quality review and
quality account 2013/14
responsive
committed
effective
An introduction to Quality
Professor Sir Bruce Keogh
NHS Medical Director Department of Health
Mr David Bennett
Chief Executive of Monitor
Quality Accounts now represent a critical
part of the overall quality improvement
infrastructure of the NHS. Their introduction
in 2010 marks an important step forward in
putting quality reporting on an equal footing
with financial reporting.
The Government’s White Paper, Equity and
Excellence: Liberating the NHS, set out how
the improvement in quality and healthcare
outcomes would be established.
Quality Accounts demonstrate a relentless focus
on improving service quality. This compliments
the duties set out in Monitor, independent
regulator of NHS Foundation Trusts, current
quality governance guidance.
Boards are ultimately responsible for quality of
care provided across all service lines and they
must ensure that Quality Accounts:
❙❙
demonstrate commitment to continuous,
evidence based quality improvement;
❙❙
set out to patients where improvements
are required;
❙❙
receive challenge and support from local
scrutineers;
❙❙
enable Trusts to be held to account by
the public and local stakeholders for
delivering quality improvements.
To improve accountability the Quality Account
must provide progress against previously
identified improvement priorities, or explain
why such priorities are no longer being
pursued. Demonstrate how the review of
services and patient, public and, where
appropriate, governor engagement has led to
these priorities being set.
This will realise the vision of an open and
transparent NHS, enabling the success of the
NHS Foundation Trust governor model to
become autonomous and locally accountable.
The published evidence shows that public
disclosure in itself does not generally drive
improvement, but rather it is the organisational
response that Trusts put in place to improve
their record on quality that drives improvement.
Quality Accounts are beginning to demonstrate
quality improvements for the things that matter
most to patients.
This joint statement to the NHS sets the context nationally and underpins the South Western
Ambulance Service NHS Foundation Trust approach to continuous quality improvement.
2013/14 03
quality account
Part 1 – A statement on quality
from the Chief Executive
As we enter a new financial year, I am pleased to have this opportunity to reflect on the quality of
care and services we have delivered and to look forward to the developments and initiatives planned
going forward.
Each year I seem to report on significant change both in the NHS in general and our Trust specifically.
Last year was no different and there have been a number of changes to the services we provide
including a large increase in NHS 111 services and a reduction in patient transport services.
We now deliver the NHS 111 service in Devon, Somerset and Cornwall and the Isles of Scilly as well
as in Dorset, which was launched in the previous year. Our consolidated experience of delivering
call-handling and triage services has greatly benefited the patients who have used the service and
contributed to improved job satisfaction and morale of the staff working for 111.
Most of the areas where we provided patient transport services came up for re-tender during 2013
with the result that the Trust now provides PTS services only in Bristol, North Somerset and South
Gloucestershire and the Isles of Scilly. Although reduced numerically, there has been no let off in the
drive for quality and innovation.
Alongside these service changes, we have continued to work on the integration of the expanded
SWASFT created by the acquisition of the former Great Western Ambulance Service. The emphasis
has been on ensuring the best practice from each organisation is adopted and implemented across
the wider operating area which includes the communities of: Cornwall and the Isles of Scilly, Devon,
Somerset, North Somerset, Dorset, Wiltshire, Gloucestershire, South Gloucestershire, Bristol, Bath
and North East Somerset, and Swindon.
The Board of Directors and I have always made time to meet and speak with our hard-working staff
across the Trust. The expanded area makes this even more important. When I visit staff, I am always
impressed by their attitude, commitment and professionalism and sense of pride in SWASFT. This
was reflected in the unannounced Care Quality Commission (CQC) inspection which took place in
February 2014. The CQC reported noted the positive way in which staff responded to the inspectors,
explaining what, why and how they perform their role. It also recorded some of the pleasing
comments made by patients about our staff. I congratulate and applaud the staff and volunteers of
SWASFT for their collective efforts and achievements over the year.
In January 2013, Professor Sir Bruce Keogh, National Medical Director of the NHS, announced a
comprehensive review of urgent and emergency care and in November 2013, the first stage of
Transforming Urgent and Emergency Care in England was published. The report identified that there
was an opportunity to bring about a shift from patients being treated in hospital to treatment at
home. It specified that by supporting and developing paramedics and providing direct access to GPs
and specialists, around half of all 999 calls requiring an ambulance could be managed at the scene
without an unnecessary trip to hospital. I am pleased to include information in this quality report
showing that we are already achieving this level of outcome.
I was, therefore, delighted to invite Sir Bruce Keogh to visit our clinical hub in Dorset during March
2014. This hub houses one of our three 999 control centres, the Dorset NHS 111 control centre, the
Dorset and Somerset Out-of-Hours Doctors Service, and the innovative single point of access (SPoA)
for Dorset. Accompanied by Nigel Acheson, Regional Medical Director for NHS England South, Sir
Bruce was able to see integrated services in action and how they provide seamless patient care.
In 2014/15, we will continue to drive through improvements in experience and clinical outcomes for
patients and to enhance patient safety, putting this at the centre of every decision made. Our plans
include implementing the Electronic Care System, which will enable us to deliver even better clinical
outcomes for patients, through improved pathway management, data sharing and informed decision
making.
We have a long experience of implementing quality changes, based on an established knowledge
base. As a key provider of emergency and urgent care within such a large geographical area, it is
imperative that we work closely with other healthcare providers in the South West. This collaborative
approach to improving quality will ensure that services become more clinically effective and timely,
more patient-focused and, ultimately, safer.
I confirm that, to the best of my knowledge, the information in this quality report is accurate and
reflects a balanced view of SWASFT, its achievements and future ambitions.
Ken Wenman
Chief Executive
2013/14 05
quality account
Part 2 - Priorities for Improvement and
Statements of Assurance from the Board
of Directors
A review of quality improvement priorities made within SWASFT in 2013/14
Providing quality services to its patients remains a top priority for the Trust. During 2013/14 the Trust
reviewed and realigned its mission statement, vision, identified its values and updated its strategic
goals.
The values agreed by the Board of Directors demonstrate the emphasis that the Trust places on
the individuality of patients and staff, and the commitment the Trust has to delivering high quality
services.
Values
❙❙
Respect and dignity: We value each person as an individual, respect their aspirations and
commitments in life, and seek to understand their priorities, needs, abilities and limits;
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Commitment to quality of care: We earn the trust placed in us by insisting on quality and
striving to get the basics of quality of care – safety, effectiveness and patient experience –
right every time;
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Compassion: We ensure that compassion is central to the care we provide and we respond
with humanity and kindness to each person’s pain, distress, anxiety or need;
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Improving lives: We strive to improve health and well-being and people’s experiences of the
NHS;
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Working together for patients: We put patients first in everything we do, by reaching out to
staff, patients, carers, families, communities, and professionals inside and outside the NHS.
The Trust’s long term strategic goals and the corporate objectives reflect quality priorities. These
include national priorities for ambulance trusts and local commitments agreed with the Clinical
Commissioning Groups, responsible for commissioning services, and our Council of Governors.
The corporate objectives set for 2014/15 have been directly aligned to the newly revised strategic
goals and show the recurrence of quality throughout the strategic approach.
Strategic Goals and Corporate Objectives
Safe, Clinically Appropriate Responses; Delivering high quality and compassionate care to patients in
the most clinically appropriate, safe and effective way.
Right People, Right Skills, Right Values; Supporting and enabling greater local responsibility and
accountability for decision making; building a workforce of competent, capable staff who are flexible
and responsive to change and innovation.
24/7 Emergency and Urgent Care; Influencing local health and social care systems in managing
demand pressures and developing new care models. Leading emergency and urgent care systems,
providing high quality services 24 hours a days, seven days a week.
Creating Organisational Strength; Continue to ensure the Trust is sustainable, maintaining and
enhancing financial stability. In this way the Trust will be capable of continuous development and
transformational change by strengthening resilience, capacity and capability.
Performance and progress against these are all reported within the Trust Integrated Corporate
Performance Report which is presented to the Board of Directors at each publicly held meeting, and
is available on our website.
In 2013/14 the Trust reviewed its Quality Strategy. This important document ultimately aims to
ensure delivery of high quality, cost effective emergency and urgent healthcare services to people in
the Trust area.
The strategy demonstrates that the Trust’s approach to the delivery of high quality care is patientcentred and partnership-based, whilst engaging staff. It builds upon the already established
integrated approach to service planning and delivery, which will:
❙❙
Achieve the highest standards of patient safety;
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Achieve the highest standards of staff safety;
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Ensure quality remains at the top of the Trust’s agenda;
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Support staff to achieve the highest standards of professional clinical practice and
effectiveness;
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Promote the right behaviours and visible leadership from all staff from board to frontline;
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Continuously improve the quality of patient experience;
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Continuously improve the quality of staff experience;
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Achieve the highest standards of quality governance;
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Ensure early warning alerts are in place to inform the Board of any issues affecting quality;
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Ensure clear accountability and responsibility for quality;
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Foster a ‘quality culture’ encouraging staff to speak out when quality could be further
improved.
2013/14 07
quality account
2013/14 Quality Priorities
In 2013/14 the Trust published a Quality Account building on its continuous quality improvement
journey and setting out its priorities for the year ahead. Priorities are listed under three categories,
patient safety, clinical effectiveness and patient experience. The priorities from 2013/14 are restated
below as they appeared in the Quality Account, along with an overview of the Trust’s performance:
Patient Safety
Priority 1 – Identification of Sepsis - why a priority?
❙❙
Sepsis is a life-threatening condition that arises when the body’s response to an infection
injures its own tissues and organs;
❙❙
There are 100,000 cases of sepsis each year in the UK, with an estimated 37,000 deaths;
❙❙
Sepsis can arise from infection in a huge variety of sources, including minor cuts and bladder
and chest infections;
❙❙
Sepsis can lead to shock, multiple organ failure and death especially if not recognised early
and treated promptly;
❙❙
Research shows that simple interventions,-such as giving IV antibiotics and fluids in the first
hour, can reduce the risk of death by over one-third, yet international guidelines representing
these interventions are delivered to fewer than one in eight patients in the NHS;
❙❙
The key to saving lives lies in early recognition and immediate treatment.
Aims
❙❙
Increase the number of patients with sepsis who are rapidly identified and treated by
ambulance clinicians;
❙❙
Reduce the number of incidents reported regarding the lack of recognition of sepsis by 50%
by 31 March 2014.
Initiatives
❙❙
Utilise the new sepsis diagnosis code introduced to the patient clinical record during 2012 to
audit the management of sepsis;
❙❙
Explore the feasibility of pre-hospital lactate testing to aid in sepsis recognition;
❙❙
Explore the implementation of pre-hospital antibiotics.
Did we achieve this priority?
Yes, we partially achieved this priority. The introduction of the new sepsis diagnosis code in the
east and west divisions in late 2012 enabled the number of potential sepsis cases to be identified.
Analysis of the data demonstrates that 795 patients were identified as potentially suffering from
sepsis during the period August 2013 - October 2013 (the most recent data available), compared
to just 541 during November 2012 - January 2013. This represents a 47% increase in the number of
cases of potential sepsis being identified by ambulance clinicians.
Whilst the Trust aspired to reduce the number of adverse incidents reported during the year relating
to the lack of recognition of sepsis by 50%. The emphasis on sepsis has led to a significant increase
in staff awareness. This in turn has led to a growth in adverse incidents being reported relating
to sepsis. The Trust view this as a positive step to further improving care and one that reflects an
increased awareness as opposed to an increase in risk. Whilst the number of lower risk incidents
have increased due to improved reporting, it should be noted that the number of serious incidents
linked to sepsis has remained at the same level as 2012/13 with two incidents occurring.
Priority 2 – Infection Prevention and Control Monitoring - Why a priority?
❙❙
The need to improve cleanliness and reduce healthcare acquired infections remains one of the
top national priorities detailed within the NHS. The Trust remains fully committed to tackling
infection prevention and control challenges, whilst sustaining compliance with national
guidance and regulation;
❙❙
Robust policies and procedures are in place, which if followed will ensure that every
patient will receive care in an environment in which we would be proud for our relatives to
experience;
❙❙
The challenge is to objectively monitor the level of environmental cleanliness within
emergency ambulances;
❙❙
During 2012/13 the Trust piloted the use of adenosine triphosphate (ATP) monitoring on PTS
ambulances;
❙❙
ATP can only be produced by living cells, where it is their energy currency. ATP testing
involves using a swab to pick up the contaminants present on a surface. An enzymic reaction
converts the ATP present on the surface into a small amount of light, which is measured by
a luminometer. The more bacteria on the surface, the more light is produced and the higher
the reading reported.
Aim
❙❙
Implement ATP environmental monitoring, to evaluate and improve the level of cleanliness of
surfaces within the patient compartment of emergency ambulances.
Initiatives
❙❙
Implement random ATP swab testing to 10% of ambulance vehicles during each quarter of
2013/14;
❙❙
Utilise the results to highlight the importance of regular cleaning by clinicians each day and
after each patient.
Did we achieve this priority?
Yes we did achieve this priority.
2013/14 09
quality account
ATP monitoring was used throughout the year to check the standard of cleanliness on emergency
ambulances across the fleet. Whilst the aim was to swab three specific areas on 10% of vehicles
each quarter, initial experience demonstrated that far more value could be achieved from swabbing
a wider number of areas. The protocol was revised to focus more on the quality of the swabbing
process than the quantity of tests conducted. A total of 10% of emergency ambulances were
checked over the course of the year.
The results highlighted areas of good practice and enabled the Trust to focus on areas that would
benefit from further improvements. Recommendations from the initiative have been incorporated
into the 2014/15 Annual Infection Prevention and Control plan. The Trust is committed to further
expanding the application of ATP swabbing during 2014/15, by including it as a core part of the
regular unannounced inspections of ambulance stations and vehicles by the Infection Control Lead.
Clinical Effectiveness
Priority 3 – Post ROSC Care Bundle - Why a priority?
