Efficiency Review
of
The Welsh Ambulance Services NHS Trust
Undertaken by Lightfoot Solutions
in association with
Lis Nixon Associates
And
Baker Tilly
on behalf of
Health Commission Wales
and
The Welsh Ambulance Services NHS Trust
Final Report
2
Contents 1. Executive summary ...................................................................................................................... 3 2. Background to the Review .......................................................................................................... 7
2.1. Introduction ............................................................................................................................ 7 2.2. The EMS Service in Wales ................................................................................................. 8 2.3. The structure of the review ............................................................................................... 10
3. The emerging role of ambulance services in the delivery of unscheduled care .............. 11 3.1. Emerging best practice in ambulance services ............................................................. 11 3.2. Establishing equitable and appropriate standards of response across the community ....................................................................................................................................... 12
3.2.1. The Category A 8 minute response process ...................................................... 13 3.2.2. Response areas and achievable response standards ..................................... 14 3.2.3. The Category A and Category B 14/18/21 minute response standard .......... 16 3.2.4. The 14/18/21 minute response process ............................................................. 17
3.3. Emerging clinical best practice ......................................................................................... 18 3.4. The impact of technology .................................................................................................. 20 3.5. Implications of the model .................................................................................................. 21
4. Findings ....................................................................................................................................... 22 4.1. Benchmarking ..................................................................................................................... 22 4.2. Achieving the Category A 8 minute AOF target............................................................. 26 4.3. The implications of extended travel times and hospital delays ................................... 28 4.4. Calculating resource requirements for WAST ............................................................... 30
4.4.1. Unit hour requirements .......................................................................................... 30 4.4.2. Ambulance staff requirement ................................................................................ 32 4.4.3. Adjusting for overtime and relief .......................................................................... 33 4.4.3.1. Overtime .................................................................................................................. 33 4.4.3.2. Relief ........................................................................................................................ 33
4.5. Achievable performance levels and additional resource requirements under different scenarios. ......................................................................................................................... 34
4.5.1. Achievable performance levels with existing resources ................................... 34 4.5.2. Additional resource requirements to meet the 14/18/21 minute performance standards 35
4.6. Financial analysis ............................................................................................................... 38 4.6.1. Income ................................................................................................................................. 39 4.6.2. Fully absorbed cost model ................................................................................................ 39 4.6.3. Financial summary ............................................................................................................. 40 4.7. Other findings ...................................................................................................................... 43 4.7.1. Control room processes .................................................................................................... 43 4.7.2. Clinical procedures ............................................................................................................. 44 4.7.3. Organisational issues ........................................................................................................ 45
5. Conclusions and recommendations ........................................................................................ 46 5.1. Conclusions ......................................................................................................................... 46 5.2. Recommendations ............................................................................................................. 50
Appendix 1 – Suggested benchmarking measures ...................................................................... 52 Appendix 2 - Recommended deployment locations by LHB area .............................................. 57 Appendix 3 Cost model methodology ............................................................................................. 58
3
1. Executive summary
This report is the result of a project commissioned jointly by Health Commission Wales
(HCW) and the Welsh Ambulance Services NHS Trust (WAST) to review the adequacy of
the funding of WAST in order to meet its current performance targets and at the same time
to establish whether there were opportunities for WAST to improve the efficiency of its
operations.
In Section 3 of the report we outline emerging best practice in the delivery of ambulance
services and the role that the ambulance service can play in the delivery of an integrated
urgent care service. WAST is the only organisation that provides urgent care services on a
day to day basis across the whole of Wales and as such is uniquely well placed to play a
central role in the development of this new model of service delivery. Moreover, we believe
that by adopting this new model it should be possible for WAST to achieve significantly
improved standards of response and patient care relative to the standards that are currently
being achieved.
In Section 4 we set out the findings of our analysis of the efficiency and effectiveness of
WAST and our assessment of the additional resource and funding that WAST will need if it is
to meet all its key performance targets.
Section 5 of the report sets out our conclusions and our recommendations in relation to the
actions that we believe are required by the key stakeholders to enable WAST to provide a
service that compares favourably with the best performing ambulance trusts in the rest of the
United Kingdom.
The principal findings from our analysis are as follows.
WAST‟s performance in relation to the Category A 8 minute target has improved
significantly since the beginning of 2007. However there has been little or no
improvement during this period in relation to the Category A and Category B
14/18/21 minute standards
Although Wales covers a larger geographical area than other ambulance trusts in the
UK, the proportion of EMS activity that occurs in towns and cities in Wales is similar
to that of comparable ambulance trust areas in England
Wales experiences a relatively high number of 999 calls per head of population and a
relatively high proportion of these calls result in a patient being transported to
hospital. This results in pressure being placed on WAST and on hospitals in Wales
that we believe could be alleviated if suitable call triage and assessment procedures
were used and alternative care pathways were available for patients
We estimate that the total cost that WAST incurred in providing the EMS service in
2008-9 was £101.3 mil. WAST received £95.6 mil of funding for the EMS service in
2008-09 from HCW, NLIAH and the Air Ambulance Charity. The difference was
funded by income for other purposes e.g. ARRP
4
Hospital delays have a significant impact on the ability of WAST to meet its
performance targets. During the reference period for our review, WAST would have
required an additional 900 ambulance hours per week in order to compensate for the
delays in handing over patients at hospital at an annualised cost of £2.3 mil per year.
This effect is of particular significance in the South East region of the Trust.
WAST‟s performance with respect to the initial phase of allocating a vehicle to a 999
call compares poorly with other ambulance trusts in England. A significant
contributory factor to this performance gap is the lack of an Automated Vehicle
Location System (AVLS) and related mobile data systems on EMS vehicles in Wales.
This makes it difficult for WAST reliably to locate and deploy the most appropriate
vehicle to respond to a 999 call.
Once the benefits of its investment in AVLS and mobile data are available, WAST
could meet the current Category A 8 minute targets both at a national and LHB level
with its current staffing levels and overtime rates and with the level of hospital delays
that occurred during the reference period for this review. In order to do this WAST
would need to accelerate the implementation of a deployment strategy that
o is based on 7 minute deployment areas in the more densely populated areas
o matches resource more precisely to the location of activity
o relies more extensively on the use of single manned response vehicles, and
o makes more extensive use of Community First Response schemes in less
densely populated areas as the initial response to Category A incidents.
The current level of staffing does not allow WAST to meet the 14/18/21 minute
standards and also requires a reliance on high levels of overtime to fill core shifts. In
addition, the shortage of staff in certain areas is preventing WAST from undertaking
sufficient ongoing professional training. Based on WAST‟s current levels of overtime
and planned level of relief, we estimate that the cost of the additional staff required to
meet the current 14/18/21 minute performance standards would be £3,744,000. This
would rise to £8,647,000 if WAST were to operate with no reliance on overtime to
cover shifts and with the level of cover for holidays, sickness, training and other lost
hours that was recommended in a Department of Health paper published in April
2007 setting out best practices in managing ambulance trusts.
If it were fully resourced in accordance with the recommendations in this report,
WAST should be able to achieve a Category A 8 minute performance target of at
least 70% for the whole of Wales as well as meeting all the 14/18/21 minute
standards.
The current practice with respect to the 14/18/21 minute standards means that
WAST sends more double staffed ambulances in response to lower acuity 999 calls
than occurs at some other ambulance trusts. As advocated in this report, an
alternative approach which distinguishes more clearly between the requirement for
an appropriate initial assessment of the patient‟s requirements and the subsequent
5
provision of transportation once it has been determined that the patient needs
transporting to hospital could significantly reduce the number of ambulance hours
that WAST requires and also reduce the number of cases where the patient is
transported to hospital. It should be noted however that a change of this type will
require a significant change in practice within WAST as well as actions by other
stakeholders to ensure that alternative pathways are available for patients.
Consequently the benefits from this change are likely to take between 3 and 5 years
to be fully realised.
If WAST were able to match the levels of ambulance attendance and transportation
that are achieved in some trusts in England it could reduce the number of ambulance
hours required by around 410 per week by comparison with the level that was
planned in 2008/9. This would save around £1,025,000 per year in staff costs
If hospital handover times were improved so that only 10% of hospital handovers
took longer than 15 minutes this would reduce the number of ambulance hours
required by comparison with the reference period for this review by 710 per week .
This would save a further £1,966,000 per year.
If WAST were able to obtain the full benefits from lower ambulance attendance rates
and reduced hospital delays it should be possible for the Trust to meet both the AOF
Category A 8 minute targets and the 14/18/21 minute standards with a staff cost that
would be £1,876,000 lower than the level in 2008/9 based on the current overtime
and planned relief levels and would be £2,497,000 higher than the 2008/9 levels
based on the lower overtime and higher relief scenario.
If WAST were to change its operating model in the way that is advocated in this
report and was also able to obtain the full benefits of lower ambulance attendances
and reduced hospital delays outlined above, it should also be able to realise savings
of up to £280,000 in fleet costs as a result of greater use of cars and less use of
double staffed ambulances.
WAST may also be able to realise additional savings in the following areas
o reducing its administrative overheads
o reducing the number of operating centres and control rooms
It should however be noted that we have not examined these areas in any detail
during this review.
In addition to the detailed findings of our analysis set out above, we have also identified a
number of organisational issues which we believe need to be addressed if WAST is to
achieve a successful transition to the new approach to the delivery of its services that is
advocated in the report. In particular
The challenges of agreeing a common vision between WAST and its many
stakeholders about the role that WAST should play in the delivery of urgent care
across Wales has previously made it difficult for the Trust to plan its future direction
with any certainty and to communicate this to its staff. At the time of this review,
6
WAST has submitted a vision statement to NHS Wales for comment and
consideration and is also working with the seven new LHBs to include key objectives
within the LHBs own Urgent Care Plans. This offers an opportunity to establish a
jointly agreed role for WAST that will form the basis for the implementation of the
recommendations in this report
The geographical spread of the Trust, the requirement for senior management to be
located in three different regional centres and the amount of change in the senior
management team has made it difficult to establish a stable management structure.
The new management structure that has recently been introduced provides a
framework within which WAST can create the senior management team that will be
required to implement the strategy that is recommended in this report
The quality of clinical oversight, supervision and training has not had sufficient focus
at a time when the Trust has been under pressure to deliver performance. This has
been recognised by WAST and a number of initiatives are currently under way to
address these issues. However, the pressure on resource and the low levels of relief
continue to make it difficult for the Trust to release staff to undertake appropriate
levels of clinical training
The funding arrangements for WAST have been unclear in the past and require
clarification in the new NHS structure so that the link between funding and service
delivery can be made transparent
The current commissioning and performance management arrangements for WAST
do not facilitate clear lines of accountability between WAST and its commissioners
and performance managers for the delivery of the EMS service
Although WAST could achieve the AOF Category A 8 minute target for the initial
attendance at life threatening incidents with its current resource based on best
practice call cycle performance and the current levels of overtime and relief, the
current level of recurring funding that WAST receives is insufficient to enable it to
achieve the 14/18/21 minute standards. We therefore believe that WAST will require
additional funding in the short term in order to provide a fully effective EMS service
that delivers appropriate levels of clinical care to patients
From our discussions with both WAST and HCW we understand that many of the issues that
we have highlighted in this report arise from the previous structure of the NHS in Wales and
are already being addressed. In particular, the new structure for the LHBs provides a
significant opportunity to establish a jointly agreed strategy and role for WAST within the
urgent care system in Wales. We are confident that the implementation of the approach that
is recommended in this report will enable WAST to provide the people of Wales with
standards of care from their ambulance service that are comparable with the best standards
that are achieved elsewhere in the United Kingdom.
