WRITTEN STATEMENT
BY
THE WELSH GOVERNMENT
TITLE
DATE
BY
Clinical review of ambulance response time targets
29 July 2015
Vaughan Gething AM, Deputy Minister for Health
In a written statement in February about progress made in transforming the
Welsh Ambulance Service since the publication of the McClelland review, I
committed to update Assembly Members about a clinical review of the way we
measure the timeliness and quality of delivery of emergency ambulance
services.
The clinical review was led by Dr Brendan Lloyd, medical director of the
Welsh Ambulance Services NHS Trust working with the trust’s clinical
services team and Dr Grant Robinson, Wales’ national clinical lead for
unscheduled care. The review was set up to respond to the McClelland review
recommendation that the Welsh Government should consider moving from a
primary focus on the eight-minute response time target to a more intelligent
suite of targets and measures, across the whole unscheduled care system.
Professor Siobhan McClelland advised this should include a greater emphasis
on patient outcomes and experience.
Following the review, Dr Lloyd has written to me, on behalf of NHS Wales
medical directors, outlining proposals to move from the time-based
performance measures to an evidence-based approach, which focuses on
quality of clinical care and patient experience.
The eight-minute response time target was introduced 41 years ago and is
based on evidence, which suggests it only improves outcomes for people who
have suffered an out-of-hospital cardiac arrest. The clinical review has shown
there is no evidence an eight-minute response will make a difference to the
vast majority of people’s outcomes following treatment – about 95% of people
who access the Welsh Ambulance Service.
The rising and more complex demands placed on the ambulance service are
well known – if we are to meet these demands and ensure the best outcomes
for patients, we need to transform the way we deliver and measure
emergency ambulance services.
Dr Lloyd has therefore advised that a new clinical response model should be
implemented in Wales. This will be similar to the approach piloted in two
areas of England earlier this year, which has recently been expanded
following encouraging results.
Under the new model, which will be tested for 12 months from October 1,
everyone who is in imminent danger of death and needs an immediate, lifesaving response will receive one in the fastest time possible. All other patients
will receive a bespoke clinical response based on their health needs, rather
than a generic response based solely on the 41-year-old eight-minute
response model.
The new model will give clinical contact centre call handlers extra time to
triage those calls, which are not instantly identified as being an immediate
threat to life, before dispatching an ambulance resource – this is similar to the
English “dispatch on disposition” pilot.
Call handlers will have up to 120 seconds extra to ask important questions
about a patient’s symptoms; to accurately identify the nature of their condition
and dispatch the correct type of response needed – this may be an advanced
paramedic who can provide treatment at the scene or an emergency
ambulance manned by a paramedic crew to assess and treat at scene and
transport the patient to the most appropriate treatment centre as quickly as
possible
This new system will help to remove what clinicians describe as the
“unnecessarily high and unevenly-distributed clinical risk”, which leads to the
way the service currently dispatches ambulances to chase the response time
target.
The Welsh Ambulance Service regularly dispatches multiple vehicles to try
and achieve the eight-minute target – in the Cardiff and Vale of Glamorgan
area, for example, an average of two vehicles are dispatched to every call.
Sending a faster rapid response car to the majority of 999 calls means the
ambulance service can stop the clock and achieve the target but if a patient
needs to go to hospital they must then wait for a larger emergency ambulance
vehicle capable of transporting them.
The new model will introduce three new categories of calls – red, amber and
green:
Red calls are immediately life-threatening calls –someone is in imminent
danger of death, such as a cardiac arrest. There is compelling clinical
evidence to show that an immediate emergency response will make a
difference to a person’s outcome. The eight-minute target will be retained for
this group of calls with an initial target of 65% receiving an eight-minute
response.
Amber calls are from patients who will often need treatment to be delivered on
the scene and may then need to be taken to hospital. Evidence suggests that
for this type of patient timely transport to the most appropriate care facility and
clinicians has far more impact on their quality of life once they are discharged
from hospital than a response within a defined time-frame.
Patients in this category will continue to receive a fast blue light and sirens
response from the Welsh Ambulance Service but there will be no time-based
target for this group. Instead a range of clinical outcome indicators will be
introduced to measure the quality and timeliness of care being delivered by
ambulance clinicians alongside patient experience information, which will be
published every quarter.
These new indicators will build on measures, which have been tested over the
last year and are already published by the Welsh Government, including how
ambulance clinicians care for patients with stroke; fractured hips and a type of
heart attack, known as STEMI.
Green calls are non-serious incidents, which could often be managed by other
health services, including healthcare advice or through self-care. This
category also includes calls from healthcare professionals, which will be
handled in a different, planned way in the future – this approach has been
successfully tested in the Cwm Taf University Health Board area.
The McClelland review also recommended the development of a wider suite
of targets and standards, which incentivise change and provide a greater
focus on patient experience and outcomes. To support this, the Emergency
Ambulance Services Committee has developed a quality and delivery
framework and an innovative five-step ambulance patient care pathway.
This describes the Welsh Ambulance Service as a clinical service and a key
part of the wider integrated healthcare system. It includes indicators, targets
and measures for each of the five steps – how it helps people to choose the
right service for their needs; how their call is dealt with; how a response is
provided; treatment is delivered; and – if appropriate – how people are taken
to hospital.
These quality indicators will form part of a new suite of information, to be
published quarterly, making the Welsh Ambulance Service among the most
transparent in the world.
We know from the latest National Survey for Wales that 97% of people who
used the ambulance service had trust and confidence in the skills of
ambulance clinicians. This striking result shows we must focus more on the
care, compassion and continuity provided by our highly-skilled ambulance
clinicians than simply measuring the worth of the service by the time it took an
ambulance to respond to a 999 call.
This pilot leads the way for the ambulance service to be at the forefront of
future developments for patients and frontline clinicians and will put the Welsh
Ambulance Service at the heart of the unscheduled care system.
I will make an oral statement to the Assembly at the first opportunity in the
autumn to update Assembly Members further.
This statement is being issued during recess in order to keep members
informed. Should members wish me to make a further statement or to answer
questions on this when the Assembly returns I would be happy to do so.