ Regularly reports to JHOSC on implementation of the new service models from the group.

(iv) The JHOSC recognises that service models need to be implemented and that improved performance and responding to local community needs must be essential criteria. In line with this then, the JHOSC would like to see evidence of how effective the proposed service model, based on the preferred County Durham Primary Care Trust option, will deliver good health outcomes. The JHOSC will want to see evidence on the implementation and performance of the service model in 12-18 months time.

Background papers:

Rural Ambulance Services - County Durham Primary Care Trust, Sept 2008

Review of Ambulance Service Provision in Weardale and Teesdale, Durham Dales PCT and NEAS

Monitoring Rural Ambulance Services - The Patient and Public Perspective

Modernising Ambulance Services in Rural Areas consultation document.





Attachments


 PCT Report for Special meeting.pdf;
 PCT Proposals modernising Rural Ambulance Services.pdf