Archived decisions

RE/

  

17 March 2006

  
 

Health Overview and Scrutiny Committee

 

Elizabeth 11 Court, The Castle

Sir Ian Carruthers

Chief Executive

Hampshire and the Isle of Wight SHA

Oakely Road

Southampton

Winchester, SO23 8UJ

 

Telephone 01962 847338

Fax 01962 867273

E-mail [email protected]

www.hants.gov.uk

 

Dear Sir Ian

Hampshire Ambulance Reconfiguration

Additional Issues for Consideration

I am responding on behalf of the Health Overview and Scrutiny Committee to the formal consultation on the reconfiguration of Ambulance Services. In his reply to the SHA in September our Chief Executive stated that he would support further exploration of local solutions to reduce the duplication of functions supporting emergency services across Hampshire. He indicated fire and ambulance services as a possible combination that would preserve local knowledge whilst minimising management costs and overheads. In addition we had anticipated that the formal consultation on the configuration of Ambulance Services would take full account of the direction of travel set of in ` Taking Healthcare to the Patient: Transforming NHS Ambulance Services'. In particular we noted the following principles set out in that document:

    · That services should be designed round the needs of the patient and the care provided by frontline staff

    · That services should work in an integrated way with other health and social care providers in their local area.

Our view was that this approach was entirely consistent with `Keeping the NHS Local' and other key policy documents.

Clearly the position has changed since that time, particularly with regard to fire services. Having had an opportunity to review the consultation document on the configuration of Ambulance Services, published by the Department of Health on the 14 December, we have deep reservations about the proposals and the impact that they may have on front line emergency care. The suggested configuration with Thames Valley, which will combine 4 separate ambulance services, is not supported by any evidence of either savings that could be achieved or quality improvement in service delivery. We have reviewed the document in detail, and our comments are appended, the broad areas of concern are as follows:

    · The recently Published White Paper on Health Care Outside Hospital reinforces the ongoing shift in the NHS towards community based primary and secondary care services. The intention is that patients receive care as close to home as possible, particularly in rural areas where there is greater difficulty in accessing traditional district hospital and Accident and Emergency Services. As a mobile resource, with highly trained staff, the ambulance service is able to play a key role in providing a continuum of care close to people's homes. Hampshire is a predominantly rural county with significant areas that are difficult to access.

    · Local knowledge is a fundamental pre-requisite to ensuring that emergency services are able to reach people as quickly as possible. We have already experienced significant difficulties with a local Out-of Hours provider that used a call centre in Birmingham. Action has now been taken to address this problem but these proposals could undermine this progress.

    · It is clear that the ambulance service has a key part to play in co-ordinating the range of out of hours and unscheduled care that people need. The skills that ambulance staff have in call handling, providing clinical advice and working with partner organisations are developing well in Hampshire. We believe that this will be lost if the services are reconfigured as suggested. We would therefore wish to propose that further work is done to explore how ambulance services can be configured to act as a single point of telephone access for the range of unscheduled, urgent and emergency care that is required, including mobile health services in Hampshire working in partnership with health and other service providers.

    · There is no indication of the additional resources that will go the ambulance services as a result of these mergers. Our experience locally has been that reorganisation on this scale inevitably incurs costs.

    · The new roles for ambulance staff envisaged have enormous potential to improve the services provided to our population. There is no indication that the merger will increase capacity to invest in and develop these skills, or that the arrangements will extend the resources available to support training programmes.

    · The proposal is in direct contradiction of the move to strengthen commissioning and make service delivery more local. This could add to rather than reduce the administrative burden on ambulance services, effectively imposing another layer of bureaucracy.

    · The geographic boundaries proposed are an administrative convenience. They do not reflect patient flows (for example in the north east and south west of Hampshire)

    · The suggestion that Patient Transport Services, which comprise of many community and voluntary sector providers, could be run from such a remote organisation is untenable.

    · No work appears to have been undertaken to evaluate the causes of the variation in funding levels across the country. The figures for Thames Valley/Hampshire funding to population ratio is the lowest in the country, despite the fact that we are joint third in terms of calls per square mile.

    · We do accept that there is a case for centralising procurement and technology. This is however quite distinct from the suggested merger of services.

    · There has been no risk assessment of the impact of these proposals

We would therefore reject the proposed merger of Hampshire Ambulance with Thames Valley, on the grounds that it is not in the interests of either our population or the NHS in Hampshire. We would also ask that further work be done to test:

    · The procurement and other `back of office' activities that could be provided on an SHA or national basis to achieve greater efficiency

    · The scope for the ambulance service to provide the initial point of contact for all unscheduled, emergency calls, including out of hours for Hampshire.

    · The role of the emergency practitioner, integrated into out of hours and unscheduled care networks to provide an alternative source of advice in the community, reducing the need for hospital admission

    · The scope for other providers to taken on the running of ambulance services, working alongside local partners in the voluntary sector, health and social care

I hope you find these comments helpful and look forward to recieiving your comments on the question we have raised as well as the outcome of the consultation process.

