The Association of Ambulance Chief Executives (AACE) published a commissioning blueprint calling for greater integration of 999 and 111 call handling, clinical assessment and triage, and ambulance service provision in December 2019. The part played by the UK NHS ambulance sector during the Covid-19 pandemic further demonstrates its potential contribution, in terms of co-ordination, navigation and provision, to the collective delivery of integrated urgent and emergency care services alongside other providers and system partners.
NHS ambulance trusts in England operate on a regional footprint. 999 ambulance services are currently commissioned by local Clinical Commissioning Groups (CCGs), which ranges from seven to 32 for any one trust.
These function across multiple sustainability and transformation partnership / integrated care system (STP / ICS) areas – with ambulance service contracts usually negotiated through a lead or co-ordinating commissioner. Currently 111 / integrated urgent care (IUC) contracts are commercially tendered and commissioned at an STP / ICS level.
An integrated regional approach to the commissioning of 999 and 111 services has the potential to bring about significant economies of scale and quality improvements across service provision, particularly in relation to call answering, clinical assessment and triage to:
- Give patients better, faster and more appropriately delivered access to care closer to home;
- Help reduce ambulance dispatch, avoidable conveyance and pressure on A&E departments across the country;
- Result in greater synergies with wider STP / ICS partners in the primary care, acute, mental health and community sectors, transforming the integrated care system landscape;
- Facilitate the realisation of the aspirations for urgent and emergency care outlined in the Long-Term Plan (LTP);
- Enable the efficient pooling of 999 and 111 call handling and clinical advisor capacity in order to more flexibly meet demand;
- Enable trust boards – in line with their trust and enabling strategies and STP / ICS strategies – to enact longer term strategic priorities to expedite integration, reduce unwarranted variation and achieve productivity and efficiencies in line with Lord Carter recommendations;
- Provide resilience and interoperability of systems, workforce and services to deal with major incidents as demonstrated thought the recent COVID-19 pandemic.
The AACE would welcome a revision of current commissioning arrangements to address the inefficiencies of existing practices, as well as the sustained uncertainty that can result during contracting negotiations. There is the potential for greater efficiencies to be realised if the current short-termism of 111 contractual arrangements, which has tended to inhibit investment in this area, were addressed.
Furthermore, this would enable the integration of call handling and triage systems and processes, the consolidation of call handling and staff resourcing – with dual-trained staff strengthening system resilience – and the integrated management of patient flows across 999 and 111 patient pathways using interoperable platforms. There is scope to enhance the resilience of urgent and emergency care provision, the importance of which has been demonstrated throughout the Covid-19 pandemic.
From a system-wide perspective, commissioning the ambulance service at a combined STP / ICS level for these services, for a given regional geography, would leverage the ambulance sector’s contribution to fully integrated urgent and emergency care, whilst ensuring the necessary oversight and scrutiny at an appropriate strategic level. This would also facilitate the inclusion of other activity undertaken by ambulance services, in relation to prevention and public health, for example, within strategic commissioning and contracting discussions and arrangements.
In alignment with the above, AACE would welcome consideration of the following principles:
- Introduction of a single regional specification for integrated 999 and 111 provision sufficiently robust to strike the necessary balance between funding and need whilst ensuring a national standard with opportunity for localisation;
- Introduction of minimum five-year contracts for ambulance services to provide greater consistency and scope for realising trust, STP/ICS strategies and development and embedding of integrated 999 and 111 provision;
- Joint (and equal) strategic oversight by STP/ICSs within regions supported by strategic units undertaking contract management on behalf of STP/ICSs;
- Ambulance services not sitting inside any one STP/ICS control total given their provision of services within the footprint of multiple STPs/ICSs and the subsequent inappropriateness of financial alignment with just one (in accord with the above);
- The assumption of a central leadership role by NHS England/Improvement regional lead in line with the above and direction of travel outlined in the LTP.
The regional footprint of NHS ambulance trusts underpins the unique role they have the potential to fulfil in the co-ordination of integrated 999 and 111 services, out of hours access, and clinical assessment services (CAS) to ensure the most appropriate response for each patient.
The case studies featured below outline the progress of some trusts in realising this potential and the significant contribution the sector can make to the realisation of fully integrated urgent and emergency care, working with and alongside other providers and system-partners.
South Central Ambulance Service (SCAS): National Pandemic Response
As part of the response to the Covid pandemic, SCAS stood up a range of national services including the Covid Response Service (CRS), the Clinical Safety Netting Service (CSNS) and the NHS111 Covid-19 Clinical Assessment Service (CCAS).
The message to the public was to contact the NHS via 111, ideally online and if not phone, and only to contact 999 in an emergency. During the peak in Spring 2020, more than 1.2 million Covid-related calls were received by these national services, which was in addition to calls managed by core NHS111 services where demand was also considerably increased.
The initial call centre in Rotherham was stood up within a week, with various other sites and services introduced in the following weeks. Over 3,500 extra staff were brought in to work in these services, including home-working for clinicians. A range of clinicians supported the CCAS, including returning GPs, nurses, pharmacists, dentists and AHPs. It also benefited from the contribution of health care professionals who were shielding themselves.
