Agenda item

Representatives of North East Ambulance Service NHS Foundation Trust (NEAS) will be in attendance in order to outline performance against the Trust’s quality priorities for 2023-2024 and inform the Committee of the emerging priorities for the next year.

A representative of North East Ambulance Service NHS Foundation Trust (NEAS) was in attendance to provide a presentation to the Committee in relation to the organisation’s Quality Account, a document which NHS Trusts had a duty to produce each year.  The NEAS Assistant Director – Communications and Engagement (who relayed apologies from the NEAS Deputy Director of Quality and Safety (Deputy Lead Nurse)) covered the following elements:

·       Overview of quality report requirements

·       2023/24 performance (1 April – 31 December 2023)

o   Patient safety

o   Patient experience and feedback

o   999 incident volumes

o   Category 1 response performance (including benchmarking)

o   Category 2 response performance (including benchmarking)

o   Category 3 & 4 response performance (including benchmarking)

o   Hospital handover performance

·       Update 2023/24 quality priorities

Following a brief overview of the process requirements (consultation / publication) relating to the annual Quality Account (including that there was no obligation to obtain external auditor assurance this year), details were outlined on NEAS performance during the first three-quarters of 2023-2024 (April to December 2023).  Regarding patient safety, the number of recorded serious incidents (140) was significantly higher than for the whole of 2022-2023 (61), though the criteria for what constituted a ‘serious incident’ had changed to a case where the required response time had been exceeded by more than one hour (it was noted that the recording of serious incidents was not consistent across the country, so benchmarking against other Trusts was not possible).  For the ‘proportion of safety incidents per 1,000 calls’ measure, whilst the April to December 2023 figure (2.2%) was also up on the 2022-2023 data (1.8%), the final quarter for this year (January to March 2024) would likely reduce the overall rate for 2023-2024.

In terms of patient experience and feedback, it was pointed out that the top three themes for complaints (staff attitude, timeliness of response, and quality of care) also appeared as themes for appreciations / compliments that NEAS received.  Complaint numbers had been reducing since 2019-2020, and the number of appreciations for April to December 2023 (922) had already exceeded the number for the whole of 2022-2023 (812) and had surpassed the previous record (914) set in 2019-2020.

999 incident volumes between February 2023 and January 2024 (inclusive) had followed a similar trend for both the Tees Valley and Trust-wide footprint, with a broadly consistent number from March to November 2023, and a predictable increase in December 2023 and January 2024.

For the most serious ‘category 1’ incidents (cardiac / respiratory arrest), Tees Valley performance compared favourably with the data for the entire NEAS patch, with mean response times consistently below the Trust-wide average for all months from February 2023 to January 2024.  Whilst June 2023 and December 2023 saw NEAS go slightly above the average mean target response time (seven minutes) for category 1 cases, it was the only ambulance Trust in the country to be below this target in January 2024, something it was very proud of, and which reflected the significant amount of work which had been done around this measure.

‘Category 2’ incidents (including strokes and heart attacks) comprised a large number of the overall contacts made to NEAS (around 70% of all calls) and, like all other ambulance Trusts across the country, mean response times were significantly above the target (18 minutes) for every month from February 2023 to January 2024 despite improvements compared to the previous year.  Tees Valley mean response times were consistently worse than for the whole NEAS footprint (aside from January 2024) during the same period.  Guidance around this measure was issued last year, with proposals to amend the target time from 18 minutes to 30 minutes.

NEAS work around the provision of vehicle hours was outlined, with more crews put on the road than what the Trust had modelled (involving more vehicles / staff being taken on, including the recruitment of short-term assistance to aid response).  A graphic demonstrated the actual number of vehicle hours compared to the Trust’s operational plan (initiated in April 2023), with the impact on mean response times for category 2 cases against the revised 30-minute target shown.  Whilst this presented a more positive picture, NEAS acknowledged that there was a clinical reason why the target was 18 minutes, something the Trust should not lose sight of.

The average number of face-to-face incidents involving NEAS was charted, with these far exceeding planned numbers for every month from April 2023 onwards (including an all-time high in January 2024) – this raised the question of how the Trust managed such levels of demand without increased resources.  It was noted that NEAS also operated patient transport crews which could be deployed to lower-level incidents where possible to free up paramedic crews.

February 2023 to January 2024 performance for ‘category 3’ and ‘category 4’ (both urgent and non-urgent) cases was documented.  Broadly speaking, Tees Valley response times (90th centile) were well above the targets for both (less so for the whole NEAS area, though still above target), results which were partially due to inefficiencies within the wider health system (i.e. delayed handovers at hospitals) and challenges in deploying staff with the right skills.  To address the latter, NEAS was trying to develop / use Advanced Paramedic Practitioners (giving them more skills than standard ambulance crews) which aimed to benefit both patients (providing quicker care) and the whole ‘system’ (avoiding the need to take some individuals to hospital).

Hospital handover data was included which illustrated the specific pressures at the James Cook University Hospital, Middlesbrough (a site which took in more patients due to having more speciality services).  A rapid process improvement workshop was conducted to improve patient flow, and the Hospital Ambulance Liaison Officer (HALO) role had been re-introduced – such measures were working well and had been expanded across other areas of the NEAS footprint.  Elsewhere, data showed rising handover delays towards the end of 2023 / start of 2024 at both the North Tees and Darlington hospitals (the latter seeing a marked increase in delays over two hours).

