Agenda item

Ms Vicki Hirst, Stakeholder Engagement Manager at The London Ambulance Service NHS Trust (LAS), advised that Ms Pauline Cranmer, the LAS Assistant Director of Operations – NW London, had been unable to attend the meeting as she was meeting with staff to discuss progress made against the findings of the CQC inspection. 

In 2015/2016, there had been a significant increase in demand which had been about 5% greater than the increase anticipated.  Ms Hirst advised that there had been a 20% increase in seriously ill patients between September/October 2015 and September/October 2016, possibly as a result of a higher acuity of patients, more comorbidities, an older population (with more complex needs and little in the way of a support network) and improvements in identifying illnesses such as sepsis.  There had also been a societal change where residents had certain expectations about the services that they were entitled to - this also had an impact on community services and Hillingdon Hospital. 

With regard to Cat A8 calls (responding to seriously ill and life threatening calls within 8 minutes), performance had increased from 59.2% in 2014/2015 to 63.3% in 2015/2016 and performance in October 2016 had been 66.36% (although performance across the LAS had, in the past, been as low as 58%, Hillingdon was one of the better performing areas).  In Hillingdon, Cat A8 performance had increased from 62.58% in September 2016 to 66.85% in October 2016.  It was noted that 75% of Cat A8 patients in Hillingdon were reached within 9 minutes 45 seconds.  Work was underway to adjust resourcing to ensure that a 70+% was achieved across London in 2017/2018 against the Cat A8 target. 

It was noted that the number of patients managed by the LAS on the telephone was the highest in the country.  To try to further improve the service, the LAS had been working with the wider NHS to try to manage the pressure by focussing on frequent callers, HCPs, nursing and care homes and NHS 111. 

It was noted that individuals were not charged for making unnecessary calls to the LAS.  However, a lot of work had been undertaken to deal with frequent callers, many of whom suffered from mental ill health, substance misuse or were elderly.  It was noted that many mental health related calls to the LAS across London were made on Thursday evenings.  With many of these cases, a multi-disciplinary approach was needed.  The information collected by the LAS meant that the Trust could drill down to map out where the calls were coming from so that this could be analysed by the Business Development Department to identify whether the services needed were in place to meet the demand.  With regard to reducing demand, Members were advised that the LAS triaged calls to signpost or close down calls and 40% of patients that were visited by ambulance staff were left at home with further information about an alternative, more appropriate care pathway that they needed to follow. 

Ms Hirst advised that the CQC would be undertaking a comprehensive inspection of the LAS on 7, 8 and 9 February 2017.  Following the CQC's inspection in June 2015, the LAS had been placed in special measures.  The LAS subsequently published its Quality Improvement Plan in January 2016 which set out the robust actions that would be taken to get the Trust out of special measures.  NHS Improvement had conducted a review of the progress that had been made against the recommendations that had been made in the CQC inspection report.  This process had included a review of the data and documentation, a site visit, focus groups and ride-outs on response vehicles.  Five areas for improvement had been identified:

1.    Making the London Ambulance Service a great place to work;

2.    Achieving good governance;

3.    Improving patient experience;

4.    Improving environment and resources; and

5.    Taking pride and responsibility.

In terms of the progress made so far, Ms Hirst advised that 700+ frontline staff had been recruited since the original CQC inspection, 3,169 posts had been filled and 85 Hazardous Area Response Team (HART) members were now in post and fully trained.  It was hoped that the redesign of the graduate recruitment process, which provided a clear outline of what a graduate could expect when they joined the service, would help to attract more new staff.  Although many of the staff recruited from Australia stayed with the LAS, Ms Hirst was unclear about the visa situation and would provide the Committee with further information about long term recruitment plans at a future meeting.  As staff no longer stayed with the LAS for very long periods of time, consideration was being given to rotating staff around the health services (for example, there were some paramedics that had previously been nurses and some paramedics who now worked at GP surgeries). 

Improvements had been made to the Personal Development Review (PDV) appraisal process resulting in 56% being completed service wide, 52% within operations and 88% within corporate services.  All staff in Hillingdon had completed a PDV with the exception of two members of staff who were on maternity leave. 

Members were advised that:

·         605 staff had attended the bullying and harassment workshops and 30 staff had been trained to run roundtable meetings to help reduce conflict. 

·         85% of the managers had been trained in risk management and 92% of frontline staff had been trained in Duty of Candour.  A new Duty of Candour policy had been launched, aimed at all staff working for the Service and setting out the LAS commitment to embedding a transparent and open culture with the infrastructure in place to support openness.  

·         3,134 frontline staff had received training on the Mental Capacity Act as part of the 2016/2017 core skills refresher programme (over 95% of staff attended the refresher training, time for which was now included as part of the working rota). 

·         Improved local arrangements had been put in place in relation to securing drugs, additional drug packs had been purchased and more spot checks were being undertaken to ensure that staff were adhering to the Shut It, Lock It, Prove It policy.

Members queried whether there were instances where bullying and harassment allegations made by the staff, who were already under pressure, was their perception of being performance managed.  Ms Hirst advised that a significant amount of work had been undertaken with staff to clarify the difference between performance management and bullying/harassment.  Training and support had also been provided to managers.  It was noted that the CQC had to report on the information that they were given, irrespective of whether some accusations of bullying and harassment were unfounded.  Results of the most recent LAS staff survey (which measured feelings of bullying and harassment) were expected in March 2017 and Ms Hirst advised that she would be happy to return to a future meeting to update Members on the outcome. 

