Agenda item

Patrick Brooks from the London Ambulance Service made a presentation about the pressures the service had been under this winter, the proactive work the LAS has been doing with stakeholders and partners, and against that backdrop, information around response times and performance particular in relation to Borough GP practices.

LAS was the only Pan London NHS Trust which operates across the whole of London covering all the London Boroughs and the City. He outlined the number of calls taken over a typical day including over 5,000 and 6,000 to 999 and 111 respectively. There are three levels of service namely ‘hear and treat’ where people are dealt with over the phone by callers and clinicians with a range of pathways and advice suggested, then others dealt with at the scene through what is known as ‘see and treat’ and finally ‘see and convey’ where people are taken to A&E.

Currently there are 3,200 paramedics supported by 1,400 emergency medical technicians, with a broad range of skills together with 380 nursing and medical staff in control rooms and 1,300 call handlers. In NE London there are 853 paramedics and technicians who collectively carried out over 33,000 face to face responses between 1 January and 26 February 2024.

Mr Brooks outlined the various categories of calls and response times. Over the last winter period there was a call increase of 7,000 in core demand, in response to which he outlined the strategy for managing this demand.  Hospital handovers played a crucial part and the Service continued to work with its NHS partners in NE London to reduce delays and safely release ambulance crews from hospitals which has made a big difference for medics and patients, freeing up clinicians to attend to those who need the most urgent care. The main thing is to ensure patients are directed to the right pathways and minimising the number conveyed to hospital emergency departments. As things stand less than 50% of patients attended are ending up at hospital.

In response to the presentation a number of questions/observations arose. These included whether the LAS felt there are enough services in the community available to avoid escalation to hospital. The primary pathway available are the GP’s. In NEL there are a lot of community service pathways available, however the challenge comes when they reach capacity.

From a customer care perspective, issues were raised regarding how the level of harm caused by ambulance delays was evaluated and, from an acute perspective, how many individuals were driving relatives or others direct to hospital when they should be in an ambulance receiving treatment before they arrive at hospital.  Although the current response time to category 1 (life threatening) met the 7-minute national target and category 2 (emergency / potentially serious) at 29 minutes had, over the past few months, dramatically improved, it was recognised that the service did not know with any certainty on a case-by-case basis where the greatest risks sat, resulting in many unwell patients requiring treatment self-presenting to hospital.

The LAS continue to work closely with hospitals to access the ‘front door’ risk, but perhaps it would be useful to conduct an audit to assess the number of patients that should/should not have been convened to hospital by ambulance rather than self-present. It was important to note that in NEL it is not possible to self-present at a hospital emergency department.  Those individuals are required to go through an urgent treatment centre unless convened by ambulance. Of course, some will then be referred through to ED which has a knock-on effect for the whole pathway.  The LAS also has a contract for a taxi service for those patients assessed as not requiring an ambulance but needing to attend hospital.

In response to a question about community support Mr Brooks explained that the 111 service has a huge directory of robust and comprehensive community services to ensure patients go through to the right pathway through set algorithms and triage. That said the service is always keen to develop new pathways so as to promote patient care and most importantly keep them in the community, when appropriate to do so.

The work described in today’s presentation over the last 12 to 18 months had focused on partnership working at both at site and regional level. It now felt very different with real innovations coming through. It’s a constant improvement cycle and there are questions about how things can be joined up better to manage the pathways for patients generally.

Melody Williams, NELFT referenced a pilot going live on 2 April in NE London with NHS 111 press 2, a direct line through to a mental health clinician, given a significant number of calls through to LAS are to do with mental health crisis.

Ann Hepworth, BHRUT commended the LAS as a great partner for improvement who have together worked well to make some massive improvements over the past 12 months to the hospital ‘front door’ into ED. That said there is still a massive demand which continues to grow. There are two things in particular that could be done in partnership across the system to improve matters. These include getting a better shared understanding where the risks are held across urgent emergency care, so that on any given day it would be possible to identify where the real pressures are for local residents. The second is about longer-term output, given that Queens Hospital remains a significant outlier across the whole of NE London for avoidable emergency attendance compared to the Royal London for example. Consequently, there is a need to properly understand why this is happening and look to reduce it to improve people’s lives. Mr Brooks stated that it was a point well-made and agreed it’s a good time to look at new innovations and have single points of access.

Councillor Jones referencing an experience from a recent family emergency made the point about ambulances taking patients to alternative hospitals out of the BHRUT area and the concerns that the social care relationships at these hospitals (in this case Newham General) are not the same as in BHRUT. Mr Brooks stated that in general patients should be conveyed to their nearest hospital particularly where they have ongoing needs as that is where their records will be. He undertook to look into the case highlighted as it seems they should have been convened to the preferred place of care for which he apologised.

Other points raised concerned the Duty Doctor Scheme which was a great example of successful multi-disciplinary working looking after the needs of the patient, which was trialled in this area but then dropped. Mr Brooks agreed with the comments and would support its reintroduction.

It was reported that Healthwatch did a report last year on service user experiences in the Borough and 50% of respondents stated that hearing of excess waiting times on calling for an ambulance had stopped them requesting one or would deter them in the future.  It was suggested that the recent improvements should be better communicated to local residents to give them more confidence to call an ambulance should it be required.  Mr Brooks undertook to provide contact details of the patient experience team who could pass on the results of satisfaction surveys etc. 

Reference was made to the 45-minute limit that was introduced in January to ease pressure on the LAS at hospitals and the impact this has had, as well as other ways to solve the problems. Mr Brooks responded that prior to this there was no maximum wait time for crews who could spend an entire shift waiting in a hospital corridor with a patient for a hand over. This had led to hospitals introducing a whole range of improvements such as streaming and assessment of patients. This now allows crews to be released quicker and has led to response times for category 2 incidents to be brought down as reported earlier. For the record the plan is to reduce the handover time to 30 minutes.

The Chair thanked Mr Brooks for his informative presentation and for responding to questions.