❙❙
Every month the Trust responds to around 200 patients who have suffered a cardiac arrest;
25% will regain a pulse (return of spontaneous circulation - ROSC) before they reach hospital;
❙❙
Historically, the pre-hospital management of cardiac arrest patients has focused more on
resuscitating the patient to achieve a ROSC, than on delivering high quality care once it is has
been achieved to ensure that the pulse is maintained;
❙❙
The Trust focused on the implementation of evidence based guidelines introduced during
2012 through the use of a post-ROSC care bundle, based on standards recommended by the
Intensive Care Society;
❙❙
Post ROSC care consists of a number of elements:
▲▲ Patients are more likely to make a good recovery after a cardiac arrest if they are able to
maintain a reasonable blood pressure during the first two hours. Paramedics now infuse
a small dose of adrenaline and use intravenous fluids to ensure that the patients blood
pressure is maintained;
▲▲ Following resuscitation, many patients have a poor neurological outcome as a result
of brain injury caused by a lack of oxygen. Paramedics now cool patients to induce
hypothermia, as this improves outcomes;
▲▲ Many cardiac arrests are caused by a heart attack. Paramedics now obtain an ECG
(picture of the heart) to identify a heart attack early, to allow prompt treatment at
hospital;
▲▲ Clinicians use state of the art monitors to measure the amount of carbon dioxide in the
air breathed out by patients, to ensure that they are ventilated to deliver the optimum
concentration of oxygen;
▲▲ The amount of glucose in a patient’s blood is measured to identify and treat any
abnormalities.
Aim
❙❙
Improve the level of care delivered to patients who regain a pulse after a cardiac arrest, to
ensure that they are more likely to retain their pulse, and have a better chance of survival
without brain damage.
Initiatives
❙❙
Implement and monitor a post-ROSC care bundle, providing feedback to clinicians on their
performance.
❙❙
Establish a Resuscitation Group to lead on the monitoring and improvement of the care
delivered to patients following a cardiac arrest.
Did we achieve this priority?
Yes we did achieve this priority.
The post ROSC care bundle was introduced at a study day held in April 2013. A range of experts,
including one international speaker, presented on the importance of the post ROSC phase in prehospital care and the event was well attended with over 70 delegates from across the Trust area.
Comparison of baseline data on the post ROSC care bundle showed an improvement of 23.8% in
the delivery of the care bundle to this patient group, from 8.3% to 32.1%.
The Trust’s bi-monthly Resuscitation Group has been established and is now a regular fixture where
relevant research papers and their implications for clinical practice are reviewed. A selection of
clinical cases is also scrutinised by this group and carefully structured feedback is given to clinical
staff following this review.
❙❙
❙❙
❙❙
❙❙
The post-ROSC care bundle is reported regularly to the Resuscitation Group;
Clinicians receive individual email feedback on their care of patients who obtain ROSC and
are reminded of the importance of the care bundle;
Minutes from the Resuscitation Group are reported to the Clinical Effectiveness Group;
A programme of Quality Improvement activity has been started, which has included the
provision of an updated Ambulance Clinical Quality Indicator (ACQI) checklist, which provides
details of the care bundle, on each vehicle.
2013/14
quality account
11
Patient Experience
Priority 4 – Dignity Privacy and Respect - why a priority?
❙❙
The NHS has put patient safety and patient experience at the centre of delivering high-quality
care. People receiving health services need to be treated with dignity. The NHS aims to create
a culture in which there is a zero-tolerance approach to the abuse of, and disrespect to, all
patients, and likewise an expectation of the same approach from patients to healthcare staff;
❙❙
It is acknowledged that Trust staff can face many barriers to communication in the course
of their work including language, ethnicity, cultural diversity, and also vulnerability (i.e. the
effects of alcohol). Overcoming, or at the very least, recognizing these barriers will support
staff in carrying out their professional duties to the best of their abilities and ensure they treat
patients, and their families and carers, with dignity, privacy and respect. It will also encourage
patients to afford the same respect and courtesy to staff attending them;
❙❙
In 2012/13 the Trust undertook interviews with support groups for patients with dementia
or who self harm. The Trust received some very positive feedback but also some comments
about how those patients felt when attended by an ambulance crew which sometimes
included feelings of anxiety and embarrassment. Further work was recommended to consider
how patients’ perceptions could be communicated to staff attending them, and whether
any behaviour modification was required for some groups of patients. These findings have
directed the focus of this quality indicator.
Aim
❙❙
SWASFT will seek to improve its methods of communication with its patients to improve their
experience of contact with all clinicians employed by the ambulance service.
Initiatives
❙❙
Undertake a review during the first six months of 2013/14 of feedback where patients or
their family or carers have reported a less than satisfactory experience in terms of dignity,
privacy or respect. Sources will include:
▲▲ Patient Opinion website feedback;
▲▲ Have Your Say leaflet returns;
▲▲ Complaints and concerns;
▲▲ Reported incidents;
▲▲ Urgent Care Service monthly survey.
❙❙
Review and update the set of tools used to assist staff in communicating with patients, their
carers and families and implement improvements which help to ensure they are treated with
dignity, privacy and respect, learning lessons from colleagues working in more culturally
diverse urban areas such as Bristol.
Did we achieve this priority?
Yes, we did achieve this priority.
The Trust undertook a review of collective patient (patient, family member, carer, friend) feedback
that cited a less than favourable experience with regards to dignity, privacy or respect. This was also
compared with information reported by healthcare staff, both internal and external.
There were correlations between incident reports submitted from other care organisations/
professionals and complaints made by the public. During the first six months of 2013/14, the
consistent top areas of reporting for both patients/public and other caring professions were:
❙❙
Treatment/clinical management plans;
❙❙
Attitude/communication;
❙❙
Conveyance issues.
Of the complaints regarding communication issues, the most prominent was staff attitude. It is
apparent that how a person (whether patient or someone around the patient) feels as a result of
contact with the ambulance service seems to be as important as the clinical care, in influencing
whether their experience was positive or negative.
Common themes from complainants primarily referring to staff attitude include:
❙❙
Complaints regarding attitude issues are specific to individual members of staff rather than
applying to all staff members across the Trust;
❙❙
During investigations relating to staff attitude, crews often responded that the complainant
or those around them were aggressive/rude and this had a negative impact on all
communication;
❙❙
Making recommendations regarding staff attitude is problematic. Without an independent
witness to the events it is often difficult to offer an objective viewpoint on what happened.
Common themes highlighted from incident reports primarily referring to communication include:
❙❙
Poor levels of professional conduct, with regards to attitude, demonstrated by individual staff
members;
❙❙
Incident reports regarding communication issues are often specific to the one issue rather
than encompassing other elements;
❙❙
Incident reports from other healthcare professionals comment on how staff are seen to be
abrupt or challenging.
The Trust subscribes to the Patient Opinion website, an independent site where people can post their
experiences of using our services. The content of this is not coded in the same way that incidents or
complaints are - postings are rated for their level of criticism (referred to as a criticality score).
It is difficult to determine themes from the postings on the website, as there were only two posts
that made reference to a less than satisfactory experience with regards to dignity, privacy or respect.
However, what is clear from the majority of the postings on the website is that, largely, patients/
carers are able to report a very positive experience with the Trust, with no concerns in relation to
dignity, privacy or respect.
2013/14 13
quality account
Using the information gathered as part of the review of privacy, dignity and respect issues, a number
of recommendations have been identified, which include:
❙❙
Consider ways to educate patients on the service they can expect. For example the
development of an FAQ section on the internet regarding Trust policy/procedure;
❙❙
Build an online education tool using the stories provided by patients to support staff to
provide excellent customer service;
❙❙
Review complaints to identify members of staff with multiple attitude complaints within a 12
month period and consider how these staff members could be supported to help reduce the
number of complaints.
This action plan has been presented to the Learning From Experience Group and will continue to be
monitored by the group until completion.
Tools available to support staff communication with patients include:
❙❙
Access to the pre-hospitalisation communication guide that offers help to staff in conversing
with patients who may need help with communication e.g. where English is not their first
language;
❙❙
Invitation for patients to provide feedback via calling cards. The card offers a question based
on the Friends and Family Test (Based on your experience of our service, would you be happy
for a relative or friend to receive the same level of service?) and directs them to the Patient
Opinion website (or Freephone number) to provide the feedback. This card has encouraged
staff to promote feedback opportunities with collective patients and give them an option to
share their experience with the Trust, whether positive or less favourable;
❙❙
The Trust has also made a script for a film that will be available to staff online. The script uses
a real patient account in the patient’s words to demonstrate the different experiences they
had when they used the service twice in one week.
Further work to support future commitment to continuous communication improvements include:
❙❙
During 2013/14 the Trust carried out some face-to-face ‘real-time’ patient surveys in
Emergency Departments. In these surveys patients were asked specific questions around
dignity, privacy and respect. These surveys will be reviewed to further identify means to
support positive staff communication with patients in future;
❙❙
Specific work is now being undertaken to review the content of Trust plaudits (compliments)
from patients and those who support them, to understand the motivation for those who
make a specific effort to say ‘thank you’ to Trust staff. This work will help to highlight
pockets of excellence that will be translated into guidance for staff to promote improved
communication in all aspects of patient contact.
Quality Priorities for Improvement
2014/15
The Trust is accountable to its patients and service users and the Quality Account provides an ideal
mechanism for addressing this. As a Foundation Trust the Trust has a Council of Governors which is
invaluable in providing representation of the views of Governors constituents, the membership and
the public, gained through engagement activities.
The Trust consulted with its Council of Governors to obtain their opinion and input on the suggested
priorities within this report. Senior Trust personnel gave information to the Governors to facilitate
table top discussions. This enabled them to input into the construction and content of the priorities.
In developing the priorities for 2014/15, the Trust has also taken into account feedback provided by
stakeholders, including commissioners, from the 2012/13 Quality Account. This feedback has also
been taken into account in the inclusion of information within the quality overview in Part 3 of this
report.
The Trust’s commissioners have been consulted on the priority areas proposed for 2014/15, to ensure
the health community supports the areas identified.
In setting the priorities for 2014/15 consideration has also been given to Quality Account priorities
from previous years, learning from these and the benefits in focusing further on these areas. As a
result the patient safety priority continues to relate to sepsis and how this is identified and managed.
This year it will focus on sepsis in children. The indicator relating to sepsis was originally introduced
due to the identification of trends from learning through adverse and serious incident reporting and
balancing this with information reported from other organisations and the wider health community.
Whilst improvements have been made in the management of sepsis, continuing the focus in this area
will benefit patient care.
The Trust is required to submit information for a number of quality targets known as ambulance
clinical quality indicators. These are a set of indicators which have been agreed nationally by
ambulance trusts as a way of driving continuous quality improvement. Some of these are indicators
included in this quality report as mandatory indicators. The third improvement indicator this year
relates to one of these quality indicators. Analysis of the root cause of breaches to the STEMI call-toballoon (CTB) time (a treatment for patients suffering from a heart attack) will occur to identify areas
for improvement. This has been identified by local commissioners as a priority for improvement.
A major project during 2014/15, which will be a key driver for quality improvement, is the
implementation of the Electronic Care System (ECS). This exciting innovation will improve the
management of pre-hospital care and will have the technical ability to integrate with systems within
both the acute and community care settings.
2013/14 15
quality account
During 2013/14 the implementation leads for the agreed priorities were responsible for monitoring
at the appropriate working groups, for example the Infection Prevention and Control Group. In
addition, the Trust’s Quality and Governance Committee monitored the Quality Account priorities
through exception reports at its bi-monthly meetings. This structure will be continued during the
forthcoming year.
Patient Safety
Priority 1 – Sepsis - why a priority?
Sepsis is a life-threatening condition that is caused when the body over-reacts to an infection, it
results in the body injuring its own tissues and organs. There are 100,000 cases of sepsis each year
in the UK, with an estimated 37,000 deaths.
Sepsis can arise from infection in a huge variety of sources, including minor cuts and bladder
and chest infections. Sepsis can lead to shock, multiple organ failure and death especially if not
recognised early and treated promptly. Although anybody can develop sepsis, some people are
more vulnerable, such as those at the extremes of life, the very old and the very young. As a result,
children, particularly premature babies and infants, can be more susceptible to developing sepsis.
The key to saving lives lies in early recognition and immediate treatment.
Aims
❙❙
Increase the proportion of child (paediatric) patients with sepsis who are rapidly identified
and treated by ambulance clinicians;
❙❙
Embed current guidelines into practice, ensuring clinicians use common terminology (NICE
traffic light system) when communicating with other health care professionals and when
documenting their findings
❙❙
Reduce the number of adverse incidents and serious incidents relating to the treatment of
children with fever/sepsis by 50% from the 2013/14 baseline by 31 March 2015.
Initiatives
❙❙
Audit the management of paediatric patients with fever and sepsis;
❙❙
Increase awareness amongst clinicians regarding the difference between fever and sepsis in
children;
❙❙
Adopt a common paediatric recognition tool within SWASFT for face to face use;
❙❙
Appoint paediatric sepsis champions in each of the Trust operating areas to help promote this
key work stream.
Board Sponsor:
Executive Medical Director
Implementation Lead:
Clinical Development Manager West
How will we know if we have achieved this priority?
❙❙
The Trust will publish a clinical audit focusing on the management of sepsis;
❙❙
A report will be presented to the Clinical Effectiveness Group setting out the choice of
recognition tool and the impact it will have on practice;
❙❙
Share feedback from local paediatric sepsis champions through the Clinical Effectiveness
Group and other relevant working groups.
Clinical Effectiveness
Priority 2 – Electronic Care System (ECS) - Why a priority?
The implementation of Electronic Care System is an exciting innovation which will be used in the
pre-hospital arena to better manage patient care and which will also have the technical ability to
integrate with hospital and other wider health community systems. A fully managed service will be delivered, that allows the Trust to electronically capture, exchange
and report on better quality patient information. ECS will support the Trust in delivering benefits
throughout the wider health and social care community and assist the Trust to better meet the
needs of patients and support the urgent care agenda. The outcomes that will enable these benefits
across the emergency care pathway cover include:
Aims
❙❙
Deliver better clinical outcomes for patients, through better pathway management, data
sharing and informed decision making;
❙❙
Reduce the number of patients taken to Emergency Departments unecessarily;
❙❙
Improve the communication of appropriate and essential patient information across the
healthcare community; including receiving units, GPs and other parties involved with patient
care;
❙❙
Deliver improved support for Trust staff resulting in improved job satisfaction.
Initiatives
❙❙
Implementation of the Electronic Care System.
Board Sponsor:
Executive Medical Director
Implementation Leads:
Clinical Development Manager East
How will we know if we have achieved this priority?
❙❙
Implementation of the ECS according to the delivery plan.
❙❙
Delivery of the training required for Trust staff to be able to effectively utilise the system.
