To consider the report of the Corporate Director of Resources, Durham County Council and a presentation by representatives of North East Ambulance Service NHS Foundation Trust
The Committee considered a report of the Corporate Director of Resources, which provided background information regarding the 999/111 services currently provided by North East Ambulance Service NHS Foundation Trust (NEAS) and a detailed presentation by M Hunter, Emergency Operations Centre Manager (for copies see file of minutes).
The Emergency Operations Centre Manager advised that NEAS delivered a number of services including 999; 111; Clinical Assessment Service; Patient Transport Service; and the Dental Clinical Assessment Service.
NHS Pathways was designed to clinically assess patients and triage them to the correct service with a defined timescale identified for the patient. It was developed and maintained by a group of Clinicians and constantly reviewed.
Call handlers were dual trained in both 111 and 999 operations and in order to take live calls would have to undertake a four week, full-time training course and achieve a minimum pass score. Calls were regularly audited with each member of staff having five random calls monitored.
The 111 service was linked up with GP Practices, 17 Dental Hubs, Emergency Departments, 18 Urgent Treatment Centres, Clinical Assessment Service, Out of Hours GP Services and could dispatch an ambulance as if it were a 999 call. Triaging patients reduced footfall in Emergency Departments and health advisors could advise services of the arrival time, as well as giving a summary of the triage for each patient.
The Emergency Operations Centre Manager gave details about call numbers at the end of December 2021. The number of ambulances dispatched was at 17% and this was higher than the national average, which 10-15% but did not take into consideration the actual number of patients that received an ambulance. Patients who received an ambulance was closer to 7% as there were occasions resulting in lower category outcomes after reassessment by Clinicians and patients were downgraded o asked to attend a nearby service. Patients also sometimes declined an ambulance.
The demand was similar the previous year, however the 111 service performance had taken a downward turn due to a change in call patterns. Historically 111 had been an out of hours service, however demand had increased as a result of patients being unable to contact their own GP. Some days there had been a 45% increase in calls received.
During the early days of the pandemic, the national message portrayed was to ring 111 and GP practices essentially shut up shop and directing patients to 111. In conjunction, NHS England were running a campaign called 111 First, which encouraged patients to call 111 as an alternative to attending an Emergency Department. The message became that of “ring 111 for everything” and was being used as an alternative to contacting GP’s.
The service had been overwhelmed during an historically quieter period and there were also increased 999 calls. The dual training had given some protection to the service and all calls had been directed to 999 operators. This was an issue for some other localities with operators that were not dual trained.
The service became further impacted by record increased levels of Health Advisor absence. There were 350 Health Advisors, but and there were periods where up to 35% of staff were absent with COVID-19 or isolating. The Management Team had also been affected with 80% absent at one time and the 25 team leaders were operating at 50% but throughout the pandemic, the centre continued to offer the service. As a result of this substantial reduction in staff, calls had taken longer to answer.
The Emergency Operations Centre Manager confirmed that in addition to COVID-19 infections there was an increase in mental health absences, strongly suspected to be due to fatigue, coupled with being on the receiving end of extremely challenging calls, some of which were abusive. He advised that staff would be increasing from 350 to 500 over the following 6 months and recruitment was taking place.
Having considered ambulance services in other areas the Emergency Operations Centre Manager advised that the number of patients accessing 111 was double and could be that 111 was more established in the North East as this is where the pilot had been ran for three years, or it could be that patients had more difficulty accessing primary care.
Members were advised that in 2022 the service had turned a corner with demand and the abandonment rate was also reducing. It was important to share the month on month decrease as the worst point and most critical period was October with 60%, November 50%, dec 42%, January 33% and to date 19%. The service were committed to answer all calls and get the figure to 0%.
In terms of calls answered NEAS were 25th out of 35 and the speed had reduced to 6.5 6.5 minutes.
Overall this demonstrated that improvements were being made and the service were taking this seriously. Improvements had been mostly due to a large scale recruitment campaign for additional 152 Health Advisors for the 111/999 service and the service was on target with continued recruitment throughout the rest of 2022. An additional 53 staff had been recruited in February. There were also plans to recruit Apprentices and offer training and qualifications.
A third contact centre was being opened in Teesside as the service had outgrown the two that they operated from currently.
In addition, NEAS had liaised with dental services which had enabled the service to double the amount of dental appointments needed. The Dental Service was a strategy that was unique to NEAS; in other parts of the country, callers were advised to contact their local dentist but the North East 11 service were able to offer appointments within one of the 17 dental hubs.
The Emergency Operations Centre Manager advised that the impact on staff was also something that NEAS wanted to address and they would be offering a gift to all staff at the end of March to recognise their hard work and what they had been through over last two years. In addition, a Health and Wellbeing Officer was being recruited and the provision of quiet rooms for staff to use after challenging calls.
Councillor Kay referred to the dental hub which he had not been aware of and asked if he would be signposted to one of the 17 hubs if he contacted 111 in acute pain. The Emergency Operations Centre Manager advised that a patient was triaged which would determine how urgent and severe the concern was. The triage would determine how urgently a patient needed to be seen, usually between a period of between 2 hours to 3 days, however there were 500 available per week, in order to manage urgent dental concerns. If a triage resulted in time scale of 12 to 24 hours, a patient would be asked to attend a dental hub and all information was able to be transferred electronically, there was no need for a patient to contact dental service.
