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13 October 2010: Ambulance Service Network

  • Last modified date:
    18 April 2011

Thank you very much for inviting me and I am very pleased to have been able to come today.  Pleased, because this is my first opportunity to address you all, but also pleased to look ahead to the future of the ambulance service.

Late buses, spiders in the bath and not being able to get through to the Strictly Come Dancing voting lines aside, the vast majority of people who call 999 are in a fairly desperate state. 

If you need medical attention, if you need an ambulance, the knowledge that professional help is rushing to your side must be one of the most valuable services that the NHS can provide.

And you have proven time and again just how good a service you are.  Despite dealing with more calls than ever before, call handling is better than ever with the vast majority of Category A calls responded to within 8 minutes.

But behind the numbers are the individual cases that make such a huge difference to individual people. 

The White Paper

Ambulance services across the country do a good job in difficult circumstances.  And I’m afraid to say that some of those difficult circumstances are the fault of government.  Targets that pay scant regard to the evidence of what actually improves patient outcomes.  A confusing, ad hoc system of urgent care and out of hours services that leads the public into dialling 999 by default, when better more appropriate care is available elsewhere. 

Increased centralisation has long been seen as the solution.  For too long it has been a large part of the problem.  There are so many ways in which the NHS in general and ambulance services in particular can be much better if only the civil servants and politicians – and yes, I do mean me – got out of the way and let you and your colleagues across the NHS get on with the job.

That, in essence, is what the White Paper is all about.  As its name implies, Equity and Excellence: Liberating the NHS, is about setting NHS organisations free to achieve their potential.  It’s about treating the NHS and the professions like grown ups.  It’s about trusting that – working in partnership with your colleagues across the Health Service, other emergency services and in local government – you can organise yourselves from the bottom-up better than we in Westminster ever could from the top-down.

From empowering general practice to design and commission local services to turning every NHS Trust into a Foundation Trust, with the additional freedoms that go with Foundation Status.  From getting rid of every politically-motivated, process-driven top-down target that cannot prove its worth, to giving patients a genuine choice over their own care and making sure that their choices have a real impact on providers.  The White Paper will shift the NHS’s centre of gravity.

A locally-led, clinically-led Health Service, where what matters are not tick-box targets but real, measurable health outcomes.

Ambulance Service reform

This is very much the case for ambulance services.  Where targets distort priorities and impede patient care, then they must go.  Now of course, the speed with which an ambulance can arrive at the scene can be vital to the overall clinical outcome.  It can, and often does, mean the difference between life and death.  But that is not the case in all situations.  By taking a blanket approach, an obsession with speed can actually get in the way of good patient care.  An example is the target for reaching all Category B calls – calls that may involve injuries, illness or the exacerbation of an existing medical condition – within 19 minutes.

The fact is there is no clinical evidence to support the ‘B19’ target.  A recent study by Sheffield University found that just 5% of Category B calls could actually be described as serious, with half requiring no intervention by ambulance staff at all. 
Is this really the best way of driving change in Ambulance Services?  I’m not sure it is.  That is why we are looking at things like the B19 target to see if there are things we can do differently, things we can do that will demonstrably improve patient care.

Across the NHS, we are developing a range of clinical outcome indicators, quality standards designed by those on the ground delivering the care. 

And while we are removing targets that don’t count, like the 4 hour wait in A&E, we will strengthen those that genuinely improve patient outcomes, such as the Category A, 8-minute target. 

We all know there are some problems with the A8 target.  Sometimes, because of the target, an ambulance may be sent to an emergency before the exact nature of the call is understood.  The result is that many vehicles are dispatched only to be ‘stood down’ as further information comes to light.  Clearly not a good or effective use of crucial ambulance resources.  But these are problems we now have an opportunity to fix. 

Outcomes Framework

The clinical quality indicators are a part of a fundamental change in how we do things in the NHS.  They will promote excellence and equality, they will be clinically not politically led.  They will be focussed on outcomes, on actually improving the care we give to people. And they will be integrated, so for example the indicators for A&E will mesh with those for Ambulance Services.