7
2. Background to the Review
2.1. Introduction
Since its establishment in 1998 there has been a history of performance issues at WAST. In
2006, as a result of widespread concerns about the way in which the Trust was being
managed and its failure to meet the performance targets set for it by the Welsh Assembly
Government, the Wales Audit Office was commissioned to produce a report into the
problems that the Trust was facing and a new Chief Executive - Mr Alan Murray - was
appointed to run the Trust. The Audit Office Report which was published in December 2006
identified a large number of areas of concern relating to the way that the Trust had
previously been managed and made a number of recommendations for improvements.
Following the publication of this report, a significant number of changes were successfully
introduced by the new management team and a follow up review by the Audit Office
published in June 2008 found that significant progress that had been made in a number of
areas resulting in clear improvements in performance against the required targets and
standards. In particular performance with respect to the Category A 8 minute target had
improved by around 10 percentage points and performance in relation to GP Urgent
journeys had also improved. However, there had been litlle or no improvement in
performance with respect to the standards for attendance by an ambulance within 14/18/21
minutes.
Subsequent to the publication of the follow up report, there have been further discussions
between WAST and HCW about the actions that the Trust needs to take in order to address
the issues identified by the Audit Commission and the resources that it requires to meet the
current performance standards on a consistent basis. In particular WAST expressed
concerns that its current level of funding was insufficient to allow it to maintain the level of
resource that would be required to meet the current performance standards in view of the
particular challenges that it faces as a Trust – including in particular the problems caused by
extended hospital delays in certain parts of Wales. At the same time Heath Commission
Wales was concerned to establish whether WAST was adopting best practice with respect to
the effectiveness and efficiency of its operational, clinical and financial processes.
Consequently HCW and WAST agreed to jointly commission this review to establish
how WAST‟s performance and cost efficiency compares with that of other
comparable ambulance trusts in the rest of the United Kingdom
the level of resource that WAST requires in order to meet the required AOF targets
and performance standards,
the potential for obtaining cost savings from operating in a more efficient way, and
the opportunities that might exist for WAST to contribute to a more efficient and
effective delivery of unscheduled care services from adopting emerging best
practices in the delivery of ambulance services as seen elsewhere in the United
Kingdom.
8
2.2. The EMS Service in Wales
The role of the EMS service at WAST has three components
To respond within the required time to 999 calls received by the Trust
To respond to requests from doctors to transport to hospital patients whose doctor
has determined that they need admission
To transport patients from hospital or between hospitals where the hospital
determines that the patient requires a double staffed ambulance for the joiurney in
question
On average in 2008/9 WAST responded to 5750 999 emergency incidents, 1020 urgent
incidents and 210 transfers each week.
At the outset, 999 calls are categorised into three categories of urgency by the calltaker
using a telephone based triage system called the Advanced Medical Priority Dispatch
System (AMPDS) as follows
Category A - immediately life threatening condition/injury
Category B - serious but not life threatening condition/injury
Category C - neither life threatening or serious condition / injury
In the first quarter of 2009 the percentage of 999 incidents to which WAST responded in
each category were as follows
Category A – 41%
Category B - 43%
Category C - 16%,
The response to an emergency incident has the following two components,
an initial response to provide immediate attention and to establish what the patient‟s
requirements are and if appropriate
the provision of transportation to hospital – in most cases in a fully equipped double
staffed emergency ambulance.
In Wales in the first quarter of 2009, 72% of all 999 incidents resulted in a patient being
transported to hospital.
With effect from 1 April 2009, WAST is required to meet the following performance targets in
relation to its EMS service, as detailed in the Annual Operating Framework (AOF)
1. 65% of all Category A incidents across Wales must be responded to by a suitable
responder within eight minutes of the chief complaint being verified by the calltaker
and a minimum level of 60% must be achieved in every LHB area. This target has to
9
be met on a month-by-month basis as well as on a year-to-date basis. This response
target is important in cases such as heart attacks where early resuscitation is
provided. The type of response can be a fully equipped ambulance, a Rapid
Response Vehicle (RRV), an emergency services co-responder, for instance Fire
and Rescue Service and the Police, or a Community First Responder scheme.
In addition to these AOF targets there are standards which were set for Wales in 1999
for the response times of ambulance crews capable of transporting the patient to
hospital, where the first responder was not an ambulance crew. Whilst these are not
AOF targets they are standards that are aimed at in order to ensure that there is a
suitably equipped ambulance at the scene of the incident to support on scene care and
transport appropriate patients to hospital or other services. These standards are
2. 95% of all Category A incidents must also be attended by a fully equipped
emergency ambulance within a specified time of the start of the incident which is set
at 14 minutes in Cardiff, 21 minutes in Powys, Ceredigion, Gwynned and Anglesey
and 18 minutes elsewhere in Wales
3. 95% of all Category B incidents must be attended by a fully equipped emergency
ambulance within the 14/18/21 minute time period from the start of the incident
4. 95% of all Urgent calls must be in hospital within 15 minutes of the time when the
doctor specified that the patient should arrive
Over the year to 31 March 2009, WAST achieved a performance level of 60.7% across
Wales for Category A performance at 8 minutes, 85.07% for Category A performance at the
14/18/21 minute standard and 78.55.% for Category B performance at the 14/18/21 minute
standard.
The rest of this report analyses the factors that affect WAST‟s ability to meet these targets
and standards, identfies the resources that would be required to achieve these goals and
suggests how WAST might be able to change its practices in a manner that delivers better
results for patients in Wales while enabling WAST to adopt a more cost effective operating
model
10
2.3. The structure of the review
Our review consisted of the following four complementary work streams:
1. A benchmarking exercise that compared WAST‟s performance and efficiency based
on a number of selected indicators with two broadly comparable English ambulance
trusts – South Western Ambulance Service Trust and East of England Ambulance
Service Trust
2. An analysis of the demand profile to which WAST is required to respond together
with a review of the deployment strategy and rota structure by comparison with best
practice in other ambulance trusts to assess the extent to which performance could
be improved by enhanced operating procedures and the extent to which additional
resource might be required in order to meet the performance standards. The
reference period for this analysis was a 13 week period from 3 November 2008 to 2
February 2009.
3. A review based on structured interviews of the effectiveness of WAST‟s processes
and systems, and current operational and clinical procedures together with a review
of the current commissioning practices.
4. An analysis of the fully loaded costs that WAST incurs in providing the EMS service,
an analysis of the way in which WAST uses its income to fund the EMS service and a
comparison of the current cost model with good practice both in ambulance trusts
and in other organisations.
11
3. The emerging role of ambulance services in the delivery
of unscheduled care
3.1. Emerging best practice in ambulance services
The ambulance service is an integral part of a healthcare system that exists to meet patients‟
needs when they have an unplanned medical emergency. In order to provide this service in
the best interests of the patient it is highly desirable that ambulance services are planned
and delivered in the context of an overall plan for the provision of unscheduled care services.
In this context, the provision of both ambulance response and other elements of the
unscheduled care system have been the subject of a number of reviews in recent years with
a view to making the provision of care more appropriate, more responsive to patients‟ needs
and more efficient. In Wales this includes the Delivering Emergency Care Strategy that was
announced in February 2008
A key theme in these initiatives is the recognition that the current system of providing
unscheduled care is inefficient and in many cases does not meet the patient‟s needs in the
most effective way. In particular, they recognise that addressing the patient‟s needs in a
timely and appropriate manner whilst at the same time preventing unnecessary admissions
to hospital should be a high priority for a well managed unscheduled care system. In this
context they also recognise that appropriate assessment and triage of the patient‟s needs at
the point at which the patient accesses the healthcare system is key to the delivery of the
most appropriate service and the best outcome for the patient.
In recognition of this fact, there has been a significant change in the past three to four years
in the way in which ambulance trusts in England respond to 999 emergency calls. At the
core of this is the recognition of the need for a separation between the response to the initial
emergency and the assessment of the patient‟s needs from the subsequent process of
transporting the patient to hospital once it has been determined that this is the most
appropriate response. This has led to an increase in the number of cases where a single
staffed response car staffed by a paramedic attends an incident prior to a decision to deploy
an ambulance. There has also been an upskilling in the capabilities of the staff employed by
ambulance trusts to enable them to assess the needs of the patient and - where appropriate
- to treat the patient at home or at the scene of the incident. As a result, in trusts that have
adopted this model of response there has been a significant reduction in the proportion of
patients who are transported to hospital with rates of transportation to hospital now below
55% in some cases by comparison with the 72% transportation rate that is seen in Wales.
In parallel with the trend to place more reliance on the use of single responders for the initial
assessment of the patient‟s needs, the English ambulance trusts are also required to meet a
significantly higher standard of initial response to life threatening Category A incidents than
currently applies in Wales. The response standard that applies to the English trusts is to
attend 75% of all Category A incidents within 8 minutes from the time that the caller is
connected to the trust‟s switchboard. This compares with the AOF target that applies in
12
Wales which requires that WAST responds to 65% of Category A incidents within 8 minutes
from the time that the calltaker has determined the nature of the emergency. The effect of
this is that the response time in relation to Category A incidents in Wales is around 80
seconds longer than it is in England as shown in Figure 1 below. It should be noted
however, that the move to the new „Call Connect‟ performance standard in England has
required significant investment in both resources and technology and took over two years to
achieve. The benefits that the English trusts have obtained from this investment in terms of
their ability to respond quickly to incoming calls also makes it difficult to undertake a direct
comparisons of their performance with WAST.
Figure 1 – The Category A 8 minute response standards
The overall effect of these changes has been that English trusts are now placing a
significantly greater reliance on single staffed vehicles to provide the initial response to
Category A calls and are also experiencing an increasing number of cases where a single
staffed vehicle is the only response that is required for Category B and Category C incidents.
By contrast in Wales double staffed ambulances still constitute the initial response for 70%
of all 999 calls. The issues associated with the greater use of single staffed response
vehicles are discussed in more detail below.
3.2. Establishing equitable and appropriate standards of response
across the community
A key consideration when determining the most appropriate way for an ambulance service
to meet its performance targets is the need to establish equitable standards of response
across the whole community whilst at the same time recognising the implications of the
standards that are agreed in terms of both practicability and cost effectiveness.
The overarching consideration in determining the achievability of the performance targets is
the way in which geography, demography, transport, road and health infrastructures
influence the amount of resource that is required to achieve the target in question. This is
13
materially different when considering the response to the Category A 8 minute target and the
Category A and Category B 14/18/21 minute standard.