The presentation concluded with commentary around what had been achieved, and what was still to do, in relation to the Trust’s 2023-2024 quality priorities:

·       To continue working with system partners to reduce handover delays (Patient Safety): Thematic analysis of handover delays undertaken, with particular focus on cases of moderate harm or below (had previously focused on more serious cases).  Work with partners to improve data-sharing and standardise reporting (improving whole ‘system’ effectiveness) also completed.  To begin addressing the need to understand the impact of handover delays on patients, an ambulance dataset had been introduced to start establishing outcomes for patients after handing them over (unaware of what happens to them currently) and ascertain the impact of hospital / ambulance interventions.

This priority would not be carried forward to 2024-2025 but would instead become business-as-usual.

·       Respond to patient safety incidents in a way that leads to service improvements and safer care for all our patients (Patient Safety): Several achievements noted, including a quality and safety profile review to inform local safety priorities, further development of governance procedures, transition to and training on PSIRF (Patient Safety Incident Response Framework), and the introduction of three patient safety partners.  With regards work still to do, the Trust was on track to complete all serious incidents and actions by the end of March 2024.

This priority would not be carried forward to 2024-2025 but assurance was given that NEAS would continue to focus on patient safety matters.

·       Implementation of clinical supervision (Clinical Effectiveness): Policies and procedures had been developed, with an audit roadmap for Clinical Team Leaders (CTLs) introduced to understand individual clinical performance.  Protected time for discussions was provided (particularly relevant for those crews / staff who were often working in isolation), with clinical staff also given five hours to support any development needs identified through supervision.  Looking ahead, an electronic audit tool and dashboards were to be developed, as well as a bespoke university module to help ensure all CTLs have the appropriate skills, knowledge and experience (to be completed in 2024).

This priority would not be carried forward to 2024-2025 but clinical effectiveness considerations would continue around ‘Martha’s Rule’ (prompt access to a second opinion of an individual’s condition).

·       To increase service-user and colleagues’ involvement in our patient safety and patient satisfaction activities (Patient Experience): NEAS Board, Trust partner, and stakeholder involvement in developments around this priority were highlighted, including the introduction of patient safety partners and the establishment of multi-disciplinary working groups for PSIRF implementation and patient safety improvement activities.  A patient feedback group still needed to be created, along with a patient and carer feedback survey (post-investigations), with wider involvement from patients and colleagues to be sought in relation to recruitment activities.

This priority would not be carried forward to 2024-2025 – NEAS would instead be focusing on the triangulation of data and making sense of the information it collected.

The Committee opened its reply to the presentation by probing those instances where patients were having to wait a significant time (beyond the target) for a response.  NEAS stated that much of this had been as a result of staff capacity (the Trust had filled the roles for which it was funded for), though some could also be attributed to demand pressures and handover delays at hospitals.  In terms of the latter, 30 minutes was the expected time for handover (15 minutes to pass the patient into the care of the hospital, and 15 minutes to re-stock) – the average for NEAS was 23 minutes, though this can increase during certain points of the year.  It was noted that once handover delays begin, they can be very difficult to rein in.

Reflecting upon public awareness of the challenges in relation to ambulance response times / handover delays, Members asked if there was any evidence of people preferring not to make contact with NEAS and instead making their own way to hospital for treatment.  The Committee was informed that the North East had benefitted from relatively stable relationships between health bodies which helped tackle pressure points more effectively than in other parts of the country.

Attention was drawn to the NHS 111 phoneline service, with the Committee querying if advice was consistent between that and the 999 number around who to contact in an emergency / non-emergency.  NEAS advised that call-handlers across the region were dual-trained and that the same operators would answer whether 111 or 999 was used – the amount and order of questions may, however, be different depending on which number was dialled.

The Committee expressed concern that the positive developments around hospital handovers may slip if this was no longer an explicit priority for 2024-2025.  NEAS gave assurance that the focus on ensuring timely handovers would not be lost (particularly since the issue had received national media interest) and that this was linked to the Trust’s overriding commitment to patient safety.  Members were also informed that the Secretary of State now received weekly briefings around this topic.

A question was raised about whether the Fire Brigade still acted as responders to ‘category 3’ incidents.  NEAS stated that the Fire Brigade did not act as paramedics but did have a role as community first responders – as such, they will be dispatched to certain cases if available.  The Committee also noted local schemes where different personnel were responding to certain incidents / environments (e.g. falls within care homes) – NEAS requested further details around these reported schemes if clarity was required.

With reference to the use of additional staff, the Committee asked if NEAS had been supported with extra finance for recruitment.  The Trust confirmed that commissioners had recognised the need for further resourcing and had provided significant additional funding to meet demand for services.

The Committee concluded the session by emphasising that caution would be needed that the move to increasing the category 2 target response time to 30 minutes (instead of the previous 18-minute aim) did not negatively impact patient outcomes – Members were advised that this would be fed back to the relevant NEAS personnel to see if both targets could be monitored in the future (which may also aid national benchmarking), and that the Trust was trying to be smarter about how it categorised calls (this used to be done by clinicians but, following a pilot, was now classified at the point of the call being made by the call-handler (with clinical input if required)).  Improved categorisation of incidents should help patients to receive better response times depending on their need.

AGREED that…

1)    the Quality Account-related update on North East Ambulance Service NHS Foundation Trust Quality Account performance in 2023-2024 be noted.

2)    a statement of assurance be prepared and submitted to the Trust, with final approval delegated to the Chair and Vice-Chair.