2013/14
quality account
17
Priority 3 – Primary Angioplasty - Why a priority?
When someone experiences a heart attack, the priority is to remove the blood clot obscuring the
blood vessel as soon as possible to minimise the damage caused to the heart. Primary Angioplasty is
the definitive treatment for a heart attack, which involves hospital specialists inserting a small tube
through a vein, into the blocked blood vessel within the heart. A tiny balloon at the tip of the tube
is then inflated to squash the blockage. A stent (small piece of wire mesh) expands with the balloon,
and remains in the blood vessel to ensure that it remains open. The sooner patients reach a hospital
that can deliver this specialist procedure, the better their outcome is likely to be.
The time that it takes from the initial emergency call to the balloon being inflated to relieve the
clot during primary angioplasty is known as the call-to-balloon (CTB) time. The national target is
to achieve a call-to-balloon time of under 150 minutes, which is reflected in the ambulance clinical
quality indicator (ACQI) for patients who suffer from a heart attack. Local thresholds are set for the
percentage of patients receiving such timely intervention.
Aim
❙❙
Improve performance against the locally set threshold of 84% for the number of patients
achieving a call-to-balloon time of 150 minutes for primary angioplasty.
Initiatives
❙❙
Complete a root cause analysis of CTB breaches;
❙❙
Develop and implement an action plan to enable achievement of the local CTB target of 84%.
Board Sponsor:
Executive Medical Director
Implementation Lead:
Clinical Development Manager North
How will we know if we have achieved this priority?
❙❙
Achieve 84% CTB local target by 31/03/2015;
❙❙
Provide evaluation report and plans to sustain performance to participating CCGs and Lead
Commissioner.
Patient Experience
Priority 4 – Friends and Family Test (FFT) - why a priority?
Quality Account guidance recommends that trusts look at local and national indicators as sources
for proven indicators where they overlap with local priorities. As a result, this year the Trust has
included the Friends and Family Test as a priority for 2014/15. This test was introduced in other
parts of the NHS in 2013, and asks patients whether they would recommend the hospital wards,
emergency departments and maternity services to their friends and family if they need similar care
and treatment. Asking all patients this question is aimed at giving hospitals a better understanding
of the needs of their patients and enabling improvements.
Implementation of this is a key part of NHS England’s current business plan. The Trust does not
underestimate the significance of the introduction of this indicator, and the local value of having
a consistent indicator about how patients ‘rate’ our services. Due to its importance it has been
included in the priorities for 2014/15.
Aim
SWASFT has proactively encouraged feedback from its patients both positive and negative. We have
worked on developing a range of feedback mechanisms to allow patients, their carers and families to
tell us about their experiences. Patient feedback gives a rich source of insight into the overall patient
experience and is used to help inform the refinement and development of our future services.
NHS England states that the FFT ‘aims to provide a simple headline metric which, when combined
with follow-up questions, is a tool to ensure transparency, celebrate success and galvanise improved
patient experience.’ SWASFT can use this measure, together with supporting questions to help
understand the important elements that drive patient satisfaction across its various services.
Since April 2013, the FFT question has been asked in all NHS in-patient and A&E departments across
England. From October 2013, all providers of NHS-funded maternity services have also been asking
women the same question at different points throughout their care. The implementation of the FFT
across all NHS services is an integral part of NHS England’s business plan for 2013/14 – 2015/16 and
it has committed to extending the FFT to the all NHS-funded services, including ambulance services,
by the end of March 2015. In addition, from 1 April 2014, all NHS trusts providing acute, community,
ambulance and mental health services in England are required to implement the FFT for staff.
2013/14 19
quality account
Initiatives
The initiatives include:
❙❙
Implement staff Friends and Family Test according to the NHS England guidance;
❙❙
Write to NHS England explaining our experience to date of eliciting patient feedback to help
inform the detailed FFT guidance, so that it can account for the different approach that may
be required for ambulance trusts (expected towards the end of June 2014);
❙❙
Carry out segmentation analysis of our patient base in preparation for full implementation of
patient FFT;
❙❙
Undertake a feasibility study of how we might conduct the patient FFT;
❙❙
Early implementation of FFT in one service line by 1 October 2014;
❙❙
Full implementation of patient FFT;
❙❙
Internal promotion and reporting of FFT scores as they become available;
Board Sponsor:
Executive Director of Nursing and Governance
Implementation Leads:
Senior Patient Experience Manager and Patient Engagement Manager
How
❙❙
❙❙
❙❙
❙❙
will we know if we achieve this priority?
We will have mechanisms for asking the FFT for both patients and staff.
We will be able to report FFT by service line;
We will be able to track FFT by time;
We will be able to publish FFT internally.
Statements of Assurance from the Board
Statutory statement
This content is common to all healthcare providers which make Quality Accounts comparable
between organisations and provides assurance that the Board has reviewed and engaged in crosscutting initiatives which link strongly to quality improvement.
1
During 2013/14 the South Western Ambulance Service NHS Foundation Trust provided and/or
sub-contracted three relevant health services:
▲▲ Emergency (999) Ambulance Service;
▲▲ Urgent Care Service (NHS 111 and GP Out-of-Hours);
▲▲ Non Emergency Patient Transport Service.
1.1 The South Western Ambulance Service NHS Foundation Trust has reviewed all the data
available to them on the quality of care in all of these relevant health services.
1.2 The income generated by the relevant health services reviewed in 2013/14 represents 97.61%
per cent of the total income generated from the provision of relevant health services by the
South Western Ambulance Service NHS Foundation Trust for 2013/14.
2
During 2013/14, 1 national clinical audits and 0 national confidential enquiries covered
relevant health services that South Western Ambulance Service NHS Foundation Trust
provides.
2.1 During that period South Western Ambulance Service NHS Foundation Trust participated in
100% national clinical audits and 0% national confidential enquiries of the national clinical
audits and national confidential enquiries which it was eligible to participate in.
2.2 The national clinical audits and national confidential enquiries that South Western Ambulance
Service NHS Foundation Trust was eligible to participate in during 2013/14 are as follows:
▲▲ National Ambulance Non Conveyance Audit.
2.3 The national clinical audits and national confidential enquiries that South Western Ambulance
Service NHS Foundation Trust participated in during 2013/14 are as follows:
▲▲ National Ambulance Non Conveyance Audit.
2.4 The national clinical audits and national confidential enquiries that South Western Ambulance
Service NHS Foundation Trust participated in, and for which data collection was completed
during 2013/14, are listed below alongside the number of cases submitted to each audit or
enquiry as a percentage of the number of registered cases required by the terms of that audit
or enquiry:
▲▲ National Ambulance Non Conveyance Audit - 290 cases (100%).
2013/14 21
quality account
2.5 The reports of 1 national clinical audits were reviewed by the provider in 2013/14 and South
Western Ambulance Service NHS Foundation Trust intends to take the following actions to
improve the quality of healthcare provided:
▲▲ Participate in the 2014/15 National Ambulance Audit of Non Conveyance.
The reports of 17 local clinical audits were reviewed by the provider in 2013/14 and South
Western Ambulance Service NHS Foundation Trust intends to take the following actions to
improve the quality of healthcare provided:
▲▲ Continue to reinforce the importance of good quality record keeping which underpins
clinical quality reporting;
▲▲ Work to ensure that all clinical audits cover the whole Trust area to inform service
delivery across the region;
▲▲ Following successful trials of drug interventions for patients who have overdosed,
continue to engage with the Medicines Management Group to inform medicines
evaluation and procurement;
▲▲ Work with the Clinical Development team to reiterate the importance of reducing on
scene times for patients with a suspected stroke;
▲▲ Work with the sepsis clinical sub group to develop a programme of work improving
recognition of suspected sepsis and trialling the feasibility of pre-hospital point of care
testing for lactate;
▲▲ Ensure that the outputs of clinical audit are used to inform the work of the Quality
Improvement Paramedics.
3
The number of patients receiving relevant health services provided or sub-contracted by
South Western Ambulance Service NHS Foundation Trust in 2013/14 that were recruited
during that period to participate in research approved by a research ethics committee was
341.
4
A proportion of South Western Ambulance Service NHS Foundation Trust income in 2013/14
was conditional on achieving quality improvement and innovation goals agreed between
South Western Ambulance Service NHS Foundation Trust and any person or body they
entered into a contract, agreement or arrangement with for the provision of relevant health
services, through the Commissioning for Quality and Innovation payment framework. Further
details of the agreed goals for 2013/14 and for the following 12 month period are available
on request from www.swast.nhs.uk.
The monetary total available for the Commissioning for Quality and Innovation payments, for
all service lines, for 2013/14 was £3,564,833 and for 2012/13 was £2,558,968.
5
South Western Ambulance Service NHS Foundation Trust is required to register with the
Care Quality Commission and its current registration status is ‘registered without compliance
conditions’. South Western Ambulance Service NHS Foundation Trust has the following
conditions on registration:
▲▲ None.
The Care Quality Commission has not taken enforcement action against South Western
Ambulance Service NHS Foundation Trust during 2013/14.
6
South Western Ambulance Service NHS Foundation Trust has participated in special reviews
or investigations by the Care Quality Commission relating to the following areas during
2013/14:
An unannounced inspection of:
▲▲ Outcome 2 – Consent to care and treatment;
▲▲ Outcome 4 – Care and welfare of people who use services;
▲▲ Outcome 10 – Safety and suitability of premises;
▲▲ Outcome 16 – Assessing and monitoring the quality of service provision;
▲▲ Outcome 17 – Complaints.
The final report was published in March 2014 and the South Western Ambulance Service NHS
Foundation Trust was assessed as being compliant with these standards.
South Western Ambulance Service NHS Foundation Trust intends to take the following
actions to address the conclusions or requirements reported by the Care Quality Commission:
▲▲ None (assessed as compliant).
South Western Ambulance Service NHS Foundation Trust has made the following progress by
31 March 2014 in taking such action:
▲▲ Not applicable.
7
South Western Ambulance Service NHS Foundation Trust did not submit records during
2013/14 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which
are included in the latest published data.
8
South Western Ambulance Service NHS Foundation Trust Information Governance Assessment
Report overall score for 2013/14 was 68% and was graded green.
9
South Western Ambulance Service NHS Foundation Trust was not subject to the Payment by
Results clinical coding audit during 2013/14 by the Audit Commission.
2013/14 23
quality account
10. South Western Ambulance Service NHS Foundation Trust will be taking the following action
to improve data quality:
▲▲ Maintain and develop the existing data quality processes embedded within the Trust;
▲▲ Hold regular meetings of the Information Assurance Group to continue to provide a
focus on this area;
▲▲ Ensure completion and return of the monthly Data Quality Service Line Reports;
▲▲ Continue to provide Data Quality Assurance Reports to the Board of Directors.
▲▲ Where external assurance of data quality is required commission an independent review
from Audit Southwest, the Trust’s internal audit provider.
Key Performance Indicators
This section includes the mandatory indicators which the Trust is required to include in this report.
Further performance information, including Category A Performance by Clinical Commissioning
Group, is shown in Part 3 of this report.
Category A Performance (Whole Trust)
Performance
Category A
Target
Performance
2013/14
2012/13
Jun to
2012/13
Mar
Jun to Jan
(SWASFT) (GWAS)
National Highest
Lowest
2012/13
Average
Trust
Trust
Apr to May*
2013/14** 2013/14** 2013/14**
Red 1
75%
73.15%
73.01%
75.3% 75.8%
Red 2
75%
77.23%
75.93%
76.9%
(SWASFT)
76.8%
(GWAS)
75.5
80.6
71.0
74.6
78.8
70.1
Performance
Category A
Performance
19 Minute
Target
95%
2013/14
95.76%
2012/13
(SWASFT)
95.36%
2012/13
Apr to Jan
(GWAS)
95.7%
National
Average
2013/14**
96.1
Highest
Lowest
Trust
Trust
2013/14** 2013/14**
97.8
80.0
*In 2012/13 the reporting of Category A 8 minute response times was split into Red 1 and Red 2 with effect from 1 June 2012, previously performance was
reported on a combined basis.
**Highest/Lowest Trust reporting has been noted for each indicator independently, current information from YTD 2013/14 reported at the end of February.
For clarification, Category A incidents are those with patients with a presenting condition which may
be immediately life threatening and who should receive an emergency response within 8 minutes
irrespective of location, in 75% of cases. Red 1 calls are those requiring the most time critical
response and cover cardiac arrest patients who are not breathing and do not have a pulse and other
severe conditions such as airway obstruction. Red 2 calls are those serious but less immediately time
critical and cover conditions such as stroke and fits. In addition Category A patients should receive
an ambulance response at the scene within 19 minutes in 95% of cases. A19 performance is based
on the combination of both Red 1 and Red 2 categories of call.
The Trust is assessed against the delivery of the Red 1, Red 2 and A19 performance targets quarterly
by Monitor. The position at the start of quarter four 2013/14 showed the Trust had breached the
Red 1 performance target for four consecutive quarters (including quarter three of 2013/14). Details
of this breach have been reported within the Annual Governance Statement, which forms part of
the Annual Report. This includes assurance of the action taken to improve the position (as well as
discussions with Monitor) and the performance for the final quarter of 2013/14 is 76.86%. The Trust
maintained its Monitor Green Governance Risk Rating throughout the year.
In addition, during the final quarter of 2013/14 the Trust received an unannounced CQC inspection,
which included the outcome relating to the quality of service provision. The inspectors requested
information on current Red 1, Red 2 and A19 performance. They were provided with documentation
and assurance of the processes which had been implemented to achieve Red 1 performance in
quarter four, and the improvements that had already been delivered at the time of the inspection.
The lead inspector also spoke with commissioners, who confirmed their satisfaction with the
progress made. The CQC did not make any recommendations or impose any compliance conditions
following their inspection.
The South Western Ambulance Service NHS Foundation Trust considers that this data is as described
for the following reasons:
❙❙
The Trust has robust data quality processes in place to ensure the reporting of performance
information is both accurate and timely;
❙❙
Information is collated in accordance with the guidance for the Ambulance Clinical Quality
Indicators;
❙❙
This information is reported to the Board of Directors monthly in the Integrated Corporate
Performance Report;
❙❙
Additional scrutiny on the quality of performance information has also been received this year
with the delivery of an internal audit report on Red 2 performance information.
