Old Colwyn East Residents’ Association
Minute of a talk by Mr Jason Williams, Program Manager of the Welsh Ambulance Service about “The Way Ahead for the Ambulance Service”
Jason introduced himself to the association and said that there had been lots of developments in the ambulance service over the last 12 to 24 months, he said he would give an introduction about the developments and then take any questions.
He opened by saying that he has been in the service for twenty one years, sixteen years in South Wales. He then moved to North Wales with responsibility for Training and Development for all paramedics and staff in North Wales, a recent job that he has taken on is that of Locality Analyst Officer for Conwy and Denbighshire, based at Rhyl ambulance station. This means that he is responsible for the vehicles, staff and estates in Conwy and Denbighshire. He offered himself as a conduit for any matters to do with the ambulance service from the residents.
The service entered a period 24 months ago when a chief Executive went sick and during his absence another 4 Chief Executives came and went in quick succession. The feelings of those executives as each left, was that the Welsh Ambulance Service was a failed service. This attitude had a very bad effect on morale amongst those working very hard within the service.
Twelve months ago, Mr Alan Murray entered service as the new CEO. He picked the service up and was described as a breath of fresh air. He told the members that they were not that bad; they could get back on track and deliver a first class service to the people of Wales.
He developed an Organisation Plan setting out goals and objectives and how the service would get there. He gave a copy of the Organisation Plan to the association for information.
A main goal was looking at what was done and the way that it was achieved, a decision was made that actually the service was very good ambulance service; he described it as one of the best in the whole of the country, having the most highly trained staff to the highest quality in the country. The staff use the most drugs and make the most interventions with patients in the country and the training standards delivered have the highest awards in the whole of the country. It was important therefore to look at what was going wrong.
The answer was very simple when analysed. Every time that the service was seen to fail, the service was trying too hard and therefore a decision was taken to WORK SMARTER NOT HARDER.
Questions were asked such as “What are we dealing with?” and “What do our patients need?” A decision was taken with National Assembly policy and National policy was that what we needed was appropriate care for the patients that we serve.
Previously all patients that were responded to by Welsh Ambulance went to a Casualty Department of a hospital, unless they specifically said they did not want to.
To illustrate, he used the example of someone who phoned the ambulance for toothache, which happens quite a lot, the person would be taken to the Casualty Dept. because even though the paramedic was the most qualified paramedic in the country, he or she did not have the autonomy to say that is an inappropriate call.
An audit showed that 90% of patients would be inappropriately taken to a casualty department.
Jason pointed out that it has been in the news about ambulances parked up outside casualty departments, and this was a contributory factor. Patients were jamming up the beds as they went through the time consuming casualty system (Triage/treatment/discharge)
A decision was then taken to be quite radical in Wales and start looking at patients and making some decisions that not all patients need to go through a hospital.
Also where they do need to travel, they do not all need to travel in a conventional ambulance. There was also a perception amongst patients that if an ambulance arrived, they were going to be transported.
A trial was started running Rapid Response Vehicles (RRVs), regularly seen on our roads. There are lots of these vehicles in operation now. A brave decision was taken to cut the number of conventional ambulances in favour of getting more RRVs. Public perception when they saw a car arrive they did not automatically think they were going to hospital, they were more willing to open up to the paramedic, talk and discuss their symptoms. The paramedic had more time to make a decision on more appropriate care. A lot of that appropriate care was looking at minor injury units and arranging for patients to be taken there by one of a variety of ways.
Once the paramedic has carried out first aid, he or she can discuss with a patient who needs to attend a hospital a more appropriate place to go where the patient may be seen quicker. The person could be advised to go in a car or by taxi arranged by the service. There are other vehicles within the service which are not fully equipped moving hospitals with a paramedic. There are two other grades of operative that are just as competent as paramedics but have not got the extra skills such as those used in immediate life threatening incidents where a paramedic is able to do more than the other two grades. They are Emergency Medical Technician and High Dependency Unit Staff Member. The latter is trained specifically in transportation of potentially ill patients, such as stroke victims or chronic chest problems; they have limited amounts of medical training.
The Emergency Medical Technician has every skill of a paramedic apart from the skills of putting needles into patients using advanced airway techniques and the drug regimes.
The resources were then examined and trying to map the resources to the patients. Another necessary audit was what happened in the call centres and how the patients could be filtered to the appropriate response.
A new CAD system was developed which would pick up on the patients and flag the appropriate response which could then be moved closer to the patient.
It was apparent that one of the biggest failures as an ambulance service is that we are measured on the time that it takes to respond to the patient and not the clinical outcome, ie does the patient get better?.
The service is measured on an 8 minute response standard; the analogy of the problem is if the service gets to the patient in 9 minutes and saves his life, the service has failed. If the operative gets there in 7 minutes and the patient dies, the service has succeeded. This is a very strange way to be monitored and funded against.
That is the standard that exists and has to be lived and coped with. Two years ago the performance standards in Wales were running at 46 % ~ 48%. Of all the 999 calls received that percentage of those calls met the 8 minute standard. With all the changes identified in the Modernisation Plan the service in Wales after 12 months is running at 76% which is a huge achievement in such a short time. There is support from the Welsh Assembly and the service has been made a special case in order to get a new fleet of ambulances in 6 months.
The staff have been approached to work in a different way, previously they were mobilised from the station or building. This cuts down the response time because with the fastest ambulance, the operative still has to record the message, leave and secure the station, open the garage because the ambulance must be secure; two to two and a half minutes could be lost in this way. With map reading time, half of the response standard time was lost. The operatives needed to be in their vehicles on the road and ready to go, Sat Nav has also helped the response.
