AnEvaluationofearlystagedevelopmentofrotatingparamedicmodelpilotsites

FinalReport

JanetteTurner–UniversityofSheffieldJuliaWilliams–UniversityofHertfordshireJune2018j.turner@sheffield.ac.uk

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Headlinesummary...................................................................................................................3

Whatisthisreportabout?...................................................................................................3

Whataretheoverallconclusions?.......................................................................................3

Howdidtheauthorsreachtheseconclusions?...................................................................3

Arethereotherspecificfindings?........................................................................................4

Whatdoesthereportrecommend?....................................................................................4

1. Background.......................................................................................................................5

2. Aimsandobjectives..........................................................................................................7

3. Methods............................................................................................................................8

4. Resultsofqualitativeanalysis.........................................................................................10

4.1 Pilotsitemodels......................................................................................................10

Characteristicsofrotationalschemes................................................................................13

PrimarycareandMDTcomponents...............................................................................13

Rotationalprogress........................................................................................................13

Primarycarescopeofpractice.......................................................................................14

Availabilityfor999calls..................................................................................................15

Workingpatterns...........................................................................................................15

Summaryofoperationalmodelfindings........................................................................16

4.2 Factorsandpracticalconsiderationsrelatedtoimplementation............................19

Keylearningpoints.............................................................................................................25

Contractingandclinicalgovernancearrangements.......................................................25

Staffrecruitment............................................................................................................26

Financeandfunding.......................................................................................................28

4.3Broadissuesidentifiedbykeystakeholders................................................................32

PartnershipsbetweenambulanceserviceandMDT......................................................32

EmergencyOperationsCentre(EOC).............................................................................33

Specialistandadvancedparamedicsexperiences..........................................................36

Paramedicprescribing....................................................................................................38

Strategyandfitwithstrategicplans...............................................................................39

CodesetsforidentifyingSPrelevanturgent999calls...................................................40

Informationsystems.......................................................................................................40

5. Pilotschemesactivityandprocesses.............................................................................43

5.1Potentialcallpopulation..............................................................................................43

5.2Pilotschemeactivity.....................................................................................................45

SouthCentral..................................................................................................................46

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EastLincolnshire.............................................................................................................47

Newcastle.......................................................................................................................50

5.3Summaryofquantitativefindings................................................................................52

6. Summaryandconclusions..............................................................................................53

Recommendationsfornextsteps......................................................................................54

Limitations......................................................................................................................56

References..............................................................................................................................56

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HeadlinesummaryWhatisthisreportabout?Thisreport,commissionedbyHealthEducationEngland,aimstoevaluatethedevelopmentofarotatingparamedicmodelofcaredeliverydesignedtoaddressboththecareeraspirationsofspecialistparamedicsandthecombinedworkforceissuesinambulanceservicesandprimarycaresothatall,notjustsome,ofthehealthcaresectorscanbenefit.Thefundamentalprincipleofthismodelisthat,ratherthanworkingwithinasingleenvironment,aspecialistoradvancedparamediccan“rotate”throughdifferentsectorsofthehealthcaresystemwhilstremainingemployedbyoneemployer.

Whataretheoverallconclusions?Therotationalmodelrepresentsasubstantialchangeofserviceprovisionbothintermsofscopeandcomplexity.RotatingsuitablyqualifiedandexperiencedparamedicsthrougharangeofhealthcaredeliverysettingsisfeasibleandlikelytoheraldbenefitsbothinrelationtorecruitmentandretentionofParamedicsinambulanceservices,aswellasimpactingonpatientexperience.Thisapproachtointegratedhealthcaredeliverywillimproveinterprofessionalandmultidisciplinaryteamworkingaswellasfacilitatingparamedicstofullyutilisetheirextensiveskillset,knowledgeandexpertisewithoutdepletingambulanceservices’workforce.Thiscanonlybeofbenefittopatientmanagement,experiencesandpotentiallypatientoutcomes.However,thereiscurrentlyinsufficientdatatoestimatethenetbenefitofthiswork.

Howdidtheauthorsreachtheseconclusions?Fourpilotsiteswereestablishedandevaluatedthroughavarietyofmeansincluding:• Interviewswith30participantsfromavarietyofbackgrounds.Participantsunanimouslyagreed

thatarotationalmodelshouldcontinuebutthereisaneedforflexibilitywithinthemodeltoensurethatlocalneedsaremet,whetherthisbeinchoiceofareasofrotation,lengthofrotation,oravailabilityofmodeldelivery.Theinterviewsrevealedthatbothparamedicsandotherhealthcareprofessionalslearnedagreatdealabouttheircolleagues’individualprofessionalrolesandthatparamedicseasilyintegratedintomulti-disciplinaryhealthcareteamsbringingexpertise,knowledgeandskillsthatareextremelyrelevantandversatile.Thebiggestconcernshighlightedbystaffwere:

o Thatthismodelmaynotbeadoptedacrossthecountry,whichifthisweretobethecasewasidentifiedasawastedopportunity

o Theneedtoconsideranewapproachtofundinghealthcareprovisiontosustaintheseroles

o ParticularemphasisisneededtodevelopingtheEOCcomponentbylearningfromserviceswerethishasbeenhistoricallywellestablished

o Whetherthistypeofroleshouldattractahigherpaybandthaniscurrentlyindicated• Quantitativeanalysisofpilotsiteactivity.Pilotsitesprovidedaggregatedearlydataonactivity

andassociatedprocessesofpatientmanagement(e.g.workload,conveyancerates,seeandtreatrates)asasnapshotofhowrotationalparamedicsaremanagingthepatientstheyattend.Thisshowed,dependingoncalltypeandorigin(primarycareorambulance)SPsmanageahighproportionofcallsinthecommunity(70-93%)andthereareearlyindicationsthathospitalconveyancecanbereducedwithinlocalpopulationswhererotationalparamedicsareoperating.

Aneconomicevaluationhasbeenreportedseparately.