Councillor Kay commended the service but advised that many service users would be unaware and asked how this was being communicated and promoted to the public. The Emergency Operations Centre Manager advised that dental access was a problem nationally and he had worked closely with a dental clinician for three years, part of the project was to create an electronic system but this would be a long progress.
In the short term, 111 was about to launch pilot service where at the very outset of the call an automated message would route the caller to the appropriate local service. This would transfer patients to call handlers trained in dental calls and signpost them. With regards to marketing, the service had deliberately not been promoted and they would be reluctant to as of the 466 appointments that were offered, the utilisation was 98-99% on a weekly basis. At the point of asking for more dental appointments they were ony offering 250. Dental problems equated to 10-15% of 111 calls, it had been the forgotten element of 111 and NEAS were at the forefront in driving some different ways of working. If a patients need was great enough, they tended to call 111 despite not advertising the service.
Councillor Gunn thanked the Emergency Operations Centre Manager for the presentation and reminded him that it had been required for scrutiny due to major concerns regarding the ambulance service causing nervousness and anxiety. She congratulated the service on what they had been able to do and understood the issues regarding capacity and the limitations with amount the funding they had, however Members had a responsibility to residents and she asked how Members could provide residents with confidence in the ambulance service, as they were anxious - and not just older people, but people of all ages.
The Emergency Operations Centre Manager advised that it was important to note that prior to the pandemic, NEAS delivered exceptionally well and 111 had continually been in the top 6 of the best providers in the country. It had slipped a little in last two years, but residents should be assured by the fact that they had delivered and were on the road to recovery again.
The Chair asked whether the dental service was going to be enhanced again so that residents could be made aware that it existed and M Cotton, Assistant Director of Communications NEAS, reminded Members that the 111 service was commissioned as an urgent care service for when patients required urgent treatment that was not 999. It had been developed around assessing the clinical need for caller. He explained that over the previous two years the model had been confused. What was being suggested was that 111 was promoted as an alternative route to other services when it was not set up to do that. The concern in promoting the service was that it was not an advice line but an urgent care right and if promoted for otherwise, it would become a service for low priority treatment and increase the number of calls. It had been confirmed that 98% of appointments were utilised and if advertised that would increase and in turn, affect call handling times.
The delivery of the service and what others would like it to deliver was something for wider discussion, but not for NEAS as a provider.
In response to a question from Councillor Robson with regards to the number of calls on psychiatric matters the Emergency Operations Centre Manager confirmed that a significant number of calls were received regarding mental health episodes and the service had good links with crisis teams and offered a transfer process, so if the outcome of triage recommended that a patient needed to be seen by a mental health professional or crisis team, they could refer that patient. All calls were taken through triage, as some patients did not require crisis team intervention and could speak to in-house Clinicians instead.
Councillor Charlton-Lainé complimented NEAS for being independently proactive in making improvements. She understood the reasons that pathways could not be advertised, but with regards to the time, she wanted to speak about her on personal experience. She asked having called 111 and been assessed and given a time scale, did the patient need to be seen within that time and did it take into account that the patient may be sat in the emergency department for longer periods.
The Emergency Operations Centre Manager confirmed that this was an ongoing issue and that terminology had changed and most dispositions would be that a patient had to contact a service within time frame and once contact within clinical environment had been made, the recommendation from pathways had been met. With regards to urgent treatment centres, the appointment booking centres worked well and they tried to work around emergency departments to assist with arrival times, however he had heard anecdotally, that due to general footfall from other patients, there were increased pressures in the Emergency Department which impacted on waiting times.
The Chair appreciated the presentation and suggested that a further update be provided in 6 months.
Councillor Quinn advised that she had been made aware of the dental service via social media. She referred to waiting times for drop offs at hospital and was alarmed at how many ambulances were queuing outside of Darlington Hospital and people waiting to be discharged who could not go home as still waiting for ambulances coming in.
P Liversidge, Chief Operating Officer, NEAS, advised Members that there were still a lot of infection control measures as there was a level of protection required to reduce infection. Handover delays were improving and workforces were getting back to normal. Delays were improving and the Trusts were working collectively to deal with patients in the community and create new pathways of care to avoid Emergency Departments.
Councillor Quinn reiterated the importance of hygiene which in her opinion should continue, as during early lockdown stages it was proven in reducing the spread of infection.
Councillor Hovvels advised that the presentation had demonstrated how much progress had been made and she wanted to place on record, her appreciation to the staff who had continued to deliver all services, during an extremely difficult time. She also welcomed the offer of a gift to thank staff.
The Principal Overview and Scrutiny Officer advised that there had been a request for NEAS to provide a heat map or analysis of pattern of service requests within County Durham and they were considering the request. The Assistant Director of Communications advised that he was investigating how the data could be provided and the information would be circulated to the Committee in due course.
That the report and presentation be received.