To Follow

The Chairman welcomed Christine Masson, Bromley Group Manager – London Ambulance Service, Graeme Marsh, System Partnership Transformation Manager – London Ambulance Service and Darren Farmer, Director of Ambulance Operations – London Ambulance Service to the meeting to provide an update on the London Ambulance Service (LAS).

The Bromley Group Manager informed Members that the focus of the LAS in Bromley was moving towards ‘team-based working’, where a group of staff worked together all of the time. This allowed the staff to form a better bond and increased the face-to-face interaction with managers, which provided opportunities to communicate important information. At the sites where team-based working was already in place, there had been a reduction in sickness absence which impacted on better ambulance provision. It offered a robust opportunity to communicate local messaging in terms of the capacity available at hospitals. It also provided an increased opportunity to undertake operational workplace reviews where the team of managers were completing ride outs with ambulance crews. This helped to improve the quality of service provision, identifying best practice and areas of learning. The clinical supervision allowed the discussion of both failed and successful referrals and how they could be improved. They were currently participating in a feedback trial with Lewisham. The System Partnership Transformation Manager advised that this was a system to support crews, providing feedback on what had happened to a patient in order to aid their knowledge and learning. This trial would be rolled out much further, with the software implemented at multiple hospital sites across London.

In terms of recruitment, the Bromley Group Manager advised that there had been a pan-London focus on training and recruiting more clinicians, call handlers and dispatch staff. This would allow the patient waiting times for an ambulance to be kept as safe as possible, and the most urgent patients prioritised. As a service, the LAS had recruited more than 900 front line ambulance staff and 400 call handling staff (111 and 999 provisions) – an increased workforce meant that there were more people available to respond to patients. The vacancy rate in Bromley had reduced, from 18% at the end of 2022, to currently just over 6%. A number of trained paramedic staff had been lost to PCNs provisions as they provided an opportunity for staff to not work unsociable hours, which was particularly attractive to those staff with families. Looking ahead, they aimed to recruit more than 1,400 frontline staff as part of the 2023-24 improvement programme to meet the levels of demand across London. The LAS had continued to work with colleagues in other blue light services, and in November 2022 had participated in a live multi-agency major incident exercise – this allowed crews and managers to put their response to a major incident into practice.

In response to a question regarding recruitment of St John’s Ambulance Cadets, the Bromley Group Manager advised that the LAS did not have a programme whereby they asked staff to volunteer to help out with the Cadets – some staff did, however others volunteered their time in different areas. If staff were able to give their time, they would actively support it. The LAS were recruiting a younger workforce, including recruiting directly from universities. Whether those recruited chose to stay within Bromley after they completed their course was a challenge, as they may request to be transferred to a more central location as there tended to be more of a variety in terms of ambulance call outs. The Director of Ambulance Operations advised that the LAS had a strong relationship and worked closely with the St John’s Ambulance community, and this was an area of focus. It was noted that, nationally, levels of volunteering were quite low, and the King’s Coronation was being used as a springboard to improve this.

The System Partnership Transformation Manager advised that work was being undertaken in relation to clinical safety, and ensuring that the right resources were provided, to the right patients, at the right time frame. This was an area that they were continuing to invest in and appoint additional staff to – they had looked at changing rotas, allowing staff to work half their time out on the road and the other half in the control room. The LAS were also working with partners to reduce pressures on the Accident and Emergency (A&E) department, as well as utilising the resources available – including maximising referrals into services such as same day emergency care services. Paramedics completed a mandatory training session which included a module based on referrals and what services were available. They were also promoting the MiDos system which provided access to a directory of services that patients may be suitable for. Other areas of work included:

-  Clinical teams developing a frailty pathway with the PRUH – ambulance crews were directed to a geriatrician-led department, rather than going via A&E.

-  Clinical teams producing a prompt sheet – this helped gather details that may not come readily, and reduced the need for conveyance.

-  Care homes – maximising interactions and implementing the use of a universal care plan. This was a template providing information about a patients, including their wishes about going to hospital and treatment to be received. Engaging with care homes to encourage all patients to have a plan to provide a clear indication for ambulance crews.