The South Western Ambulance Service NHS Foundation Trust is taking the following actions to
improve these percentages, and so the quality of its services, by:
❙❙
The development and implementation of a red performance recovery plan. This is a
comprehensive plan developed in conjunction with all areas of the Trust and commissioners
to identify where and how improvements to performance can be achieved.
2013/14 25
quality account
Ambulance Clinical Quality Indicators (ACQIs):
ACQIs are designed to reflect best practice in the delivery of care for specific conditions and to
stimulate continuous improvement in care. They were initially introduced in 2010/11, and since this
time ambulance trusts have been working nationally to agree and improve the comparability of
the datasets reported. In May 2013 a national benchmarking day was led by SWASFT’s Research
and Audit Manager. The day aimed to capture the process maps from each trust and look at any
differences in data collection and validation points before submissions. The largest variations were
found in the application of the inclusion and exclusion criteria, and not in the application of the
criteria to measure performance. The results of this work have been shared with the National
Ambulance Clinical Quality Group and the National Medical Directors Group and a programme of
work is being developed nationally to progress key actions during 2014/15. This will include:
❙❙
Updates to the technical guidance issued to ambulance services, including bespoke guidance
for users of electronic record solutions;
❙❙
Establishing a robust method of peer review to provide assurance on quality and
comparability of data.
Whilst there are currently no national performance targets, local thresholds have been agreed with
the Trust’s commissioners and these are shown in the table below. In addition the data on the
indicators is used to reduce any variation in performance across trusts (where clinically appropriate)
and drive continuous improvement in patient outcomes over time.
Lowest
Trust Performance
(Apr to Nov 13)*
2012/13
Highest
Trust Performance
(Apr to Nov 13)*
Outcome from Stroke for Ambulance Patients - %
of suspected stroke patients (assessed face to face)
who receive an appropriate care bundle
National
Average
(Apr to Nov 13)
Outcome from Acute ST-Elevation Myocardial
Infraction (STEMI) - % of patients suffering a STEMI
and who receive an appropriate care
bundle
Year to date
2013/14
(Apr to Nov)
Indicator
Commissioner
Local Performance
Thresholds
Further ACQI information is contained in Part 3 of this report and details of all ACQIs are contained
in SWASFT’s monthly integrated corporate performance report presented to the Trust Board of
Directors and available on the Trust’s website.
80.5%
89.8%
66.7%
96.3%
99.4%
91.8%
84.2%
85%
89.8%
(SWASFT)
94.7%
(GWAS)
95.8%
95%
97.3%
(SWASFT)
100%
(GWAS)
*Highest/Lowest Trust reporting has been noted for each indicator independently.
Data for these indicators is not currently available for information after November 2013. The longer
timeframe for the production of this clinical data is due to the manual nature of the collection
process and the delays experienced in collecting some of the data from third party sources.
The South Western Ambulance Service NHS Foundation Trust considers that this data is as described
for the following reasons:
❙❙
The Trust has robust data quality processes in place to ensure the reporting of performance
information is both accurate and timely;
❙❙
Information is collated in accordance with the technical guidance for the Ambulance Clinical
Quality Indicators.
The South Western Ambulance Service NHS Foundation Trust is taking the following actions to
improve these percentages, and so the quality of its services, by:
❙❙
The provision of emails to staff every time they attend a patient in cardiac arrest achieves
ROSC on arrival at hospital. These feedback emails have been well received by those staff
concerned, enabled constructive discussion and review of care bundle delivery at station level
and will enable the Trust to identify any recurrent issues or concerns to help inform future
service/process developments;
❙❙
Undertaking a programme of quality improvement activity across all regions, supported by
two quality improvement paramedics.
An appropriate care bundle is a package of clinical interventions that are known to benefit patients’
health outcomes. These actions are the ‘must dos’ but do not include all the clinical actions that may
take place during the treatment of the patient.
Staff Survey:
One of the key findings in the 2013 national staff survey relates to staff recommending the Trust as
a place to work or receive treatment. Staff were asked to rate their answer on a five point scale from
strongly disagree to strongly agree. Staff responses were then converted into scores. The table below
shows SWASFT’s performance compared to last year, and other trusts performance.
Staff Survey Indicator
Staff recommendation of the trust as a
place to work or receive treatment
Performance
2013
3.31
National
Performance
Average
2012
2013
3.39
(SWASFT)
3.15
Highest Trust Lowest Trust
Performance Performance
2013
2013
3.08
3.31
2.72
(GWAS)
South Western Ambulance Service NHS Foundation Trust considers that this data is as described for
the following reasons:
❙❙
The Trust actively encouraged all staff to complete and return the staff survey by visiting all
stations and work areas to promote the survey;
❙❙
Responses to the survey were collated and reported to the Trust by an external source.
2013/14 27
quality account
South Western Ambulance Service NHS Foundation Trust is taking the following actions to improve
staff engagement, and so the quality of its services, by:
❙❙
Reviewing the results of the 2013 staff survey with each of the locality managers to develop
suitable targeted action plans for their individual areas aimed at improving response rates
and performance across the Trust;
❙❙
Ensuring that staff have the opportunity to give feedback on this point through implementing
the Friends and Family Test for Staff by Q1.
National Reporting and Learning System:
All trusts are required to provide confidential reports of patient safety incidents to the National
Reporting and Learning System (NRLS). This information is analysed to identify common risks to
patients and opportunities to improve patient safety. These incidents are identified through the
Trust’s incident reporting processes, and of the 6883 incidents reported in 2013/14, 1429 have been
identified as relating to patient safety.
The reporting of a high level of patient safety incidents to the NRLS has continued during 2013/14.
The National Patient Safety Agency recognised that organisations that report more incidents usually
have a better and more effective safety culture, stating ‘you can’t learn if you don’t know what the
problems are’.
2013/14**
Indicator/Date
Total Incidents Reported
to NRLS
1 Oct to
31 Mar
National
Average
2012/13
01 Apr to
30 Sep
01 Oct to
31 Mar
01 Apr to
30 Sep
Highest
Trust*
Lowest
Trust*
01 Oct 12 to 31 Mar 13
699
730
604
496
273
749
50
Number of Incidents
Reported as Severe Harm
2
21
12
6
4
12
0
Number of Incidents
Reported as Death
0
0
1
0
2
8
0
*Highest/Lowest Trust reporting has been noted for each indicator independently.
**This information is sourced from the Trust’s incident reporting system based on the criteria used in NRLS reports. All other information in this table is
published by the NRLS based on the data they received and collated from the Trust during their reporting periods. Information is published in arrears, and
therefore the most recent information available from the NRLS relates to the period 1 October 2012 to 31 March 2013.
South Western Ambulance Service NHS Foundation Trust considers that this data is as described for
the following reasons:
❙❙
The Trust has a good culture for reporting of adverse incidents;
❙❙
Information is provided to the National Reporting and Learning System (NRLS) electronically
through the upload of data taken from the Trust’s adverse incident reporting system;
❙❙
This information is then reported back to the Trust in aggregated reports by the NRLS;
South Western Ambulance Service NHS Foundation Trust has taken the following actions to improve
this number, and so the quality of its services, by:
❙❙
Continued to encourage the reporting of adverse incidents by all members of staff so
learning can occur at all levels of the Trust;
❙❙
Reviewed the mechanisms for learning from adverse incidents to ensure this is done quickly
and effectively, and disseminated to staff so they have confidence in the reporting system;
❙❙
Reviewed the mapping of coding of patient safety incidents with the NRLS to ensure
reporting is consistent with national requirements.
2013/14 29
quality account
Part 3 - Quality Overview 2013/14
Additional Quality Achievements and Performance of Trust against selected metrics
This section provides an overview of other performance metrics for the Trust.
The indicators and information contained within this section of the report have been selected to
describe the Trust’s continuous quality improvement journey. They build on the indicators reported
in the previous Quality Reports and where possible historical and national benchmarked information
has been provided to help contextualise the Trust’s performance.
The remaining indicators contained in this Quality Report continue to follow the existing themes
of the report and have been categorised into patient safety, clinical effectiveness and patient
experience.
Right Care
The Trust established its Right Care initiative in 2010/11. This continues to focus on ensuring patients
who contact the 999 service receive the most appropriate care in the right place, at the right time,
delivered through a wide range of developments all aimed at improving the appropriateness of care
given to patients.
Based upon the October 2013 Ambulance Clinical Quality Indicator performance data, the Trust
conveyed 83,517 fewer patients annually to Emergency Departments across the South West
compared to the national average. If the Trust conveyed patients at the level achieved by the
lowest performing Trust within England, this would have resulted in an additional 140,864 patients
attending South West Emergency Departments.
The Right Care Action Group continues to focus actions on the three key areas:
❙❙
Culture – ensuring that SWASFT staff, other healthcare providers and the public anticipate
hospital attendances only when they are necessary;
❙❙
Clinical Support – training and supporting clinicians so they can feel confident in making
decisions about the most appropriate care for patients;
❙❙
Communication – ensuring a high level of effective communication with SWASFT staff,
external stakeholders, and the general public.
Clinical Guidelines
In 2013/14 the Trust won a Shared Learning award from the National Institute of Health and Clinical
Excellence (NICE). As part of the preparation for acquisition of the Great Western Ambulance Service
NHS Trust, the Trust was keen to combine best practice from both organisations. Every member
of staff received a copy of the new guidelines prior to 1 February 2013, to ensure all patients
received the same high standard of care. This resulted in an award recognising best practice in the
implementation of clinical guidelines, which was voted for by over 1000 healthcare professionals at
the NICE annual conference.
Single Point of Access Pilot
During 2013/14 the single point of access service based at the control room in St Leonards has been
running a pilot scheme aiming to reduce pressure on acute hospitals and to ensure the best patient
care. The scheme, run in conjunction with the Royal Bournemouth Hospital NHS Foundation Trust,
has access to two dedicated Emergency Care Practitioners (ECPs) from 8am to 8pm each day. They
are able to make non-urgent home visits to patients with more complex medical conditions who may
become vulnerable without medical assessment.
CQC Inspection
On Tuesday 11 February 2014 the CQC commenced an unannounced inspection of the Trust. The
lead inspector confirmed this was a routine inspection, and that it was not triggered as a result of
any concern.
The inspection occurred over five days, involved a total of four inspectors and assessed the Trust’s
compliance with five outcomes:
❙❙
Outcome 2 – Consent to Care and Treatment;
❙❙
Outcome 4 – Care and Welfare of people who use services;
❙❙
Outcome 10 – Safety and Suitability of Premises;
❙❙
Outcome 16 – Assessing and monitoring the quality of service provision;
❙❙
Outcome 17 – Complaints.
The outcome of the inspection was very positive. The final report, which is publicly available on the
CQC’s website confirms that the Trust is fully compliant with all outcomes assessed.
The report includes some really pleasing comments made by patients, including that staff are ‘kind’,
‘professional’ ‘caring’, and that ‘they do a fantastic job’. There are also many references within the
report to the positive way staff have responded to the inspectors explaining what, why and how
they do their role
Whilst this was an excellent outcome for the Trust, the inspection did provide an opportunity for
constructive criticism from the inspectors, and they did make some minor observations of areas
the Trust could consider improving. The Trust is taking these comments forward as part of its
commitment to continuous quality improvement.
The CQC are in the process of changing the way that they inspect health and social care
organisations. The new regime has been implemented for acute trusts, and will be introduced for
ambulance trusts during 2014/15. Guidance documents are expected to become available early in
2014/15, and any future inspections will follow the new regime.
2013/14 31
quality account
Patient Safety
All three core service lines for the Trust: A&E; Patient Transport Service and Urgent Care Service,
are covered in the patient safety measures reported. The table below reports other patient safety
measures monitored.
Other Patient Safety Measures
Adverse Incidents
2013/14
2012/13
6787
5604
Moderate Harm Incidents
18
N/A*
Serious Incidents
78
54
*Introduced with effect from 1 April 2013.
The Trust has a central reporting system for adverse incidents, including near misses. The National
Reporting and Learning Service (NRLS) state that there is an emerging evidence base that
organisations with a higher rate of reporting have a stronger safety culture.
A fundamental part of the Trust’s risk management system is appropriately managing serious
incidents to ensure lessons are learnt. Serious Incidents are identified through a systematic review
of both adverse incidents and patient feedback. All incidents which are believed to potentially meet
the nationally set criteria for a serious incident are passed to the clinically qualified Serious Incident
Manager for preliminary review, before being circulated to the Director led decision making group.
The Trust has seen an increase in serious incidents in 2013/14 and analysis of the information has
shown that there is an equal split between serious incidents identified between North and East/West
divisions for the A&E Service line. There is a similar, equal divisional split for the serious incidents
identified from the Clinical hubs. It is important to note that the proportion of serious incidents
as a percentage of patient contact activity remains very low. The Trust has contributed to the
National Ambulance Service Medical Directors (NASMeD) review of serious incidents reported by all
ambulance trusts. This identified very similar themes to those being seen at this Trust.
Serious incident investigations are heard by Serious Incident Review Meetings, these meetings are
chaired by a clinical director or deputy director; all staff involved in the incident are invited to attend
as this provides the best opportunity for the Trust to identify learning. Learning can either be at a
local, Trustwide or at times national level, for example referring learning to NHS Pathways to help
them improve the national system. A Serious Incident Action Plan is maintained to monitor progress
against actions identified.
From 1 April 2013, a Duty was introduced for all NHS trusts to report to patients or their next of
kin where it is identified that moderate or severe harm has resulted from care provided by the Trust
(where this has not already been identified as a serious incident). The Trust developed a process for
management of these incidents and agreed this with our commissioners.
The Trust continues to report information relating to adverse incidents, moderate harm incidents
and serious incidents to a variety of forums, in order for themes and trends to be identified. Having
a centralised team monitoring the incoming incidents provides another mechanism to support
trend analysis. Working groups within the Trust receive reports on incidents relating to their remit.
In addition the Trust has a Learning From Experience Group receiving reports on incidents and
considering these alongside complaints, claims, safeguarding and workforce reports in order to
collectively and individually identify trends, and recommend improvements in practice. The Trust’s
commissioners also receive comprehensive reports on adverse incidents as required.
During the year the Trust has introduced an additional newsletter, called Reflect. This provides a
mechanism for feedback from all levels of incidents to be reported to all staff. Previously it was
likely that only the staff involved in the incident, or those working within the same area, would hear
of feedback. Now a bi-monthly publication provides specific feedback on learning. This newsletter
complements the existing suite provided to staff including the weekly bulletin from the Chief
Executive, Clinical News, Hubbub and The Mercury.
