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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:
- 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.
- 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.
- 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?
