Ambulance required for the Wales Ambulance Trust

After thirteen reports or audits since 2006 - will the Welsh Government
finally take action on the long-standing problems in the Wales Ambulance Trust?
(Pic : BBC Wales)

A major review into the Welsh Ambulance Trust – chaired by Prof. Siobhan McClelland – reported back last week. You can read the report for yourself here (pdf).

The Assembly debated the findings yesterday, and unanimously approved a – by their standards – pretty strongly-worded, 10-point motion demanding significant actions in response.

Just before that debate, Health Minister Mark Drakeford (Lab, Cardiff West) announced a £9.5million upgrade to the ambulance fleet – no doubt welcome but, for reasons that will become apparent, unlikely to make much of a difference.

The Wales Ambulance Service Trust (WAST)

The WAST was formed in 1998 – so before the Assembly came into being - after a review recommended the four regional ambulance trusts were merged into a national service. The idea was this would remove "artificial boundaries" and be more cost effective. At the time of the McClelland review, WAST employed 2,500 staff and had a budget of £159million, with a fleet of over 300 vehicles and 90 ambulance stations.

We might think of the ambulance service in terms of pure emergency services. However, the WAST provides more than that:

• Unscheduled care – The emergency "blue light" ambulance service we all recognise, responding to 999 calls, as well as occasional urgent transport from GP surgeries.
• Planned patient care services (PCS) – Non-emergency transport to take people to pre-planned/scheduled outpatient clinics. I guess these include the "ambulance buses" you see from time to time.
• Health Courier Services – A sub-section of the PCS work, including moving hospital and clinical items. I'm not sure if this includes urgent organ transplants too.

There are other ambulance services not provided by WAST:

• Wales Air Ambulance – A charitable organisation reliant on a mix of fundraising and state-support from local health boards (LHBs) and the Welsh Government. Its three crews generally act as an ambulance in places ambulances can't go, or for quick cross-country transport to specialists.
• Emergency co-responders and first responders – These are usually volunteers, or specially trained individuals (like firefighters), who provide emergency care until a paramedic arrives on scene.

The Key Issues

Governance & Accountability

After growing concerns about its performance, and the fact it's been under heavy scrutiny since it was established, it's said WAST, "has been reviewed....more than any part of the Welsh NHS." It's claimed there've been at least THIRTEEN reviews or audits of WAST since 2006 – this is the latest – so it's totting up at roughly two a year.

Of those reviews, at least two were in-depth – internal and independent - between 2006 and 2009. There was also an opportunity to look at governance arrangements when the LHBs were reorganised in 2009.

In terms of governance, at the moment ambulance services are :

• Commissioned by the Welsh Health Specialised Services Committee, or WHSSC (never heard of them).
• Accountable to the LHBs.
• Governed by the Welsh Government.

So there are – in effect – three bosses.

Stakeholders said there was a "lack of ownership and co-ordination" of ambulance services due to these confused commissioning arrangements. There were also concerns about a lack of accountability to LHBs – who WAST are contractually obligated to provide services for.

It boils down to the question of who are WAST answerable to? It appears nobody knows. These stakeholders were clear though that they wanted ambulances services to "run locally" but "overseen nationally". Isn't that what the arrangements are like anyway?

Not plugging or anything. I'll just leave this here.

Funding, Management & Staff

In terms of funding, for unscheduled/emergency care the arrangements are pretty straightforward. The Welsh Government funds LHBs who fund WHSSC and eventually money makes its way to WAST.

"Funding per call" is around £195, which is lower than similar ambulance trusts in England. Though staff think they get enough funds to run the service, it's said funding isn't being properly targeted towards delivering desired service outcomes (i.e the 8 minute target) – for example, regional differences in funding, where SE Wales gets 68% of calls but doesn't get 68% of funds.

The management structure is one of these bureaucratic mazes which depress me each time I see one. It's said problems in management haven't been dealt with down the years, despite changes in top personnel. Some concerns were raised about the leadership skills of senior managers too.

There are high sickness levels amongst ambulance staff, which is usually one of the first signs of low morale or poor working practices. Considering the scrutiny they're under, you can understand why. You would expect ambulance service staff to have more overtime, but it's suggested staff rosters are "inconsistent" and "lacked capacity at peak times".

I think it's worth pointing out that nobody blames paramedics or frontline ambulance staff for these problems. They appear to be lions led by donkeys – management and political.