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Arethereotherspecificfindings?• Freedomtodevelopcreativeandflexiblerotationalmodelshasbeencentraltotherapid

implementationofthepilotsites.• Differentfundingmodelsseemtodeterminewhetherornottheparamedicwillrespondto

Category1callswhennotonanambulanceplacement.• Noconsensusastowhetherthisisaroleforexperiencedparamedicsorwhetherinthefuture

thiscouldbearolefornewregistrantsaswell• Pre-registrationeducationprogrammesshouldincludeplacementswithinthesesettingsto

familiarisefutureworkforcewithworkinginalternativesettings• Paramedicprescribingwasseenasanadditionalbenefittothemodel,althoughitwas

recognisedthatitmaynotmakemuchdifferenceinrealityaswiththeexpansionoftheroleofcommunitypharmacistmanyoftheissuescouldbemanagedthroughPGDs.

• Detailedplanningforclinicalgovernanceprocesses,contractsandfinancialarrangementsisneededtoprotectorganisationsandstaff.Oncesetupthesecanbemoreeasilyreplicatedasschemesexpand.

• Clarityofroles,activitiesandworkloadiscrucialtodevelopingmanageableprimarycareandMDTcomponents.

• Lengthofrotationineachcomponentisnotstraightforward.Longerrotations,particularlyinprimarycaresupportlearningandrelationshipbuildingbutshorterrotationsincreasevarietyandbettersupportshiftrotapatterns.

Whatdoesthereportrecommend?Recommendationsinclude:• Extendedfundingtofullyevaluatetheimpactofthisnewmodelofhealthcaredelivery• Furtherconsiderationoftheoptimaltimingandchoiceofrotationalplacements• Furtherexplorationastowhetherthismodelwillenhanceparamedicretentionandrecruitment

toambulanceservices• Developsome‘exemplar’sitesofbestpractice,whereastrongcommitmenttoresearchand

evaluationcanhelpdrivethemosteffectivemodelsthatpositivelyinfluencepatientcare.• Establishworkstreamstopromotenationalstandardsineducationbutmaintainlocalcontrolto

developrelevantinfrastructureandtailortherotationalmodelaccordingtolocalhealthcareneed

• Carryoutfurtherresearchtounderstandthedefinitiveimpactonpatientoutcomes,patientexperienceandcosteffectiveness.

• CollaboratewithCCGs,STPsandotherstakeholderstoensuretherotationalparamedicmodelisintegratedwithstrategichealthplans.

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1. Background

HealthEducationEngland(HEE)hasembarkedonaprogrammeofworktodevelopaclinicallyeffectiveandsustainablemodeltomaximisethecontributionofparamedicswithinprimarycare.ThisworkfitswithinabroadercontextofboththeGP2020workforceprogrammeandtheAmbulanceImprovementProgramme.Theimpetushascomefromasetofdistinctbutinter-relatedfactorsthathaveresultedinseriousstrainonthedeliveryofemergencyandurgentcaretothepopulation.Themainchallengesare;

• Persistentannualrisesindemandforemergencyandurgentcareservicesacrossallsectors.Forambulanceservicesinparticularthisequatestoa5%increaseeachyear.

• CongestedhospitalsthatcausecrowdinginEmergencyDepartmentsaneffectofwhichisdelaysinthetimelyhandoverofpatientsbyambulancecrewswhichinturnreducescapacitytorespondto999calls.

• Constrainedfinancialresources–the2017NationalAuditOfficereportonambulanceservicesreportedthatoverthe4yearperiod2011/12–2015/16financialresourceshadincreasedby16%butactivityby30%.1

• SubstantialworkforcegapsacrossmanyNHSsectorsbutwhichisparticularlyacuteinemergencymedicine(includingnursing),primarycareandambulanceservices.

Theseareofcoursecomplexproblemsthatwillrequiremultiplesolutionsinordertoresolvethembutthereisonespecificproblemthatisthefocusofthisworkandthatisthecompetitionthathasarisenforthegroupofspecialistandadvancedparamedicpractitionerswithexpertiseinthemanagementofurgentcareproblems.

Theyearonyearrisesindemandforemergencyambulanceserviceshasalsomeantasubstantialchangeinthecase-mixofcallsandastheproportionofpatientscallingforurgentproblemshasincreased,thoseforgenuinelylife-threateningemergencieshasdecreased.Asaconsequenceambulanceserviceshavehadtoadapt.Onechangehasbeenthedevelopmentofspecialistandadvancedparamedicrolesthathaveincreasedtheclinicalskillsofacohortofstaffsothat,whereappropriate,theycansafelyassess,treat,referordischargepatientswithurgentproblemswithouttheneedtotakethemtoanemergencydepartment.Thisroleisnotnew,ithasdevelopedoverthelast15yearsalthoughprogresshasbeenpiecemeal,butthereisasubstantialbodyofevidenceshowingthatspecialistoradvancedparamedicpractitionerscanprovideasafe,clinicallyandcosteffectiveservicethatiswellreceivedbypatients.2Thisrolehasbecomeallthemoreimportantasemergencyandurgentcareandbroadernationalhealthpolicyhasshiftedtowardsamodelofprovidingmorecareclosertohome.3,4Italsomeansthereisnowacareerpathwayforparamedicsthatallowsthemtodeveloptheirclinicalroleandexpertisewhilstremainingclinicallyoperational.However,ithasalsocreatedagroupofhealthcareprofessionalswhoseskillsarevaluedoutsideambulanceservicesandinparticularbyprimarycarewhereithasbeenrecognisedtheycanbeasubstantialassettomanagingtheprimarycareworkloadinanenvironmentofsubstantialshortagesofGPs.Thishasmeantthatinrecentyearsambulanceserviceshaveseensignificantattritionoftheirspecialistworkforcetootherpartsofthehealthsectorincludingprimarycare,butalsotootherservicessuchasdisabilityassessmentwheretheyareofferedbetterworkingconditions(noshifts)andoftenahigherpayband.Forambulanceservicesthisnotonlydepletestheirparamedic

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workforcebutalsotheylosetheirmostexperiencedstaffinwhomtheyhavemadeasignificantfinancialinvestmenttosupporttheirdevelopment.Forspecialistandadvancedparamedicsamoveawayfromtheambulanceserviceallowsthemtobetterusetheirskills(whichisnotalwaysachievedwhentheyarepartofaresponseplantoalltypesofcall)andabetterworklifebalance.Yetwhilstthismaybethebestmoveforsome,notallspecialistparamedicswhohavelefttheambulanceservicehaveabandoneditentirely.Manyretainbankcontractssothattheycanstilldosomeambulanceserviceshiftstomaintaintheiremergencycallskillsandindeedcontinuetodowhattheyjoinedtheambulanceserviceforinthefirstplacebutinamorecontrolledway.Othersreturnafteraperiodworkinginanothersector.Thisisagainforambulanceservicesbutalossforaprimarycareservicethathasalsomadeaninvestment.