Other Patient Safety Measures
Central Alert System (CAS) Received
2013/14
2012/13
232
142
The Central Alert System (CAS) is an electronic web-based system developed by the Department of
Health, the National Patient Safety Agency (NPSA), NHS Estates and the Medicines and Healthcare
products Regulatory Agency (MHRA). This aims to improve the systems in NHS Trusts for assuring
that safety alerts have been received and implemented. During 2013/14 the Trust acknowledged
100% of CAS within 48 hours, thereby meeting the national requirement. In 2013/14 the Trust
implemented all relevant CAS within the timeframe specified.
2013/14 33
quality account
Clinical Effectiveness
The Trust is committed to maintaining excellent standards of clinical effectiveness, developing its
existing practice and processes through the review of learning, audit, guidance and best practice.
The tables below show the Trust’s Category A Performance by Clinical Commissioning Group. In the
2012/13 report information was supplied by Trust division, this has been changed as a direct result of
feedback from stakeholders.
Clinical Commissioning
Group
No of
Incidents*
Red 1
Performance
2013/14*
No of
Incidents*
Red 2
Performance
2013/14*
No of
Incidents*
A19
Performance
2013/14*
1,086
70.44%
34,834
76.67%
35,650
94.24%
651
78.49%
18,919
82.49%
19,562
97.77%
1,619
78.88%
49,548
81.98%
50,796
95.91%
946
71.56%
29,463
78.17%
30,380
95.88%
1,503
83.63%
47,081
81.78%
48,421
97.86%
North Somerset
737
63.36%
10,510
67.70%
11,246
93.15%
Bath & NE Somerset
570
71.50%
7,647
74.10%
8,208
94.71%
1,810
78.17%
25,645
78.50%
27,387
97.87%
743
62.71%
10,464
66.36%
11,206
96.75%
Gloucestershire
1,945
69.10%
28,729
71.92%
30,668
94.44%
Wiltshire
1,379
58.73%
21,548
64.38%
22,891
90.72%
Swindon
744
88.70%
10,537
87.70%
11,249
99.00%
13,763
73.15%
295,515
77.23%
308,283
95.76%
Kernow
South Devon & Torbay
NEW Devon
Somerset
Dorset
Bristol
South Gloucestershire
Trust
Due to the changes in the clinical commissioning groups which came into effect from 1 April 2013 comparative historical data is not provided.
Urgent Care Service
The Urgent Care Services, both GP Out-of-Hours and NHS 111 are monitored through the assessment
against national quality requirements. These quality requirements cover a number of different areas,
including the auditing of calls, the auditing of patients experiences.
In the 2012/13 report the Trust identified that full reporting of the national quality requirements
in relation to the Urgent Care Services would be included in this year’s report. This information is
reported in the Integrated Corporate Performance Report, presented to the Board of Directors at
each meeting, and available on the Trust’s website.
GP Out-of-Hours Service
The table below shows the achievement of the national quality requirements.
Quality Requirement
Target
Somerset &
Dorset
Gloucester
QR1 - Providers must report regularly to NHS Commissioners on their
compliance with the Quality Requirements
Compliance
Compliant
Compliant
QR2 - Percentage of Out-of-Hours consultation details sent to the
practice where the patient is registered by 08:00 the next working
day
95.00%
99.47%
Compliant
QR3 - Providers must have systems in place to support and encourage
the regular exchange of information between all those who may be
providing care to patients with predefined needs
Compliance
Compliant
Compliant
QR4 - Providers must regularly audit a random sample of patient
contacts (audit should provide sufficient data to review the clinical
performance of each individual working within the service)
Compliance
Compliant
Compliant
QR5 - Providers must regularly audit a random sample of patients’
experiences of the service
Compliance
Compliant
Compliant
QR6 - Providers must operate a complaints procedure that is
consistent with the principles of the NHS complaints procedure
Compliance
Compliant
Compliant
QR7 - Providers must demonstrate their ability to match their
capacity to meet predictable fluctuations in demand for their
contracted service
Compliance
Compliant
Compliant
QR10a - All immediately life threatening conditions (walk in patients)
to be passed to the ambulance service within 3 minutes of face to
face presentation
95.00%
n/a
n/a
QR10b - Definitive Clinical Assessment for Urgent cases presenting at
treatment location to start within 20 minutes - not applicable to this
service as a separate clinical assessment is not carried out between
presentation and clinical consultation at walk-in-centres
95.00%
n/a
n/a
QR10b - Definitive Clinical Assessment for Less Urgent cases
presenting at treatment location to start within 60 minutes - not
applicable to this service as a separate clinical assessment is not
carried out between presentation and clinical consultation at walkin-centres
95.00%
n/a
n/a
QR10d - At the end of an assessment, the patient must be clear of
the outcome
Compliance
Compliant
Compliant
QR11 - Providers must ensure that patients are treated by the
clinician best equipped to meet their needs in the most appropriate
location
Compliance
Compliant
Compliant
QR12 - Urgent Consultations (presenting at base) started within 2
hours
95.00%
92.73%
100%
QR12 - Less Urgent Consultations (presenting at base) started within
6 hours
95.00%
98.11%
100%
QR12 - Urgent Consultations (home visits) started within 2 hours
95.00%
87.50%
97.67%
QR12 - Less Urgent Consultations (home visits) started within 6 hours
95.00%
95.68%
98.29%
QR13 - Patients unable to communicate effectively in English will be
provided with an interpretation service within 15 minutes of initial
contact. Providers must also make appropriate provision for patients
with impaired hearing or impaired sight
Compliance
Compliant
Compliant
2013/14 35
quality account
NHS 111
The Trust commenced delivery of the NHS 111 service in Dorset with full launch effective during
March 2013. During 2013/14 additional 111 services delivered by the Trust became live. In September
the Trust launched the Devon 111 service, and in November 2013 and February 2014, the Trust
started delivering the services in Somerset and Cornwall and the Isles of Scilly, respectively.
The Trust took the opportunity to learn from the implementation of the service in Dorset to ensure
smooth transition for the delivery of services in the other three counties.
The table below shows the activity levels for the four counties in 2013/14, and the achievement of
the national quality requirements for these areas.
Quality Requirement
Target
Activity (Total calls answered)
N/A
QR1 - Providers must report regularly to NHS
Commissioners on their compliance with the
Quality Requirements
Compliance
QR2 - Providers must send details of all
consultations (including appropriate clinical
information) to the practice where the
patient is registered by 8.00 a.m. the next
working day.
Dorset
204,307
95.00%
Compliant
97.75%
Devon
80,383
Compliant
98.46%
Somerset
52,201
Compliant
97.42%
Cornwall
and IOS
8,678
Compliant
Not
Available
QR3 - Providers must have systems in place
to support and encourage the regular
exchange of information between all those
who may be providing care to patients with
predefined needs
Compliance
Compliant
Compliant
Compliant
Compliant
QR4 - Providers must regularly audit a
random sample of patient contacts (audit
should provide sufficient data to review
the clinical performance of each individual
working within the service)
Compliance
Compliant
Compliant
Compliant
Compliant
QR5 - Providers must regularly audit a
random sample of patients’ experiences of
the service
Compliance
Compliant
Compliant
Compliant
Compliant
QR6 - Providers must operate a complaints
procedure that is consistent with the
principles of the NHS complaints procedure
Compliance
Compliant
Compliant
Compliant
Compliant
QR7 - Providers must demonstrate their
ability to match their capacity to meet
predictable fluctuations in demand for their
contracted service
Compliance
Compliant
Compliant
Compliant
Compliant
QR8a - No more than 5% of calls abandoned
before being answered
QR8b - Calls to be answered within 60
seconds of the end of the introductory
message
5.00%
2.09%
1.27%
1.18%
1.63%
95.00%
91.55%
92.85%
92.36%
91.65%
Quality Requirement
Target
Dorset
Devon
Somerset
Cornwall
and IOS
QR9a - All immediately life threatening
conditions to be passed to the ambulance
service within 3 minutes
100.00%
86.61%
85.49%
86.33%
89.99%
QR9b - Patient callbacks must be achieved
within 10 minutes
100.00%
44.86%
38.44%
36.76%
31.02%
QR13 - Patients unable to communicate
effectively in English will be provided with
an interpretation service within 15 minutes
of initial contact. Providers must also make
appropriate provision for patients with
impaired hearing or impaired sight
100.00%
Compliant
Compliant
Compliant
Compliant
QR14 - Providers must demonstrate the
online completion of the annual assessment
of the Information Governance Toolkit at
level 2 or above and that this is audited on
an annual basis by Internal Auditors using
the national framework
Compliance
Compliant
Compliant
Compliant
Compliant
QR15 - Providers must demonstrate that
they are complying with the Department of
Health Information Governance SUI Guidance
on reporting of Information Governance
incidents appropriately.
Compliance
Compliant
Compliant
Compliant
Compliant
Ambulance Clinical Quality Indicators
The tables below, and overleaf, show Trust performance for further ACQI. As previously stated one
of the Trust’s selected priorities for 2013/14 is the development of a Post ROSC Care Bundle.
Return of spontaneous circulation (ROSC) at time of
arrival at hospital (Overall)
Lowest
Trust Performance
(Apr to Nov-13)*
Highest
Trust Performance
(Apr to Nov-13)*
National
Average
(Apr to Nov-13)
2012/13
Indicator
Year to date
2013/14
(Apr to Nov)
Ambulance Clinical Quality Indicators
24.6%
24.4%
(SWAST)
25.8%
25.9%
39.5%
16.9%
63.3%
77.0%
43.2%
(GWAS)
Percentage of Face Arm Speech Test (FAST) positive
stroke patients (assessed face to face) potentially
eligible for stroke thrombolysis, who arrive at a
hyperacute stroke centre within 60 minutes of call
52.6%
55.0%
(SWAST)
61.3%
(GWAS)
*Highest/Lowest Trust reporting has been noted for each indicator independently.
2013/14 37
quality account
Ambulance Clinical Quality Indicators: Ambulance calls closed with telephone advice or managed without
Calls closed with telephone advice
Lowest
Trust Performance
(Apr-13 to Feb-14)*
Highest
Trust Performance
(Apr-13 to Feb-14)*
National
Average
(Apr-13 to Feb-14)
2012/13
Indicator
Year to date
2013/14
(Apr to Feb)
transport to A&E departments (where clinically appropriate)
6.4%
6.7%
(SWASFT
7.2%
5.9%
11.7%
2.2%
36.1%
51.6%
25.4%
(GWAS)
Incidents managed without the need for transport to
A&E
51.2%
51.6%
(SWASFT)
47.8%
(GWAS)
*Highest/Lowest Trust reporting has been noted for each indicator independently.
As stated earlier in this report, in November 2013 the first stage of Transforming Urgent and
Emergency Care in England was published. The report identified that there was an opportunity to
bring about a shift from patients being treated in hospital to treatment at home. It specified that by
supporting and developing paramedics and providing direct access to GPs and specialists, around
half of all 999 calls requiring an ambulance could be managed at the scene without an unnecessary
trip to hospital. The table above shows the percentage of calls closed with telephone advice and
those managed without taking the patient to an Emergency Department.
Clinical Quality Improvements
Quality Improvement Paramedics
The role of the Quality Improvement Paramedic (QIP) is to identify best practice, review current Trust
performance, work with operational staff to identify areas for improvement and develop and test
changes to practice. The Trust now has a QIP in each of its divisional areas, working in collaboration
with the Research and Development team and wider Medical Directorate colleagues.
They have been responsible for facilitating quality improvement collaboratives which aim to engage
clinical staff and identify barriers to the delivery of optimal care. Several of these events have been
held during 2013/14, some internally and others with partner agencies to improve the delivery and
organisation of care from call taking to clinical interventions at scene.
Through the use of ‘Plan, Do, Study, Act’ cycles, staff led interventions have been identified and
evaluated to allow the most effective ideas to be shared to spread the positive change. Post ROSC
care and the timely conveyance of stroke patients to appropriate centres have been two of the areas
where quality improvement work has focussed this year. The Trust has also enjoyed sharing quality
improvement methods with a wide audience who attended study days hosted by the College of
Paramedics.
Inaugural Research Day
The Trust held its inaugural research showcase on 15 July 2013 in Taunton, Somerset.
The aim of the event, hosted by the Trust’s Research and Audit Team, was to showcase some of
the research currently being undertaken within the Trust and to promote engagement with staff
and students, highlighting some of the ways in which they can become involved in, and develop,
a research career. The event brought together a multi-disciplinary group including a wide range
of staff grades, students from two of the Trust’s University partners (Plymouth University and the
University of West of England Bristol), and representatives from the research community and Higher
Education Institutions (HEIs).
The speakers presented on a range of projects, including both recently completed and open studies:
❙❙
Stroke Pathways - The Peninsula Collaboration for Leadership in Applied Health & Care
(PenCLAHRC) led on this operational research, which used discrete event modelling to assist
with the delivery of thrombolysis in acute ischemic stroke. The project created computer
simulations that explore the different ways in which people who have suffered a stroke are
managed between arriving at hospital and receiving thrombolysis. The simulations consider
the number and level of healthcare;
❙❙
Professionals involved with each case, the time of day or night, and how busy the different
hospital departments involved in this pathway are. The simulations allow the benefit to be
measured (in terms of patients free of disability) from alterations to the emergency pathway
for stroke;
❙❙
REVIVE Airways - This project is a randomised, feasibility study, funded by the National
Institute for Health Research (NIHR) and seeks to determine whether the proposed design
will allow comparison of supraglottic airway devices (SADs) with current practice during prehospital cardiac arrest;
❙❙
Lucas in Cardiac Arrest: the LINC study - This international trial compared conventional
cardiopulmonary resuscitation (CPR) methods with a mechanical chest compression device
and simultaneous defibrillation;
❙❙
The OAK study - is funded by the National Institute for Health Research from the Research
for Patient Benefit Programme (NIHR RfPB) and aims to examine whether the Ambulance
Paramedics and ECPs can use FRAX® (the WHO Fracture Risk Assessment Tool) to assist GPs
in improving the future fracture risk in patients that fall. This feasibility study seeks to explore
whether ambulance clinicians can obtain the necessary information to estimate a patient’s
fracture risk, and if the GPs will act on the information given to them. The study will help
the team to design a full trial. The full trial will find out if the ambulance crew can collect
information from people that fall and help GPs to target treatment for osteoporosis at those
patients most likely to have a future fracture.
