New Model for Urgent Care Ambulance Transport Hambleton, Richmondshire & Whitby CCG

Background

One of the biggest causes of increased 999 Ambulance demand is the rise in calls from Health Care Professionals (HCP) across the care system for urgent same day 999 ambulance transport. All calls flow through to the same 999 control room to sit in the same pool of urgent and emergency calls made by members of the public. It is akin to pushing outpatient flow through the front door of A&E.

For ambulance demand, there was never such a thing as urgent care – there was a 999 (Emergency) or a Patient Transport (Routine) entry point and nothing else. Together with our innovator CCGs, 365 Response has redesigned the 999 flow and has created a new care pathway for all HCP urgent care referrals for ambulance conveyance, with astonishing results in quality, response times and Red Performance.

NHS Hambleton, Richmondshire and Whitby CCG is in the rural North East of England encompassing the North Yorkshire Moors, serving 142,000 patients. In late 2014, due to consistently poor ambulance response times and negative impact on flow, the CCG and 365 Response collaborated to design a new model of care for HCP requested ambulance responses.

It pays to be brave

The CCG established that the real cause of 999 delay was coming from bunched HCP calls based on the traditional models of GP home visits, and the impact of all HCP calls arriving on the 999 stack at the same time, thus making it vital to conceptualise a new pathway for urgent care transport.

The CCG’s patients had been experiencing significant delays for urgent same day 999 transfers and hospital admissions after being assessed by their GP either at home or in the GP Practice. The National Ambulance Targets for HCP calls are based on a triage system in the control room known as HCP Card 35. This means that even though a senior clinician in hospital or in the community has already assessed the patient’s need and determined the response required, the call must go through the same process as someone on the street calling 999. It also means these HCP calls are often at the bottom of the acuity stack and have much longer waiting times than the requested four-hour response time.

In the situation that an ambulance is allocated a call, it can frequently be diverted to other higher acuity Red 999 while in transit to the HCP referral. Mixing health care professional urgent (four hour) ambulance requests in the same pathway as Red and higher acuity Green calls directly from the public often means longer waiting times for ambulance response to HCPs, GPs and community staff. This results in patients who are in urgent need of hospital or alternative care admission waiting long periods. The wait causes further deterioration in their condition requiring them to attend A&E late in the day, subsequently causing ambulance queuing, exit blocking, increased risk of admission and reduced access to diagnostics.

Objectives

The solution needed to make an immediate impact on flow by:

  • Reducing waiting times for GP/HCP assessed patients requiring urgent same day ambulance transfer
  • Improving safety for patients by reducing long wait times and reducing risk of deterioration
  • Bringing forward the ambulance arrival times at A&E to increase the chance of same day discharge and no admission
  • Improving ambulance turnaround times through earlier and smoother attendance
  • Supporting the CCG’s 999 ambulance service provider to improve response times and outcome indicators
  • Helping the CCG’s 999 ambulance provider reduce demand/cost pressures and test a new tariff for urgent care 999 transport

The Solution

Using the innovative award-winning National Urgent Care Transport Framework for Health and Social Care, created by 365 Response and hosted by NHS Shared Business Services (SBS), a fully qualified and CQC compliant transport provider was procured to provide a dedicated urgent care ambulance service directly for GPs in the HRW CCG area.

Having won the HSJ Value Award, the 365 Response framework has also been highly commended by the Government Public Procurement Office for its brave innovation in the sector. It is the first national standard for urgent care transport that defines the exact skills needed, the vehicle type and the scope of practice for urgent care transport. The framework directly addresses the issue of every region having contrasted urgent care transport services causing mass variation in quality, response times and pricing across the UK.

How it works

Due to the procurement process built into the Framework, HRW CCG achieved a fast-track go-live at significantly reduced cost due to the best price always being procured for the commissioner. The procured transport provider is commissioned to respond to bookings within two hours from the time of request to time of arrival with the patient.

Clinicians book journeys via a dedicated telephone line directly to the provider to access the service. This ensures a consistently timely response to deliver earlier and smoother attendance at hospital.