Thepictureiscomplexbut,theattritionratesforspecialistparamedicsishighlysuggestiveofaworkforcegroupwhosecareerandworkaspirations,insomecases,arenotbeingmetsolelywithinanambulanceservicesetting.Forprimarycare,insomeinstancestherecruitmentofspecialistparamedicsworkstotheiradvantagebutonlyiftheystay.Morebroadly,adepletedambulanceserviceworkforcewillmeanthat,whenpatientsdoneedanemergencyresponse,theyarelesslikelytogetthisinatimelyway.Inessence,thereisagroupofhealthcareprofessionalswheredifferenthealthcaresectorsarecompetingwitheachotherforthesamestaff–theyareall“fishinginthesamepond”withanendresultthat,fromasystemperspective,therewillalwaysbealossandagain.

TheHEEinitiativetohelpresolvethisproblemistosupportthedevelopmentofarotatingparamedicmodelofcaredelivery.Theaimistobetteraddressboththecareeraspirationsofspecialistparamedicsandthecombinedworkforceissuesinambulanceservicesandprimarycaresothatall,notjustsome,sectorscanbenefit.Thefundamentalprincipleofthismodelisthat,ratherthanworkingwithinasingleenvironment,aspecialistoradvancedparamediccan“rotate”throughdifferentsectorsofthehealthcaresystemalthoughemployedbyonlyone.

Theperceivedbenefitsarethatforthespecialistparamedicsitprovidestheopportunitytofurtherdeveloptheirurgentcareskillsandputthemtouseinareaswheretheyareofmostvaluesotheseskillsareutilisedacrossbothambulanceserviceandprimarycaresectors.Forambulanceservicestheexpectationisthatarotationalmodelwillimproveretentionofspecialistparamedicstaffandbetterutilisetheirskillstorespondtotherighttypeofcallswheretheyhavemostbenefit.Forprimarycareithasthepotentialtoprovideamoreconsistentandresilientserviceiftheycanutilisealargercohortofstaffwithplannedsupportonacontinuousbasis.Forthehealthcaresystem,atscaleandinthelongerterm,themodelshouldcontributeto

• Increasingthenumberofpatientswhoaresafelyandappropriatelymanagedoutsideanacutehospitalsetting.

• ReducingthenumberofGP999calls,unnecessaryEDattendancesandunplannedhospitaladmissions.

• Improveambulanceserviceresponsetoemergencycallsbymakingmoreresourcesavailablethroughfewerhospitaltransfersandreducinghandoverdelays.

Forpatientsandtheircarers,thereshouldbeanincreaseinsafe,appropriateandseamlesscareclosertohomeandimprovedsatisfactionandexperience.

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Insummary,theaspirationsoftherotatingparamedicmodelaretobetterutilisethespecialistskillsofadvancedparamedicpractitioners;delivermorecareclosertohomewherethisisclinicallyappropriateforpatientsandprovideanalternativecareerpathwayforambulancecliniciansthatsupportstheirdevelopmentandprovidesopportunitiestoworkacrossdifferentsettingsratherthanwithinasingleproviderorganisation.TothisendHEEhaveprovidedfundstoasmallnumberofpilotsitestohelpthemdeveloparotationalparamedicmodel.Aspartofthisprocesstheyhavealsocommissionedanindependentevaluationofthesepilotsites.Thisreportdescribestheearlyevaluationofthesepilotmodels.

2. Aimsandobjectives

Alongtermevaluationobjectivewouldbetoassesswhethertherotationalparamedicmodelsachievedtheintendedbenefits.Beforeimpactcanbemeasured,thereareimportantquestionsthatneedtobeaddressedaroundthefeasibilityofdesigning,settingupandimplementingtherotationalparamedicmodel.Adetailedanalysisoftheseprocessescanprovidevaluableinsightsintothepracticalissueswhichneedtobeconsideredforasuccessfulnewcaremodeltobeoperationalised.ThisinformationisofvaluetobothexistingschemeswheresharedlearningcanbeusedtoovercomeproblemsandtothewiderNHSwhereitcaninformplanningwherenewschemesarebeingdevelopedorconsidered.

ThepilotsiteswereselectedandfundsallocatedinDecember2017withanenddateofMarch2018.ThereforeforthisfirstevaluationperiodthepilotsiteshavebeenoperationalforonlyashortperiodwhichnecessitatedfocussingourinvestigationonthekeyissuesconcernedwithsettingupandimplementingarotationalparamedicmodelintheHEEselectedpilotsites.Theoverallaimistoassessifestablishingarotationalmodelisfeasible.Theobjectivesaretoexplorethebroadcomponentsthatcontributetooperationaldeliveryofarotationalmodelincluding:

• Identifyingthecriticalfactorsthatcontributetotheimplementationofanoperationalrotationalmodelinpractice

• Reviewingtheexperiencesandperceptionsofspecialistparamedicsandrelatedprofessionalgroups

• Exploringthescopeandpotentialforfurtherdevelopmentandpotentialimpactonthebroaderemergencyandurgentcaresystem

Thisisthereforeprimarilyadescriptivestudydesignedtoidentifyandcharacterisetheearlyexperiencesoftherotationalparamedicpilotsites.