3.2.1. The Category A 8 minute response process
The primary purpose of the Category A 8 minute target is to provide lifesaving services to a
patient who has suffered a heart attack within a timeframe that carries a reasonable chance
of resuscitation. In this context the response can consist of any suitably trained person who
has access to a defibrillator which they have been trained to use and does not have to
consist of a vehicle capable of transporting the patient. (The provision of suitable
transportation for a Category A incident is is covered by the 14/18/21 minute standard).
In order to meet this standard, a trust has to plan with a high level of certainty to have a
suitable level of response resource available that is capable of attending these life
threatening incidents within the time that is allowed for the response. The amount of
resource that is required to deliver this standard of response is determined by the likely
location of the incident and the amount of time that the responder has available to travel to
the incident.
The time that is available for the responder to travel to the scene of the incident is the time
that remains within the 8 minute response window once
the response vehicle has been identified by the dispatch centre
the responder has been notified of the incident and
the responder is in the response vehicle and beginning to travel to the scene of the
incident.
In the case of WAST, the time that is available for the responder to travel to the scene of the
incident - assuming best practice processes and technology - is 7 minutes as summarised
in Figure 2 below
Figure 2 – The components of the Category A response process
14
The implication of this is that it is only possible to reach a Category A incident within the 8
minute window where there is a response resource that is already available and positioned
within a 7 minute drive time of the incident at the time that the 999 call is received.
Consequently in determining the amount of resource that is required to meet the standard it
is necessary to identify the locations where Category A incidents are most likely to occur and
to plan the deployment of the Trust‟s response resource within those areas.
3.2.2. Response areas and achievable response standards
A typical area that could be covered within a 7 minute drive time is shown in Figure 3 below
Figure 3 – A 7 minute deployment area in Caerphilly
By identifying those areas where Category A incidents are most likely to occur it is then
possible to identify the optimal location of response vehicles within 7 minute „drivezones‟ to
maximise the likelihood that the incident will receive a response within the 8 minute
response window. Deployment planning of this type has played a very significant role in
enabling English trusts to meet the new Call Connect standard. A similar approach is already
utilised by WAST in North Wales and is under development within the South East and
Central and West regions. It should be noted however that WAST‟s current technology
systems do not support a technological solution similar to that which is used by the English
ambulance trusts and they are therefore using paper based systems to support this
approach to deployment.
Where adequate resource is available and it is deployed in this way, a high level of Category
A performance is often achieved – in some cases in excess of 85%. However, it is clear that
this approach to deployment, which requires the provision of a dedicated response resource
which is fully funded by the ambulance trust, will only be cost effective in those more densely
populated areas where there is a sufficiently high level of activity to ensure that the response
vehicle undertakes a reasonable level of activity.
15
Typically urban area activity of this type, where there is a high probablility of 2 or more
category A incidents occurring in any 24 hour period within a „drivezone‟, accounts for
between 70% and 80% of the activity within the area of an ambulance trust. This leaves
between 20% and 30% of the Category A incidents where an alternative model is required
for the provision of initial response.
The areas outside the more densely populated urban areas fall into three groupings as
follows
Mid sized market towns where there is a predictable level of daily activity, but there
are less than 2 Category A incidents on average per day
Smaller towns and large village communities where there is occasional activity but
there is less than 1 Category A incident on average per day and
Sparsely populated rural areas where activity is widely spread and there are no
material concentrations of population
In the mid sized market towns, it is not realistic or cost effective for the ambulance trust to
provide a dedicated resource solely to respond to Category A incidents within the 8 minute
response window. However, it is possible for the ambulance trust to establish a retained
(paid for) response scheme in collaboration with the local health community and possibly
also involving the Fire and Rescue Service and the Police which can provide an appropriate
level of initial response for that community. In these cases it is realistic to expect that an
initial response provided by a scheme of this type will meet or exceed the 65% Category A
standard.
In the smaller towns and larger villages, it is more difficult for an ambulance trust to provide
an assurance of a suitable level of initial response without the involvement of volunteer
responders. In many parts of the United Kingdom there are a large number of communities
of this type which are more than a 7 minute drive from the nearest town and where typically
there will be at most one or two Category A incidents per week. The only practical way of
providing an initial response in these areas within the 8 minute window is through a voluntary
Community Responder scheme. Where such schemes exist they can provide a high level of
initial response to their local community, but the development of schemes of this type is time
consuming and requires a high level of commitment from the local community. It should be
recognised, however, that although the community responders are volunteers, the
infrastructure necessary to support, manage and deploy community responders has its own
cost that has to be borne by the ambulance trust.
In the sparsely populated areas, which are outside the reach of a community response
scheme, it is unrealistic for an ambulance trust to plan to achieve any sustained level of
category A 8 minute performance and in general ambulance trusts find it difficult to achieve
levels of Category A performance above 40 - 50% outside the urban areas and the larger
market towns.
16
3.2.3. The Category A and Category B 14/18/21 minute response
standard
The 14/18/21 minute Category A and Category B standards in Wales require that a fully
equipped ambulance attends the incident within the specified time window measured from
the start time of the incident. This corresponds to similar 19 minute standard that applies to
ambulance trusts in England.
This standard exists in order to address three separate requirements as follows
In the case of a Category A incident where the initial response has been by a
community responder or another responder that is not provided directly by the
ambulance trust the standard ensures that this lay response is backed up within an
appropriate time by a suitably trained responder provided by the ambulance trust
In the case of a Category B incident the standard ensures that there is an appropriate
initial response to the incident by a suitably trained responder provided by the
ambulance trust
In the situation where it is determined that the patient requires urgent transportation
to hospital the standard ensures that a suitable transportation resource will be made
available within an appropriate time.
It is however particularly important for the efficiency and effectiveness of the ambulance
service that the performance standards for the initial response and for the subsequent
transportation of the patient are addressed separately. Indeed, if this distinction is not
recognised within the performance standard, it will not be possible to obtain the benefits that
would otherwise be available from the more extensive use of single staffed response
vehicles to undertake the initial assessment of the patient‟s requirements.
The reason for this is that in those cases where it is appropriate to send a single staffed
vehicle to an incident it will take a minimum of 10 minutes from the start of the incident
before it is clear whether transportation is required. In most cases this leaves insufficient
time for a double staffed ambulance to travel to the scene within the available time window
should this be required. Moreover in many cases where transportation to hospital is required
it will not be necessary for this to be provided immediately in a fully equipped emergency
ambulance.
However, if the performance standards are interpreted to apply to both the initial response
and also to the arrival of the transportation resource it is necessary to send a double staffed
ambulance to every Category A and Category B incident whether or not a single staffed
response car has also been dispatched to respond to the incident. This has two effects.
Firstly it significantly reduces the potential benefits of any investment in single staffed
response vehicles in terms of their potential to reduce the ambulance attendance and
transportation rates. Secondly it requires the Trust to maintain a level of resource in the form
of double staffed emergency ambulances which is higher than it would otherwise need to be.
As a result, it is increasingly being recognised that a more appropriate approach is to
establish separate performance standards for the initial response to incidents and for the
17
subsequent transport requirement. This means that the standard for the initial response
relates to the attendance by a fully equipped response vehicle. A second standard can then
be established for emergency transportation which requires that where an urgent request
has been received for transport by an emergency ambulance, the transporting vehicle
arrives at the scene within the appropriate time window measured from the time at which the
request for transportation is received.
The current position with respect to the appropriate interpretation of the 14/18/21 minute
response standards in Wales is unclear. The standards which were drafted in 1999 are
clearly response standards rather than transportation standards. However, the standards
predated the wider use of single staffed response vehicles and therefore refer to the
response provided by WAST taking the form of a fully equipped ambulance rather than a
fully equipped response vehicle as is the case in England. As a result it is open to
interpretation whether a single staffed response vehicle is a suitable initial response to meet
the 14/18/21 minute standard for both Category A and Category B incidents and at the time
of our review this issue remained unresolved.
3.2.4. The 14/18/21 minute response process
Unlike the case with the Category A 8 minute target it is possible to develop a deployment
strategy that will ensure that all of the regions within Wales have a response by a fully
equipped emergency vehicle within the 14/18/21 minute standard. In order to be able to
meet this standard, however, WAST requires sufficient transportation resource to be able to
respond not only to the normal daily levels of activity, but also to peak levels of activity and
to provide the required level of cover and transporting capacity across all the geographic
regions in Wales. The factors that determine the amount of resource that is required to meet
this standard are
The predicted average and peak level of activity at each hour for each day of the
week
The volume of activity and the geographic area that can be covered by an ambulance
operating in more rural areas
The percentage of incidents that require transportation to hospital
The length of time that it takes an ambulance to complete a job, including in
particular
o the time taken to reach the hospital
o the time taken to return from hospital and
o the time taken to hand over the patient to the care of the hospital staff.
In calculating this resource requirement it is also important to recognise that the same
double staffed ambulance resource is also required to meet the performance standards for
Urgent incidents as well as responding to Category C incidents and Hospital Transfers. In
18
this context, ambulance trusts are examining options for providing transport to hospital in
cases where the patient‟s condition does not require them to be accompanied by a
paramedic or in a double staffed vehicle. This includes the more extensive use of an
intermediate tier of high dependency vehicles that can be staffed by two intermediate staff or
the use of patient transport service vehicles in the same way as is provided for patients who
are attending hospital for planned appointments.
3.3. Emerging clinical best practice
Ambulance services are increasingly recognising that in order to meet patients‟ clinical
needs in the most appropriate way they need to reconsider all aspects of their activities. This
extends from the initial way that calls are triaged through to the range of alternative
treatments that can be offered to the patient at the patient‟s home as well as the alternatives
that exist to hospitalisation.
At the level of callhandling, there are significant differences between ambulance trusts in the
way that calls are classified by call takers. There are a number of factors that affect the rate
of classification which make benchmarking of this measure difficult. In WAST at the time of
our review Category A call classification was around 40%. In other trusts it ranges from as
high as 45% to below 30%. One key consideration that influences the percentage of calls
that are classified as Category A is the calltaker‟s knowledge of the call triage system and in
particular the extent to which supplementary questions are used to clarify the nature of the
incident. We understand that WAST has been working hard recently to ensure that calltakers
are trained in the use of the supplementary questions and that the proportion of calls
classified as Category A had fallen to 37% in the course of June 2009.
In trusts with the lower rates of Category A calls, effective use of the supplementary
questions is often combined with a clinical desk where a caller may be passed from the
calltaker to a nurse or paramedic who continues to talk to the patient whilst at the same time
a vehicle is travelling to the incident. This may result in the incident being downgraded to a
lower categorisation. In the case of Category C incidents in particular this also provides
opportunities for rerouting patients to alternatives to an ambulance. This may be NHS Direct
or an Out of Hours service or may result in the patient attending a minor injuries unit without
the need for an ambulance. An appropriately resourced clinical desk also allows paramedics
who are on scene to discuss suitable treatments with a colleague and provides information
about the alternatives that are available. We understand that WAST has already trialled the
use of clinical nurse advisers to triage Category C emergency calls by telephone and is keen
to extend the use of this service.
