Blackpool Overview & Scrutiny Committee:
7 March 2006
AGENDA ITEM 6
HEALTHCARE COMMISSION CORE STANDARDS:
LANCASHIRE AMBULANCE SERVICE NHS TRUST
1.0
Matter for consideration
1.1
The Committee is asked to consider the assurances and supporting evidence
provided by Lancashire Ambulance Service NHS (National Health Service)
Trust so that a view can be formed by the Committee in respect of the Trust’s
performance.
1.2
In creating the Healthcare Commission’s new approach to assessing and
reporting on the performance of NHS Trusts, the new annual health check
process invites local authorities’ overview and scrutiny committees to assist
with this process.
2.0
Recommendation
2.1
To recommend to the Committee that the evidence and assurances presented
to the Committee in support of Core Standards C19, C21 and C24 demonstrate
that Lancashire Ambulance Service NHS Trust is striving towards full
compliance in meeting these core standards, and that this information is
reflected in the Committee’s response to the Trust in support of the Final
Declaration Process.
3.0
Background
3.1
As requested by the Committee Lancashire Ambulance Service NHS hereby
presents evidence in support of the following core standards:
 C19 – Healthcare organisations ensure that patients with emergency health
needs are able to access care promptly and within nationally agreed
timescales, and all patients are able to access services within national
expectations on access to services;
 C21 – Healthcare services are provided in environments which promote
effective care and optimise health outcomes by being well designed and well
maintained with cleanliness levels in clinical and non-clinical areas that meet
the national specification for clean NHS premises;
 C24 – Healthcare organisations protect the public by having a planned,
prepared and, where possible, practised response to incidents and emergency
situations, which could affect the provision of normal services.
4.0
Core Standard 19 – Prompt care within nationally agreed timescales and
within national expectations
4.1
The first point to note in respect of this item is that this standard will be
measured under the existing targets and national targets form of assessment.
This means that measurement is gathered by the Department of Health’s
reporting mechanisms of which the Trust is required to submit performance
information.
4.2
Existing target indicators for ambulance trusts: These are defined by the
Healthcare Commission as the statutory ‘must do’ targets in relation to Accident
and Emergency services as follows:




Category A (life-threatening) calls meeting eight minute target: All
ambulance trusts to respond to 75% of category A calls within eight
minutes
Category A calls meeting 14/19 minute target: All ambulance trusts to
respond to 95% of category A calls within 14 minutes (urban) or 19
minutes (rural)
Category B (serious but not immediately life-threatening) calls meeting
14/19 minute target: All ambulance trusts to respond to category B calls
within 14 minutes (urban) or 19 minutes (rural)
Thrombolysis – 60 minute call to needle time: A shared performance
indicator across the ‘health economy’ required to deliver a 10% increase
per year in the proportion of people suffering from a heart attack who
receive the clot busting thrombolytic drug within 60 minutes of calls for
professional help
The Trust’s performance at the time of preparing this report is as follows:
Indicator
Target 2005/06
Performance
2005/06 to date
Performance in
January 2006
Category A/19
calls meeting
19 minute
target
95% or more
98.28%
98.44%
Category A
calls meeting 8
minute target
75% or more
75.53%
76.44%
Category B
calls meeting
national 19
minute target
95%
95.77%
96.14%
Thrombolysis
– 60 minute
call to need
time
68% for Health
economy across
Lancashire
1st qtr = 61%
2nd qtr = 69%
3rd qtr = 61%
Not yet
available for
final quarter
For Health Economy
4.3
It should be noted that the inclusion of the Thrombolysis indicator is new for
2005/6. Since notification of this new ‘must do’ indicator the Trust has been
taking action to urgently widen its thrombolysis strategy. Following an
unsuccessful bid to Commissioners for further funding the Trust has self-funded
the provision of training to all front-line staff in the administration of
thrombolysis. Additional essential equipment (12-lead Electrocardiograms) has
been fitted to vehicles and stocks of the thrombolytic drug have been procured.
4.4
The Committee should note however that there is some risk to the achievement
of this ‘health economy’ wide indicator which could, in the result of failure, have
some impact on the overall assessment of Lancashire Ambulance Service NHS
Trust’s overall performance rating.
