Contents

LOCAL CONTEXT

Review of 2008-09

Looking Ahead

REFORM, MODERNISATION AND EFFICIENCY

CURRENT SERVICE PROVISION

service reconfiguration

MINISTERIAL PRIORITIES FOR ACTION 2008-2011

AMBULANCE SPECIFIC PRIORITIES

NIAS PROPOSAL TO DELIVER AMBULANCE SPECIFIC MINISTERIAL PRIORITIES

OTHER MINISTERIAL PRIORITIES – AMBULANCE RELATED

RESOURCE UTILISATION

Efficiency Savings

Income and Expenditure

Capital Investment Plan

MEASURES TO REDUCE ADMINISTRATIVE BURDEN AND MAXIMISE RESOURCES

GOVERNANCE

INVESTING FOR HEALTH

USER EXPERIENCE

APPENDIX

Appendix 1

LOCAL CONTEXT

The Northern Ireland Ambulance Service (NIAS) faces a range of significant challenges and major issues over the period covered by this Trust Delivery Plan. Chief among these is the need to deliver improved performance and service modernization in terms of both speed of response and quality and efficacy of clinical treatment provided in line with Ministerial Priorities while also ensuring that financial requirements are met, in particular the need to balance income and expenditure.

Review of 2008-09

During 2008-09, NIAS delivered a 5% improvement in Category A, life-threatening emergency calls (Cat A) responded to within 8 minutes, averaging 67% against a target of 70% for N. Ireland. Peak response was in February with 70% of Cat A calls responded to within 8 minutes. NIAS is committed to delivering the fastest possible response to Cat A calls as the rapid provision of paramedics at scene of incident offers the greatest potential for effective clinical intervention leading to positive outcomes and enhanced patient experience.

NIAS operated within budget, balancing income and expenditure, supported the introduction of significant acute hospital service changes throughout Northern Ireland, and absorbed a 6% increase in emergency calls over the previous year.

During the year, NIAS worked with colleagues, in particular DHSSPS and Health Boards, to introduce proposals jointly agreed as being necessary to further improve ambulance services including response and clinical quality, thereby contributing to improved health and well-being and saving lives. Bids submitted through the Comprehensive Spending Review (CSR) process have secured additional investment funds (Capital £17 million & Revenue £12.1million) to support service improvement and modernization.

In addition, NIAS extended the provision of paramedic-delivered thrombolysis originally piloted in the Western Board area) to the whole of N. Ireland ; developed and refined automatic vehicle location and satellite navigation technology in our fleet and control rooms; extended alternatives to automatic emergency ambulance response and transportation for appropriate emergency and non-emergency calls; increased the number of singe paramedic response vehicles in operation; secured funding for and procured significant numbers of emergency ambulances, non-emergency ambulances, rapid response cars and clinical equipment such as defibrillators essential for effective clinical care.

Looking Ahead

Plans and proposals for ambulance service development for the CSR period, 2008-11, are driven primarily by the Programme for Government endorsed by the NI Assembly and delivery is undertaken within the context and confines of the supporting Budget approved by the NI Assembly. The Minister for Health has outlined specific priorities in his Priorities for Action (PfA) related to the Programme for Government. The immediate and prime priority for NIAS remains the requirement to deliver faster response to life-threatening emergency calls within 8 minutes within available ambulance resources.

NIAS has extracted ambulance-specific priorities from the PfA and presented DHSSPS and Health Commissioners with proposals to deliver improved ambulance response in line with PfA. Funding has been identified through the CSR process to progress these proposals. The CSR process also places a requirement on NIAS, as with all other NI HSC Trusts, to deliver 3% per annum Efficiency Savings, which amounts to £4.5million over the three-year period.

Consequently, NIAS has revisited options for improving response performance in light of our experience during 2008-09 and refined plans to deliver PfA priorities and service development within stated resource constraints. In addition to Ministerial PfA priorities and particularly the primary requirement to deliver improved response times, endorsed by the NIAS Trust Board, NIAS has a range of other key challenges to address or progress during the year. While not necessarily or explicitly referenced in plans, it will be necessary to progress these challenges in addition to specific priorities if we are to continue to seek to deliver a balanced ambulance service providing quality clinical care appropriate to the individual patient as quickly and efficiently as possible.