A further development which WAST is also discussing is the provision of an information hub.
This can involve a bed bureau function that maintains a central information source that can
identify where there are available beds for patients. It can also be a source of information
about the available resources to meet patients‟ needs including information about services
provided by social services and voluntary services as an alternative to taking the patient to
hospital. This can also provide a more integrated link between the ambulance service, NHS
19
Direct and Out of Hours services – something that WAST is particularly well placed to do
because both the EMS service and NHS Direct Wales are now within a single trust. In this
context we understand that WAST has submitted an expression of interest in accordance
with the Assembly‟s Invest to Save initiative to implement NHS Pathways jointly with health
and Social Care partners in Wales.
In addition, WAST already has a relatively high proportion of its front line staff who are
paramedics which provides a good starting point for the transition to the alternative response
model. However there will be a requirement for a change in working practices from the
current position where the majority of paramedics work primarily on double staffed
ambulances and are currently accustomed to receiving backup in almost all cases when they
are working on single staffed response vehicles. The future model will put significantly
greater emphasis on paramedics being able to work alone in the first instance and spending
a larger proportion of their time in single staffed response vehicles. An additional issue that
will need to be addressed is the number of incidents that are attended by a single staffed
vehicle. The new model will require paramedics to act as first responders in areas where
activity is relatively low. In some cases - notably in towns where the expected level of activity
is less than two Category A calls per day - it may be more appropriate for these staff to
become part of a community medical team and to provide support for admissions avoidance
and long term conditions management rather than requiring them to act solely as a response
resource to 999 calls.
In this context, it will also be appropriate for WAST to consider more extensive use of
Specialist Practitioners. Different trusts have developed different practices towards the use
of schemes of this type and in a number of cases these schemes have proved to be very
effective in treating the patient at home or providing support for minor injury units and so
helping to reduce the number of cases where Category B and Category C incidents require
ambulance attendance or transportation. The introduction of Specialist Practitioners is part of
WAST‟s five year workforce plan and we understand that recruitment is currently under way
to fill these roles.
A further possibility in terms of the development of clinical services that can be provided by
ambulance trusts is demonstrated by the fact that some ambulance trusts in England have
begun to set up and operate minor injury units themselves as part of an admissions
avoidance strategy.
Clearly developments of the type outlined above cannot be achieved without careful
planning. But they are indicative of the changes that are under way within the ambulance
service and they will lead to ambulance trusts which are very different organisations from
what they have been in the past. This requires them to be more closely integrated in to the
unscheduled care system with a different range of clinical capabilities and skills and with a
very different leadership from the traditional ambulance service. This is fully recognised by
WAST and the trust is working hard with its partners in health and social care to achieve
these outcomes.
20
3.4. The impact of technology
The ability of an ambulance service to deliver a high quality service to patients in its area is
critically influenced by the technology that the trust has at its disposal. There are a number
of key components to this technology which affect the ability of the trust to operate at the
highest levels of performance. These are
Computer aided dispatch (CAD) systems which manage the deployment of vehicles
and their dispatch to individual incidents
Automatic vehicle location systems (AVLS) which are able to identify at all times the
exact location of vehicles and to provide this information to the CAD system. This
enables the CAD to track vehicles throughout the day to optimise the way in which
vehicles are deployed and dispatched to incidents and to calculate the exact times
that are taken by vehicles to mobilise and travel to the scene of an incident
Mobile data systems that allow the dispatch centre to communicate automatically
with response vehicles and which provide sat nav guidance to the crew to find the
quickest route to the incident
Automated caller line identification systems which speed up the process of identifying
the location of an incident by showing the calltaker the address of a landline from
which a call is being made
An electronic patient record system in the form of a handheld device that can be
used by ambulance crews to speed up the recording of the details of an incident and
provide an electronic record of these details for subsequent use
Historically WAST‟s technology infrastructure has been a significant hindrance to its ability to
perform at a level comparable with other ambulance trusts. In particular the absence of a
suitable radio system in Wales prevented the introduction of AVLS with the result that it was
only possible to identify where a vehicle was by contacting the crew by phone and asking
them to confirm their location. WAST estimate that the absence of AVLS has resulted in a
level of Category A performance that is 5 percentage points below where it would otherwise
have been. We understand that the business case for mobile data and AVLS has now been
approved and these benefits are likely to be introduced during 2009-2010.
The majority of ambulance trusts in England either have introduced or are currently planning
to introduce the current generation of CAD systems and it is on these systems that CAD
providers are currently focusing their development efforts. WAST currently operates with a
legacy CAD system that has been superseded by a more up to date system from the CAD
provider. As a result, although the system will be maintained, it will not benefit from the
enhancements that will be applied to the later system and over time the performance of the
current system will lag behind. Consequently the system will have to be upgraded or
replaced in the near future if WAST is to maintain a level of performance that is comparable
with other Trusts. We understand that WAST is currently developing a plan to replace the
current CAD system during 2009/10.
21
The limitations of the current CAD and the lack of a mobile data system also means that
WAST cannot obtain the full benefits of an automated caller line identification system.
Although as shown in Figure 1, the current performance standard does not include the time
taken to answer the call and identify the location of the incident, nevertheless the absence of
this technology is delaying the response to the patient and will become a key requirement if
WAG were to decide to change the performance standards to start from the time that the call
is answered.
3.5. Implications of the model
There are significant benefits in terms of efficiency and effectiveness for WAST to move in
the direction outlined in this Section. These include
Impoved patient experience
More effective and efficient use of operational resources
Leverage on the investment that has already been undertaken
Better and more fulfilling roles for staff both in front line and support roles
Greater integration with the rest of the NHS in Wales in the delivery of urgent care
In many ways WAST is well placed to move in this direction. It is the only organisation within
the NHS in Wales that has an overview on a day to day basis of the pattern of demand for
unscheduled care. In addition, WAST has the considerable advantage relative to ambulance
trusts in England of already having completed a merger with NHS Direct Wales and it also
provides the support for the Out of Hours in part of the region. Furthermore it already has a
relatively high proportion of its staff who are paramedics.
However it would also pose significant challenges and would require change in organisation
and practices. In particular it would require
Willingness of staff and the public to accept the change to single staffed response
Further upskilling of staff in control
Further upskilling of clinical staff
Further upskilling of financial/support staff
Investment in appropriate technology to support the change
The rest of this report assesses the current position of the Trust in relation to its existing
mandate, its current performance effectiveness and its readiness to move in this direction.
22
4. Findings
4.1. Benchmarking
Appendix 1 sets out a proposed set of benchmarking data which – if it were collected for
different ambulance trusts - would allow a full comparison to be made of the effectiveness
and efficiency of WAST in comparison with other ambulance services. Currently a subset of
this data is available from different trusts and based on the available data we have prepared
the following comparisons between WAST and two high performing English trusts with a
similar geographical pattern of activity to that seen in Wales – South Western Ambulance
Service and East of England Ambulance Service
Table 1 – Selected Benchmarking data
23
The main conclusions from these figures are as follows:
999 calls per head of population – WAST receives one call per year for every 6.2
people in Wales by comparison with one call per 6.5 people in the case of South
Western Ambulance Service and one call per 9.9 people in the case of East of
England Ambulance Service
24
Average income per call received – WAST receives 9% less income per call received
than South Western Ambulance Service and 22% less than East of England
Ambulance Service. WAST receives 8% more EMS calls than South Western
Ambulance Service but 14% fewer calls than East of England Ambulance Service.
Dividing the EMS income by the number of calls gives the following figures.
o WAST - £195 per call
o South Western Ambulance Service - £209 per call
o East of England Ambulance Service - £250 per call
Average income per head of population – WAST receives 6% less income per head
of population in EMS funding than South Western Ambulance Service and 24% more
per head of population than East of England Ambulance Service. Dividing the EMS
income by the population headcount gives the following figures
o WAST - £31.35 per head of population
o South Western Ambulance Service - £32.88 per head of population
o East of England Ambulance Service - £25.24 per head of population
Headcount – WAST has a whole time equivalent headcount that is 11% more than
South Western Ambulance Service total headcount and that is 30% less than East of
England Ambulance Service. However for frontline services WAST has a headcount
that is 6% lower than South Western Ambulance Service and 39% lower than East of
England Ambulance Service.
EMS Vehicles – WAST has 5% more EMS vehicles than South Western Ambulance
Service and 29% fewer vehicles than East of England Ambulance Service.
Area covered – with an area of 20,640 Square KM in which to operate WAST covers
15% more area than South Western Ambulance Service and 6% more than East of
England Ambulance Service.
The comparisons above demonstrate the difficulty of basing a comparison of the efficiency of
an ambulance trust on any one benchmarking measure. Under the measure of funding per
999 call, WAST received a lower level of funding than either South Western Ambulance
Service or East of England Ambulance Service in 2007/8. However, under the measure of
funding per head of population WAST received a lower level of funding than South Western
Ambulance Service but a higher level of funding than East of England Ambulance Service. It
is therefore necessary to consider a range of complementary measures in order to gain a full
understanding of the external factors that affect the ambulance service as well as the
efficiency with which the service is operated
Table 2 below provides a further ranking for the three trusts using certain publicly available
indicators.
25
Table 2. Comparison of WAST with benchmark trusts on selected benchmark metrics
As can be seen from the rankings above the indicator where WAST scores highest is the
number of incidents responded to per member of front line staff and the measurement of
income per member of frontline staff. This reflects the fact that WAST is currently operating
with high levels of overtime and low levels of relief thereby running the service with fewer
frontline staff than would be recommended.
Table 3 compares WAST‟s performance in relation to key call cycle measures with the
performance of an area within the East of England Ambulance Trust consisting of Essex,
Norfolk, Suffolk and Cambridgeshire – a geographic area that is highly comparable with
Wales in terms of the proportion of activity that occurs in sparsely populated areas.
26
Table 3 – WAST call cycle performance against East of England benchmark area
This underlines that the key difference in the management of the call cycle between WAST
and East of England Ambulance Service lies in the initial phase of call handling, the
allocation of a vehicle to an incident and the time it takes for the vehicle to arrive at the
scene of the incident. This reflects the availability of resources, the investment in technology
that is available to support the call handling and dispatch processes and the effectiveness
with which the deployment plan and other Control room processes are managed. WAST
compares well with East of England Ambulance Service with respect to the remainder of the
call cycle once a vehicle has arrived at the scene of the incident. The table also highlights
the fact that in trusts such as East of England Ambulance Service which have lower hospital
transportation ratios the amount of time spent at the scene of the incident by the attending
vehicle increases.
4.2. Achieving the Category A 8 minute AOF target
Our analysis of the distribution of Category A activity within Wales has confirmed that, with
the appropriate resource and infrastructure, it is possible for WAST to meet and even to
exceed the current 65% target by adopting a structured approach to response based on the
principles of separating initial response from transportation.