TerminologyusedinthisreportTheterms“specialist”and“advanced”paramedictendtobeusedinterchangeablytodescribeaparamedicwithenhancedclinicalskillsthatareadditionaltothosegainedduringpre-registrationtraining.Theseencompassacomplexrangeofspecialistskillsandeducationallevels.Forconsistencyandbrevitywehaveusedtheterm“specialistparamedic”todescribeallenhancedpractitionersexceptwheretheinterpretationofdatarequiresadistinctiontobemadebetweenthedifferenttypesofpractitioner.

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3. Methods

ThepilotsiteswereselectedinDecember2017andbeganoperatingbetweenDecember2017andFebruary2018anddatahasbeencollectedfortheperiodJanuarytoApril2018.Therotatingparamedicpilotsitesincludedhavethereforebeenoperatingforashortperiodoftime(14weeksorless)andatsmallscale.Wehavetakenapragmaticapproachtodatacollectionananalysisinordertomaximisethevalueofinformationavailablewithinthistimeframe.Thefocusisassessingthefeasibilityofdesigningandimplementingarotationalmodelandsowehavetakenaprimarilyqualitativeapproachthatallowsustoexploreindetailtherangeoffactorsthathavecontributedtothesuccessfulimplementationofarotationalmodelusingtheexperiencesofthosewithfirst-handexperienceofmakingthishappen.Conventionally,qualitativeresearchgenerateslargevolumesofrichdatathatiscomplexandtimeconsumingtoanalyse.Forthisprojectwemanagedanalysisinawaythatallowsustomakesenseoftheseexperiencesandidentifycommonthemesthatwillbeofvalueasmodelsprogressusingrapidanalysis.Theaimhasbeentogeneratebroadheadlinesthatneedtobeconsideredandwhichcanbecomparedacrosstheindividualpilotsitestoidentifysimilaritiesanddifferences.Tosupportthiswehaveusedasteppedapproach.

Stage1–DevelopmentofastudyframeworkWedevelopedanoverarchingframeworktoprovideastructuredandsystematicapproachtodatacollectionandanalysis.Thiswasdonein3ways:

• WeusedtherotatingparamedicmodeldescribeintheHEEdocument“Therotatingparamedic–ahowtoguide”5asthebasicconceptualframeworktosetoutsomeofthekeythemeslikelytobeimportant.Fromthisdocumentweidentifiedthesuggested3componentmodelofrotationthroughAmbulanceEmergencyOperationsCentre,PrimarycareandMultidisciplinaryTeam(MDT)communityservices.Wealsoidentifiedbroadthemessetoutthatwouldneedtobeconsideredwhichincludedscopeofpracticewithineachrotation;clinicalgovernance;identificationofsuitablecalls;educationandtrainingrequirements.

• Eachpilotsitehadmadeanapplicationandprovidedahighlevelplansettingouttheirintendedmodel.Weusedthesedocumentstoidentifyadditionalthemeswhichincludedstrategicfitwithambulanceserviceandwiderurgentcaresystemdevelopments;partnershipdevelopment;commissioningandfinancialconsiderations.

• InFebruary2018aworkshopwasheldwhereeachofthepilotsitespresentedtheirintendedmodelandprogress.Informationfromthesepresentationsanddiscussionswereusedtobegintoidentifysubthemesofinterest,forexamplenumbersofrotationalparamedics,timesallocatedtoeachrotationetc.

Stage2–QualitativedatacollectionThisframeworkenabledustomaptheessentialcriteriaacrosskeythemeswhichwerethenusedtodevelopthequestionsfordetailedinterviewswithkeystakeholdersineachpilotsite.Questionsweredesignedtoexploreeachkeytheme,identifychallengesandhowtheyhadbeenresolved,futureplansandanypotentialrisks.Theseinterviewsprovidedthemainsourceofdatatoexplorethekeythemes.Timingwasimportantasthepurposewastodescribetherotationalmodelsin

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actualpractice(ratherthandescribingplansnotyetrealised).Thismeantweneededtogivealongenoughtimeformodelstohavebeenworkingbuthavesufficienttimetoanalysecomplexdata.ThepilotsbecameoperationalbetweenDecember2017andFebruary2018andsotheinterviewswereconductedinApril2018whenpilotshadatleastafewweeksofoperationalexperience.Weusedacombinationoffacetofaceandtelephoneinterviews,withatotalof30interviewsconductedacrossthepilotsites.Thesecomprised:

• 7Specialistparamedicsand1AdvancedNursePractitioner(workingasanambulanceserviceemployedadvancedpractitioner)

• 4Specialistparamedicmanagers(including2rotationalmodelclinicalleads)• 2projectleads(non-clinical)• 4AmbulanceServiceseniormanagers• 2GPs• 8MDTstaff• 1practicemanager• 1commissioner

Stage3–QualitativedataanalysisInterviewswereaudiorecordedandtranscribedandenteredintoMAXQDA18softwareforanalysingqualitativedata.Qualitativedatawasexaminedbythreeresearchers(JW,JT,PEW)forrelevancetothekeythemesandsubthemesidentifiedinthestudyframeworkandadditionalsubthemesidentifiedfromthedata.ThesedataweresupplementedwiththedetailedinformationavailableinthepilotservicehighlevelplansandpresentationsattheFebruaryandlaterMarchworkshops.Concisedescriptionsofeachpilotsitemodelwereconstructedandwehavethenmappedeachthemeandsub-themeandcomparedthemacrossthepilotsitestoidentifysimilaritiesanddifferencestakingintoaccountcontextualfactorssuchasdevelopmentalstageandhowlongindividualschemeshavebeenrunningfor.Giventhetimeconstraintswehaveprimarilyconstructedsummarytablestoprovideahighlevelsummaryofimportantfactorsandproducedanoverallassessmentoftheprogressofpilotsitesforeachbroadthemeandfeasibilityinrelationtotheoriginalconceptualframework.Stage4–QuantitativeanalysisofpilotsiteactivityThequalitativeworkprovidesadescriptionandanalysisofthedevelopmentandimplementationofpilotsitemodelsintermsoftheirdesignandfunction.Pilotsiteshavealsoprovidedaggregatedearlydataonactivityandassociatedprocessesofpatientmanagement(e.g.workload,conveyancerates,seeandtreatrates)asasnapshotofhowrotationalparamedicsaremanagingthepatientstheyattend.