4.5
New target indicators for ambulance trusts: The Healthcare published the
new national indicators on 11 January 2006. In summary, the indicators cover
the following areas:





4.6
Compliance with National Institute for Clinical Governance (NICE) and
the latest version of the Joint Colleges’ ambulance liaison committee
(JRCALC) guidelines on self harm, overdose and poisoning
Infection Control
Participation in audits
Response to ‘Talking healthcare to the patient’
Smoke Free NHS
For each of the aforementioned indicators the Trust is required to provide
answers to questions in relation to each indicator. Following publication of the
indicators the Trust is gathering its evidence in support of the indicators. A brief
summary is noted below:
4.6.1 Compliance with NICE/JRCALC: The Trust is on schedule to return positive
evidence in support of this indicator. For example the Trust’s unique and
powerful electronic patient record system is the method by which the Trust
ensures that there is rapid access to the national database of the National
Poisons Information Service (TOXIBASE). The Trust is providing copies of the
JRCALC guidelines to all staff. The Trust is working in partnership with other
agencies in respect of self-harm systems and protocols.
4.6.2 Infection Control: The Trust’s Medical Director, Dr Richard Fairhust, acts as the
director of infection prevention and control, a requirement of the indicator. The
Trust has produced and published an annual report on the state of healthcare
associated infection in the last 12 months, with updates on the Action Plan
reported to the Board every two months.
4.6.3 Participation in Audits: The Trust confirms that it has participated in the
required national audits relating to treatment of acute myocardial infarction
(AMI) and out of hospital arrest. The Trust also confirms that it uses the
required assessment process for stroke patients, also a requirement of the
indicator.
4.6.4 Response to ‘Talking healthcare to the patient’: In anticipation of the
publication of the ambulance service review ‘Taking healthcare to the patient’,
the Trust appointed an Unscheduled Care Lead. The post-holder has
facilitated the development of an Unscheduled Care Strategy with evidence of
new initiatives taking shape in Lancashire, for example, Hyndburn and Ribble
Valley and Blackburn with Darwen Out of Hours project. The joint project
involves paramedics working with General Practitioners’ Out of Hours service to
provide assistance to patients. Paramedics are required to develop more
diagnostic and assessment skills. A further example is the Walk in Centre at
Skelmersdale at which a paramedic will be based and available to assist and
treat patients. These are just two examples of a number of projects in support
of ‘Taking Healthcare to the Patient’.
The Trust is due to complete a second baseline assessment against the
recommendations within ‘Taking Healthcare to the Patient’, and has confirmed,
in its draft business plan for 2006/07, that the document will be the over-arching
driver for future working.
4.6.5 Smoke Free NHS: The Trust will be assessed on progress towards becoming
smoke free by the end of 2006. The Trust Board approved in principle to a
‘Tobacco Control’ policy at its meeting in November 2005. Staff and
management representatives are working together to plan for the
implementation of the policy with effect from 1 April 2006.
5.0
Core Standard 21 – Healthcare provided in effective, well designed and
well maintained environments. Cleanliness levels to meet national
specification for clean NHS premises
5.1
The Terms of Reference for the Trust’s Vehicle Design Group is to consider all
new vehicles against strict European legislation design standards, and in
accordance with the Disability Discrimination Act. Membership comprises of
management and staff members with input from patients’ user groups. The
Patient Services Transport fleet is on average less than 4 years old and
includes design features such as specially developed wheelchair seats and
darkened windows for patient privacy.
The Trust’s distinguishable ‘yellow’ emergency ambulances are an example of
compliance with design standards. Other aspects include standardised
operating equipment. An Equipment Advisory Group supports the process of
ensuring well designed and effective ambulances. Their role is to discuss any
new equipment and vehicles.
The Infection Control Committee also considers new vehicles and equipment
from an infection control point of view. In addition to the points noted in section
4.6.2 the Trust has a dedicated Infection Control nurse who has the
responsibility of ensuring the Trust completes an annual audit and resulting
action plan and annual report.
6.0
Core Standard 24 – Planned, prepared and where possible, practiced
response to incidents and emergency situations
6.1
At the point of Draft Declaration the Trust advised the Healthcare Commission
that it was not yet able to fully comply with the requirements of Core Standard
24, and submitted an action plan to the Strategic Health Authority to set out
how the Trust would achieve compliance by 31 March 2006.
Much work has been continuing in the area of emergency and business
continuity planning. In the first instance members of the Trust Board have
received training and guidance in the new legislative requirements contained in
the Civil Contingencies Act 2004 (the Act). In addition to the Act, the
Department of Health produced draft guidance on emergency planning and this
was finally circulated in final format in December 2005. Having taken two years
to plan, the Trust took place in the largest emergency planning exercise
‘Northern Synergy’ recently which afforded much learning and the opportunity
for testing plans. The Trust is therefore taking this learning and revising its
emergency and business continuity plans in readiness to claim full compliance
by 31 March 2006.