Our analysis is based on the following assumptions
WAST will provide a dedicated response resource to respond to at least 75% of
Category A incidents within 8 minutes in any area („Urban areas) where there are 4
27
or more Category A and Category B incidents per day within a 7 minute drivezone
area
WAST will ensure that there is a suitable response resource available to respond to
at least 70% of all Category A incidents within 8 minutes in any area („semi urban‟
areas) where there are between 2 and 4 Category A and Category B incidents per
day within a 7 minute drivezone area. This may be a dedicated trust resource or may
be a response scheme developed jointly with the local health community
WAST will seek to develop appropriate community response schemes in other areas
(„rural‟ areas) where there are less than 2 Category A and Category B incidents per
day within any 7 minute drivezone area. Category A performance in these areas is
currently 40%, and WAST should aspire to raise performance in these areas to 50%
by developing additional schemes
WAST has fully deployed AVLS and mobile data
The urban and semi urban areas we have identified in each of the LHB areas where we
recommend that WAST should locate its deployment points for its vehicles are listed in
Appendix 2.
Based on these assumptions, the levels of activity in these three areas in each of the LHB
areas and the possible levels of performance in each of the LHB areas and across WAST is
as follows
Table 4 –Category A activity and potential performance by LHB area
This shows that Wales does not have an unusually large proportion of its activity in rural
areas by comparison with English trusts of comparable size. Moreover, with the exception of
Powys, no LHB area has a level of rural activity which is out of line with similar geographical
areas in England which already achieve Category A performance at levels which are at least
as good and in many cases higher than the performance levels indicated in Table 4.
28
Consequently it should be possible for WAST to achieve the levels of performance indicated
with a suitably resourced response model of this type.
In order to achieve these levels of performance, however, WAST will have to place greater
emphasis on the use of single staffed response vehicles which are the key resource that is
required in order to achieve a reliable and consistent level of Category A performance with at
least 50% of all Category A calls in the urban areas being attended in the first instance by a
single staffed response vehicle. In addition, focused attention is required to ensure that there
is an appropriate initial response resource – either in the form of a double staffed ambulance
on a standby point or an appropriately funded first responder scheme – in all the semi urban
areas that have been identified.
In addition to these initiatives, WAST also needs to increase the use of Community
Responder schemes and on-site static defibrillators at locations where Category A incidents
are likely to occur. The existence of schemes of this type are an important contributory factor
to the overall level of the initial response to Category A incidents, particularly in rural areas.
In a number of English ambulance trusts initial response of this type contributes up to ten
percentage points of the overall Category A 8 minute performance. By contrast in Wales this
type of response currently contributes only around five percentage points to overall category
A performance, with Community Response schemes contributing less than two percentage
points to overall Category A performance in the first quarter of 2009. We understand that
WAST plans to appoint a National First Responder manager with the objective of
significantly improving the contribution from these types of scheme.
4.3. The implications of extended travel times and hospital delays
The length of time for which an ambulance is committed to any incident before it is available
to attend a subsequent incident is a key factor in determining the amount of resource that an
ambulance trust requires. Where ambulances are committed to incidents for longer than
expected this has a significant impact on the ability of an ambulance trust to meet its
performance targets. The two factors that have the greatest influence on the variability of
the job cycle time for an ambulance are extended travel times to hospital and delayed
handovers at hospital.
In ambulance services which achieve relatively high levels of utilisation of their ambulance
resource, the average time for which an ambulance is committed to an incident in a highly
populated urban area with a local hospital in the vicinity is around 62 minutes as
summarised in Figure 4 below
29
Figure 4 – The best practice ambulance call cycle in urban areas
This incident cycle time enables an ambulance trust to plan on the basis that an ambulance
will complete its involvement in any incident in one hour (this is referred to as one „unit
hour‟). However, when the time taken to travel to the hospital or to hand over the patient is
extended, the „unit hour‟ has to be increased to take into account this additional time. In the
case of an extended travel time to hospital, the effect on the incident cycle time is further
compounded by the fact that the vehicle in question has to travel a longer distance both on
the inward journey to the hospital and on the return journey. This can have a significant
effect on the availability of ambulances and consequently the number of vehicles that are
required to respond to a given level of activity.
In the same way, when the handover of the patient at the hospital takes longer than 15
minutes, this also has an effect on the amount of resource that the trust needs as the vehicle
is unavailable to attend a subsequent incident
The overall impact of extended travel times and hospital delays is shown in Table 5 below
which indicates that additional resource is required to compensate for these effects in each
of the new LHB areas.
Table 5 – Extended travel times and hospital handover times by LHB area
30
4.4. Calculating resource requirements for WAST
4.4.1. Unit hour requirements
In order to meet the Category A 8 minute AOF target, as well as preparing for the change
towards the response model outlined in Section 3.2 above, WAST needs to be able to
provide sufficient single staffed response vehicles to respond to a minimum of 50% of the
anticipated Category A incidents in all the urban areas identified. In addition, in order to meet
the 14/18/21 minute standards, WAST also has to plan to have sufficient double staffed
ambulances to attend all the Category A and Category B incidents that may require an
ambulance to transport the patient to hospital as well as having sufficient ambulances to
respond to Category C, Doctors Urgent and Hospital Transfers incidents in a timely fashion.
As outlined in Section 3.2.3 above, the interpretation of the Category A and Category B
14/18/21 minutes standards has a significant effect on our findings. At present WAST is
interpreting these standards on the basis that a double staffed ambulance is required to
attend a Category A or a Category B incident within the 14/18/21 minute time window in 95%
of cases where an ambulance arrives on scene. As a result, WAST is currently sending
ambulances to a high proportion of all 999 incidents even where a single staffed response
vehicle has also been sent to the incident. Moreover, since it is not clear at the start of an
incident whether an ambulance will be required, the only way in which the standard could be
met consistently and reliably would be to send an ambulance immediately to every incident
where a vehicle attends. This requires WAST to increase still further the number of
ambulances that are sent to incidents
Based on this interpretation of the 14/18/21 minute standard (the „Base case‟ scenario),
Table 3 sets out our estimate of the average number of rapid response vehicle („ RRV‟) and
ambulance hours that WAST would require per week to meet all the performance targets
and standards in each LHB area in 2009/10. This shows that WAST would require an
additional 1100 RRV hours per week together with a further 1118 ambulance unit hours by
comparison with the current planned rotas to deliver the 14/18/21 minute standards as well
as the AOF targets.
Table 6 – Unit hours required - Base case scenario
31
If this interpretation of the 14/18/21 minute performance standards is used, any additional
investment in RRVs would be extremely inefficient as RRVs would be accompanied by
ambulances to all incidents whether or not the ambulance was required as a transport
resource. This would preclude WAST from gaining the potential benefit of the reduction in
ambulance unit hours that would otherwise be available from the more effective use of single
staffed response vehicles. Moreover, the current operating procedures in WAST result in a
significantly higher proportion of ambulances attending 999 incidents than occurs in
comparable English trusts and also results in a materially higher proportion of patients being
transported to hospital. As Table 4 shows, WAST‟s overall ambulance attendance ratio for
999 calls would be 93% if double staffed ambulances were required to meet the 14/18/21
minute standard in all cases. This compares with 81% achieved in the East of England
Ambulance Service. Similarly, the ambulance transportation ratio in Wales in Q1 2009 was
70% by comparison with 52% in East of England Ambulance Service. This results in WAST
utilising 1745 more ambulance hours per week and transporting 1108 more patients per
week to hospital than would be the case at the East of England Ambulance Service. .
Table 7– Ambulance attendance and transportation ratios
By contrast, if the alternative interpretation of the 14/18/21 minute response standards were
used which would allow the increased use of single staffed response vehicles to undertake
an initial assessment of patients as is the case in England, 410 fewer ambulance hours
would be required to meet the performance standards by comparison with the current rotas
and in addition there could be a significantly different outcome for patients by avoiding
unnecessary attendances at hospital. At the same time, however, there would also be an
increase in the time that was spent at the scene of the incident assessing the patient‟s needs
which would have to be taken into consideration in determining the overall adjustment to the
required resource
In should also be noted that the total recommended unit hours for ambulances in Table 6
includes an adjustment of 900 hours per week to reflect the effect of extended hospital
turnaround time as set out in Table 2. If the pattern of extended hospital delays that has
been observed over the past year could be addressed, this would result in a further
reduction in the amount of ambulance resource that WAST requires. However, it should also
32
be noted that any change in operating practice towards a greater reliance on single staffed
response vehicles as the initial response to incidents will involve significant changes in
working practices and will require careful planning by WAST. It would also require the
availability of alternative pathways for patients who would otherwise be taken to hospital.
4.4.2. Ambulance staff requirement
The staff resources required to fill the recommended rotas and the associated cost is
dependent on a number of factors
The number of hours that are assumed to be available per week once factors
such as sickness, holidays, training time and other anticipated non availability
(collectively referred to as „Relief‟) has been taken into account
The amount of overtime that is required to cover shift overruns and other
unanticipated hours worked („Core overtime‟)
The amount of overtime that is assumed to be worked in addition to contracted
hours to fill planned shifts („Additional overtime‟)
The additional payments that are required over and above base salary to cover
items such as unsocial hours and pension contributions („Add on costs‟)
The proportion of staff of different levels of qualification that are required to cover
shifts on different types of vehicle
The position with respect to the availability and use of front line ambulance resource in
WAST in 2008/9 is set out in Table 5 below
Table 8 – Front line staff resource, cost and available hours to fill rotas
This shows that in 2008/9 WAST had a total of 1301 front line staff with a total direct cost of
£53.6mn and an overtime rate of around 19%. Based on the 2008/9 overtime rates and the
assumption of a relief factor of 26.8% this would have produced a total of 42,522 hours
33
available to man vehicles which matches almost exactly the total of 42,502 rota hours that
were planned by WAST.
4.4.3. Adjusting for overtime and relief
The implications of this increase for the additional number of staff that WAST would require
and the associated cost of those staff depends critically on the assumptions that are made
for 2009/10 about the rate of additional overtime that it is acceptable to plan for and also the
appropriate level of relief that WAST should build into its planning.
4.4.3.1. Overtime
In our calculations, we have assumed that the amount of overtime that WAST requires to
cover shift overruns and other unanticipated extractions is 5%. This compares with an actual
rate of payment for shift overruns in 2008/9 of 4%. Based on this planning assumption the
level of additional overtime (ie overtime paid to fill core shifts) was particularly high in 2008/9
at around 14%. This is a relatively inexpensive way for WAST to increase the available
hours to fill its shifts, but it depends on the willingness of staff to work additional hours and
as such does not provide a robust mechanism for managing rosters. It also raises issues
about the extent to which a planned reliance on overtime is an appropriate HR policy. It
would therefore be imprudent for WAST to plan to continue to rely on these levels of
overtime in 2009/10 as a means of filling core rota lines.
The actual figure for additional overtime in any year will be dependent on the extent to which
vacancies are filled and other extractions are in line with plan. Our calculations of the
resource requirements that are required to meet the existing performance standards
therefore show the resource requirement under two different scenarios – a current scenario
where WAST continues to operate with the levels of overtime employed in 2009/10 and an
alternative calculation where overtime is used solely to cover unplanned extra hours at the
end of shifts or to cover occasional unanticipated peaks in sickness etc.