The new call handlers were trained to use the online NHS111 tool in order to assess whether someone’s symptoms were likely to be related to Covid. The assessment tool was continually adjusted based on the latest information available, in order to support clinical assessments and home management advice. The Directory of Services was also continually updated to enable access to the new Covid services provided locally.
The Covid Clinical Safety Netting Service was set up to support people with higher-acuity symptoms. Text messaging was used to support vulnerable people and we are testing use of video calling to enhance both the patient and clinician experiences.
In addition to these Covid services, we set up national NHS111 dental and pharmacy services. These helped to take the pressure from core NHS111 services, whilst enabling dentists and pharmacists to contribute to the national response, and crucially to enable patients to benefit from improved access to these key services.
North East Ambulance Service (NEAS): 999 and 111 provider multi-skilling health advisors
NEAS was involved in the original pilot for 111, delivering a single point of access service in the County Durham and Darlington areas. This success led to NEAS bidding for and winning the contract to deliver 111 services across the North East from 2012 and again from 2017.
NEAS were also early adopters of NHS Pathways for both 999 and 111 and use the same CAD (created by Cleric) for both. This, together with the requirement to be able to deliver both services as efficiently as possible, led to the decision to multi-skill the majority of our health advisors across both work streams.
Currently, around 60% of our health advisors are multi-skilled – new staff are trained initially on 111 and, where appropriate, are trained to handle 999 calls after around 9 months. It is recognised, however, that whilst they may be able to handle 111 calls safely and consistently, not all will be capable of managing 999 calls (this is determined during monthly discussions around their performance, audit results, confidence and approach).
- For the patient, a seamless service across 999 and 111
- Multi-skilling of staff negating the need for approximately 20 WTE health advisors per annum
- Allowance for unexpected call demand on 999 to be managed
- Effective management of the the volume of calls transferred from 111 to 999
- For the health advisors, clear progression from 111 to 999 and greater scope for flexible working
London Ambulance Service (LAS): Single London-wide Integrated UEC system
The LAS, in collaboration with regional NHS commissioners and regulators, has agreed an ambitious vision for a single London-wide UEC system which:
- integrates NHS 111 and 999 call management and provides seamless access to clinical assessment, telephone consultation, onward referral and resolution;
- provides patients with the right care, first time and parity of NHS service provision regardless of how they first access that care;
- ensures that patients have access to all necessary referral pathways, including direct booking where available to continue appropriate management of their care throughout the London health and care system.
The scale and complexity of this programme has required LAS to work with organisations across the capital in new and innovative ways to implement and test proof of concepts safely and at pace.
This has involved working with multiple organisations including EDs, urgent treatment centres, GP hubs and practices, mental health services, rapid response services, community services, NHS England and the Healthy London Partnership. There has been particular focus in North East and South East London where LAS operates an IUC CAS for patients calling NHS 111.
The concept was tested by running a ‘perfect day’ on 30 September 2019 in one STP, which provided an opportunity to test integration of the UEC system and pilot the concept of greater NHS 111 and 999 pathway integration by providing access to all existing services ‘downstream’.
The day was built on the principal of the ‘perfect week’, which is frequently undertaken in hospitals to utilise all possible resources and streamline pathways to assess the impact on the patient journey and staff processes, but also to identify gaps and better ways of working, quantify reduction in ED attendances and provide a better patient and staff experience. In the 12-hour period we saw a reduction in conveyance to ED to 51.6% from 64.1% on the same day the previous year, a reduction in 30-minute handover delays and successful hear and treat of 41.5% with no clinical incidents or complaints.
With a population of 8.9m, and an additional 2m commuters and visitors who travel into London on an average day, there are over 4.5m contacts to access urgent and emergency care through NHS 111 or 999 calls or online in London every year. This is likely to increase year on year given London’s changing population needs.
The integrated UEC project is a long-term strategic journey. To date, LAS has:
- collaborated with partners across the system to develop a shared strategic vision to integrate the NHS 111 and 999 clinical pathways and improve outcomes;
- tested the feasibility of integration by implementing a wide range of new patient pathways for 16 hours on a single day;
- launched the referral of complex, lower acuity 999 category 5 patients to local NHS 111/IUC CAS providers for clinical assessment by clinicians experienced in complex primary care, referral and resolution, giving the LAS 999 clinical hub capacity to focus on clinical assessment and reducing avoidable ambulance dispatch;
- expanded a mental health joint response car service across London in partnership with mental health trusts to address physical and mental health needs or patients, improve patient experience and reduce conveyance rates;
- established a discovery group to design the future digital and operational standards which enable greater consistency in referrals across London.
During the initial months of the Covid-19 pandemic the integration of urgent and emergency care enabled the seamless transfer of patients between 111 and 999. The number of senior clinicians providing call back clinical advice to patients in emergency operation centres was increased with senior clinical oversight playing a fundamental role in ensuring patients were directed in the most appropriate way across 111 and 999.