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4. ResultsofqualitativeanalysisTheresultsofthequalitativeworkarepresentedusingthreebroadheadings;

• adescriptionofeachpilotsitemodelandasummarycomparisonofeachmodelandhowthey“fit”withtheinitialsuggestedHEEframework

• adescriptionandsummaryofthepracticalissuesidentifiedthatarekeycomponentsofturningarotationalparamedicmodelplanintoanoperationalservice

• explorationofbroaderissuesthathaveanimpactorpotentialimpactonfuturedeliveryandsustainabilityofarotationalparamedicmodel.

Wehavehighlightedimportantfactorsidentifiedacrossindividualthemesandsubthemestoprovideanoverviewofthemodelsandimportantmessagesidentifiedwhichwillbeofvalueforfuturedecisionsanddevelopment.

4.1 PilotsitemodelsTheHEEdevelopmentworkprovidesanexamplerotationalparamedicmodelillustratedinFigure1.Figure1:Examplerotatingparamedicmodel.

Thismodelisnotintendedtobeprescriptiveandisaspirationalbutprovidesastartingpointforconsiderationofthepilotmodels.Theoverallpremiseisthatpatientsgetrightcarefirsttime,specialistparamedics(SPs)aretargetedtothosepatientswheretheirskillsareofmostvaluefreeingupambulanceresourcesandreducinghospitalconveyancesandmangingsomeprimarycarepresentationsmayreducethenumberofrequestsfor999ambulancesmakingtheurgentcaresystemmoreefficient.

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HEEinitiallyawardedfundsto3organisationstosupportpilotrotationalschemes.Onerecipient(EastMidlands)haveusedtheirfundstodeveloptwodistinctmodelsintwolocalitiesandsowehavedescribed4rotationalparamedicpilotschemes.Duringtheprojectanadditionalorganisation(YorkshireAmbulanceService)werealsoawardedfundstosupportdevelopmentofrotationalmodelsincludingaprimarycarecomponentinLeeds,andexpansionoftheexistingSPschemeinSheffieldtoincludeprimarycareelements.Howeverthesewerenotoperationalduringthedatacollectionperiodforthisstudyandsohavenotbeenincludedintheanalysis.Figure2providesabriefdescriptionofeachofthe4pilotschemesincludedinthestudy.Thisreflectstheplannedmodelandnotnecessarilyallactivitiesorrotationalcomponentshaveyetbeenachieved.Table1providesasummaryofkeyfeaturesofeachmodeltodate.Figure2:Descriptionofpilotrotationalschemes

SouthCentral SouthHardwick(Derbyshire)DevelopedbySouthCentralAmbulanceService.SplitbetweenSPsprimarycareandambulanceoperations.Primarycareishomevisits,urgentcareclinicappointmentsandtelephonetriage.MDTcomponentiswithinprimarycare.AmbulanceoperationsplannedasmixofEOCandfrontlineresponsetoappropriateurgentcarecalls.OriginallySEHampshirebutcurrentlystartedinReading

DevelopedbyHardwickCCGandEastMidlandsAmbulanceService.BuiltaroundSPsbasedwithinalocalityMDT(SPAtriage,OT,Physiotherapist,ANP,communitymatron,socialcareetc).CasesgeneratedfromSPA;directrequestsforurgentvisitsfrom3GPsurgeries;ambulanceservicecategory4fallsandcategory3calls.PrimarycarecomponentisintegratedwithMDT.EOCcomponentnotyetimplemented.

EastLincolnshire NewcastleDevelopedbyEastMidlandsAmbulanceService.Initialphase1modelSPsrotatingthroughEOCand999responsetotargetedcalls.Continuousrotationbyclinicians(i.e.EOCisnotforasetlengthoftime).Phase2SPswillrotatethrough3GPpractices(includingMDTs)with5dayblocksbasedinpracticeandotherweeksrovingresponderstoGPrequestswithinaspecifiedareaand999urgentcalls.

DevelopedbyNorthEastAmbulanceService.SPsrotateonadailybasisthroughGPhomevisits,EOCandOutofHoursurgentcare(MDTcomponent)providingresponsetourgentcarecalls.TheoutofhoursserviceisprovidedbyNEASsoambulanceservicebased.Includemorethanonecomponentwithinasingleshift.

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Table1:Currentrotationalparamedicoperationalmodels SouthCentral SouthHardwick(Derbyshire) EastLincolnshire NewcastleRotationalmodelPrimarycareMDTEOC

YesbasedinpracticeEmbeddedwithinPCNo

Referralsfrom3practicesYesbasedinMDTNo

Yes-notpracticebasedWithinPCYes

YesbutbasedinASOutofhoursurgentcare

Startdate 1stDecember2017 22ndJanuary2018 22ndJanuary2018 February2018CurrentoperationPrimarycare

1SPinGPpracticeDec172SPinGPPracticeApril182SPinGPPracticeMay18Mon-Fri10:00–18:00

Seebelow

4SPsrotatingthrough1GPpracticein5dayblockseach

3Band7AP1band6Mon–Fri09:30–17:00GPhomevisitsfrom1practice.Maximum7slotsthatcanbebooked

MDT

EmbeddedinPrimaryCare 2SPMon-Fri09:00-17:00MDTandurgentGPreferrals,Cat4fallsSat–Sun09:00-17:00category3and4999calls

Withinprimarycare

Outofhoursservice(SP,nurses,GPs)from18:00Mon-FriandSat/Sun.Telephonetriageandhomevisits.

EOC Notstarted Notstarted 4SP(1ANP)7dayservice11:00–19:00EOCrotationalparamedicsupportsoperationalSPsbyidentifyingsuitablecalls.Rotateeveryfewdaysona4weekrota.

Mon–Fri18:00–21:30andSat/Suntelephonetriagefor999andNHS111.

Responseto999calls Yesinitiallywhenservice10-2forrestofshift.NosinceGPhourshaveextended.