And while the NHS will no longer jump on the every word of ministers or the Department, it will be very much accountable to the patients and public it serves.  It will be for local commissioners and providers, working with an increasingly wide group of partners, to determine the most appropriate performance levels based on the clinical needs of their patients.

And it’s happening already.  I am particularly pleased at how ambulance services are working with us to develop these indicators, and on behalf of the millions of people who will benefit, I thank you for your support.  The agreed set of indicators will be set out in the NHS Outcomes Framework, due in December. 

24/7 integrated urgent and emergency care

But it is not enough to say what the expected level of performance will be and then be done with it.  We need to do more than that.

As I said before, the approach to urgent care and out of hours services has sometimes been a bit confusing.  We need to sort this out if the public are to retain confidence in the care they receive.  And we need to sort this out if we want to change people’s default dialling of 999.

Responsibility for commissioning urgent and out of hours care will lie with GP Consortia.  While GPs may not themselves deliver that care, they will ensure that its design and operation meet the highest standards of safety and quality.

We need to end the confusion over what different services provide.  People today are presented with a bewildering range of urgent care centres, walk-in-centres, minor injuries units, GP-led Health centres and GP practices.  Even of some A&E departments that, despite the name, aren’t actually A&E departments!  Organisations can help by being clear as to the services they provide so that people don’t put themselves at risk by turning up expecting treatment that isn’t available.

And we need to do more to make the complex web of NHS services easy for people to navigate.  Who do you call at 3 in the morning when your child is sick?  What do you do if you’re away from home and have forgotten your medication?  If it’s an emergency, you dial 999.  But what about when it is not an emergency, what then?

Of course, there is NHS Direct, which does an excellent job.  But more than 8 out of 10 people don’t know the number.  If you are at home you could call your GP.  But out of hours, depending on where you live, you might be sent all around the houses before you actually speak to someone who can help.  Not what you need when you are looking after a sick child.  Despite the excellent work of so many people in the NHS, the system itself gets in the way of providing excellent care.

This is why we are rolling out a new number – 111.  With the vastness and complexity of the National Health Service, its beauty is in its simplicity.  111 is as instantly memorable as, and I hope will become as deeply ingrained in the national psyche as, 999.  If it is an emergency, dial 999.  If not, dial 111.  It’s as easy as that.

111 will help patients find the right care, in the right place, right away.  It also means that you can focus ambulance services on patients with the most serious conditions.  It will be a more joined-up service.  Patients won’t have to endlessly repeat information or be assessed multiple times.  And if a patient does need an emergency response, because of the consistent clinical assessment used across the system, 111 can send the call directly to the ambulance control room for immediately dispatch.

It has already been launched in County Durham and Darlington, working closely with North East Ambulance service.  By the end of the year, it will be available in Nottingham, Lincolnshire and Luton.  Learning and adapting the service as we go, it is casting its net wider and wider across the country. 

When 111 is rolled out across the whole country, it will replace the NHS Direct phone number.  Until then, NHS Direct will continue to provide its current service.  In the long term, while the phone number will no longer exist, I do expect that NHS Direct will continue to have an ongoing role, alongside other providers, in delivering the new 111 service.

Conclusion

The White Paper heralds an exciting time of change for urgent and emergency care.  But they will not be changes imposed on you from the centre.  The changes are about empowering you to work with colleagues across the NHS and to shape the services you provide to the best of your ability.

This is about enabling ambulance services to be as good as they can be.  It’s a challenge for you to work with your colleagues in primary, secondary and community care, with local authorities and with patients to develop high quality, integrated local services.  Not compromised by distorting targets but freed to shape and design services for the benefit of patients.

This conference is an opportunity to talk through a lot of what is happening and Matthew Cooke [National Clinical Director for Urgent and Emergency Care] is here to join in and reflect on today’s discussions. 

I am under no illusion that this will be a challenging time for ambulance services.  But it also an exciting time.  One that has the potential to unlock real improvements for staff and patients.  One where you will be in control.  One where we can transform services for the better.

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