The Welsh Ambulance Service Trust reviews the Amber category

The Emergency Ambulance Services Committee (EASC) are the commissioners of ambulance services in Wales. As a provider, the Welsh Ambulance Service Trust (WAST) are under increased pressure from the growing number of 999 calls.

Calls that come through the 999 system are prioritised as red (immediately life threatening), amber (serious but not immediately life threatening), or green (neither serious or life threatening). Prior to October 2015 , the majority of calls had to be responded to in eight minutes. This was driving staff to send the nearest vehicle just to hit the time target, rather than providing the most appropriate care.

Changing of the system from an eight-minute response time to the Red, Amber, Green (RAG) model has meant that those in the Red category can be prioritised. However, the length of response time for patients in the Amber category has proved to be a patient safety and experience concern. This has led to the following questions being asked:

• Are amber patients safe?
• What’s making ambulances take longer to reach patients?
• Did removing the time-based target cause harm?

The EASC commissioned Picker to evaluate staff views of the Amber category through one-to-one interviews and focus groups, and public opinion through an online survey.

Challenges

The staff research gave interesting insights into their frustrations. The focus group highlighted that there was a lot of pressure on call handlers who were some of the lower-paid staff groups and often involved in difficult and challenging situations. Their roles required them to follow a script, which sometimes made it difficult for them to prioritise the incident accurately.

There was a lack of resources both in terms of the number of staff and available ambulances, which was made worse by long delays transferring patients into the Emergency Department. This, in turn, put more pressure on staff and led to high sickness rates, particularly amongst call handlers.

Police, GPs and nursing homes made a substantial number of calls to the service; some operational staff felt that the ambulance service was used as a “safety net” by some GPs and didn’t feel able to challenge their calls, and nursing homes frequently called about patients that had fallen. Operational staff also felt that some police officers don’t fully understand how the prioritisation process works.

Not every one that called 999 wanted an ambulance, some wanted advice and the control room staff did not always know what pathways were available to them.

Methods

EASC commissioned Picker to assess the perceptions about how the ambulance service should be used. Participants were asked:

• To categorise certain scenarios by urgency
• Rate how helpful they would find different information and options
• When they call 999, what options they would expect to be given to them.

Picker conducted six interviews with Operations Managers and three focus groups with a mix of: clinicians, call handlers, dispatchers and paramedics.

Public opinion was gathered via an online survey, which received 1000 responses. This explored the public perceptions and expectation of the ambulance services for an urgent clinical condition.

Analysis of the research was fed back to the EASC review team, where the key areas for learning were discussed.

Outcomes

It was found that WAST could improve the experience of staff and patients in the amber category by providing more clinically trained staff in the control room. This would give call handlers the back-up to refer calls where they thought the script wasn’t working, or the person needed clinical advice rather than an ambulance.

WAST has introduced the role of call handler supervisor to oversee the team and advise them when they are handling a difficult case. This would increase the support for call handlers and give them the opportunity for career progression.

Staff suggested ways to minimise calls from GPs, nursing homes and the Police.

A key suggestion was to look at the prevention of such a large volume of calls through educating the public on what the ambulance service is for and the availability of minor injury units and other primary care solutions.

Impact

• A significant financial investment has been made to expand the staffing of the clinical desk.
• WAST is taking fewer people to hospital despite an increase in calls.
• The research from Picker reassured WAST that members of the public understood and supported the RAG model.

Going forward

As a result of the Amber Review report, a number of initiatives have already been put in place and there are more actions planned:

• The current ambulance quality indicators are to be reviewed to ensure the continued focus is quality of care, as requested by the public.
• Ambulance availability has become the focus for improvement.
• Handover delays remain high and work is being done to reduce this.
• Staff sickness remains high and WAST have introduced a comprehensive plan to reduce this.
• The public perception exercise will be repeated to make sure the service is delivering what the public wants.

We are continuing our work with the Welsh healthcare services to help embed personal experiences and perceptions into system-level changes.

Picker’s research gave us the insight to change our policy in a way that benefitted our staff and the public.

Ross Whitehead, Paramedic and Assistant Chief Ambulance Services Commissioner, NHS Wales