Cat4falls.Cat3&4weekends.Cat1ifavailable

Yes–urgentcarecallsCat1ifavailable

No

Exclusions Under18years;mentalhealthproblems;palliativecarerequiringdrugs

Under18years;mentalhealthproblems;palliativecarerequiringdrugs;pregnancy

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Characteristicsofrotationalschemes

Thepilotschemeshaveadoptedavariableandflexibleapproachtothedevelopmentoftheir

rotationalschemeswithdifferencesinthehowmanycomponentssuggestedbytheHEEexample

modelhavebeenincorporatedandthedurationoftimeSPshavespentineachrotational

component.Therearesomekeymessagesidentifiedfromthewaysthese4schemeshave

implementedarotatingparamedicmodel.

PrimarycareandMDTcomponentsTherehasbeenaliberalinterpretationofprimarycareandMDTcomponents.IntheSouthCentral

schemethesehavebeenconsideredwithinaprimarycaresitewhichmakessenseif

multidisciplinaryteamsarebasedwithinlargepractices.WithintheSouthHardwickschemetheSPs

arefirmlyembeddedwithinatrueMDTwiththeprimarycarecomponenttodeliverhomevisits

linkinginthroughthisservice.InrealitythemodelsreflectprimarycareandMDTasa“blended”

componentratherthantwodistinctandseparateservices.TheEastLincolnshireschemeisadopting

asimilarapproachalthoughthiswasnotyetoperational.IncontrasttheNewcastlemodelthathas

identified3separatecomponentswiththeMDTelementprovidedbytheOutofHours(OOH)

serviceNEASarealreadycontractedtoprovide.Itistheirviewthattyingtherotationalmodelinto

existingservicesspeedsupprocesses,ismoreefficientandreducescosts.Forexample,asproviders

oftheOOHserviceNEASalreadyhadaccesstoandlicencesfortheprimarycareSystem1

informationsystemandstaffnewhowtouseitwhichsubstantiallyreducedtrainingandlicensing

costsfortheGPurgentvisitwork

RotationalprogressForthemostparttheeffortssofarhavebeenbasedinsettingupindividualcomponentstoget

startedratherthanallindividualcomponentsatthesametime.Thisisalsoreflectedbythesmall

numbersofSPscurrentlyinvolved-largernumberswouldsupporthavingstaffineachcomponent

butschemesaren’tlargeenoughyettofacilitatethis.

"Ithinkthechallengeisgrowingatapacethatitisachievableaswell,intermsoftheworkforcethatwe'vegotatthemoment.We'rekeenthatallofourindividualpartnershipsareasuccess,sowedon'twanttospreadourselvestoothinly,andjeopardisethat.Soit'skindofgrowingatapace,accordingtothestartinglevelsthatwe'vegotineacharea."

TheSouthCentralpilothassofarconcentratedondevelopingtheprimarycarecomponentand

gettingthatoperational.ThiswasseenasaprioritytotryandreducetheriskofGPsemployingSPs

themselves.

“…thereasonwhyweputthisbusinesstogetherwasabouttheportfolioworking.Ithinkpersonallygonearethedayswhereyoujoinedtheambulanceservice,youstayedintheambulanceserviceuntil,youknow,yougotthebadback,mentalhealthissuesorwhatever,gonearethosedays.Butwhatwe’renowseeingispeoplejumpingship,butifwecankeepthosestaff,keepthosestaffengaged,dotheportfolioworking,allowthatrotationtowork,wewillengageandkeep

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thosestaff,whichwillagainbenefiteverybodybecausewe’resharingaworkforcebutthey’restillstayingwithintheambulanceservice,sowe’renottrainingthemupandthenlosingourexperienced,mostqualifiedstaff,westillkeepthem.Sothat’sgottobeabenefitagainintermsofthewholeambulanceserviceandintermsofeducationandsupportandsystemsandclinicalandpatientcareandoutcome.”

HowevertheydoenvisageatwocomponentmodelofPrimarycarethenambulancewithamixof

EOCandfrontlineresponding.SimilarlytheSouthHardwickschemehasonlydevelopedtheMDT

componentandtheSPstherearenextrotatingintoanacutehospitalsettingratherthanEOC.These

firstplacementshavebeendesignedtokeepSPsinasinglecomponentforanextendedperiodof

timesotherehassofarbeennoopportunityforrotation.Howeverthishasprovidedtheadvantage

ofallowingtheSPstheestablishthemselvesinanewenvironment,developtheirworkingpatterns

andprocesseswiththeirhostorganisations,developtheirclinicalskillsandforgepositive

relationshipswithinthisnewsetting.

Converselytwootherschemeshavebeenrotatingstaffastherotationalperiodshavebeenmuch

shorter.TheEastLincolnshirepilothasrotatedagroupofSPsthroughEOCwithoneinEOCatall

timestohelpimprovetargetingof999callstotheoperationalSPsandimproverelationshipsand

communicationwithEOCstaff.Rotationalperiodsareshort(days)overa4weekrota.

AlthoughonlyjuststartedtheGProtationalattachmentwillbein5dayblocksfor1SPatatimewith

theothersproviding“roving”responsetoGPurgentrequestsand999urgentandoneinEOC.This

willbeanexampleofapoolofstaffrotatingatfrequentintervalsacross3components–GP

practice;GPand999urgentresponseandEOC.WithintheNewcastlemodelSPsrotateacross

componentswithinthesamedaytobestmaximiseuseoftheirtimeso,forexample,onaweekday

12hourshiftanSPwilldo8hoursGPvisitsthen4hourstelephonetriageinEOC.Weekendand

nightshiftsareamixofEOCandOOHsorotatingthrough2componentsonashiftbyshiftbasis.

Thesemodelsprovidevarietyforstaffandconsistentexposuretothedifferentcomponentswithout

longgapsawayfromanyindividualcomponent.