4.4.3.2. Relief
The level of relief that WAST builds into its plans is also a critical factor affecting staff
numbers and costs. A level of relief has to be built in to resource planning to cover factors
such as holidays, sickness, training and other planned and unplanned absence. The main
components of relief are
Annual Leave
Public holidays and time off in lieu
Sickness
Training
Maternity leave
Other (including staff management duties, internal meetings, union representation
etc)
34
It is generally recognised that best practice staff management in ambulance trusts would
apply a relief factor of 35% to cover these factors - a level recommended in a Department of
Health paper released in April 2007.
In practice, there is considerable variation in the relief factors that ambulance trusts apply in
their resource planning. For example, whilst WAST plans at 26.8% in the case of the
services used for comparative purposes the South Western Ambulance Service uses a 35%
relief planning assumption, whilst the East of England Ambulance Service plans at a level of
28% . However, since most of the other factors resulting in staff being unavailable for work
such as holidays and sickness are non discretionary and the resulting absence has to be
covered from the relief factor, it is typically the ongoing training component which suffers
when trusts are unable to operate at a sufficiently high level of relief and this is currently the
case in WAST based on the current relief factor of 26.8%. It is therefore highly desirable
from a staff management perspective that WAST should increase its relief factor from its
current low rate as soon as it is able in order to be able to plan for appropriate ongoing
professional training for staff.
The precise level of relief that WAST needs to incorporate into its planning depends on the
detailed training requirements of its staff. We have not undertaken an analysis of the training
days that WAST needs to set aside to ensure that its staff maintain the appropriate levels of
ongoing training and we have therefore undertaken our analysis of the resource implications
of adjusting the relief factor based on the 35% rate that is included in the Department of
Health publication.
4.5. Achievable performance levels and additional resource
requirements under different scenarios.
4.5.1. Achievable performance levels with existing resources
As Table 9 shows, if WAST continued to operate with its current levels of staff and current
overtime and relief factors, but was also able to match the best practice call cycle
management processes that are operational in the high performing English trusts, we
believe that it would be possible for WAST to meet the 65% Category A 8 minute AOF target
in 2009/10 and to meet the 60% standard in each of the LHB areas under each of the
following three scenarios.
1 Hospital delays continue at the level observed during the reference period for this
study
2 70% of hospital handovers are achieved within 15 minutes
3 90% of hospital handovers are achieved within 15 minutes.
35
Table 9 – Achievable performance levels with current establishment
However, Table 9 also confirms that - based on the current operating model - WAST would
not be able to meet either the Category A or Category B 14/18/21 minutes standards or the
standard for Urgent journeys under any of these three scenarios based on the current
operating model. In addition, if WAST were to operate with a lower level of overtime and a
higher relief factor it would only be able to meet the Category A 8 minute performance
targets if hospital delays were reduced significantly below the levels observed during our
review.
4.5.2. Additional resource requirements to meet the 14/18/21
minute performance standards
Based on the analysis outlined in Section 4.4 above, we have analysed the additional staff
requirement and the associated costs for WAST under the following scenarios with respect
to the 14/18/21 minute standards
1 WAST sends a double staffed ambulance to all Category A and Category B incidents
which requires a vehicle to attend (The „Base Case‟ scenario)
2 WAST continues to send double staffed ambulances to the majority of Category A
and Category B incidents as at present (the „Current response‟ scenario)
3 WAST reduces its ambulance attendance at all categories of incidents to the best
standards achieved by English trusts (the „Reduced attendance‟ scenario)
4 WAST reduces its ambulance attendance rate to the English benchmark and 90% of
hospital handovers are achieved within 15 minutes (the „Full benefits‟ scenario)
36
As Table 10 shows, in order to meet all the performance standards under the Base Case
scenario, WAST would require a minimum further 99 staff to enable it to produce the
necessary hours to fill the rotas. This calculation is based on the assumptions that the Trust
continues to operate with its current rates of overtime and planned relief and that hospital
delays remain at the level observed during the reference period for this report. If the Trust
reduces its reliance on overtime to the level that is required to cover frictional factors such as
overruns at end of shifts and occasional unexpected sickness a further 163 staff would be
required and this would add a further £1,679,000 to the cost base. Moreover, increasing the
relief factor from 26.8% to 35% would require WAST to employ a further 82 staff and would
add a further £3,206,000 to the total cost bringing the total additional cost of filling the new
rotas to £8,647,000
Table 10 - Staff requirement – Base Case scenario
Table 11 shows the potential reductions in the ambulance hours and the related financial
savings that could be achieved relative to the Base Case Scenario if WAST were able to
operate based on a different interpretation of the 14/18/21 minute standards and was also
able to reduce the number of cases where an ambulance attendance was required at
Category B and Category C calls. This shows that the number of ambulance hours required
could be reduced by a total of 1524 per week from these initiatives. Moreover Table 12 also
shows that the required hours could be reduced by a further a further 710 hours per week if
90% of hospital handovers could be achieved within 15 minutes.
37
Table 11 – Savings in unit hours and cost relative to ‘Base case’ scenario
The staffing and financial implications of these different scenarios relative to the position in
2008/9 is summarised in Table 12.
Table 12 Staff requirement and costs under alternative scenarios
38
This shows that under the Current Response model where WAST is not required to send an
ambulance to every Category A and Category B incident to meet the 14/18/21 minute
standards, but where the full benefits of the new response model have not yet been realised,
WAST would require 57 more staff at an additional cost of £2,370,000 in order to meet all its
performance targets on the assumption that it maintained its current levels of overtime and
relief. The staff requirement would increase to 224 at an additional cost of £4,017,000 if
WAST were to reduce its reliance on overtime to cover core shifts. The staff requirement
would increase further to 305 staff at an additional cost of £7,144,000 if WAST were to
increase its planned relief factor from 26.8% to 35%.
Table 12 also shows that if WAST were able to obtain all the potential benefits of lower
attendance rates and reduced delays at hospital, it would be able to meet all its performance
targets and standards with 33 fewer staff and at a cost that was £1,876,000 lower than in
2008/9 based on the current levels of overtime and relief. The staff requirement under this
scenario would increase to 110, but the overall cost would still be £386,000 lower than in
2008/9 if WAST were to operate without relying on overtime to fill core shifts. The staff
requirement under this scenario would increase further to 184 at an additional cost of
£2,497,000 if WAST were to increase its planned relief factor from 26.8% to 35%.
4.6. Financial analysis
Our financial analysis consisted of the following four distinct work streams:
The identification of the income streams for WAST for the year 2008/09,
The development of a fully absorbed cost model identifying the cost of delivering
EMS in Wales based upon 2008/09 figures,and
A financial summary of the impacts of the various proposed changes within the
report.
39
4.6.1. Income
Based upon the information provided by WAST, the Trust received the following income in
2008/9:
Table 11 – WAST sources of income 2008/9
4.6.2. Fully absorbed cost model
In order to ascertain the costs of delivering EMS within Wales we have produced a cost
model which aims to identify the fully absorbed cost of the services using the methodology
set out in Appendix 3.
For the purpose of this exercise, the Air Ambulance Service was included within the analysis
of the cost of providing the EMS service
The results from the summary cost model for the year 2008/9 are as follows:
40
Table 12 – Fully allocated cost by service line
By comparing the income in Table 11 with the fully absorbed costs of each of the service
lines we can see that based upon the model developed there was a shortfall in EMS funding
in 2008/9 of £5,747,000. However it must be noted that the cost model has not been built on
a detailed analysis of cost consumption, rather on an agreed approach to allocating
overheads, the result of which is that there could be a margin of error in the allocation of
overheads.
4.6.3. Financial summary
Whilst the work we have performed relating to income and fully absorbed costs highlights a
potential shortfall in EMS income of £5.7m we believe that further activity analysis is required
in order to identify the „true‟ costs associated with delivering each of the activities undertaken
by WAST. Clearly there is an element of cross-funding within the Trust and therefore the
Trust should consider ways in which to bring each of its “service lines” into a recurrent
breakeven position.
We were also asked if the achievement of a £2m costs saving for EMS was possible. There
are a number of areas where we believe further investigation may result in opportunities for
significant savings. These include:
Control & Administration - Based upon the comparison table above we believe that
there may be potential savings within the back office functions at WAST and this is
an area that needs further examination. For example WAST has over 100 more
members of staff in either the Control & Manager and Administrative roles than
SWAST. Furthermore the comparison of numbers is not on a like for like basis with
the numbers for WAST being based upon whole time equivalents and the numbers
for South Western Ambulance Service being based upon total people employed.
The cost of staff and directors at WAST is £91,098,000 with an average costs per
whole time equivalent of £33,678. The average cost of staff employed at South
Western Ambulance Service WAST is £31,945 but as mentioned before the
numbers are not wholly comparable. However what is clear is that the number of
staff employed by WAST in these non frontline roles is significantly higher than the
number employed by South Western Ambulance Service The possible savings
41
would depend upon how many of these non frontline roles are indeed excessive,
below we summarise the potential savings:
5% of roles could be removed - £168,390
10% of roles could be removed - £336,780
25% of roles could be removed - £841,000
50% of roles could be removed - £1,683,900
We have not undertaken any analysis in the course of this review to validate the
extent to which these activities might be streamlined and savings realised. Moreover,
the above numbers assume a linear relationship which may not be true.
Nevertheless, they serve as an indication as to the potential savings that might be
available.
Fleet Costs - A further area of potential cost savings would arise if WAST moves
towards a model that utilises more RRV‟s and fewer double staffed ambulances.
The scope for such savings in the fleet running costs is suggested by a comparison
of fleet costs with South Western Ambulance Service. The average fleet cost per
vehicle at South Western Ambulance Service is £20,554 which is 18% lower than
the average fleet cost at WAST of £24,182.
Based on the assumption that the average cost of an RRV for WAST is £10,000 per
year and the average cost of a double staffed ambulance is £30,000 per year, WAST
would obtain savings of £280,000 per year from the change in the mix of vehicles
that would result under the Full Benefits scenario
Operating centres and control rooms - One factor that has a significant effect on the
cost base of WAST is the number of operating centres and control rooms that the
Trust currently supports. At present WAST operates from three operational centres in
St Asaph, Cwmbran and Swansea and operates five control rooms including both the
EMS and NHS Direct locations. In the course of this review we have not undertaken
any analysis of the potential opportunities that might exist for reducing costs through
a reduction in the number of control rooms and operating centres and therefore we
can not provide any estimate of the potential savings that might be available from this
area. However, this is an area which should be examined in the context of any
detailed review of the Trust‟s cost base.
At the same time, the additional resources that WAST requires in order to meet its
performance targets will increase the Trust‟s cost base. The tables below summarise the
financial impact of the proposed changes to the operating model.