2013/14 39
quality account
A representative from the College of Paramedics, illustrated some of the developments within the
paramedic profession that have led to a change in focus and delivery of care and explained why
ambulance staff need to be, at the very least, research aware. She gave examples of career pathways
and funding opportunities that could be explored by those interested in becoming career researchers.
The Trust’s own Research Paramedics shared their experience of starting off on their research journey
and provided an insight into some of the requirements for undertaking a Masters in Clinical Research
(MRes). They explained that there is a competitive process for the NIHR places and that the course
is demanding but rewarding and is equipping them well for a future career with research as a key
component.
The event was supported by a representative from one of the Trust’s lead NHS health libraries. Staff
were provided with information, tools, hints and tips on searching for evidence to support their
learning and to promote evidence based pre-hospital practice and research skills. There was a display
dedicated to the library services with copies of resources available for staff to take away.
A poster display included some of the ongoing research and quality improvement projects conducted
by staff and some that involved collaborations with Higher Education Institutions (HEIs) and other
Trusts. There was also a dedicated display for student projects and two prizes were awarded for
these on the day.
The event was shared with a global audience through social media. Over 300 ‘tweets’ were sent
during the event, which resulted in over 300,000 twitter impressions. The event was so successful
that it will become an annual showcase of research activity.
Patient Experience
Patient experience and patient engagement provides the best source of information to understand
whether the services delivered by the Trust meet the expectations of the patient, including assessing
whether a quality service is provided.
The table below shows some of the Trust’s existing methods and quantitative information on service
user experience.
Patient Experience Measures
2013/14
2012/13
Complaints, Concerns and Comments
1020
923
Patient, Advice and Liaison Service (PALS) –
Lost Property, signposting to other services etc
711
1150
Health Service Ombudsman complaints upheld
1
0
Compliments
1454
1261
When noting the number of comments, concerns and complaints received it is important to consider
that the Trust proactively invites feedback from patients and their representatives.
The information for 2012/13 is a combined figure for the former GWAS Trust and SWASFT. The
reason for the clear reduction in PALS from 2012/13 to 2013/14 is a change in the processes for
categorising and handling comments, concerns, complaints and PALS, which were reviewed to
identify best practice during acquisition.
Compliments
The Trust receives telephone calls, letters and emails of thanks from many patients every week.
Wherever possible this gratitude is passed directly onto the actual members of staff who attended
the patient or service user.
In addition during the year the Trust had introduced the use of ‘wordles’ - visual representation of
the key words included in the compliments received. These are shared on the Trust’s intranet so that
all staff can see the type of positive feedback that the Trust receives about the work that they do.
The picture below is a year end summary of the compliments received for 2013/14, the larger the
word/phrase the more frequently it was used.
2013/14 41
quality account
Patient Engagement
During 2013/14 the Trust has continued to develop its patient engagement activities. Engagement
helps to ensure that the Trust’s services are responsive to individual needs, they are focused on
patients and the local community, and support SWASFT in improving the quality of care provided.
The patient engagement team source patient stories for use at the start of each Board of Directors’
meetings, and Council of Governors meetings. These can be written testimonies which are read
out by a member of the forum, or more recently have involved audio and video patient interviews
obtained by the Patients Association as part of our annual membership of this organisation.
Patient Opinion
Patients and their relatives and carers can post details of their experience on the website Patient
Opinion, and this can be viewed publicly. The Trust responds to every post relating to SWASFT on
Patient Opinion. Where the feedback is negative or indicates service failure, the reporter is invited
to contact the Trust directly with further details. This information would be passed to the Patient
Experience Team to process. Where the response is positive but there is insufficent detail the patient
engagement team will respond requesting additional information in order to be able to process the
information as a compliment direct to the member(s) of staff involved.
In total in 2013/14 224 stories relating to the Trust had been posted on Patient Opinion, as at 7 April
2014 these accounts of patients’ experience had been viewed 57,866 times.
The headlines of the top three stories, based on number of times they have been viewed, are shown
below.
‘The paramedic could not have been kinder or more caring.’
‘There was nothing any of them could have done better.’
‘I am confident that everything that could have been done was done for my wife.’
A trial was undertaken early in 2013/14 on the use of a business card being handed out to patients
inviting them to share their feedback via Patient Opinion and to answer the Friends and Family Test
question. The trial initially focussed on the Patient Transport Service, but this business card has now
been rolled out to all A&E frontline vehicles and the GP Out-of-Hours Service.
The Trust has improved the use of social media during the year to promote the Trust’s engagement
methods, including Patient Opinion.
Surveys
The patient engagement team is working towards standardising the Trust’s approach to patient
surveys which are conducted as a contractual requirement. This includes ensuring that the Friends
and Family Test question is asked consistently across all feedback mechanisms and the inclusion of a
national ambulance service patient quality indicator as developed by the National Ambulance Service
Patient Experience Group (NASPeG).
The patient engagement team has also carried out some face to face research with patients. This has
included trialling a realtime patient feedback survey tool in the Royal Cornwall Hospital NHS Trust
and the Royal Devon and Exeter NHS Foundation Trust.
During 2013/14 147 patient and public involvement events were attended, staffed predominantly
by volunteers drawn from clinicians, managers, administrators, Governors and community first
responders. Examples of the types of events include county shows, community fetes and fairs,
school and college visits and public health awareness days. These events provide a fantastic
opportunity to engage with existing patients and potential service users, informing them about
the services provided and obtaining their views on these. The events also provide an opportunity
to deliver proactive health checks, 7876 members of the public received a ‘know your blood
pressure check’ and 220 people within the community received a free NHS Health Check, covering
blood pressure, body mass index, blood glucose and cholesterol levels. The results are provided
immediately and where necessary recommendations about further medical care, such as attending
their own GP, are made.
2013/14 43
quality account
Assurance Statements - Verbatim
Clinical Commissioning Groups (CCG)
South West Commissioning Support (including combined Clinical Commissioning Group commentary)
South Devon and Torbay Clinical Commissioning Group (CCG) is the Lead Commissioner for the 999
part of the South Western Ambulance Service NHS Foundation Trust (SWASFT) organisation and
NEW Devon CCG is the Lead Commissioner for the Devon 111 Service. South West Commissioning
Support (SWCS), who manage the 999 contract on behalf of Commissioners, have provided a
combined commentary on the performance of the organisation. SWCS have put routine processes
in place with SWASFT to agree, monitor and review the quality of services throughout the year
covering the key quality domains of safety, effectiveness and experience of care.
Commissioners appreciate your sharing of the draft Quality Account for 2013/14 and are pleased to
accept the opportunity to comment. Commissioners have monitored the safety, effectiveness and
patient experience of the service provided by SWASFT during 2013-14. The Trust’s engagement in
the quality contract monitoring process provides the basis for commissioners to comment on the
quality account including performance against quality improvement priorities and the quality of the
data included.
Commissioners are very pleased to have worked alongside SWASFT during 2013/14 to maintain
and further improve the quality of commissioned services. The Trust is a responsive, dynamic and
innovative organisation, and has worked hard to develop excellent working relationships with
commissioners. SWASFT has taken on extra responsibilities over the past year including NHS 111
provision but commentary is primarily based on knowledge of the Trust as a provider of 999 services.
New Devon CCG does recognise the proactive and collaborative work undertaken by the joint 111
Clinical Action Group. The Trust makes an important contribution to the health and wellbeing of the
population within CCG localities through the services it provides and is committed to providing safe,
high quality, clinically effective care. The achievements noted in the Quality Account for 2013/14
demonstrate this.
South Gloucestershire CCG highlights SWASFT’s acknowledgement that this has been a challenging
year for the NHS and the local health economy. Taking into account the acquisition of Great Western
Ambulance Service (GWAS) in 2013 – the Trust now provides ambulance services in Devon, Dorset,
Somerset, Cornwall and the Isles of Scilly, Bath, Swindon, North East Somerset and Bristol, North
Somerset and South Gloucestershire (BNSSG). Also, the underlying organisational change that
the Trust has managed with little demonstrated impact on quality of services. The Trust should be
commended for this.
Quality Accounts are intended to help the general public understand how their local health services
are performing and with that in mind they should be written in plain English. The Trust has
produced a comprehensive, well written Quality Account. It is easy to read and clearly set out. All
the relevant sections required are present and it is clearly presented in the format required by the
Department of Health Toolkit. SWASFT has been open and transparent regarding the challenges and
concerns and the CCGs acknowledge this transparency.
Commissioners have reviewed and can confirm that the information presented in the Quality
Account appears to be accurate and fairly interpreted, from the data collected. The Quality Account
demonstrates a high level of commitment to quality in the broadest sense and is commended. The
information it contains accurately represents the Trust’s quality profile and contains appropriate
statements of assurance from the Board. It reflects some of the very good work undertaken by the
organisation and sets out clearly the quality ambitions and achievements of 2013/14 and sets the
direction for 2014/15 (building upon elements of the 2013/14 priorities). Commissioners support
objectives which have clear outcomes for patients describing how this intervention has made a
difference to them.
Performance
Following the publication of ‘Transforming Urgent Care in England’ in November 2013, there was
the opportunity to shift the care of patients to home rather than necessarily transfer all 999 calls to
hospital.
New Devon CCG is pleased to be the lead commissioner for the Devon 111 service. They recognise
that 2013/14 has been challenging for the organisation. The Trust has recruited and trained a large
number of new call handler staff which may indicate why the key performance indicator relating to
the target for call backs within 10 minutes has not been achieved. They are assured that SWASFT are
fully sighted on the priorities for the implementation and delivery of the service and look forward to
working closely with the Trust to continue to develop the service over the coming year.
Whilst Wiltshire CCG recognises the challenges that a rural locality presents and they will continue
to work collaboratively to improve patient outcomes, they are disappointed that Category
Red 1 performance for Wiltshire was only 59.05%. North Somerset CCG have also expressed
disappointment with the performance for Category A type calls which are significantly below target
for their area. They look forward to the acquisition benefits being realised in order to enable the
promised improvement.
B&NES CCG are of the opinion report is very well presented and broadly covers the areas and overall
performance, however there is no real recognition of the drop in the response standards within the
North region (old GWAS) and the subsequent drop in quality for the public within some of this area.
It would be useful to incorporate within the report the need for improvement in the North, as this
will provide greater necessity on SWASFTs part to improve. It’s good to see B&NES call to balloon
CTB objectives in the report.
2013/14 45
quality account
Within the report, North Somerset CCG would like to have seen information pertaining to the
performance of ‘Green’ category calls which are performance areas with locally agreed targets for
the ‘North Division’. This was considered important as patient experience and feedback pertains to
these calls that comprise the majority of responses and include, suspected stroke with no serious
symptoms, fractured arm/leg, fall with injuries.
Governance
Somerset CCG notes that there was evidence of engagement with the Council of Governors in the
development of the draft Quality Account and setting improvement priorities for 2014/15 (though
engagement appears to have been more passive than active). There was no engagement with
patients and staff.
There has been reporting against mandatory ambulance performance indicators, ambulance clinical
quality indicators. It was positive to see reporting against Out-of-Hours Clinical Standards and NHS
111 Clinical Standards, and these are congruent with CCG quality monitoring. Somerset CCG believes
it would be helpful to have had commentary on actions being taken to improve those areas of
poorer performance to reassure patients and the public. In future it would be helpful to see relevant
reporting against each contracted service in the three domains of quality: patient safety, patient
experience and clinical effectiveness.
Gloucestershire CCG mentions that during 2013/14 there have been robust arrangements in place
with SWASFT and Gloucestershire Hospital NHS Foundation Trust (GHNHSFT) to agree monitor and
review the quality of services. The Clinical Quality Review Group has met on a quarterly basis and
brings together GPs, senior clinicians and managers from both SWASFT and Gloucestershire CCG.
Assurance has been received throughout the year from the Trust in relation to key quality issues,
both where quality and safety has improved and where it occasionally fell below expectations
with remedial plans put in place and learning shared wherever possible. They very much welcome
SWASFT’s strong focus on patient experience and quality of care, which demonstrates a joint
commitment to delivering high quality compassionate care.
Quality Improvement Measurement
There is evidence of comparison of performance and data with peers - in respect of nationally
mandated quality indicators for stroke care bundle for ambulance patients and outcome for patients
suffering acute STEMI.
North Somerset CCG would like to have seen more detailed analysis of ambulance response
information relating to STEMI and Stroke care for patients, given this was commissioned as a priority
area for improving outcomes across BNSSG several years ago, and could inform future consideration
in the centralisation of key emergency services e.g. the ambulance service request to consider cardiac
arrest centres.
In relation to the Trust taking actions to improve data quality, Somerset CCG is of the opinion that
the challenges raised through the Urgent Care Service have not picked upon and addressed. Also
within the report there is no clear reference to systems for assuring the validity of data supplied.
The Trust has partially reported on engagement in agreeing CQUIN schemes with commissioners there is some mention of CQUINs but no actual reporting against CQUIN performance.
Clinical Effectiveness
Achievement noted by Commissioners includes the undertaking of a range of national and local
audits and using the outcomes to inform priority work for 2014/14. Somerset CCG highlights that
the Trust reported on participation in only one relevant national clinical audit which pertained to
national ambulance non-conveyance. There were no actions reported for outcomes from national
clinical audits, outcomes have been reported for local clinical audits.
There is good information pertaining to the launch of a research focus in the organisation.
Achievements of note which the Trust should be commended upon include the undertaking of a
variety of clinical research and promoting this throughout the organisation via the inaugural research
day. Also the shared learning award from the National Institute for Health and Clinical Excellence
(NICE) on the implementation of clinical guidelines.
Somerset and Swindon CCGs point out there is no review of performance against any of the
published NICE quality standards.
Patient Safety
Achievement which the Trust should be commended upon includes having a robust and thorough
complaints and incidents process, which indicates that lessons learnt are quickly fed back into the
organisation to inform practice and learning.
Somerset, Swindon and North Somerset CCGs are of the opinion the Quality Account needs
to be strengthened to demonstrate learning is being implemented from Serious Incidents, and
improvements being made to areas of sub-optimal performance. The organisation has reported on
patient safety incidents and serious incidents during 2013/14 and it is positive to see this quantitative
information reported, but it would be helpful to have had information on the common types of
patient safety incident reported and the key themes from lessons learned and the actions taken to
improve service provision as a result.