7.0
Witnesses/representatives
7.1
As requested by the Committee members a representative from the Trust, to be
confirmed, will attend the meeting to provide a short presentation and answer
the Committee’s questions.
Relevant officer:
Jillian Harvey
Tel: 01772 773005, e-mail jillian.harvey@las-tr.nhs.uk
Appendices attached:
Appendix 6 (a): National Target Indicators for Ambulance Trusts
Background papers:
None.
Websites and e-mail links for further information:
www.healthcarecommission.org
Glossary:
AMI
JRCALC
NHS
NICE
Acute Myocardial Infarction
Joint Colleges’ Ambulance Liaison Committee
National Health Service
National Institute for Clinical Governance
Appendix 1
New national target indicators for ambulance
trusts
As part of the Healthcare Commission’s annual health check, we will be using 5 indicators to
assess the performance of ambulance trusts against the new national targets (as described in
National Standards, Local Action: Health and Social Care Standards and Planning Framework
2005/2006 – 2007/2008, published by the Department of Health in July 2004).
Table of contents:
Compliance with National Institute for Clinical Excellence (NICE) and the latest version of
Joint Royal Colleges' ambulance liaison committee (JRCALC) guidelines on self harm,
overdose and poisoning. ............................................................................................7
Infection control..........................................................................................................9
Participation in audits ............................................................................................... 10
Response to 'Taking healthcare to the patient' ......................................................... 11
Smoke free NHS ...................................................................................................... 12
Compliance with National Institute for Clinical Excellence (NICE) and the latest
version of Joint Royal Colleges' ambulance liaison committee (JRCALC)
guidelines on self harm, overdose and poisoning.
Full indicator name:
Processes in place to ensure compliance with NICE guidelines on the assessment and
initial management of self harm by ambulance services and the latest version of JRCALC
guidelines on overdose and poisoning.
Target:
Substantially reduce mortality rates by 2010 from suicide and undetermined injury by at
least 20%
Rationale:
The 'Saving lives: our healthier nation' target has been to reduce the mortality rate from
suicide and undetermined injury by at least one fifth by 2010. This indicator will assess
trusts on their processes to ensure compliance with NICE guidelines on the assessment
and initial management of cases of self harm (published in July 2004) and with the latest
version of JRCALC clinical guidance on overdose and poisoning.
Construction:
Trusts will be assessed on the systems and protocols they have in place to meet key
requirements set out in NICE guideline 16, 'Self harm, the short-term physical and
psychological management and secondary prevention of self harm in primary and
secondary care, the assessment and initial management of self harm by ambulance
services' and JRCALC clinical guidelines on overdose and poisoning.
The assessment will be carried out using a new data collection, including questions
designed to test compliance with the following elements of the NICE guidelines:
1) That the trust ensures that there is rapid access to TOXBASE (the national database of
the National Poisons Information Service) and the NPIS (National Poisons Information
Service) so that their crews can gain additional information on substances and/or drugs
ingested in cases of self poisoning in order to assist in decisions regarding urgent
treatment and the transfer of patients to the most appropriate facilities (ref 1.3.1.11).
2) That the trust has worked in partnership with emergency department and mental health
trusts to develop locally agreed protocols for ambulance staff to consider alternative care
pathways to emergency departments for adults who have self harmed, where this is
appropriate and does not increase the risks to the service user (ref 1.3.1.4).
3) That the trust regularly updates ambulance staff about any change in local
arrangements for services available for the emergency treatment of people who have self
harmed (ref 1.3.1.14)
4) That the trust routinely audits incidents of overdose, both to ensure that interventions
are being used consistently and effectively, and to monitor adverse incidents (ref
1.3.1.15).
The assessment will also include questions designed to test compliance with the Joint
Royal Colleges' ambulance liaison committee (JRCALC) guidance, particularly:
1) That the trust has processes in place to ensure that JRCALC guidance on overdose
and poisoning is routinely followed, for example:
a. all clinical staff have access to clinical guidelines that are compliant with the latest
version of the JRCALC guidelines; and/or
b. they have evidence in the form of minutes of either adoption of JRCALC guidelines or
adoption of JRCALC with local modifications which have been approved, and minutes as
such, by their clinical governance committee or medical steering committee or appropriate
local equivalent; and/or
c. evidence of auditing clinical practice against these standards, such as local audit
reports.