Performance

In the last few weeks, we learned only 53.3% of emergency calls were responded to within the 8 minute target time laid down by the Welsh Government (who aim for 65%).

WAST dealt with 530,000+ calls in 2012-13, and the number of calls they received significantly increased since 2005-06. "Life threatening calls" have increased by 30% alone over that period.

WAST consistently failed to reach the 8 minute target during 2012-13, though they've done better in previous years. They've also failed to reach targets for lesser emergencies that need a response in 30 minutes to an hour.

There are several reasons given for this. Most of them are perfectly reasonable and unavoidable, I'm afraid to say :

• Poor weather hampering ambulances.
• Topography and geography. I think we'll all have seen ambulances on "blue light" calls stuck in traffic jams or narrow side streets.
• Particular problems in sparsely populated areas. You can't guarantee where an emergency call will come from as well as factoring in the long distances travelled.
• Handover delays at A&E departments. Every hour an ambulance is held up at an A&E department is an hour that ambulance is out of action, putting more pressure on the fewer ambulances left on the road.

It's said that while speed is important in some medical emergencies – like a heart attack - an 8 minute target is a "blanket measure". This is a critical point I'll come back to later.

Recommendations

There were four key recommendations, and 12 recommendations overall :

• Emergency ambulance services should be considered a clinical service (focused on unscheduled care), with PCS services separated. I think that translates as, "Stop using emergency ambulances to transport people who can/should make their own way to hospital."
• PCS services should be provided by LHBs themselves. AMs from all parties have backed these first two recommendations.
• Development of a non-emergency "111" service to, presumably, discourage people using 999 for medical non-emergencies. It's worth noting current problems in the English 111 service though.
• A clear need for funding and accountability changes.

Relating to that last point, the report proposes three strategic options:

1. Retaining a national ambulance service as a "special health board" funded directly by the Welsh Government. It would clear up the "three bosses" issue, as ambulance services would be directly accountable to the Welsh Government. However, it might not be fully integrated into locally-run PCS services. Plus there's the problem of setting up a new health board in the first place.
2. A new commissioning model, with ambulance services commissioned directly by LHBs. WAST would remain, but services would be accountable to and funded by individual LHBs, creating a "local focus". Some of the drawbacks include a lack of commissioning skills in the Welsh NHS, and it might not be different enough from current arrangements.
3. Ambulance services run and funded by LHBs alone. WAST would be dissolved and ambulance services locally controlled in their entirety. This is probably the most radical proposed change. It would increase "competition" between LHBs in terms of performance, and the LHB would be entirely accountable for ambulance services. However, there is the issue of staff transfers as well as the prospect of bigger differences in performance between different LHBs.

999 problems

I don't think WAST's problems come down entirely to management and governance. Look at the list of reasons for poor performances. Wales (generally) has poor roads and long travel times to hospitals in some areas – which are set to become even longer (in some cases) thanks to the hospital reorganisations. That's probably why members of the public are worried about downgrading local A&Es.

We don't have the infrastructure to enable across-the-board 8 minute response times. Maybe the Welsh Government's targets are too high, and we need a redefinition of what a "life threatening emergency" is. We're in danger of becoming obsessed with the target, not the standard of care.

An example was given where if an ambulance reaches an emergency in 7 minutes and the patient dies – they've hit the target. If it's 9 minutes and they live – they've missed it.

In terms of the strategic options, I'd go for option three – dissolving WAST and handing ambulance services over to LHBs. It might make it clearer which parts of Wales have problems with response times so the Welsh Government can pinpoint what's causing them and take appropriate action.

The fact there've been thirteen reviews or audits in seven years reflects badly on Cardiff Bay. They must've shelved so many of these things you've got to wonder why they're commissioned in the first place!

This latest review is unlikely to go that way. However, I'm bracing myself for only minimal changes as I have low expectations when it comes to Welsh Government and LHB responses to health issues now. They're either incredibly pushy – as in the case of hospital reorganisations - or ultra-conservative and risk-averse.

The Welsh Government didn't set up a national ambulance service, but it's been their responsibility since 1999 to sort out problems. They clearly haven't, or been too scared to make significant changes for whatever reason.

For all the reviews, questions and motions, the key question remains paramount:

How many people have been put in unnecessary danger because of this?