Ms Hirst advised that there were 12 vehicle hubs in London, two of which were in North West London (Brent and Hillingdon) and would going live on 15 December 2016 (the soft launch would take place this week).  These hubs included teams that provided a more consistent approach by preparing the vehicles so that they were ready to use first thing in the morning.  It was noted that drivers were available to pick up vehicles and take them back to the hubs and replenish the onboard stocks (this would happen at least every 24 hours).  In addition, the LAS had procured 60 fast response unit (FRU) vehicles in September 2016 and the Trust was looking to ensure that none of its vehicles were more than seven years old.  Ms Hirst advised that she would provide the Committee with an update on the hubs at a future meeting.

With regard to the patient experience, Members were advised that leaflets were now available in all LAS vehicles to provide information about how to give the Trust feedback and how to contact the service.  Mental Health Nurses had been introduced at the clinical hub to provide better care to patients who were experiencing a mental health crisis and a pre-booked transport solution was in the process of being rolled out across the whole Trust for community health care assessments which was expected to be completed by January 2017. 

It was noted that the graduate recruitment process had been redesigned and that the Emergency Operations Centre and Patient Transport Centre safeguarding were continuing.  Training and inductions for new clinical recruits also continued.  A safeguarding supervision lead had been appointed and several focus groups had been held with staff and managers. 

Members were advised that, since airing the first programme on 27 September 2016, the three part BBC documentary 'Ambulance' had prompted a huge surge of interest in joining the LAS.  The series had illustrated the challenges faced by LAS staff but also showed the staff's compassion and kindness. 

In terms of involving staff, the Trust had been working to embed its vision and values across the service and had started a 'Making the LAS Great' communications campaign (which included visibility days at Hillingdon Hospital, Chief Executive road shows and regular briefings).  Regular communication was undertaken with all staff about the progress made against QIP targets with key themes covered each month. 

It was noted that LAS staff neither wore bodycams nor had cameras in their vehicles as there were issues around patient confidentiality.  However, there had been an increase in the abuse levied at staff by patients.  Although staff were encouraged to report any incidents, consideration could be given to the use of cameras to reduce the risk and increase patient safety.

Although it was understood that there were private ambulance services operating in the area, Ms Hirst was not aware of a partnership between the LAS and DHL and would investigate the matter and forward her findings on to the Committee. 

Ms Hirst was aware that an application for Foundation Trust status had been submitted by the LAS.  However, as the LAS had not had a robust Board or management team in place, she was not sure of the progress that had been made.  Ms Hirst would investigate this matter further and forward the information on to the Committee. 

Members were advised that all of the 'must do' issues raised in the CQC inspection report had been addressed and monthly meetings were being held to monitor progress with a monthly report published on the LAS website.  However, these reports only showed the progress of that particular month and did not represent the progress during that had been made in its entirety.  With regard to the 'should do' actions, the LAS had looked at what could realistically be achieved within 6-12 months.  This had resulted in the issue of disposable blankets, cleanliness audits and discussions with the unions about meal breaks. 

Ms Hirst advised that the longest LAS shift lasted 12 hours with a compulsory 30 minute break.  However, there were times when staff were with a patient at the end of their shift and they couldn't just leave them.  There were also times when short breaks could be built into a shift, e.g., when a patient had just been dropped off at hospital and staff could be 'taken off the road' if they highlighted that they needed this.  However, there were times when there were so many calls received by the LAS that it made it difficult to take a break. 

Concern was expressed that some staff might deliberately not take their 30 minute break so that they could leave work half an hour earlier.  It was suggested that, if staff had been working for 11½ hours without a break, this could impact on their performance which could then lead to performance management steps being taken which could then be deemed to be bullying or harassment.  Ms Hirst advised that the LAS had tried to allocate break times but that this had proved contentious.  Furthermore, although staff were supposed to return to the station for their breaks, it could take some of them up to forty minutes just to get there from their last call.  It was noted that longer breaks had been organised for staff for debriefing after a blue light call to work through any issues before they went out on another call.  Discussions with the staff and the unions about breaks were currently underway. 

With regard to the 2016/17 Quality Improvement Programme appended to the report, Members queried what the information therein actually meant.  Ms Hirst noted that the report picked up on elements that had been included within the LAS workplan but appreciated that, as a standalone document for someone external to the LAS, it would not make much sense.  She noted the feedback and advised that she would look at how this could be improved.

There were only three bariatric vehicles covering the whole of London.  A Working Group had been set up by the LAS to look at how the needs of this growing population could be met.  It was noted that manual handling training was undertake by all staff every year as equipment developments were regularly introduced.  Ms Hirst advised that she could provide an update at a future meeting of the Committee. 

Members were advised that a winter plan was in place to help deal with factors such as the weather, excess alcohol and Christmas parties and it was anticipated that the annual pan London media campaign would run again this year (last year the campaign had been "Eat, Drink, Be Safe").  There were also plans to run treatment centres in central London based in areas of anticipated/historic high demand. 

The Chairman advised that the Committee was supportive of the LAS and Members felt that the staff did a good job in sometimes difficult circumstances. 

RESOLVED:  That:

1.    Ms Hirst provide Members with updates on the following issues at a future meeting of the Committee;

a.    Staff survey results, particularly in relation to bullying and harassment;

b.    Vehicle hubs;

c.    Action taken by the LAS to address the needs of bariatric patients;

d.    Long term recruitment plans and visas;

2.    Ms Hirst investigate the relationship between the LAS and DHL (if any) and forward her findings on to the Committee;

3.    Ms Hirst investigate the progress of the LAS FT application and forward the information on to the Committee; and

4.    the presentation be noted.