2) That, in line with JRCALC guidance which states ‘It is not uncommon to find patients
who have or claim to have taken an overdose and subsequently refuse treatment or
admission to hospital. If, despite reasonable persuasion, the patient refuses treatment, it
is not acceptable to leave them in a potentially dangerous situation without any access to
care’, the trust has policies in place for the care of those at risk but refuse care.
Note: All questions are subject to approval by the Department of Health’s review of central
returns (ROCR) process. Any revisions or updates to the indicator construction arising out
of the ROCR process will be made in early 2006 and updated on our website.
Data source and period:
Special data collection (as at March 31st 2006)
Infection control
Full indicator name:
Infection control
Target:
Achieve year on year reductions in MRSA levels, expanding to cover other health care
associated infections as data from mandatory surveillance becomes available.
Rationale:
Tackling healthcare associated infection cannot be left to clinical staff alone; senior
mangement commitment, local infrastucture and systems are also vital. Winning ways:
working together to reduce healthcare associated infection in England makes clear that
each organisation should have a director of infection prevention and control to:
- oversee the implementation and monitoring of infection control policies
- be responsible for the infection control team within the healthcare organisation
- report directly to the chief executive and the board and not through any other officer
- have the authority to challenge inappropriate clinical hygiene practice as well as
antibiotic prescribing decisions
- assess the impact of all existing and new policies and plans on infection and make
recommendations for change
- be an integral member of an organisation’s clinical governance and patient safety teams
and structures
- produce an annual report on the state of healthcare associated infection in the
organisation(s) for which they are responsible and release it to the public
Construction:
The indicator is based on the responses to the following questions:
1. Does the trust have a director of infection prevention and control? (Answers: Yes/No - if
post currently filled on a temporary or acting basis pending a permanent appointment
please answer yes, if post exists but is vacant please answer no).
2. Has the trust produced an annual report on the state of healthcare associated infection
in the organisation within the last 12 months? (Answers: Yes/No).
3. Has the trust published the annual report on the state of healthcare associated infection
in the organisation (for example, as hard copy, on internet)? (Answers: Yes/No).
4. Does the trust have a written implementation plan to address the issues identified in its
annual report on the state of healthcare associated infection? (Answers: Yes/No).
The responses to the four questions will be combined to give an overall indicator score,
with each answer carrying equal weight.
For further information on the Director of Infection Prevention and Control see
http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/HealthcareAcquire
dInfection/HealthcareAcquiredGeneralInformation/HealthcareAcquiredGeneralArticle/fs/en
?CONTENT_ID=4002303&chk=bPWxLy
Note: all questions are subject to approval by the Department of Health’s review of central
returns (ROCR) process. Any revisions or updates to the indicator construction arising out
of the ROCR process will be made in early 2006 and updated on our website.
Data source and period:
Special data collection (as at March 31st 2006)
Participation in audits
Full indicator name:
Participation in audits
Target:
Substantially reduce mortality rates by 2010 from heart disease and stroke and related
diseases by at least 40% in people under 75, with a 40% reduction in the inequalities gap
between the fifth of areas with the worst health and deprivation indicators and the
population as a whole.
Rationale:
The priorities and planning framework (2003/2006) states that providers should participate
fully in comparative clinical audit and take account of the results to support local and
national clinical governance. In particular, 'Taking healthcare to the patient: transforming
NHS ambulance services' states that measures of patient outcomes and experience
should be used to promote evidence based practice and to assess how far ambulance
services are delivering high quality care.
The Joint Royal Colleges' ambulance liaison committee clinical practice guidelines
recommends the use of FAST (Face Arm Speech Test). FAST requires an assessment of
three specific symptoms of stroke: facial weakness, arm weakness and speech problems.
Research by the Stroke Association has shown that FAST has been highly successful in
the correct diagnosis of suspected stroke. In turn, prompt identification of stroke
enhances the speed by which an appropriate emergency response can be initiated.
Numerator:
This indicator will be scored on a 6-point scale (0 - 5), scoring 1 point for answering 'Yes'
and 0 points for 'No' to each of the following questions:
1) By the March 31st 2006, has the ambulance trust continually participated in the
national audit of treatment of acute myocardial infarction (AMI) and out of hospital cardiac
arrest by;
a) consistently submitting the full core data set for patients meeting the inclusion criteria
for the joint 2005/2006 ASA/JRCALC AMI Audit,
b) consistently submitting the full core data set for patients meeting the inclusion criteria
for the 2005 ASA National Cardiac Arrest Audit,
c) consistently using the Lotus Notes database on CCAD/MINAP to audit outcomes for
patients treated by the ambulance service with suspected AMI,
d) regularly reviewing and making use of those findings to inform and improve patient
care?