Table 15 shows the financial impact of funding the „Base Case‟ operating model based on
the changes to staffing levels that are required to fill the new rosters, the costs of reducing
overtime from the current level of 19% to 5% and an adjustment to change relief from the
current 26.8% to 35%. Table 16 shows the associated costs of moving to the new model
using more RRV‟s and fewer double staffed ambulances and assuming that all the benefits
identified in Section 4.5 in terms of reduced ambulance hours have been realised. (Please
42
note that these costs relate simply to the costs of frontline staff and do not reflect any
savings associated with the change of fleet.)
Table 15 – Funding requirements for the ‘Base Case’ operating model
Table 16 – Funding requirement for the ‘Full Benefits’ operating model
Based upon the information above it is clear that if WAST were to start to change its
operating model in line with the recommendations in this report at the same time as reducing
the levels of overtime worked and increasing the relief factor by the full amounts indicated
there will be a significant level of investment required. However against this investment
there should also be savings in fleet costs and other operating efficiencies associated with
changing the model which have not been quantified at this stage. It should also be noted
that the additional staff required to fill the new rosters are to deliver a 95% performance
against the 14/18/21 minute standard, not the Category A 8 minute AOF targets, which as
stated earlier can be met from existing resources under the conditions identified
In terms of the question of what level of cash releasing CIP the Trust can achieve, based
upon the above and assuming that both relief and overtime are operated at the levels
specified, it is clear that under the current operating model the Trust is not able to operate a
43
cash releasing CIP whilst at the same time delivering its AOF performance targets.
Moreover, the Trust will require additional funding if it is to meet the 14/18/21 minute
standards. However, if the full benefits of the new operating model could be obtained the
Trust would require an additional funding of only £2.5mil, and offset against this could be the
potential savings highlighted above.
4.7. Other findings
In the course of our work we also reviewed WAST‟s operational readiness to adopt the
practices that are advocated in this report in comparison with best practice at other
ambulance trusts. These included a review of Control room processes, Clinical practices
and the overall organisational structure of the Trust. Our findings in respect of these
considerations are set out below
4.7.1. Control room processes
WAST currently operates three Control Rooms, one based in each of the three regions.
Each of the control rooms is managed by a Utilisation Manager and performance
management takes place within the regional management structure. At the time of our
review, control practices varied across the different regions and we identified a number of
areas where there were opportunities for improving the efficiency and effectiveness of the
control processes.
Across all the three control rooms the dispatch process was slower than we would have
expected despite the fact that the information from the call takers was available to
dispatchers almost immediately. The approach to vehicle deployment relied heavily on the
use of double staffed ambulances and was inhibited by the absence of system status
planning software, mobile data and vehicle location technology which the Trust plans to
introduce later this year. In addition, we believe that there is potential for improved utilisation
of community and static responders with appropriate investment in the necessary
infrastructure to support this.
The Trust‟s proposed new structure which includes a Trust wide head of the Control should
serve to improve and coordinate operational practices across the three Control Rooms and
accelerate the work that is already underway within the Trust‟s National Control Steering
Group to standardise control processes and systems. Moreover, further improvement in the
effectiveness and efficiency of Control Staff should be possible through consolidating the
performance management arrangements that WAST has recently put in place. In this
context, the Trust is currently working with Landmark Consulting to implement a structured
approach to performance management that will apply across the three control rooms and the
managers in the South East have already received training in this process.
The Trust has also recognised the need to improve its deployment and utilisation of Rapid
Response Vehicles (RRVs) and has been in discussion with Staff Side Organisations
concerning the introduction of modern operational procedures. The current operating model
predominantly uses double staffed ambulances and therefore any change in the model so as
44
to make greater use of Rapid Response Vehicles would require a material change in
organisational culture and behaviour.
There is also significant scope for WAST to leverage the benefits of the co-location of NHS
Direct within the Control Centres and to increase the proportion of Category C calls that are
handled by means of telephone triage. In particular, the move to Vantage Point House in the
South East Region provides a control room that, with the appropriate technology, would be
capable of providing an integrated single point of contact for the local health economy.
We understand that WAST is developing a Clinical Contact Strategy for the advancement of
its Control Centres and discussion is taking place with some „Out of Hours GP‟ providers
about further opportunities that exist for integrated working. Systems for managing Category
C calls are also being developed in conjunction with WAG and we understand that WAST
have worked closely with WAG to establish alternative pathway of care for low acuity calls
which draws on similar work that has been undertaken elsewhere in the UK. A number of
PDSA cycles have been used to establish the benefits of providing telephone nurse triage
for Category C calls. Based on this work we have been informed that the Clinical Desk
model is currently operational in both Central and West and the South East regions and is an
integral part of the new Clinical Control Centre strategy.
The Trust has also included within the 2009-2010 LDP submission its intention to link CAS
(the NHS Direct Software) and the Alert 2000 CAD (the Ambulance software) so as to widen
the availability of Category C triage to all Nurses in NHS Direct Wales. The Trust has also
submitted an „Invest to Save‟ bid in collaboration with health partners to implement NHS
Pathways as a single clinical triage platform within Wales.
4.7.2. Clinical procedures
From our review we believe that there is scope for further improvements in clinical practice
at each stage of the patient pathway. In this context it is essential that a common vision is
agreed for WAST among all the key stakeholders which can then be communicated clearly
to staff. This vision should be of a clinical service with a huge role to play in the delivery of
the unscheduled care agenda both nationally and locally as outlined in this report rather than
solely as an emergency response and transportation service. Moreover, the clinical strategy
needs to be understood within the Trust as clearly complementing the delivery of
performance standards. As research demonstrates, clear clinical gains can be made from
early intervention by trained health professionals.
In the control rooms we believe that significant opportunities exist for greater integration
with NHS Direct and Out of hours providers and that these opportunities should be
maximized. In particular, the clinical advice that is already available to callers to NHS Direct
could be made available more extensively to EMS callers as well as to paramedics and other
ambulance staff. There is also an opportunity to better influence the management of patients
across the system by capacity managing ambulances going to the various A & E
departments and in time beginning to develop other alternative points of access.
We also believe that the clinical supervision and support available to operations teams
could be enhanced. During our review we saw little evidence of any input from the control
room for front line staff if they have a problem and it was also difficult to ascertain the
45
numbers of paramedics, technicians and clinical team leaders at each station. Moreover,
there was little evidence of sharing best practice either within or between Regions. We also
understand that, although WAST has now established a clear plan for providing clinical
training for staff at all levels, there have been difficulties in releasing staff to undertake the
training at the current levels of overtime and relief.
A further issue is that turnaround times at hospitals vary widely. There is currently limited
understanding of what factors influence these times and little sharing across Wales of best
practice developments used at local level. WAST is working towards alleviating the delays
and the use of the touch screens at the hospitals to record handover times is a very positive
initiative, but this is mitigated by poor processes in the hospitals which need to be addressed
in order to solve the ongoing problems caused for WAST by extended hospital delays.
WAST recognises the need to strengthen its clinical processes and a number of initiatives
are currently under way that are designed to address these issues. We understand that a
draft clinical strategy and vision document has recently been developed which is
underpinned by various other strategies e.g paramedicine, nursing, clinical effectiveness and
Partners in Health. The Clinical Contact Strategy is also in final draft. Both documents will
now be taken through a consultation process to ensure wide and meaningful stakeholder
engagement and input before the documents are presented to the Trust Board. In addition,
the current implementation of the new role of Clinical Team Leader should ensure that
paramedics have clinical leadership at a local level. WAST is also introducing a new role of
Specialist Practitioner which will take paramedics/nurses through the novice to expert
framework and will complement the role of the Clinical Team Leaders. The development of
these new roles and indeed the CCS is dependent on the development of robust clinical
supervision and mentorship networks throughout WAST. Regional Professional Advisory
Groups and the National Clinical Advisory Group will ensure professional issues are
addressed, action taken and lessons learnt and shared across the Trust.
4.7.3. Organisational issues
The fact that WAST operates from three regional offices and the senior management team
are spread across these three locations makes the management of the Trust a particular
challenge. A new organisation structure has recently been introduced with the objective of
streamlining the management structure and a number of senior appointments have been
made or are currently planned, including a new Director of Human Resources and a new
Regional Director in Central and West. However at the time of our review the Trust did not
have a substantive Operations Director, two of the three Regional Directors had only
recently been appointed and there was no head of control for the Trust as a whole. It will
therefore be important that the Trust ensures that the new management structure is
implemented effectively and that there is a strong focus on the effectiveness of the senior
management team.
A further issue for WAST is the current arrangement for funding and performance
management. HCW is the principal funding organisation for the EMS service in WAST, but it
does not have responsibility for commissioning other elements of the urgent care system.
However, WAST also receives funding from a number of other sources including NLIAH and
WAG. As a result, there is currently no one organisation that is responsible for funding the
46
fully loaded cost of providing the EMS service. The basis on which funding is currently being
provided and will be provided in the future (whether on the basis of journeys, attendances or
incidents that are responded to) is also unclear due to the current reorganisation of the NHS.
The arrangements for the performance management of WAST are currently through the
North Wales Regional Office and it is unclear how this process holds the two parties to
account for the delivery of their respective responsibilities. The establishment of the new
LHB structure provides the opportunity to revisit this structure possibly through the
appointment of a nominated LHB to act as the lead commissioner and performance manager
for WAST.
5. Conclusions and recommendations
5.1. Conclusions
WAST has made significant progress since the original Audit Office report in 2006. There
have been a number of positive developments in the way that the Trust is now operating and
Category A performance in particular has improved significantly during this time. However,
the results of this review show that that there are still some fundamental issues that are
preventing WAST from performing at a level that is comparable with similar organisations
elsewhere in the UK. As a result patients in Wales are not receiving a level of service that is
commensurate with that achieved by other ambulance trusts elsewhere in the United
Kingdom..
The key findings from our benchmarking analysis and our asessment of the the current
efficiency and effectiveness of WAST are as follows
WAST‟s performance in relation to the Category A 8 minute target has improved
significantly since the beginning of 2007. However there has been little or no
improvement during this period in relation to the Category A and Category B
14/18/21 minute standards.
Although Wales covers a larger geographical area than other ambulance trusts in the
UK, the proportion of EMS activity that occurs in towns and cities in Wales is similar
to that of comparable ambulance trust areas in England
Wales experiences a relatively high number of 999 calls per head of population and a
relatively high proportion of these calls result in a patient being transported to
hospital. This results in pressure being placed on WAST and on hospitals in Wales
that we believe could be alleviated if suitable call triage and assessment procedures
were used and alternative care pathways were available for patients
We estimate that the total cost that WAST incurred in providing the EMS service in
2008-9 was £101.3 mil. WAST received £95.6 mil of funding for the EMS service in
47
2008-09 from HCW, NLIAH and the Air Ambulance Charity. The difference was
funded by income for other purposes e.g. ARRP.
Hospital delays have a significant impact on the ability of WAST to meet its
performance targets. During the reference period for our review, WAST would have
required an additional 900 ambulance hours per week in order to compensate for the
delays in handing over patients at hospital at an annualised cost of £2.3 mil per year.
This effect is of particular significance in the South East region of the Trust.
WAST‟s performance with respect to the initial phase of allocating a vehicle to a 999
call compares poorly with other ambulance trusts in England. A significant
contributory factor to this performance gap is the lack of an Automated Vehicle
Location System (AVLS) and related mobile data systems on EMS vehicles in Wales.