Yours sincerely

Cllr Dr Raymond J Ellis C.Chem FRSC

Chairman, Health Overview and Scrutiny Committee

cc

Cllr Ken Thornber

Cllr Fred Charlton

Cllr P March Jenks

Cllr Erica Outan

Appendix One

Detailed Commentary on the Consultation Document

Paragraph

Number

9

10

11

12

13

14

15

17

18

20

25

30

31

32

42

43

44

45

50

55

61

Commentary

General Observations

The term `Trust' used throughout this document denotes an Ambulance Trust

The SHA document is very bland providing little detailed information and presenting just one option. Of more relevance is the DoH document that lies behind it and is also subject to consultation. This commentary therefore focuses on this second document. This can be accessed by clicking here

There is no evidence provided to support the position that the 11 Trusts suggested will be able to provide improved care. Significant emphasis is however placed on alignment with regional office boundaries and it is made clear that any configuration that crosses these will not be supported centrally. This creates an immediate tension between the intention to provide services that are patient centred and artificial administrative boundaries.

There is reference to `other emergency services', however these are not defined and there is no reference to the way in which Trusts could work to develop better local arrangements.

The data presented shows enormous variation in funding allocation per million population- our area is the lowest, despite being joint third in terms of rurality. There is no evidence that any action is being taken to explore this nor any reference to impact of PbR. Our Trust has consistently made the case that they are not fully funded for all their activities.

The issues associated with the introduction of new staff roles are not developed throughout this document. Locally we are already aware of the pressures on training budgets as a result of the financial pressures faced by the Trust. There are also capacity considerations in terms of the availability of suitably accredited training centres.

Links with other OOH, unscheduled and emergency care need to be made locally to ensure these services are able to meet the different needs of different communities. No consideration has been given to this prerequisite.

Working within communities will only take place if there is proper alignment with community services.

Local experience has been that call centres must have local knowledge to be able to respond quickly. We have evidence that a call centre for OOH, based in Birmingham, was not able to provide a quality service to our population in south west Hampshire.

The commissioning capability of PCTs is not well developed. Consequently the service specifications/ plans underpinning funding are not robust. There also needs to be a better understanding of health needs to inform planning. There is some way to go before this can be achieved locally.

A management team covering an area of will inevitably be remote. This is incompatible with the stated intent of working with local communities, without the points outlined above being addressed.

To date little evidence has been provided to support the shift of care from acute to community services - rather community services in Hampshire are under greater pressure than ever and this in turn is causing additional demands for adult services. Whilst any reduction in bureaucracy is to be welcomed these services will need an appropriate infrastructure in order to allow highly skilled front line staff to operate optimally.

How will infrastructure and capacity be improved through these arrangements?

The geographic boundaries proposed are an administrative convenience. They do not reflect patient flows (for example in the north east and south west of Hampshire) No other options have been explored, for example better alignment with fire services to make better use of estate vehicle maintenance and procurement.

If the objective of the restructuring is to secure more timely patient centred care then boundaries should reflect the patient's pathway through the system. Full consideration must be given to the way in which isolated rural communities are served.

Specifically, what action is being taken to remove artificial boundaries between organisations and improve co- terminosity with other services? SHA will not be providing services.

The intention to rationalise procurement is welcomed but the options for so doing do not appear to be fully explored. At present, without greater clarity about local arrangements it is likely that staff confidence will be undermined by the proposals.

No consideration has been given to co-terminosity with local government at a sub-regional level. Planning and co-ordinating a response to major incidents does need to have a regional perspective but it is equally important that local authorities can properly contribute to this work. Noting the reference to `other emergency services' the proposals do little to progress this to achieve better congruence across communities.

Where is the evidence to support the claim made for these improvements? There is local evidence of a historic underfunding of these services that needs to be addressed. What work has been done to test the impact of PbR on the funding of these services- are they affordable in the current financial climate?

How will good practice be identified and captured given the timetable for implementation suggested. In the same way that the SoS has given a commitment that PCTs would not relinquish provider services without local consultation we would expect a similar commitment from Trusts. Key stakeholders must include all tiers of local government, other emergency and unscheduled care providers as well as LAAs and LSPs.

We have only been presented with one option- this infers that there may be at least two.

The importance of building relationships at a regional level has been noted, however there is a corresponding need to ensure that there are equally strong working relationships with those involved with actual service delivery. The failure of this document to address this is a recurring flaw.

No work appears to have been undertaken to evaluate the causes of the variation in funding levels across the country. The south east (B) funding to population ratio is the lowest in the county, despite the fact that we are joint third in terms of calls per square mile.

What is the rational for transferring PTS to the new Trusts? These services are vital, usually strongly supported by community and the voluntary sector.

What is `best' and how will this be delivered

The case for bringing together procurement training and back office functions has already been acknowledged. The fact remains however that those delivering these services must be integrated into local communities and providers.

The reference to audit draws out a recurring theme in the document that seems to assume that these services can be performance managed into delivery. This is not the case and inevitably leads to greater bureaucracy and cost.

This is a key paragraph that reflects many of the comments made above. Intent to achieve this however is not sufficient

What levels of savings are envisaged

How will the working environment change

What level of funding will be set aside to meet the training needs of staff and is there capacity in the programme to support the rapid roll out of such a programme.

Whilst the Trust must have local autonomy the fact remains that our health economy is under severe pressure. This is reducing the level so service provide to our population and it is disingenuous to ignore this fact.