2) Does the ambulance trust use the FAST* assessment for stroke patients?
* (see http://libraries.nelh.nhs.uk/emergency/ for the JRCALC Clinical Practice Guidelines
for use in UK Ambulance Services).
Construction:
Parts 1 and 2 are added together to give an overall indicator score between 0 and 5.
Note: All questions are subject to approval by the Department of Health’s review of central
returns (ROCR) process. Any revisions or updates to the indicator construction arising out
of the ROCR process will be made in early 2006 and updated on our website.
Data source and period:
Special data collection (as at March 31st 2006)
Response to 'Taking healthcare to the patient'
Full indicator name:
Response to 'Taking healthcare to the patient: transforming NHS ambulance services'
Target:
To improve health outcomes for people with long term conditions by offering a
personalised care plan for vulnerable people most at risk; and to reduce emergency bed
days by 5% by 2008 (from the expected 2003/2004 baseline) through improved care in
primary care and community settings for people with long term conditions.
Rationale:
'Taking healthcare to the patient: transforming NHS ambulance services' sets out how
ambulance services can be transformed from a service focusing primarily on
resuscitation, trauma and acute care towards becoming the mobile health resource for the
whole NHS - taking healthcare to the patient in the community. This will include
supporting those patients with long term conditions and helping to reduce the number of
emergency bed days used, through increasingly more care provided at the scene where
appropriate.
To support the review's direction, recommendations focus upon:
- improving leadership, both clinical and managerial, so that organisation structure, culture
and style match new models of care
- improving the consistency and quality of care provision
- improving efficiency and effectiveness
- supporting performance improvement
- developing the workforce
Construction:
This indicator will be scored on a three point scale (0 - 2), scoring one point for answering
'Yes' and zero points for 'No' to each of the following questions:
1. Is there evidence that the ambulance trust discussed the implications of 'Taking
healthcare to the patient: transforming NHS ambulance services' with the local
health/social care community?
2. Has the ambulance trust developed a local implementation plan for delivering the
recommendations set out in 'Taking Healthcare to the Patient: transforming NHS
ambulance services'?
Overall indicator:
Questions 1 and 2 will be added together to give an overall indicator score between 0 and
2.
Note:
All questions are subject to approval by the Department of Health’s review of central
returns (ROCR) process. Any revisions or updates to the indicator construction arising out
of the ROCR process will be made in early 2006 and updated on our website.
Data source and period:
Special data collection (as at March 31st 2006)
Smoke free NHS
Full indicator name:
Trusts assessed on their progress towards becoming smoke free by the end of 2006
Target:
Reducing adult smoking rates (from 26% in 2002) to 21% or less by 2010, with a
reduction in prevalence among routine and manual groups (from 31% in 2002) to 26% or
less.
Rationale:
The ‘Choosing health’ white paper sets a requirement for the NHS to become smoke free
by the end of 2006. Smoking is the single greatest cause of preventable illness and
premature death in the UK. Seven out of 10 adult smokers say they would like to give up,
but due to the addictive nature of nicotine, most smokers find it hard to quit. For smokers
who give up, the chances of getting a serious or fatal disease are greatly reduced.
Ambulance trusts should take action to provide comprehensive support for smokers who
want to give up. Guidance for hospital trusts on meeting the smoke free NHS requirement
and implementing an effective smoke free policy in their trusts may be found in the Health
Development Agency publication ‘Guidance for smoke free hospital trusts’, elements of
this guidance may be useful to ambulance trusts in creating and implementing their own
smoke free policies.
Construction:
Trusts will be assessed on their progress towards becoming smoke free by the end of
2006. The assessment will be carried out using a new data collection, details of which are
to follow. Trusts that have yet to become smoke free will be expected to demonstrate that
they have robust and realistic plans to do so.
Trusts will be asked:
1) As at March 31st 2006, does the trust have a smoke free policy in place, in line with
‘Choosing health’? Yes/No
2) If ‘No’ to question 1, has the trust adopted and advertised a firm date for implementing
a smoke free policy? Yes/No
3) Does the trust widely advertise its local NHS Stop Smoking services? Yes/No
Note: all questions are subject to approval by the Department of Health’s review of central
returns (ROCR) process. Any revisions or updates to the indicator construction arising out
of the ROCR process will be made in early 2006 and updated on our website.
Data source and period:
Special data collection (as at March 31st 2006)