PrimarycarescopeofpracticeTherearedifferencesinthescopeofworkfortheprimarycarecomponent.TheSouthCentralmodel

includesbeingbasedsolelywithinaGPpracticeforseveralmonthsandcarryingoutamixofhome

visits,practiceconsultationsandtelephonetriage.TheSouthHardwickpilotenablesGPsfrom3

practicestodirectlyrequesthomevisitsonlyfromtheSPbasedintheMDT.Inbothofthese

schemesitwasthoughtthathavingtheSPsavailabletostarthomevisitingearlyinthedayhelps

smoothdemandforurgentambulancerequestsforthosewhodoneedtogotohospitalreducing

theafternoonspikewhichoccurswhenhomevisitsbyGPsdon’tstartuntillatemorningorearly

afternoon.TheEastLincolnshiremodelwillbeahybridofpracticebasedworkandGPhomevisits

whereastheNewcastlemodelhasverytightlycontrolledtheGPcomponentbycurrentlyprovidinga

maximumnumber(7)ofGPhomevisitsonlyfromasinglepractice.Thereweredifferingviewson

thescopeofprimarycarepracticewithsomethinkingclinicworkingvaluablewhereasothers

thoughtrapidlyturningaroundpatientsin10minuteappointmentscouldpotentiallyleadtoSPs

becomingburntoutanddisillusionedunlesstheworkloadiswellmanagedandcontrolled.Aclear

15

messagefromthepilotschemesthatdidemergewasthatscopeofpractice,tasksandactivities

needtobeclearandagreedfromtheoutsetandthatgoodsupportandmentorshipisinplace.

"Becauseoneofthethingsthatisevidenceisthatwhenourcliniciansdorotateintoprimarycare,theyneedgoodsupportandmentorshipfromtheGPs,andfromthepractices,to,Isuppose,improvetheirconfidenceandcapabilities.So,ifyouaresimplyfillingagap,thenyou’renotnecessarilygoingtogetthatsupport."(Amb:SeniorManager)

Availabilityfor999callsTherearedifferencesintheextenttowhicheachschemehasembeddedresponseto999calls.In

SouthCentralSPsrotatingthroughtheprimarycarecomponentdonotrespondtoany999calls.

SimilarlyinNewcastletheSPsontherotationalmodelarenotincludedinthe999operationalplans.

InHardwickandEastLincolnshirethereissomeprovisionforSPstorespondtourgent999calls

relevanttotheirskills.InSouthHardwickthisisconfinedtocategory4fallsonweekdaysand

category3and4callsatweekendsalthoughreferralshavebeenlow.InEastLincolnshirethelarger

poolofSPsrespondtosuitable999callssupportedbytheSPonrotationthroughEOC.Inbothof

thesepilotsitesSPscanbeaskedtorespondtocategory1callsiftheyareavailableandthereisno

otherresource.InpracticetheSPshavereportedtheyarerarelyaskedtorespondtocategory1

calls.

Availabilityfor999callsalsohighlightedtworelatedissues;

• WhetherSPstaffwearambulanceuniformornot-Thereweremixedviewsandpolicieson

whetherSPswhereambulanceuniformornot.Asageneralrule,whereSPswerenot

respondingto999calls(sooutofplan)andbasedsolelyinprimarycarethepreferencewas

tonotwearuniformasthiswaslessconfusingforpatientsandconformedtothesamerules

asotherprofessionalgroupsworkinginsurgeriesalthoughthiswasnotuniversal.IfSPswere

respondingto999calls,eitherasatargetedresponsetolowcategoryurgentcallsor,

infrequently,acategory1callthentheydidwearuniform.Thedecisionaboutwhetheror

notuniformisusedisdependentontherotationalelementandifthescopeofworkincludes

providinganambulanceresponse.

• Typesofvehicle–relatedtouniformisalsowhetherSPsworkusinganambulancevehicleor

unmarkedcarsandsimilarprinciplesapplyinthatwhereSPsareprovidinganambulance

responsetourgentcallsthenambulancevehiclesareused.Whereaprimarycarebased

serviceisbeingprovidedthiswasvariable.TheSouthCentralschemedoesuseSPsin

ambulancevehicles(anduniform)onthebasisthattheremaybeinstanceswheretheyare

inthevicinityofaseriousemergencyandshouldbeabletorespondtothatandhavethe

equipmenttomanageit.Incontrast,theNewcastleschemeonlyusesleasecarswithbasic

equipmenttoprovidetheGPhomevisitingservice.Thisisfarlesscostlythananambulance

vehicleandalsoensuresthehomevisitingserviceisn’tcompromisedbySPsbeingdiverted

toambulancecalls.

WorkingpatternsInalloftheschemestheSPsareambulanceserviceemployeeswithannualisedrotas.Therewas

variationinhowthishasbeenimplementeddependingontherotationalcomponent.TheSouth

Centralschemewhichhasconcentratedondevelopingtheprimarycareelementpredominantly

usesa5dayrotathatfitswithprimarycareworkinghourswithoccasionalambulanceshiftstomake

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uphours.Staffvaluedtheambulanceshiftsastheyfeltitimportanttomaintaintheiremergency

skills.Theother3schemesused7dayrotas(althoughintheEastLincolnshireschemetheplanned

Primarycareelementincludesa5dayperiodbasedinaGPsurgerythen7dayswhenprovidinga

combinedGPhomevisitandambulanceurgentcareresponse).TheNewcastleschemeutilisesthe7

dayrotabyincorporatingall3componentsintotherotatoensureSPsareutilisedeffectivelyby,for

example,providingGPoutofhoursresponses(theMDTcomponent)atnightsandweekendsanda7

daypresenceinEOC.TheSouthHardwickschemealsouseda7dayrotabuthadlesssuccessin

termsofeffectiveutilisationoftheSPsparticularlyatweekends,inpartbecausethetargetingof

suitablecategory3and4callswasnotveryeffective.Thelessonlearnedfromthissiteisthatfor7

dayworkingthereneedstobesomeclearidentificationandplanningoflikelyworkloadsoutof

hoursandmechanismsputinplacetosupportallocationofappropriatereferrals.Theyhave

consideredarangeofoptionstoimprovethisinthefutureincludingbetterreferralofCategory3

and4callsbyEOC,whichshouldbehelpedwhenthereisabigenoughpoolofSPstoincludeanEOC

rotationalcomponent,butalsoexploringthescopetomanagedirectreferralsfromothersources

suchasNHS111andnursinghomes.

