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Working closely with ambulance services could save the healthcare system millions, the NHS efficiency champion says. Kaye McIntosh asks how STPs can seize the opportunity
In the ongoing and ever-more complicated game of musical chairs that is NHS reorganisation, there is one service in each region that has oversight of what is happening across STPs.
Often overlooked and regarded as a transport service rather than an integral part of the system, ambulance services can bring experiences of different pathways and models from one area to another.
Operating on a much larger scale than STPs, there are just 10 ambulance trusts covering the whole of England: South Central Ambulance Service Trust alone covers a population of more than four million people, from Portsmouth to Oxford and beyond.
They are one of the main gateways to the NHS. When hospitals are overloaded, ambulances stack up outside and costs to the NHS escalate; equally, if paramedics have no alternative to taking people to A&E, emergency departments can become overwhelmed and money drains away.
Unlocking the productivity of the ambulance service could save the NHS millions, according to a report from NHS efficiency champion Lord Patrick Carter, published in September.
If more people could be safely diverted from A&E during their 999 call and paramedics were able to treat more patients at the scene, the NHS could save £300m a year by 2021 through reduced demand for emergency departments and the knock-on effects of hospital admissions, the report outlines.
Expertise on hand
Hilary Pillin, a consultant to the Association of Ambulance Service Chief Executives, says ambulance services have a wide range of skilled clinicians on hand, who can support people with complex and multiple conditions.
‘The category one calls, the most critical, are about 10% of the workload, so there’s a lot more we can offer, providing care in a community setting, and that could be really enhanced by greater integration with the other providers within STPs,’ she says.
The combined expertise that ambulance services can offer – of call-handling and telephone systems experience on the one hand, and clinical knowledge on the other – could be incredibly useful.
But integration sometimes runs into stumbling blocks, such as difficulties in sharing access to medical records and not having direct referral pathways.
‘It could be much smoother for the patient if there was direct referral into the community or diabetic team,’ Ms Pillin points out, instead of patients having to go back to their GP and start the journey all over again.
Different services are working on different models, she says, for instance joining up 111 and 999 with clinical teams comprising midwives, pharmacists, mental health nurses and GPs, or having paramedics and mental health nurses in cars, going out to people in crisis.
‘There are lots of initiatives happening in isolated pockets because one CCG will commission it but another won’t, so you can see examples of things working really well that could be done on a regional basis if someone would just look at how it all fits together across a wider area,’ Ms Pillin says.
Integrated urgent care South Central Ambulance Service can compare different models of care. In the Thames Valley, it operates an integrated urgent care system, spanning Buckinghamshire, Berkshire and Oxfordshire.
The contract, which started in 2017, covers 10 CCGs and allows patients to reach pharmacy, mental health and specialist dental services with a single call to 111.
The Thames Valley system was an STP-wide procurement process with providers bidding for the £8m contract. Funding is on a per-patient-contact basis, with additional payments under the Commissioning for Quality and Innovation system.
In contrast, South Central is in Hampshire co-designing a model with the STP to cover the one county. Philip Astle, chief operating officer, says: ‘We suggested building a model that has some variances in it, so we could test it out for a year before going to procurement.’
So, what’s the advantage to South Central, given the risk inherent in designing a system with no guarantee of winning the contract? ‘It is very much in our interest that we are at the forefront of designing it so that we can make sure whatever comes out at the other end is deliverable,’ Mr Astle says.
The benefits of integrating urgent and emergency care with the wider NHS are clear, he adds. South Central can compare Thames Valley with Hampshire and the number of people ending up in A&E was 2% lower under the Thames Valley system – meaning it saved £1.25m.
One particular innovation in that area is linking with the Samaritans helpline. ‘It’s very much a portal. People call, and it’s a seamless transition, as if the Samaritans are sitting in the same room,’ South Central chief executive Lena Samuels says.
It’s one example of the kind of idea she’s constantly seeking, she adds. ‘We can use innovation to look at how we deliver a service that is responsive and makes the patient’s life easier, getting them the right outcome at the time when they need it.’
East Midlands Ambulance Service
Ripley in Derbyshire is home to a scheme that is transforming care. The mental health hub brings together paramedics, the police, mental health nurses and approved mental health act professionals (AMHPs).
Derbyshire Constabulary has been running a scheme since 2016 but in October, East Midlands Ambulance Service joined a new six-month pilot, funded by the police and crime commissioner.
Peter Bainbridge, ambulance operations manager for Derbyshire, says: ‘The health service can be complicated to navigate and often defaults to us or the police, so this was a chance to get the right care for the patient on the first attempt’.
Mental health hub
The scheme operates between 4pm and midnight, the times of peak demand for out-of-hours mental health care.
Eight to 10 cases per shift require ambulance service input, 90% of which can be assessed and supported over the phone by the team of a paramedic, a mental health nurse and an AMHP, rather than face to face – generating huge savings in time and money.
The police or ambulance service triage the call and pass it through to the mental health hub.
‘We’ve had patients who historically would have ended up in the emergency department – which wouldn’t have been the best place for them – where we’ve been able to put in place other plans to support them and made sure we have an agreed care [plan] in place, going forward,’ says Mr Bainbridge.
Having the technology to share patient records is key. With one recent caller, the team saw she was in touch with mental health services and was due for a review.
They were able to bring it forward, reassuring the patient and making sure she was safe in the meantime. ‘She was happy with that, rather than going to hospital being discharged without being any further forward.’
The police want to see the scheme reduce the number of people they need to detain under section 136 of the Mental Health Act, where that could be avoided by earlier support.
Mr Bainbridge hopes that ‘over time we will see a reduction in demand on our operational crews because patients will be signposted correctly and not end up on the conveyor belt to the emergency department’.
The scheme is monitoring the effect on ‘high-impact’ callers, the most frequent users, as identifying the right support for them could be transformational.