Minutes:
Jason Killens and Estelle Hitchon from the Welsh Ambulance Service delivered the presentation and answered the members’ questions.
Challenge:
The key concern is the removal of emergency response cars in Monmouth and Chepstow, and therefore the response time to something like a heart attack or serious farm accident in those areas.
We recognise those concerns. We are setting out to use our available resources in the most efficient way, to get the best service for patients. It is true that the data used is from 2019, and much has changed since then; in May, we did modelling with a different company to test whether what we were doing still gives us an improvement in response times and the answer to that is yes. While the scale of the benefit is reduced, due to the disruptions and losses in emergency departments, we still see an improvement in red and amber performance. The roster changes won’t entirely fix the problems that we have in the timeliness of our responses, but they will help.
The models are reassuring but what is the plan if the response times fall?
We monitor performance on an hourly basis. If performance deteriorates, we would first consider what is happening around that e.g. there is more activity, more lost capacity at emergency departments, etc., but otherwise we would respond either with changes to the local cover profile, additional people, tweaks in the hours of production, or other measures. It should be remembered that we are putting in extra ambulances and extra urgent care resources in response to the change in ambulance rosters.
With fewer ambulances in these areas, will the air ambulances be used more?
We aren’t taking ambulances away but putting more in. There’ll be more ambulances nationally and locally – in excess of 30 additional nationally, with 40 additional hours across the fleet in Monmouthshire per week. We are not responsible for Welsh Air Ambulance but are aware that with their modelling on the proposed changes to their operational basis, there is no detriment in access for those patients who need Air Ambulances or their road responses – there is no connection between what they’re doing and what we’re doing, except that both are about making best use of available resources.
With a hub-based situation, the problem is the 8-minute time – physically, an ambulance can’t get from a central location to areas in Monmouthshire in that time period. The software model might result in improved overall average response time, but it won’t be applicable to outlying areas that will get a worse response time?
We are not closing stations. We plan to invest in and maintain a physical presence in Monmouth. There are no plans to close either Monmouth or Chepstow stations as a result of this roster change.
The average red times are for ABHB but that’s largely urban – it would be helpful to see red times for Monmouthshire. Is there going to be another full emergency response ambulance in Monmouth, replacing the rapid response vehicle? With emergency services, is over capacity not better than meeting capacity?
We agree about over capacity. Our fleet’s utilisation rate is currently much too high, which leads to the long waits for patients. A lot of our work is to bring down that utilisation rate. We are commissioned to deliver a service on a health board level, which is why we have used data at that level. We aren’t resourced to deliver those targets in every locality every day. We work with averages, as a result. Not every ambulance works every hour of the week – some will be staffed, 12, 16, 18 hours a day. In some cases where we have additional capacity, we will operate the vehicle for a longer period of time. In some cases, there are additional vehicles going in. We can supply the committee with specific data for Monmouth.
How do you link with ambulance services in England?
On a day-to-day operational level with England, we take calls for each other and pass them back and forth, with us occasionally responding into another patch e.g. Herefordshire, and they will respond to some of ours, especially for Red calls.
Regarding “safely closing episodes of care”, what impact is treating people where an episode happens going to have on the primary health care team?
As a hypothetical example: an elderly person with COPD is short of breath and can’t access primary care for some reason, so calls 999 – at the moment, we would respond and probably convey the patient to the emergency department. It is likely that they just need antibiotics. Now, we can send a paramedic practitioner to the scene who will assess the patient, write a prescription for the antibiotics, arrange for the pharmacy to deliver them, and inform the GP. The patient can therefore stay at home instead of being taken by ambulance to an emergency department, waiting outside for a long time, then potentially be exposed to additional risk once inside – and while waiting outside, the ambulance is not available for anyone else in the community. So, if we can close the episode of care safely and appropriately in the community, it will be better for the patient and the overall health system. It has to be part of how we improve the service and our patients’ experiences.
Treating at home needs to be more holistic – another bit of the NHS needs to complement what you’re trying to do.
We completely agree, and therefore continue to work with partners across the NHS to create opportunities for our clinicians to refer to other parts of the system. We can’t continue to convey the same number of patients to emergency departments – there are better ways. But we need support from health boards to achieve that aspiration.
Can you confirm that when 999 is called, it goes to a call centre, then they make the decision about a road or air ambulance – how is that determined?
On dialling 999 the person is connected to a BT operator who will ask which emergency service is needed. If the answer is ambulance, the call goes to the north or south Wales control room. The call handler asks a series of questions, at which point an ambulance is dispatched. Further questions are then asked about the patient to determine if further help is needed, including the air ambulance, based on ‘dispatch criteria’. So, the type of patient and problem is the critical aspect, not the location.
The Monmouth station plans are good. Where will more local ambulances be located? Residents will be concerned about the red response times; given the time to get across rural areas, I fail to understand the rationale of downgrading the stations in Monmouth and Chepstow.
We are adding in more ambulance capacity as a result of this change. But the rurality point is a good one: no matter how many vehicles were available, it simply isn’t possible to service every location in 8 minutes, due to geography and the road network. To improve our chances of getting to more calls more quickly, we have the community first responder scheme: 6-700 individuals across Wales responding to calls in their community to provide life-saving intervention while awaiting the ambulance. We are investing in this group, adding capacity, training, and advertising new recruits, particularly in rural patches. We recognise there is more to do to support rural communities and believe that the CFR scheme is the way to do that.
Chepstow ambulance station closed a long time ago but there is a rest area for emergency response vehicles. How does that manage the large, combined population of Caldicot and Chepstow, and with such a distance from Royal Gwent and The Grange?
It is a Community Response bay – it is not a full station but there are resources that work from there. There is no intention to change or reduce the locations that we work from as a result of the roster changes. We are happy to write a full response separately about the operation of Chepstow Response bay.
Chair’s summary:
We have discussed the proposals in detail and have explained our concerns on behalf of our residents in terms of the capacity and timeliness to attend critical incidences in a rural county. We understand that the Trust has undertaken detailed modelling to predict demand patterns and to evidence the changes they are proposing. Whilst the committee recognises that the Trust is making these changes with the aim of utilising its resources to give the best possible service to communities, I’m sure the Trust appreciates that we have concerns and that we are championing on behalf of our residents. The Committee is reassured that there are no plans as a result of the roster changes to close any of the stations in Monmouthshire and that the Trust intends in its Business Plan to invest in its physical presence. Equally, the Committee is reassured to hear that the Trust is putting in extra ambulances nationally and over additional hours in Monmouthshire as part of these proposals and the Trust will continue to monitor performance and response times. Whilst we may not fully support the Trust’s proposals, we do appreciate wholeheartedly the opportunity to discuss these with the Trust, in order to better understand the decision it is taking and to reflect the concerns of our community. We would like to thank Jason for the opportunity to talk to you and understand how busy you are, so your attendance today has been very much appreciated and valued by this Council. I would like to thank all Members, including those not on the Committee for their input on this important issue.