Representatives of West Midland Ambulance Service have been invited to attend the meeting to explain the contributing factors underlying the deteriorating trend in response times in Shropshire – especially rural areas – and discuss what is being done to address these concerns 

Michelle Brotherton - General Manager for West Mercia, Mark Docherty - Director of Clinical Commissioning and Service Development and Diane Scott - Deputy Chief Executive Officer, West Midlands Ambulance Service will be present at the meeting.

Dr Julie Davies - Director of Strategy and Service Redesign and Emma Pyrah - Commissioner Urgent Care, Shropshire CCG will also be present.

To follow:  WMAS Performance information for Shropshire February 2016, a report on comments received by Healthwatch regarding the Ambulance Service and a presentation provided by West Midlands Ambulance Service.   These will all be available in advance of the meeting.  

The Chairman welcomed the following representatives and thanked them for attending the meeting:  Mark Docherty – Director of Clinical Commissioning and Service Development (WMAS), Michelle Brotherton – General Manager for West Mercia and Executive Nurse (WMAS), Cliff Medlicott – Community Response Manager (WMAS), Murray MacGregor – Communications Director (WMAS), Julie Davies – Director of Strategy and Service Redesign (Shropshire CCG) and Emma Pyrah – Commissioner Urgent Care (Shropshire CCG).

The Director of Clinical Commissioning and Service Development introduced a presentation (copy attached to the signed minutes).  He acknowledged the challenge faced by the Ambulance Service in Shropshire and that meeting red targets in the county had been a struggle and continued to be so.  Activity was increasing and February 2016 had been 23% busier than February 2015.  Sometimes a day could be 30% busier than expected which caused major challenges.  If more resources were available then the service could respond to the increase in activity. 

He also stated that the change in clinical models at the hospitals had led to more ambulances travelling to Princess Royal Hospital relative to Royal Shrewsbury Hospital and this had led to an increase in job cycle time which had averaged 65 minutes, but in the last week had been 96 minutes.   Service reconfigurations could be challenging for ambulance services and must be properly resourced. A ‘vortex effect’ meant that resources could be sucked into the centre and an ambulance in Telford could end up in Wolverhampton or even further away.  This was partly why response times were challenged.

The Chairman asked if WMAS was involved in the Future Fit discussions and it was confirmed that this was the case.

The CCG Director of Strategy and Service Redesign said that the CCG did factor growth into the WMAS contract which was not done by all CCGs.  It had also done some modelling in relation to stroke and maternity and paediatric services moving to Telford and £500,000 had been added to the contract reflecting that reconfiguration.

The Committee were informed that ambulance turnaround delays at Royal Shrewsbury Hospital and Princess Royal Hospital.  It was clarified that paramedics had to stay with a patient until a clinical handover was made at the hospital.  Ambulances were often delayed by over an hour and some Ambulance Services classified this as a serious incident.  Although WMAS did not, it did measure these occurrences.  If it was possible to reduce the turnaround delays of over one hour, it would equate to having an extra ambulance on the road straight away.

The Committee was concerned to hear that Shropshire had recently experienced ‘zero status’ for a period of time when the county had run out of ambulances as a result of hospital delays.   This was not happening frequently but it was unacceptable that it had happened at all.  The help of the whole health economy was needed to deliver a better and safe ambulance service. 

The Director of Strategy and Service Redesign, Shropshire CCG, explained that the CCG was working closely with WMAS and SATH through the Strategic Resilience Group.  Both CCGs had supported HALOs and these had started work in December along with two corridor nurses at each site from 10 am to 10 pm.  The impact of this had been disappointing.   She said that SATH would be asked to update the Strategic Resilience Group on the reasons for this. She also agreed to ask SATH for a clear definition of the role of Corridor Nurse. 

The Director of Clinical Commissioning, WMAS, reported that an urgent meeting had been requested between the CCG, WMAS and SATH to address this issue.       

Members asked if there were any exemplar sites for hospital handovers.  Some hospitals, eg Sandwell, were able to manage pressures in a way that did not impact so severely on the Ambulance Service.  The Director of Strategy and Service Redesign emphasised that a challenge faced by SATH was that there was nowhere close by to divert an ambulance to, as in other areas of the West Midlands.

In response to questions and comments from Members, the Director of Clinical Commissioning agreed that it was essential to get the system as a whole right.  He referred to Shropshire having one of the highest rates of non-conveyance in the region, which was particularly good in relation to the average age of the population.  A tipping point of 56 minutes had been identified – if an ambulance attended for longer than this time, the patient was less likely to go to hospital.  Admission avoidance would help prevent frail elderly patients from decompensating in hospital.  However attendance for this length of time was not always possible due to resource constraints.  He felt that it was important to stop talking cost and start talking value - that WMAS offered value and that with a bit of investment, the value of the service could increase significantly further.   

A Member of the Committee representing an electoral division bordering Wales said that expectant mothers were concerned that an ambulance would not convey them to hospital in time if needed.  She emphasised the need for a good relationship with services over the border and getting ambulances back if they left the area. 

The Committee discussed the significant funding issues facing all those delivering services in Shropshire and the need for the actual costs of delivering a safe health service in a sparse county to be recognised.  The Director of Strategy and Service Redesign confirmed that Shropshire did not get funded differently even though it cost more to deliver services in sparse rural areas.    Challenges needed to be made through the Strategic Transformation Programme. 

The Committee felt that in the meantime it was important to maximise the resources that were available.  Members heard that in other parts of the country Ambulance Services were working with Fire and Rescue Services.  The Director of Clinical Commissioning, WMAS, felt that a person choosing to call the Ambulance Service would not want a fire engine and fire officer to attend and emphasised the need to deploy medically competent people.  However, the Committee remarked that a number of Community First Responders were previously Fire Fighters and it had heard that the Fire and Rescue service was willing to work with the Ambulance Service.  Diane Steiner, Acting Consultant in Public Health, remarked, although a fire officer could not act as a paramedic, they could be given additional training to enable them to attend medical emergencies to provide support whilst waiting for an ambulance to arrive and were well dispersed throughout the county, so could have a positive impact on call-out times.

The Committee also heard about a pre hospital acute medical service pilot starting in April which would involve a GP providing advice within the WMAS governance structure and targeting frail and elderly patients.  It was hoped that this pilot would fund itself but the risk was being taken by the CCG.  A report back on this was requested.   

Shropshire Council’s Director of Adult Services recognised the work of WMAS within a complex environment.  He felt that there was a renewed appetite to look at the system as a whole and to look at value, not cost.  He referred to measures to reduce Delayed Transfers of Care, avoid admissions and he was optimistic about inroads into these issues.

The Committee also heard about a review by the CCG into inappropriate use of the Ambulance Service and frequent callers.  It was agreed to share the outcomes of this report with the Committee.

It was agreed that reports on the following be brought back to the Committee at its meeting on 25 July 2016:

·         An update on the action taken and the effectiveness of this on the handover situation at RSH and PRH (SATH, WMAS and CCG representatives to be present)

·         An update on discussions and work undertaken on the potential for Fire and Rescue Service joint response to medical emergencies

·         Outcome of the high intensity user scheme review

·         An update on the effectiveness of the pre-hospital acute service with GP in car

The Member for Cleobury Mortimer also requested information to be forwarded on coverage provided by Community First Responders, to include numbers, distribution, qualifications and access to 4 x4 vehicles. 

Members suggested that the Portfolio Holder for Rural Services and Communities be asked to attend the next meeting.  It was also suggested that there was a role for Members of the Council in encouraging appropriate use of the Ambulance Service through attendance at Patient Groups and other forums.