This makes it difficult for WAST reliably to locate and deploy the most appropriate
vehicle to respond to a 999 call.
Once the benefits of its investment in AVLS and mobile data are available, WAST
could meet the current Category A 8 minute targets both at a national and LHB level
with its current staffing levels and overtime rates and with the level of hospital delays
that occurred during the reference period for this review. In order to do this WAST
would need to accelerate the implementation of a deployment strategy that
o is based on 7 minute deployment areas in the more densely populated areas
o matches resource more precisely to the location of activity
o relies more extensively on the use of single manned response vehicles, and
o makes more extensive use of Community First Response schemes in less
densely populated areas as the initial response to Category A incidents.
The current level of staffing does not allow WAST to meet the 14/18/21 minute
standards and also requires a reliance on high levels of overtime to fill core shifts. In
addition, the shortage of staff in certain areas is preventing WAST from undertaking
sufficient ongoing professional training. Based on WAST‟s current levels of overtime
and planned level of relief, we estimate that the cost of the additional staff required to
meet the current 14/18/21 minute performance standards would be £3,744,000. This
would rise to £8,647,000 if WAST were to operate with no reliance on overtime to
cover shifts and with the level of cover for holidays, sickness, training and other lost
hours that was recommended in a Department of Health paper published in April
2007 setting out best practices in managing ambulance trusts
If it were fully resourced in accordance with the recommendations in this report,
WAST should be able to achieve a Category A 8 minute performance target of at
least 70% for the whole of Wales as well as meeting all the 14/18/21 minute
standards.
The current practice with respect to the 14/18/21 minute standards means that
WAST sends more double staffed ambulances in response to lower acuity 999 calls
than occurs at some other ambulance trusts. As advocated in this report, an
48
alternative approach which distinguishes more clearly between the requirement for
an appropriate initial assessment of the patient‟s requirements and the subsequent
provision of transportation once it has been determined that the patient needs
transporting to hospital could significantly reduce the number of ambulance hours
that WAST requires and also reduce the number of cases where the patient is
transported to hospital. It should be noted however that a change of this type will
require a significant change in practice within WAST as well as actions by other
stakeholders to ensure that alternative pathways are available for patients.
Consequently the benefits from this change are likely to take between 3 and 5 years
to be fully realised.
If WAST were able to match the levels of ambulance attendance and transportation
that are achieved in some trusts in England it could reduce the number of ambulance
hours required by around 410 per week by comparison with the level that was
planned in 2008/9. This would save around £1,025,000 per year in staff costs
If hospital handover times were improved so that only 10% of hospital handovers
took longer than 15 minutes this would reduce the number of ambulance hours
required by comparison with the reference period for this review by 710 per week .
This would save a further £1,966,000 per year.
If WAST were able to obtain the full benefits from lower ambulance attendance rates
and reduced hospital delays it should be possible for the Trust to meet both the AOF
Category A 8 minute targets and the 14/18/21 minute standards with a staff cost that
would be £1,876,000 lower than the level in 2008/9 based on the current overtime
and planned relief levels and would be £2,497,000 higher than the 2008/9 levels
based on the lower overtime and higher relief scenario.
If WAST were to change its operating model in the way that is advocated in this
report and was also able to obtain the full benefits of lower ambulance attendances
and reduced hospital delays outlined above, it should also be able to realise savings
of up to £280,000 in fleet costs as a result of greater use of cars and less use of
double staffed ambulances.
WAST may also be able to realise additional savings in the following areas
o reducing its administrative overheads
o reducing the number of operating centres and control rooms
It should however be noted that we have not examined these areas in any detail
during this review.
In addition to the detailed findings of our analysis set out above, we have also identified a
number of organisational issues which we believe need to be addressed if WAST is to
achieve a successful transition to the new approach to the delivery of its services that is
advocated in the report. In particular
The challenges of agreeing a common vision between WAST and its many
stakeholders about the role that WAST should play in the delivery of urgent care
49
across Wales has previously made it difficult for the Trust to plan its future direction
with any certainty and to communicate this to its staff. At the time of this review,
WAST has submitted a vision statement to NHS Wales for comment and
consideration and is also working with the seven new LHBs to include key objectives
within the LHBs own Urgent Care Plans. This offers an opportunity to establish a
jointly agreed role for WAST that will form the basis for the implementation of the
recommendations in this report
The geographical spread of the Trust, the requirement for senior management to be
located in three different regional centres and the amount of change in the senior
management team has made it difficult to establish a stable management structure.
The new management structure that has recently been introduced provides a
framework within which WAST can create the senior management team that will be
required to implement the strategy that is recommended in this report
The quality of clinical oversight, supervision and training has not had sufficient focus
at a time when the Trust has been under pressure to deliver performance. This has
been recognised by WAST and a number of initiatives are currently under way to
address these issues. However, the pressure on resource and the low levels of relief
continue to make it difficult for the Trust to release staff to undertake appropriate
levels of clinical training
The funding arrangements for WAST have been unclear in the past and require
clarification in the new NHS structure so that the link between funding and service
delivery can be made transparent
The current commissioning and performance management arrangements for WAST
do not facilitate clear lines of accountability between WAST and its commissioners
and performance managers for the delivery of the EMS service
Although WAST could achieve the AOF Category A 8 minute target for the initial
attendance at life threatening incidents with its current resource based on best
practice call cycle performance and the current levels of overtime and relief, the
current level of recurring funding that WAST receives is insufficient to enable it to
achieve the 14/18/21 minute standards. We therefore believe that WAST will require
additional funding in the short term in order to provide a fully effective EMS service
that delivers appropriate levels of clinical care to patients.
Nevertheless, our review has confirmed that, following the merger with NHS Direct, WAST is
uniquely placed to contribute to the delivery of a high quality urgent care service in Wales.
Moreover, there are significant opportunities for WAST to change the way that it operates so
that it is able to deliver an improved and more cost effective service. Indeed we see no
reason why these standards should not be comparable to those that are achieved in
England. In particular we believe that, based on the resources that we have recommended,
WAST should be able to achieve a performance standard of at least 70% for Category A
performance and also to meet suitably defined 14/18/21 minutes response and
transportation standards for both Category A and Category B incidents. It should also be
50
possible for WAST to reduce significantly the current reliance on emergency ambulances for
transportation to hospital and also to reduce the overall number of patients who are
transported to hospital by a combination of suitable initial assessment and the availability of
alternatives to hospital for patients to access. However, for these benefits to be achieved
WAST needs to work closely with the rest of the urgent care system in Wales and to
operate within a more clearly defined planning and performance management structure than
has occurred previously.
The new LHB structure which becomes operational on 1 October 2009 provides a unique
opportunity to establish an agreed strategy and a new governance and operating framework
for WAST based on these findings and our recommendations which are set out below. .
5.2. Recommendations
In line with our findings and conclusions set out above we would like to make the following
specific recommendations with respect to the future direction of the Welsh Ambulance
Service
WAST‟s vision of its future direction needs to be based on the principles set out in
this report, agreed with the Welsh Assembly Government, the new LHBs and other
key stakeholders and communicated to its staff
WAST should establish with WAG and the LHBs a clear interpretation of the 14/18/21
minute standards that apply to both Category A and Category B incidents
WAST should agree with the LHBs a plan to significantly reduce the ambulance
attendance and transportation ratios for Category B and Category C calls.
WAST should ensure that the structured approach to the deployment of RRVs and
other initial response vehicles set out in Section 3.2.2 above is implemented
effectively
WAST should ensure that the benefits of the new management structure are realised
as soon as possible
The Director of Operations should ensure that the Trust‟s performance management
and performance improvement processes are reinforced, deliver consistency of
performance and are used to enable the changes that are recommended in this
report. This should include a mechanism for defining and sharing best practice for
operations staff across the three Regions
The National Control Development Lead should establish common operational and
clinical practices that will operate in each of the control rooms and develop training
programmes and performance management methodologies for control room staff
51
WAST should improve the clinical input that is provided from the Control rooms for
both patients and front line staff and make better use of the potential that exists from
the co-location of ambulance control and NHS Direct through the implementation of
the Clinical Control Room Strategy
WAST should continue with its plans for the introduction of Specialist Practitioners
and Clinical Team Leaders
WAST in partnership with the LHBs should proactively seek to increase the number
of co-responder schemes and community responder schemes that operate in the
semi urban and rural areas and should ensure that there is an appropriate support
and deployment infrastructure to support this.
WAST should establish a clear staff development plan and agree with the LHBs a
level of relief that will allow staff to undertake the training that is required to maintain
their ongoing professional development
WAST should proceed with its plan for the implementation of a new CAD system as
soon as possible. This is necessary to enable WAST to improve service resilience by
allowing the sharing of information across the control rooms as well as enabling the
Trust to benefit from additional functionality that is not available in the current legacy
CAD system
WAST and the LHBs should review the Trust‟s current regional configuration in the
context of the proposals for communications hubs and the need to deliver a cost
effective control function.
In preparation for establishing new funding contracts, WAST should complete a
review of the fully loaded cost of providing the EMS and PCS services in order to
establish a sound basis for establishing the funding requirements and the contract
currency for the two services.
WAST should agree with the LHBs an appropriate subset of the measures outlined in
this report that can be used to benchmark its performance on a regular basis against
similar ambulance trusts elsewhere in the United Kingdom
WAG in conjunction with the new LHB‟s should develop and agree the future
planning and delivery arrangements for WAST, ensuring a clarity and focus upon
outcomes and performance
WAST should undertake a strategic review of its support services to establish
whether there are alternative ways in which these services could be provided at
lower cost
WAST and the LHBs should develop a fully costed plan to implement the actions
required to deliver the new delivery model and should establish a joint programme
management farmework to oversee the implementation of the plan
58
Appendix 3 Cost model methodology
The cost model that is summarised in section 4.7.3 was developed using the following
process:
The year to date costs for period 11 were extracted from the cost centre reports at
Oracle Level 2 (Directorate Level);
The costs and income elements were identified on the cost centre reports;
The costs were then reconciled at the directorate level to the total costs reported for
the entity (Ambulance Trust Level);
We removed the income elements from the “costs” that are to be used in the costing
model;
The month 11 costs were extrapolated into a 12 month costs (agreed with WAST as
a factoring of 11*12);
We then identified which facilities should be costed within the Emergency Medical
Services and agreed these with WAST, they are:
o Provision and operation of Emergency Ambulances;
o Provision and operation of Air Ambulances;
o Operation of WAST call centres; and
o Despatch of all ambulances.
We identified which of the directorates could be directly attributed to EMS and treated
other directorates as “overheads”;
We then allocated the “overhead” directorates into the operating directorates simply
by using the total costs of the operating directorates to apportion the overheads;
Totalled the direct operating costs and the allocated overhead costs to give a fully
overheaded cost for each of the “EMS” directorates;
From the overheaded “EMS” directorates, allocated the costs into the operating
areas (Oracle P3 Level) that they cover using the direct costs;