Patient Experience
The Trust has reported on patient experience and identified improvement priorities in relation to this.
The Trust is to be commended on having a good process to quality monitor call handling which
quickly establishes and facilitates areas for improvement for individual staff.
2013/14 47
quality account
External Inspections and Regulations
The Trust reported on the unannounced Care Quality Commission (CQC) inspection undertaken in
February 2014. The CQC made no recommendations, or imposed any compliance notices as a result.
The Trust should be commended upon receipt of an excellent review and congratulated on the
outcome. The positive report highlighted the high opinion patients have of staff when they come
into contact with them.
Staff Survey
It is positive to see the report against staff survey and recommendation of a place to work and
actions to improve this.
Review of Quality Priorities for 2013-14
The four priorities based around patient safety, clinical effectiveness and patient experience were
well presented within the report. SWASFT reviewed their progress against 2013/14 priorities
achieving three out of four:
Patient Safety
Priority 1: Early identification of Sepsis (partially achieved)
Commissioners welcome the focus on this important clinical issue. The report highlights the work the
Trust has done to improve the early identification of sepsis, which is a major cause of unexpected
death in the UK. South Devon and Torbay CCG are particularly keen as a commissioner to ensure
people with sepsis are identified and treated within the ‘golden hour’ and the work SWASFT has
done to date, and plans to do next year will be a major support to that initiative.
Through the use of the new diagnostic code 68% more potential cases of sepsis have been
identified, which offers the opportunity for improved outcomes.
The Trust highlighted two further initiatives:
❙❙
Explore the feasibility of pre-hospital lactate testing to aid sepsis recognition
❙❙
Explore the implementation of pre- hospital antibiotics.
New Devon CCG are of the opinion it would be helpful to understand if there were any outcomes
resulting from these initiatives which have improved outcomes for patients.
The Trust has reported that whilst they were aiming for a decrease by 50% in incidents relating to
lack of recognition of sepsis by staff, the number of adverse incidents in relation to sepsis has risen;
this should be seen as a positive outcome of an increase in staff awareness.
Priority 2: Infection Prevention and Control Monitoring - introduction of adenosine triphosphate
monitoring (achieved)
Commissioners welcome the Trusts commitment to improving Infection Prevention and Control
monitoring and commend SWASFT in achieving this priority. The report presents work undertaken
to improve hygiene and to protect patients from acquiring infections. The Trust has reported against
this quality improvement priority to improve cleanliness in the ambulance environment. In particular
the use of adenosine triphosphate (ATP) monitoring as part of the assurance process during vehicle
inspections (achieved implementation of ATP swabbing in 10% of areas). Furthermore SWASFT are
extending ATP swabbing during 2014-15, to include ambulance stations, which will undoubtedly
assist in raising staff awareness and the importance of following best practice. Commissioners
recognise that to swab 10% of a very large fleet of vehicles is quite a task and should be applauded.
The introduction of ATP swabbing is commended and the future planned work supported by South
Devon and Torbay CCG. The Trust has ensured that the lessons learnt from the ATP monitoring have
been incorporated into the 2014/15 annual Infection Prevention and Control plan. Somerset CCG are
of the opinion that though areas of good practice and actions for improvement were identified, it is
felt that actions have not been detailed and it would have provided further assurance to have had
this information.
Clinical Effectiveness
Priority 3: Post return of spontaneous circulation (ROSC) care bundle (achieved)
Commissioners welcome the Trust’s focus on the support and recovery of patients immediately
following cardiac arrest. They fully support the clinical strategies being implemented to improve
patient outcomes in the area of ST Elevation Myocardial Infarction (treatment for patients suffering
from a heart attack). Patients who have suffered a cardiac arrest and have a return of spontaneous
circulation (ROSC) and the timely conveyance of stroke patients have been two of the areas where
quality improvement work has focussed this year. It is pleasing to see the improvement in the
delivery of this care bundle to patients over the past year. The implementation of the care bundle
resulting in a 23% increase in its delivery to 32.1% is a good outcome. They look forward to hearing
what the Trust’s expectation is with respect to what percentage the trajectory will continue to
increase next year.
Although the data presented shows an improving position within the Trust, Wiltshire CCG remains
concerned that within Wiltshire this improvement does not seem to be evident when compared with
the 2012/13 outturn.
New Devon CCG is mindful of the ROSC objective and the mentioning of ‘cooling’ and that NICE
guidance may change this.
2013/14 49
quality account
Patient Experience
Priority 4: Dignity, privacy and respect (achieved)
There is detailed reporting on the quality improvement priority for dignity and respect for patients
with focus on improving communication with patients. A significant focus on complaints is
welcomed post-Francis.
The Trust has written about types of complaints and concerns received and common themes and has
identified a number of recommendations for improving patient experience. This was missing in the
last Quality Account and South Devon and Torbay CCG are pleased to see that it is included this year.
The Trust has highlighted an innovative and varied approach to gaining feedback from patients
including face to face consultations within the emergency department. There has been utilisation
of questions similar to those in the Friends and Family Test (FFT). It is pleasing to note that the
Trust uses the patient experience information gathered to facilitate the improvement in practice of
individuals within the organisation and the organisation as a whole. Learning includes the way in
which communication may be perceived and the need to improve information for patients. This in
turn has provided tools and education for staff on how to improve communication with patients.
Somerset CCG mentions there is no reference to review of the complaints process and Commissioner
concerns regarding access (patient identification).
There is mention that of the complaints received the most prominent pertain to communication
- staff attitude and behavioural issues. North Somerset CCG expressed concern that the report
wording in this area could be strengthened to reflect national findings on the importance of patient
experience and highlights that there is no identification as to how the Trust is going to address these
concerns.
New Devon CCG, as the Lead Commissioner for Devon 111, would welcome specific information on
patient experience relating to this service in next year’s quality report.
Commissioners are pleased that the 2013/14 objectives will now become business as usual.
Quality Improvement Priorities for 2014/15
The Trust addresses the three domains of quality and has identified relevant priorities for 2014/15.
Commissioners support the four priorities suggested for 2014/2015 and are pleased to see these
priorities focus on improving early recognition of paediatric sepsis (which fits within the wider health
community work), electronic care system, primary angioplasty and Friends and Family Test. All are
appropriate areas to target for continued improvement and link with the Clinical Commissioning
priorities. The priorities demonstrate recognition of the need to engage with patients and their
families, support staff and advance clinical effectiveness as well as improve services across the whole
patient pathway. The CCGs would support the Trust in ensuring that this work is reflected across
all of the services provided by SWASFT where relevant, and in particular that the 111 service are
included within the initiatives set out within the child sepsis priority.
Commissioners look forward to seeing achievement of 2014/15 objectives. Bristol CCG have noted
the importance of seeing how the Trust is learning systematically from patient and user experiences
and how the advent of the crisis concordat will enable the Trust to engage well with multi agency
training between police/crisis and paramedics, in addition to achievement of national standards.
Overall Commissioners are happy to commend this Quality Account and SWASFT for its continuous
focus on quality of care. They look forward to continuing to work in partnership with the Trust
during 2014/15 and developing further relationships to help deliver their vision of healthy people,
living healthy lives, in healthy communities.
NHS Dorset CCG
Over the past 12 months South Western Ambulance Service NHS Foundation Trust (SWASFT) have
continued to focus on improving the clinical outcomes, safety and experience of patients within
the Urgent Care Service. The work that SWASFT has done throughout the year on seeking patient
feedback within Urgent Care Services and triangulating this with information from complaints and
incidents has identified key areas for service improvement and staff training. It is further worth
noting that by the end of 2013/14 financial year there were no areas of non-compliance with the
National Quality Requirements for Out-of-Hours Services.
In relation to the priorities identified for 2014/15 the focus is predominantly on the Emergency
Service (999) contract rather than Urgent Care Services. The CCG would like to note that a CQUIN
plan has been agreed for Urgent Care Services for 2014/15 that seeks to improve quality, safety and
experience of service users. The CCG looks forward to working with SWASFT over the coming 12
months to maintain and improve high quality care for the population of Dorset.
Healthwatch
Healthwatch Cornwall
Healthwatch Cornwall Response to South West Ambulance Trust Quality Account 2013/14
Do the priorities of the provider reflect the priorities of the local population?
Healthwatch Cornwall was pleased to read the Quality Account for South West Ambulance Service
2013/14 and note the improvements made last year particularly in terms of dignity and respect
where we are heartened that the Trust takes clear and robust account of issues raised by its service
users.
We feel that this process can only be strengthened by the move this year to bring in the Friends and
Family test, however we would like the Trust to consider the use of independent data gathering on
its services which should give unbiased and honest feedback, which we would be happy to support
them with.
2013/14 51
quality account
In particular for this year, the introduction of the Electronic Patient Clinical Record, whereby patient
notes can be integrated with the hospitals and the wider healthcare community, show a clear move
in the right direction for service users and fit with feedback we have received. Patients and carers or
relatives have shared their frustration that they have shared medical and case information thoroughly
with ambulance staff but that this is lost on admission to hospital and they have to go through it
again in the Emergency Department and then on a ward. We will look with interest to see how this
system works.
In Cornwall the new 111 number was introduced in February 2014 and early performance indicators
show targets were not met around call handling. There are additional pressures in Cornwall for not
meeting target call out times on red calls. We trust that these indicators of quality will be of equal
importance for the Trust this coming year too.
We would like to add that feedback received about the ambulance service has always been very
positive and shows that people in Cornwall value highly the service they receive and regard it as
efficient, professional, respectful and one in which they have confidence. Individual staff are often
praised for the care and consideration shown to patients.
Healthwatch Isles of Scilly
SWASFT services in the islands are comprehensive and probably unique: comprising routine transport
and emergency response; the Star of Life ambulance boat; and a well-equipped and supported coresponder service.
Feedback received by Healthwatch about local and regional ambulance services is consistently good,
with praise in particular for all personnel. Comments about difficulties when giving directions to
control or non-resident staff have been passed on; this does not appear to be a major problem and
could be resolved by improved, joint, local information.
Healthwatch Gloucestershire, Bristol, South Gloucestershire, Bath and North East Somerset and
Wiltshire
This is the combined response of Healthwatch Gloucestershire, Healthwatch Bristol, Healthwatch
South Gloucestershire, Healthwatch B&NES and Healthwatch Wiltshire to the South Western
Ambulance Services Trust 2013-2014 Quality Account.
Introduction
Local Healthwatch (HW) organisations are new organisations which have an important role in
promoting the voice of patients and the wider public in respect of health and social care services.
Healthwatch organisations subscribing to this response welcome and approve of the trust’s patient
centred commitment for 2014-15 indicated within the CEO’s statement, through the pursuit of
quality improvement, within the context of a quality strategy. These organisations are pleased to
note that this strategy is wide ranging, embracing a combination of staff training and development,
two way staff engagement, the utilisation of innovative technology, clinical innovations
(incorporating research), patient experience feedback and public engagement activities. They
recognise that the Learning From Experience Group is an important part of the quality improvement
process.
Sepsis
Initiatives relating to Sepsis, with a particular focus on paediatric patients is most welcome.
Healthwatch organisations recognise that measurable success is dependent on raising staff
awareness and the uniform application of the required common skill sets, supported by paediatric
champions.
Infection Prevention and Control
The enhanced monitoring of Infection Prevention and Control is very positive and welcome.
Healthwatch organisations look forward to data on random, unannounced sampling appearing,
including its distribution across the trust. Is there a possible role within this process for suitably
prepared, local PPI representatives?
STEMI and Ambulance Stroke Patients
Care bundles for STEMI and Ambulance Stroke patients are significant and welcome enhancers of
patient experience and clinical effectiveness. Data provided by the trust fulfils its obligation to QA
reporting and these organisations are pleased to note that the priority was achieved and that trust
performance outstrips local commissioner thresholds. The actions the trust is taking to improve
this service to patients is noted and welcomed, particularly the envisaged programme of quality
development across all divisions, supported by quality improvement paramedics.
The spirit of ‘localism’ does suggest, however, that the provision of localised data (as with Red 1 and
Red 2 information) would add greater meaning to the account.
An improving primary angioplasty service is good news for patients. Will this be linked to RCA
breaches of STEMI CTBs? The data on both STEMI and Stroke patients (ACQIs) is confusing to the lay
reader. Page 26 indicates performance above commissioner and national average thresholds but the
information on page 37 suggests a variation from this.
Dignity and Respect
The trust’s proactive philosophy towards Dignity and Respect is recognised and appreciated and is
borne out by patient/family/carer/ feedback. Feedback from Healthwatch organisations does not
appear in the QA?
2013/14 53
quality account
Electronic Patient Clinical Record (ePCR) System
The implementation of the ePCR is most welcome and should substantially benefit staff and patients.
Will their roll out be uniform across the region or phased?
The dedicated ECP role in Bournemouth is a noteworthy innovation and has the potential to benefit
patients across the region, if adopted by commissioners.
Healthwatch organisations note that calls closed with telephone advice is above the national average
and that the trust leads the way in non- conveyance (to EDs) rates. Some mention of alternative
conveyances to Minor Injuries/Illness Units in Gloucestershire and Wiltshire, will enhance the account.
Emergency Response Times
There continue to be ongoing concerns on emergency response times in rural areas, (Wiltshire, in
particular) Local improvement plans to address this are very welcome and HW organisations hope
these will prove successful. Supplementary, localised, information on these will significantly add to
the overall message of the account and enable local monitoring of trust performance to take place.
General Comments
Healthwatch organisations are concerned about handover delays at acute hospitals and suggest that
data on these (localised) and their impacts on performance would enhance the account.
The importance of the Right Care Action Group and its key focus areas is rightly acknowledged.
Healthwatch organisations look forward to seeing this key dimension of trust activity shining through
in the 2014-15 Quality Account allied to the announced initiatives on robust peer reviews.
The CQC visit and positive report is welcome news for both the trust and patients as it upholds the
overall performance of the trust and also offers some improvement pathways.
The trust’s interest in and commitment to research, with future patient benefit outcomes and staff
skills enhancement is much approved of by Healthwatch-It will be informative for Healthwatch organisations to eventually receive localised data on stroke
pathways. It is hoped that OAK feasibility study will see paramedics/ECPs empowered to make full
use of the Fracture Risk Assessment Tool.
Overall it is most pleasing to record that the trust is recognised has having robust, effective and wide
ranging strategies and policies in place to enhance patient safety, patient experience and clinical
effectiveness during 2014 -15.