These key challenges facing the Trust, including PfA targets, reflect the need to effectively manage the totality of the organisation and are outlined below.

  1. Deliver enhanced emergency response to achieve 72.5% of Cat A calls within 8 minutes for NI by March 2010, rising to 75% by March 2011 and deliver baseline Cat A response at Board level of 65% within 8 minutes by March 2010.
  2. Maintain financial balance and deliver efficiency savings – (cash/non cash release)
  3. Deliver other ministerial priorities for action relevant and applicable to NIAS in particular clinical prioritisation of non-emergency demand for patient transportation (fracture; dialysis; active treatment for cancer such as radiotherapy or chemotherapy; discharges, etc.)
  4. Modernise paramedic and non –paramedic staff recruitment, training and development to include development and introduction of third level paramedic qualification.
  5. Introduction of regular, planned, funded replacement programme for clinical equipment (monitor – defibrillators); accident and emergency and non emergency fleet; information and communications technology and estate development and upgrade.
  6. Develop clinical audit and supervision to assure governance requirements in relation to the quality of care provided.
  7. Deliver the Priorities for Action target on absence, reducing levels of absence to 5.5% in the year to March 2010, further reducing to 5.2% in the year to March 2011.
  8. Further development of alternative care pathways to support care in the community and alternatives to hospital attendance by emergency ambulance.
  9. Revise operational structure to support delivery of clinical and other performance objectives.
  10. Develop and introduce proposals to enhance delivery of non emergency booking and transportation of patients.
  11. Further developments of PPI/community engagement/user focus and involvement/staff engagement.
  12. Extend and consolidate information management and technology designed to manage the deployment of NIAS resources in line with patient needs.
  13. Clarify the information requirements of key stakeholders (internal and external) and extend the management information framework to accommodate.

REFORM, MODERNISATION AND EFFICIENCY

Since 2001, consistent with the Strategic Review of 2000, NIAS has implemented a challenging modernisation programme which has changed almost every aspect of service delivery. In addition, NIAS has supported and facilitated, often at short notice, acute service change linked to Developing Better Services and Acute Hospital Risk issues. The scale of the new targets arising from Programme for Government and the Budget are such that the NIAS Trust Board, having scrutinised expenditure and opportunities for efficiency savings have come to the view that these requirements cannot be met in full within current budget and service profile. To meet the new targets a more radical solution requiring service delivery reconfiguration is required.

Proposals developed have been designed to assign priority to rapid emergency response in line with the targets set and limit the likely impact on the quality of the ambulance service provided and to preserve as far as possible equity of provision of ambulance services across N Ireland. However, the NIAS Trust Board remains concerned at the risks identified within these proposals and has sought and will continue to seek to identify measures to mitigate risk. The Board is also concerned that proposals emanating from other trusts in response to this exercise will present further changes which have a detrimental effect on the delivery of ambulance services and place at risk both NIAS proposals for service reconfiguration and measures to protect service delivery to patients.

The service reconfiguration proposals are presented with the recognition that successful implementation is dependant upon the full and timely introduction of CSR revenue and capital investment outlined.

Although some additional CSR investment funding has been identified to support specific service developments, the 3% per annum efficiency savings applied to base budgets present a significant hurdle to maintaining the foundations on which current performance is delivered as the platform for future service development.

CURRENT SERVICE PROVISION

NIAS provides a range of ambulance response and transportation resources dealing with emergency calls, urgent and non-urgent calls. All emergency calls are assigned to a category reflecting clinical urgency: Category A (life threatening), Category B (non-life threatening but serious) or Category C (neither life threatening or serious but requiring some form of clinical intervention). A significant proportion of NIAS workload undertaken by emergency ambulances arises from the treatment and transportation of patients referred by GPs.