Jason went on to say that you cannot place an operative in a vehicle on the road for twelve hours without facilities. The staff were involved in the procurement process and things were decided upon such as cool boxes for drinks or food. Where they are parked in a place, a decision has been taken that the next call will be from a location near to that vicinity. Ambulances have therefore got TVs, Jason continued that this may sound like a luxury but it is tied into a future use as a training facility, where the operative can sit at the side of the road and watch a video of a new piece of equipment being used. The vehicles are air conditioned which is great for the staff and the patients. Previously, ambulances were either too hot or too cold.
All these changes to the fleet have actually come out cheaper than previously was the case because it is all managed in a very different and more efficient way and the ambulances are fit for purpose.
That was a brief overview of the last twelve months, one year of a five year plan with work carrying on a huge range of ideas. At least 95% of what is in the “Time to Make a Difference” strategic plan will happen Jason assured the members, the commitment of all members of the service is there for it to happen.
He asked for any questions
A resident said ~ that she was going to ask about vehicles being parked up around the area but the question had been answered.
Jason replied ~ that he had only been locality officer for two months and he had received around twelve official comments on this issue where people thought the operative was skiving. He stated that he was pleased to come to such a forum to explain the situation.
The service runs a demand analysis where statistics are taken over the last ten years of where the call volume was at different times to the minute of the day. Over ten years there is a definite pattern of peaks and troughs of activity showing where the next job is going to come from. The results are very reliable following initial scepticism. As a result operators can now predict with some accuracy the locality where the next call will come from. Vehicles are moved to locations nearby and the results monitored. The target is to hit 95% at the end of 5 years.
A resident asked ~ If I dialled 999 now and ask for an ambulance, where would my call go to and where would the ambulance come from?
Jason replied ~ If the call volume was ok it would go to Llanfairfechan which is the ambulance control for the whole of the North Wales region. If the volume of calls was huge it may be sent to Mersey or Avon and Somerset who would take the details and pas the information straight to the North Wales Control. The operator would take exactly the same information as North Wales call takers and by pressing a button it is sent between controls. There is no duplication. The only difference may be that a call taker with local knowledge would hit a button as soon as the address was known and an ambulance would start moving towards the address.
It cannot be predicted where the ambulance would come from; the service uses a geographical deployment system. It would probably not come from an ambulance station; it would come from the local community. The reason for all the different tiers is that the service is working to keep the paramedics in the community that they are serving.
He touched on the issue of the Welsh Neurosurgery debate that was ongoing at present. He said the service have a lot of patients that they take over to the Walton Centre from Glan Clwyd. At present they are moved on paramedic vehicles. If they have to go down to Cardiff, then potentially the ambulance is lost for a whole day. Different tiers of skill base are being put into the service so that they can move these patients and keep the paramedic in the community. The cars never transport the patient, (unless the operative feels happy to do so or for a short distance to hospital). By keeping the cars in the locality, they will never be drawn out, if they need an ambulance response, the ambulance would be moved up to back them up and transport the patient and the car would stay in the locality.
90% of the time, the vehicles and staff responding to your call would come from Conwy or Denbighshire.
The operatives on the RRVs are specially selected so that they have good local knowledge of the area.
A resident said that he would like to compliment the ambulance service. His family had occasion twice in the last few years to call the ambulance and he could not praise them enough, they came promptly, they were courteous, professional and were superb.
In reply to a question, Jason commented that the service was now a 21st century service and a wholly different one from the one which operated a few years ago. For such radical big changes to be made by the staff, they have to feel that they trust and respect and want to make those changes, the work culture within the service now lends itself to these changes, the staff have really embraced the change and felt part of it and want to move the service forward.
A resident said that in the talk, Jason had talked of the Welsh Ambulance Service and asked if South Wales had the same problems that North Wales had.
Jason replied that he came from South Wales, the service there was worse, talking about national averages, the performance for this locality before Wales merged was around 50% ~ 55%. The performance in South Wales was about 30% ~40%.
Resources were low in South Wales, not enough vehicles or staff to do the job, the vehicles and equipment was very poor standard.
North Wales had very good vehicles and standards of equipment. There were biases in different areas some were bad some good. Both response times were low and not good enough.
For the last 10 or 15 years staff have been trained at the same training establishments to the same standards on the same equipment.
Call volume in South Wales made the difference in response standards. Each patient that gets an ambulance gets the same quality of care, the difference is the time taken to get there.
The Chair asked if the geography of Wales makes things difficult with a lot of outlying places.
Jason replied that it does, In Cardiff where he worked, to get across Cardiff could take 30 ~ 45minutes. It is possible to travel 30 ~ 40 miles in that time in North Wales.
A big problem he said was the issue of street and house names and house numbers.
A name in a street could be from No 1 to No 1000. Registered house names are on the CAD system. If the operative knows that the house is number 25 in a street of 100 then the house will be roughly half way along the street.
To assist the ambulance responder, residents could think of the following points; whether you call your house a number or a name make sure it is properly displayed to be seen from the road and if you have a need to call an ambulance, and it is a difficult location to find, car in the road with hazard lights on, or late at night turn lights on in the house. This will help speed up the process of getting the ambulance to you.
A resident pointed out that in Australia, house numbers are painted on the kerb which seems a fairly sensible idea which will probably never happen in Britain.
A resident said with regard to the cars when they are being driven with headlights and blue lights showing, other drivers cannot see the indicators. He had almost had a collision with one on the A55, as it cut in 3 or 4 feet in front of his vehicle. He was unable to see the indicators which were being displayed because of the brightness of the other lights.
Jason replied that this was the first time that that had been identified and asked for the matter to be put into writing and he would ensure that the fleet department had a look at the issue.
The Chair thanked Mr Jason Williams for a very enlightening talk from which we have all gleaned a bit of information and a bit of confidence in our ambulance service. There was a round of applause.