-  Gathering data to look at falls in the community – when falls were happening and the volume of cases, and looking to improve services.

-  3-month trial of GP notification – delivering incidental finding to GP practices.

-  Community providers visiting LAS control rooms – observing call taking, despatch system and clinicians, which provided a greater idea of how the system operated and its limitations.

-  Mental health response car – mental health clinicians riding out in ambulance cars to target specialist mental health cases, to try and avoid the use of acute services.

In response to questions regarding the work with care homes, the System Partnership Transformation Manager advised that the ICS were engaging with care homes to look at how they operated, and establish a model that could be delivered across the rest of the services. The culture of conveyance to hospital and interactions between care homes and the health care system were changing positively, as they recognised their importance. The Director of Adult Social Care noted that the Local Authority had well-established relationships with care homes, and this was something that could be jointly promoted with care home managers. It was agreed that a list of the LAS initiatives mentioned would be circulated to Members following the meeting (attached at Appendix A).

The System Partnership Transformation Manager informed Members that hospital handovers had been a significant challenge during the winter period, but they had worked with the PRUH to deliver ways to alleviate some of these pressures. One element had been the use of ‘cohorting’ – having paramedic crews within the hospital environment to take patients off ambulance trolleys and help supervise their care while waiting for an A&E bed. This allowed the ambulances to be released back into the community and respond to emergency calls. Another initiative related to intelligence conveyance – the LAS control room looked at the pressures across the system, and could divert a crew to a different Trust if a hospital was struggling with capacity, and alleviate pressures in individual areas. It was noted that this resulted in better patient outcomes, but there were some limitations in terms of patients who required specialist treatment at a certain hospital.

Jonathan Lofthouse, Site Chief Executive – PRUH and South Sites (“Site Chief Executive”) said that they were endeavouring to accommodate solutions for cohorting patients, but these were not yet sufficient. With regards to the long-term plan, it was noted that the PRUH had been recognised nationally as being ‘under bedded’ for the needs of the local population – it was therefore highly likely that additional bed spaces would be opening at the PRUH and Orpington Hospital sites by winter 2023. Thanks were extended to LAS colleagues for the work undertaken with hospital staff to manage cohorting, and highlighted that they were now starting to gain traction in providing a long-term and sustainable solution. It was noted that a further update could be provided at a future meeting of the Sub-Committee.

The Director of Ambulance Operations echoed the comments of the Site Chief Executive – they understood the nature of the current issue and the interim solution of cohorting. Their areas of focus were around using teams to improve clinical knowledge, moving patients appropriately and managing them in the community. Success had been seen in relation to the urgent community response and mental health cars, and safely managing patients away from A&E.

In response to questions regarding performance figures, the System Partnership Transformation Manager said that, anecdotally, the transportation times were likely to be impacted by peak periods of traffic and congestion – however it was noted that the most acute patients would be transported under blue lights. The Director of Ambulance Operations advised that there were variations in terms of traffic speed. The long-term position regarding the contribution that traffic made to respiratory conditions needed to be acknowledged, as these were a huge burden on the system. Some of the traffic management processes being used across London had long-term health benefits that would reduce pressure on both the LAS and acute Trusts.

With regards to performance categories, the Director of Ambulance Operations advised that Category 1 related to a small group of highly acute patients with significant issues. Category 2 included strokes and heart attacks, but this also included a large group of other patients where it was not possible to gather enough details about them during the initial call to identify if they could be included in a lower category. The LAS was part of a national trial, currently looking at this group, to identify the higher acuity patients accurately and those who could safely sit in the lower acuity groups – more data would be provided from this throughout the year. It was acknowledged that the Category 2 figures were away from the national target of 18 minutes, however the agreed target for this year, and the level they were commissioned at, was 30 minutes. Their aim was to achieve the target of 18 minutes and it was considered that the trial mentioned would bring benefits and reduce this number.

The Chairman thanked the Bromley Group Manager, System Partnership Transformation Manager and Director of Ambulance Operations for their presentation. Thanks were also extended to all LAS staff on behalf of the Sub-Committee for the work they undertook. It was requested that a further update be provided to the Sub-Committee in six months’ time.

RESOLVED that the update be noted.