NIAS has experienced significant growth and demand for emergency 999 response calls over recent years and activity has climbed by approximately one third since 2001. 2006/7 showed the greatest increase at 10,000 extra calls, which was an 11.2% increase on the previous year. In addition to the111,660 emergency calls responded to in 2007/8, ambulance staff also transported 34,603 patients for GP’s and other clinical professionals and undertook 218,310 non-emergency patient transports. In total the ambulance service undertook in excess of 350,000 patient transports during the course of 2006/07. NIAS is currently projecting for 2008/9 a 5.6% increase in 999 emergency calls; a 4.7% increase in GP Urgent calls, and a 1.7% fall in non-emergency patient transport requests.

service reconfiguration

In essence the proposals to deliver Ministerial Priorities within the context of ambulance modernisation emphasize a shift in focus from patient transportation to pre-hospital care and treatment. This new focus further emphasizes the requirement for clinical prioritization to identify and prioritise life-threatening calls and interventions, providing clinically appropriate alternatives to ambulance attendance and transportation to support care closer to home thereby reducing pressure on accident & emergency departments, alongside rapid response to life-threatening emergency calls.

NIAS is committed through this process to matching supply of available resources to demand for emergency and non-emergency services. The process of matching supply to demand will be applied to all expenditure areas in the Trust – Emergency/Non-Emergency Response, Control & Communications, Non-Pay Expenditure and Administrative/Support Areas. This is viewed as being the primary means for delivering prompt response performance and quality clinical care within a sound balanced financial framework. Demonstration of effective utilization of available resources to deliver service priorities will be key to bidding for and securing additional resources to support service development proposals.

NIAS, in common with other Health Trusts, is required to deliver clinical services within available financial resources which reflect recurring efficiency savings extracted from NIAS baseline budgets by Health Commissioners. Financial Proforma FP3(T) records how NIAS will deliver the necessary savings with monitoring arrangements already in place.

1

MINISTERIAL PRIORITIES FOR ACTION 2008-2011

AMBULANCE SPECIFIC PRIORITIES

From April 2009, an average of 70% of Category A (life-threatening calls) should be responded to within eight minutes, increasing to an average of 72.5% by March 2010 (and not less than 65% in any LCG area).

March
2009 / Average of 70% of life threatening calls responded to within 8 minutes
At least 62.5% of life threatening calls responded to within 8 minutes at individual Board level
March
2010 / Average of 72.5% of life threatening calls responded to within 8 minutes by March 2010 and not less than 65% in any LCG area
March
2011 / Average of 75% of life threatening calls responded to within 8 minutes

NIAS PROPOSAL TO DELIVER AMBULANCE SPECIFIC MINISTERIAL PRIORITIES

“NIAS Investment Proposal for 2008/09 to 2010/11”, previously submitted, outlines NIAS proposals to deliver the Ministerial priorities identified above.

In essence the proposal establishes that response performance in February 2009 was broadly in line with that required for 2008/9 above and having identified the measures which have delivered that level of response performance seek to secure funds to maintain and enhance those measures and the response performance associated with them.

The key measures identified are:

1.The introduction of additional rapid response staff and vehicles to provide flexible targeted paramedic response to emergency calls

2.The introduction of additional intermediate care hours of cover to provide flexible targeted non-emergency patient transportation to increase capacity for emergency calls and timely response for non-emergency calls

3.The targeting of Accident & Emergency hours of cover, principally at week-end and nights, to match demand and provide flexible targeted paramedic response to emergency calls and patient transportation where appropriate

4.The introduction of Clinicians (GPs) to Ambulance Control to provide clinical triage of non life-threatening 999 calls and alternative care pathways which negate where appropriate ambulance transportation/attendance (pilot in the first instance).

5.The extension of paramedic delivered thrombolysis on a phased basis which commenced during 2008/9 with the extension to 12-lead defibrillator-equipped paramedics in Southern and Northern Divisions before extending into Eastern Division, thereby providing NI-wide coverage with RRV paramedic officers. Phase two (2009-10) will be the extension to all emergency ambulances with paramedics which requires significant capital investment in replacement defibrillators and staff training.

6.The introduction of Clinical Support Officers as a development of the existing operational management structure which emphasises and supports clinical excellence and supervision. This development also facilitates increased paramedic front-line response to emergency calls, supports the extension of paramedic-delivered thrombolysis, and is an essential step in the development of the ambulance paramedic role in Northern Ireland in line with national and international best practice.