It is noticed that, in its present format, the account lacks both a contents page and a glossary of
terms. Is it possible for the non- technical parts of the account to be written in a more ‘user friendly’
way?
Local Health and Overview Scrutiny Committees
Wiltshire Council - Health Select Committee
Wiltshire Council’s Health Select Committee has been invited to comment on the South Western
Ambulance Service NHS Foundation Trust’s (SWAST) Quality Account for 2013-14. The Committee
believes that the Quality Account is an accurate reflection of its performance and the progress in
moving the service forward with its partners in an innovative way.
It is noted that the last reporting year has been particularly challenging for SWAST, given the large
increase in NHS 111 services and the reduction in patient transport services, which on occasions has
impacted on their own performance especially for the rural areas of Wiltshire where response times
have also been challenging.
It must also be highlighted that there was a significant increase in call volumes with the introduction
of the NHS 111 services, particularly at evenings and weekends; SWAST must be congratulated on its
collaboration with its partners to improve the NHS 111 service and its own efforts in treating patients
in their own homes. This alone has avoided significant numbers of patients having to be admitted to
the acute hospitals.
The Committee is also pleased to note the range of additional initiatives, ranging from the
identification of cases of sepsis, infection prevention and substantial actions to improve the
outcomes for those patients who suffer a heart attack. Further work is underway during 2014 for
the roll out of defibrillators throughout Wiltshire which is welcomed.
Finally, the Committee wishes to commend the South Western Ambulance Service NHS Foundation
Trust for its own engagement with this Council and the Trust’s commitment to continue delivering
high quality, patient centered and improving timely service throughout Wiltshire.
Dorset Health Scrutiny Committee
Comment on the Quality Review and Quality Account 2013/14 of the South Western ‘Ambulance
Service
The Dorset Health Scrutiny Committee notes that the clear aim and purpose of SWAST is to improve
the quality of service to patients by using evidence based methods improved treatment. As examples
SEPSIS – utilising the new sepsis diagnosis code and the use of pre-hospital antibiotics
INFECTION CONTROL – using ATP swab testing in some ambulances
CLINICAL EFFECTIVENESS – using the Post ROSC care system
PATIENT EXPERIENCE – seeking to utilize the opinions of patients by regarding compliments as a
pathway to illustrate excellence and complaints to point to areas of concern
COMPASSION – immense care has been taken to deal with the difficulties of patients and carers
which often occur in times of great stress and emotion.
2013/14 55
quality account
The Trust is to be congratulated on the improvements in service achieved during the period of this
report.
DHSC has had contact with the Trust on a number of occasions and queries have always been
responded to in a rapid and robust manner. There have been no presentations to the Committee on
the Quality Accounts by the Trust although this has been done with other trusts on a regular basis
throughout the year and is something which ought to be considered.
The Committee has been very concerned regarding in the changes in the non-emergency transport
service (which is no loner provided by SWAST) as it affected the patients, the hospitals and other
user groups, SWAST and the NHS as a whole. The enquiry is on-going with a special meeting to be
held in June 2014.
Gloucestershire Health and Care Overview and Scrutiny Committee
Comments on the South Western Ambulance Service NHS Foundation Trust Quality Account 2013/14.
On behalf of the Health and Care Overview and Scrutiny Committee I welcome the opportunity to
comment on the South Western Ambulance Service NHS Foundation Trust Quality Account 2013/14.
As a newly elected county councillor and newly appointed Chairman of the (new) Health and
Care Overview and Scrutiny Committee (HCOSC) I have valued the attendance of the SWASFT at
committee meetings to contribute to debate and respond to members’ questions. During the course
of this year the committee has developed a constructive and robust working relationship with the
SWASFT and I hope that this will continue. I would particularly like to thank Ken Wenman and Neil le
Chevalier for attending meetings and responding to members many questions.
I would also like to thank Heather Strawbridge and the team at the Acuma House Clinical hub for
inviting members to visit this facility. This was a valuable insight into some of the daily dilemmas and
challenges faced by the SWASFT and greatly helped with our understanding of these issues.
Gloucestershire is a rural county and the committee is very concerned with the response times in
the rural areas. The committee has regularly raised this issue with SWASFT officers (and also raised
concerns through the Joint Health Overview and Scrutiny Committee) and whilst concern remains
the committee does acknowledge the work that SWASFT is doing to try to address this situation.
Hopefully the learning that SWASFT has accumulated in the South Division can be translated into the
North Division. The committee will maintain a close interest in this matter.
I do of course recognise that this has been a challenging year for the Trust following on from its
acquisition of the Great Western Ambulance Service.
North Somerset Health Overview Scrutiny Panel
The HOSP acknowledges that the QA indicators show a significant improvement and that the
identified priorities for the forthcoming year demonstrate recognition of where further improvement
is needed. The Trust’s improvement is also borne out by the recent positive Care Quality Commission
inspection of the service. Members are however concerned by the Red 1 response performance
indicator results in North Somerset and note that the Clinical Commissioning Group, whilst
acknowledging the challenges of meeting the targets in rural areas, agree that the current level of
performance against that particular indicator is not at an acceptable standard.
Borough of Poole’s Health and Social Care Overview and Scrutiny Committee
Members of Borough of Poole’s Health and Social Care Overview and Scrutiny Committee would like
to thank South West Ambulance Service NHS Foundation Trust for the chance to comment on their
account of activities undertaken to improve services over the 2013/14 financial year.
The HSCOSC are encouraged to see that a busy year of implementing organisational change for the
Trust has on the whole led to significant service improvements for the patients they serve. These
improvements include the expansion and integration of the Great Western Ambulance Service,
ensuring best practice from each organisation is adopted as an operating model moving forward.
Members also noted that learning from the Dorset model of implementing NHS 111 services was
used to launch NHS 111 services in neighbouring areas. However, in future it would be useful to gain
a better understanding of patient experience in this area as well as the key performance measures
outlined in the report. It would also be helpful to understand how the re-tendering of Patient
Transport Services leading to a reduction in the number of regions covered has impacted on the
regions no longer covered.
It is heartening to note that a recent unannounced CQC inspection was very positive with no
recommendations or compliance conditions imposed.
Members were pleased to see that in 13/14 the four priority areas of patient safety, infection
prevention and control, clinical effectiveness and patient experience have mostly been achieved. This
has meant greater identification of Sepsis at an earlier stage, improved monitoring of cleanliness in
emergency vehicles, an improvement in immediate post care for patients regaining a pulse after a
cardiac arrest and therefore improving long term health outcomes and particularly that learning and
service improvement has been achieved through a range of feedback mechanisms about patient
experience.
Moving into 14/15 we will be interested to understand what is achieved in the four priority areas:
a.
that the process of managing early identification of Sepsis is fully implemented,
b. that the predicted benefits of introducing Electronic Patient Care is achieved,
c.
that even more initiatives are being introduced to improve the life chances and health
outcomes of those suffering a cardiac arrest and finally
d. the introduction of the Friends and Family Test and how this will be used to learn and
improve services.
2013/14 57
quality account
We would like to commend the Trust on their ongoing commitment to ensure patients are receiving
the right service in the right place at the right time which reflects the emerging principles detailed in
the NHS England comprehensive review of urgent and emergency care.
Thank you once again for the opportunity to comment on an interesting Quality Review and Account.
Devon County Council Health and Wellbeing Scrutiny Committee
Devon County Council’s Health and Wellbeing Scrutiny Committee has been invited to comment on
the South Western Ambulance Service NHS Foundation Trust’s (SWAST) Quality Account 2013-14. All
references in this commentary relate to the reporting period 1st April 2013 to 31st March 2014 and
refer specifically to the SWAST’s relationship with the Scrutiny Committee.
The Scrutiny Committee believes that the Quality Report 2013-14 is a fair reflection and gives a
comprehensive coverage of the services provided by the SWAST based on the Scrutiny Committee’s
knowledge. The Committee would like to commend SWAST on achievement of all 2013/14 priorities.
Whilst the priority for sepsis has only been partially achieved, the 68% increase in potential diagnosis
and the increased awareness are significant improvements. The Committee also notes that sepsis
continues to be a priority for the coming year. This performance is reflected in the positive Care
Quality Commission inspection earlier this year.
Looking at specific performance against the quality requirements, the trust appears to be performing
well overall and is compliant against necessary indicators. The committee would like to see progress
towards achieving the ambitious 100% targets for both QR9a – All immediately life threatening
conditions to be passed to the ambulance service within 3 minutes and QR19b – Patient call backs
must be achieved within 10 minutes.
The Francis review provoked a significant challenge to public organisations involved in providing,
commissioning, evaluating and improving health care throughout the country. Local Authority
scrutiny was specifically criticised for a lack of oversight and rigor in holding NHS organisations
to account. The Health and Wellbeing Scrutiny committee undertook a spotlight review earlier
this year to further consider how to hear the voice of vulnerable people and maintain an active
challenge; in order to ensure that the work of scrutiny is as effective as it possibly can be. The review
demonstrated that it is only by working with other agencies and sharing information that scrutiny
can identify and work in partnership to improve areas that are underperforming. The challenge is
laid at the door of the County Council the NHS and other partners to work with the mechanisms of
democracy to help develop services from a person centred perspective. The Committee would like
to further explore with SWAST how this may be possible, including regular sight of NHS Friends and
Family test data and mortality rates for example.
The Committee fully supports the Trust’s Quality Priorities for Improvement and looks forward to
greater partnership working in 2014-15.
Torbay Council Health Scrutiny Board
Statement from Torbay Council’s Health Scrutiny Board on South Western Ambulance Service NHS
Foundation Trust’s Quality Account 2013/2014
South Western Ambulance Service NHS Foundation Trust’s Quality Accounts for 2013/2014 has been
considered by representatives of Torbay Council’s Health Scrutiny Board. The clarity with which the
Trust has explained how it has met its priorities for 2013/2014 and what its priorities are for the
forthcoming year is welcomed.
The Quality Accounts for each of the Trusts operating in Torbay were considered at the same time
and this allowed for the inter-relationships between the different initiatives in different Trusts to be
examined, in particular the priority around the identification of sepsis.
The Board met with representatives of South Western Ambulance Service NHS Foundation Trust,
South Devon Healthcare NHS Foundation Trust and South Devon and Torbay Clinical Commissioning
Group in February 2014 to discuss services at the Emergency Department of Torbay Hospital. It was
clear that all organisations were working together to improve services to the public. This partnership
working needs to be embedded throughout all health and social care organisations in Torbay to
ensure a truly joined-up approach for residents and visitors.
The Quality Account makes little reference to mental health and it is felt that this is an omission. The
Health Scrutiny Board will be undertaking a review of mental health services (including services for
those with learning difficulties) over the course of the coming year and would wish to invite South
Western Ambulance Service NHS Foundation Trust to participate in that work.
The Board commends South Western Ambulance Service NHS Foundation Trust for its openness and
transparency of its operations and hopes that the Trust will continue to work closely with the Board
and Torbay Council as a whole.
Cornwall Council Health and Social Care Scrutiny Committee
Cornwall Council’s Health and Social Care Scrutiny Committee agreed to comment on the Quality
Account 2013 -2014 of South Western Ambulance Service NHS Foundation Trust. All references in
this commentary relate to the period 1 April 2013 to the date of this statement.
South Western Ambulance Service NHS Foundation Trust have engaged when the committee and
attended meetings when items relating to them have been placed on the agenda.
Committee Members felt that the Quality Account provided a good reflection of the services
provided by the Trust, and provided a comprehensive coverage of the provider’s services. However,
they believed it was a complex document which was not easily understandable for the public; this
especially applies to the presentation of data. In some circumstances it may have been useful to have
a break down at a lower geographic level.
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quality account
Quality requirements appear to be being met however there are concerns about the performance
variation across the region, specifically regarding Red 1 performance and NHS 111 indicators QR9a
– All immediately life threatening conditions to be passed to the ambulance service within 3 minutes
and QR19b – Patient call backs must be achieved within 10 minutes. Performance in Cornwall
appears to be lower than other areas and it is requested that there are demonstrable improvements
in the next year.
The Committee welcome the commitment to increasing patient feedback and would like to see
regular feedback on the Friends and Family Test.
The Committee supports the Trust’s Quality Priorities for Improvement and looks forward to working
in partnership in 2014-15.
Statement of Directors’ Responsibilities
in respect of the Quality Report
The Directors are required under the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS Foundation Trust boards on the form and content of annual
quality reports (which incorporate the above legal requirements) and on the arrangements that NHS
Foundation Trust boards should put in place to support the data quality for the preparation of the
quality report.
In preparing the Quality Report, Directors are required to take steps to satisfy themselves that:
❙❙
the content of the Quality Report meets the requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2013/14
❙❙
the content of the Quality Report is not inconsistent with internal and external sources of
information including:
▲▲ Board minutes and papers for the period April 2013 to 22/5/14
▲▲ Papers relating to Quality reported to the Board over the period April 2013 to 22/5/14
▲▲ Feedback from the commissioners dated 06/05/2014
▲▲ Feedback from governors dated 02/04/2014 and 06/05/2014
▲▲ Feedback from Local Healthwatch organisations dated 13/05/2014
▲▲ The Trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 15/05/2014
▲▲ The latest national staff survey dated February 2014
▲▲ The Head of Internal Audit’s annual opinion over the trust’s control environment dated
22/5/14
▲▲ CQC quality and risk profiles dated from April 2013 to March 2014.
❙❙
the Quality Report presents a balanced picture of the NHS Foundation Trust’s performance
over the period covered
❙❙
the performance information reported in the Quality Report is reliable and accurate
❙❙
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm that they are working effectively in practice
❙❙
the data underpinning the measures of performance reported in the Quality Report is
robust and reliable, conforms to specified data quality standards and prescribed definitions,
is subject to appropriate scrutiny and review; and the Quality Report has been prepared
in accordance with Monitor’s annual reporting guidance (which incorporates the Quality
Accounts regulations) (published at www.monitor.gov.uk/annualreportingmanual) as well as
the standards to support data quality for the preparation of the Quality Report (available at
www.monitor.gov.uk/annualreportingmanual).
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quality account
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
22 May 2014 22 May 2014 Heather Strawbridge, Chairman
Ken Wenman, Chief Executive
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quality account
responsive
committed
effective
© South Western Ambulance Service NHS Foundation Trust 2014
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