Initially, 2,000 journeys per year were commissioned, thereby demonstrating that diverting a small amount of demand can have a considerable impact on flow, for instance: 7-10 HCP 999 calls per day, per CCG. With a strong background of clinical and operational expertise across 999, urgent and community care, the 365 Response team completely supported HRW CCG with full service mobilisation. Following on from this, ongoing contract management of the provider, on site and ad-hoc provider inspections and continuous quality assurance is provided by 365 Response.

Why it works

HCP ambulance requests account for up to 30% of all 999 demand. Despite this, it is a little understood sector of demand and one that can significantly influence system flow. HCP urgent care transport is the metaphorical equivalent of oil in the engine of the NHS and wider care system; getting it wrong causes A&E bunching, turnaround delays and late arrivals with an increased risk of (potentially avoidable) admission.

Because the scope of practice for the new model for HCP ambulance transport does not require an 8-minute emergency response, blue light transfer or senior skills of paramedics, the service is commissioned at approximately half the cost of that of a traditional 999 response (NAO average of 999 is £221). Incidentally, the urgent care ambulance workforce assists in alleviating paramedic workforce pressures across 999 services.

It may be assumed that this model is a threat to and may perhaps destabilise Ambulance Trusts. Ironically, the model is designed to retain and protect the scarce paramedics in NHS Ambulance Trusts for higher acuity care, use paramedic skills to best effect and help improve paramedic retention. The framework is built to divert a small cohort of 999 demand e.g. into the third and other CQC independent providers who can offer safe care within defined boundaries. By creating a new urgent care pathway exclusively for HCP triaged and generated demand enables HCPs to book, direct and manage flow across localities. This in turn supports the 999 service in its focus on emergency care.

“GPs now receive a two-hour response more than 95% of the time, taking patients to hospital earlier in the day – all managed through a single point of access and a single booking call.

“Our ambulance service has delivered significant % gains in Red performance across our CCG area since the scheme was introduced through protecting 999 ambulance resource for the Patients in most need. Our local A&E Department and Hospital wards appreciate the significant and positive impact this initiative Continues to have on their patient flow.”

John Darley, Head of Urgent Care,
Hambleton, Richmondshire and Whitby CCG

Results

HRW CCG has proven that by moving a small number of lower-acuity pre-triaged HCP journeys out of the 999 ambulance stack can have a significant effect on flow, A&E and ambulance Red performance.

The following results have been collated over a two-year period and show a dramatic improvement across the system:

  • The savings generated from the start of the contract up to June 2017 have been £1,016,698.79
  • 98% of HCP Ambulance requests now receive a response in under two hours compared with a previous timeframe of 4-6 hours (and sometimes longer), thereby reducing bottlenecks or late arrival at hospital
  • 45% cost saving on urgent transport for the CCG on the marginal rate per journey due to defined scope of practice and no requirement to access the 8-minute response skill set (Paramedic)
  • Over 20% improvement on Red 1 performance across the CCG area. This has coincided with a “survival to discharge” rate for patients who have a cardiac arrest in the HRW area rising from 0% in 2013 to 12% in 2016 due to the release of 999 ambulance resources, allowing for a quicker emergency response to attend the scene
  • Smoother admission profile for A&E ambulance attendance reducing bunching and resulting in shorter turnaround times
  • Reduction in ambulance service contract overtrade that supports 999 demand management without destabilising the income for the ambulance trust
  • Reducing risk to patients (by reducing ambulance response times) and thereby reducing risk of deterioration and enabling quicker access to diagnostics through earlier attendance at hospital
  • Contributing to consistently lower OPEL levels and supporting rapid discharge from hospital departments, which improves flow, generates capacity and reduces exit block
  • Improved satisfaction for GPs who now have greater confidence in the response time for their HCP ambulance being achieved
  • Reduced “call backs” from the ambulance service requesting a time extension. This in turn reduced the frequency of escalations to a GP red response

Performance and growth

The successful pilot was extended to a contract and the number of approved referral sites for HCPs was increased. Commissioners are now able to extend the service to approved intermediate care hubs, on day rapid hospital transfers and other approved care settings. This has increased the HCP referrals and reduced 999 demand yet further maximising the return on investment and impact for the commissioner and wider urgent and emergency care system.

Because of the NHS England Innovation Fund/SBRI for urgent care flow, this new care model is now being automated and digitised. 365 Response undertakes continual development on its technology and booking platform to enable HCPs to book, track and monitor the urgent care transport.