7.Continue to work with local communities in the development of Community First Response on a Northern Ireland basis with an emphasis on rural areas in the first instance and the provision of essential support and governance arrangements, again consistent with best practice and recent recommendations by the Health Care Commission in the UK.

OTHER MINISTERIAL PRIORITIES – AMBULANCE RELATED

The emphasis in the targets listed is on the non-emergency transportation of patients. The previous section addressed performance improvement measures for emergency response, and this section illustrates the need to consider all aspects of the ambulance service in planning delivery.

To this end NIAS will review the arrangements for provision of non-emergency transportation in conjunction with DHSSPS and Health Board Commissioners to identify and clarify eligibility for ambulance transport and to establish during 2008 a system of clinical prioritization for non-emergency ambulance transport to ensure that the limited resources available are used efficiently and targeted effectively at patients based on clinical priority consistent with the Ministerial priorities established. In undertaking this work, due consideration will be given to provision of non-emergency ambulance transport to key groups such the terminally ill.

NIAS will develop relevant plans to support delivery of the priorities identified below, where we do not have sole or lead responsibility.

  • Healthcare associated infections: in the year to by March 2010, secure an overall reduction of 35% in MRSA, MSSA and Clostridium Difficile infections compared to 2007-08.
  • Patient Experience: by September 2009, Trusts should adopt Patient and Client Experience Standards in relation to Respect, Attitude, Behaviour, Communication, and Privacy and Dignity, and have put in place arrangements to monitor and report performance against these standards on quarterly basis.
  • Service Frameworks: by March 2010, ensure the implementation of agreed standards from (i) the Cardiovascular Service Framework and (ii) the Respiratory Service Framework, in accordance with guidance to be issued by the Department in April 2009 and June 2009 respectively
  • Fractures (PSA 3.3):from April 2009, 95% of patients should, where clinically appropriate, wait no longer than 48 hours for inpatient fracture treatment.
  • A&E:from April 2009, 95% of patients attending any A&E department should be either treated and discharged home, or admitted within four hours of their arrival in the department.
  • Stroke services (linked to PSA 3.5): by March 2011, ensure that 50% of patients attending hospital within 90 minutes of the onset of stroke symptoms receive a CT scan and report within a maximum of a further 90 minutes to inform the appropriate use of thrombolysis.
  • Neonatal transport: from April 2009, ensure that a dedicated paediatric and neonatal intensive care transport service is in place on a 24/7 basis.
  • Unplanned admissions (PSA 4.3): early intervention approaches should be further developed to support identified patients with severe chronic diseases (e.g. heart disease and respiratory conditions) so that exacerbations of their disease which would otherwise lead to unplanned hospital admissions are reduced by 50% by March 2010.
  • Hospital discharges (PSA 4.4): from April 2009, 90% of complex discharges should take place within 48 hours, with no discharge taking longer than seven days. All other patients should be discharged within six hours of being declared medically fit.
  • Finance: the Department and all HSC organisations should live within the resources allocated and achieve financial balance.
  • Timely implementation of service developments: Commissioners and Trusts should ensure that not less than 90% of the monies – but ideally, of course, 100% – allocated for service developments in 2009-10 are expended during the course of the year in accordance with agreed plans, and assuming full resources are required to deliver the targets and commitments. This aim will be kept under review between the Department, Commissioners and Trusts to secure the best available balance between the overriding aim of actually improving services and the need to secure economy, efficiency and effectiveness in the full and proper use of the money available
  • Absenteeism (PSA 9.1): each Trust should reduce its level of absenteeism to 5.5% in the year to March 2010, reducing to 5.2% in the year to March 2011.
  • Investment programme – during 2009-10, Trusts must ensure that, for all key strategic projects, agreed timescales are met for the completion of business cases, project procurement, and project delivery.

RESOURCE UTILISATION

NIAS has consistently delivered services on a sound financial footing in spite of significant pressures arising from increased demand and other pressures, and met the tests of financial performance required by DHSSSPS. Information sourced from the Welsh Audit Office illustrates that NIAS does not enjoy levels of investment comparable to UK ambulance services delivering similar or higher levels of performance typically in areas of greater population density, which facilitate faster ambulance response.