SummaryofoperationalmodelfindingsThebasicdesignandoperationofthe4rotationalparamedicpilotschemeshaveeachevolvedquite

differentlyalthoughthecomponentssuggestedintheexamplemodeldescribedbyHEEhaveall

beenincludedindifferentcombinations.Eachpilothasbeencreativeinbeginningtooperatea

modelthatfitswithlocaldemand,existingpartnershipsandavailablestaff.Thisisseenasabenefit

bytheparticipantsandthisflexibilityisseenbythestakeholdersasessentialtothesuccessofan

operationalrotationalmodel.

Participantsstressedtheneedtohaveanationalmodelwithflexibilitytotailortheinfrastructureto

meetlocalhealthcareandoperationalneeds.Thereareelementsofallthreesuggestedcomponents

acrossthesitesbutnotalwaysacleardistinctionbetweenthemwithsomecreativethinkingaround

combiningprimarycareandMDTelements.Thereisalsonoobviousconsensusaroundhowlong

eachrotationalcomponentshouldbewithmarkedvariationinhowthishasmaterialisedin

operationrangingfrommonthstodaysandagaintheneedforflexibilityonthisissueisimportant.

"Ithinkthat’spotentiallyaslightdifficultyintermsofdevelopingrotationalmodelsandIthinkwearekindofatthestartofajourneyinawayinthatthereseemstobequiteawantfromtheGPsandthoseworkinginprimarycare,thattheyseemtowanttogettoknowthepractitionersandtheywantthatkindoflongevityintermsoftimeofgettingtoknowthemoveraperiodofweeks,months,potentiallyfourtosixmonthstokindofgettoknowthepractitionersandembedthemwithinthesurgery.Butthenfromanambulanceserviceperspectiveintermsofrotationthatlimitsthenumberofpeoplethatarerotatingwithinthatschemeinitially.Soifweonlyputoneortwopeopleintoasurgerytorotateforsixmonths,thenactuallyifyou’vegot12practitionerssaybasedonastationnearthatsurgeryit’sgoingtotakeanumberofyearsbeforeeachofthosepractitionershashadanopportunitytorotate.”

"obviouslywe’vehadtokindofgodownthismodelofhavingthemembeddedinthereforsixmonthssothattheGPscangettoknowthemandthingslikethat.IthinkgoingforwardIthinkaswebuildthattrustwithGPsIthinkthoserotationsneedtobealotshorter,becauseotherwiseIthinkiftheydosixmonthsbutthendon’tgoinagainforanothertwoandahalf

17

yearswhilstyouarewaitingforotherpractitionerstorotateintothere,they’llhavelostthatknowledgeandskill.SoIdothinkthatthatmovingforward,oncethatestablishmentandrapporthasbeenbuiltweneedtofindawaytomakegoingthroughthedifferentenvironmentsmorefluidormuchshorter,whetheritbeoneweekin,oneweekout.Oneweekinambulancework,oneweekinprimarycarework,oneweekincontrol,oneweekinanacutesector,orwhetheritchangesonadailybasisorweeklybasisormonthlybasis."

Theinitialfindingssuggestthatthereisnosinglepreferablemodelandindeedadegreeofflexibility

hasallowedthesepilotsitestomoveforwardinaveryshortspaceoftime.Withrespecttothe

MDT/primarycareelementlengthofrotationmayberelatedtotheplannedworkandactivities.

WhereSPsareembeddedinprimarycaretherewassomeconcordancethataminimumof3months

isneededtomakebestuseoflearningandestablishnewworkingpractices.However,wherean

ambulanceserviceisprovidingaGPhomevisitingservicecombinedwithotherrotationalelements

withinthesameday,asintheNewcastlescheme,thereisnodedicatedtimespentwithinasingle

elementbutofcourseexperienceisbuiltasthishappensonacontinuousrotasothereisnotime

awayfromthatelementwhereskillsmightbelost.

“Yes,Idon’tthinkIcouldcopewithdoingabigmassiveblockallinonegoandthenhavingtorotate,becauseifthereisafavouritebit,orabitthatyou’renotsokeenon,thenyoujustfeellike-,butifit’sturnedoveralittlebitquicker,thenyoudon’tmindsomuch,becausethenyouknowthatonceyou’vegotthoseshiftsoutthewaythenyou’reontothenextbit.Yes,andIsupposeifyou’redoingtheprimarycarestuff,ifyouleftitforawhile,youmightthinkyou’dbeneedtobecatchinguponyourskillsagain.Whereasthisway,we’redoingitallthetime”

ThelengthoftheEOCcomponentraisedsomeimportantissueswhicharediscussedinmoredetail

inthenextsectionbuttherewasaclearmessagethatEOCworkisbettersuitedtoshortperiods

withinarotacombinedwithfrontlineSPresponsethanlongblocksofweeksormonths.

Eachhastheirownpotentialadvantagesanddisadvantagesandamorerigidrequirementmaywell

havethwartedprogress.Theabilitytoadaptandflexiblyrespondbydevelopingmodels,orfirst

stepsinmodels,thathavepracticallyallowedthemtomovebeyondanideaandtohaveSPs

beginningtoworkinselectedcomponentsortorotateinshortertimeframesthanoriginally

envisagedisprobablynecessarytomovetherotatingparamedicmodelforward.

"soforourqualified,sooncethey’vequalifiedwe’resaying‘Actually,50%oftheyearneedstobeinacollaborativeworkingpartnership’personallyIdon’tmindwhatthatlookslike,providingitworksfinanciallyandfromarotapointofview,it’sobviouslythebiggestthing.So,ifaspecialistsaid‘Actually,sixweeksatatimeworksreallywellformetogoandworkinaGPsurgery’andthencomeoutandthengobackorwhatever,andthatworks."

“SoIthinktryingtofind…optimiseawaytomaintainfrequentcontactIthinkandfindingthatoptimalmodelisquitedifficult.Ithinkyoualmostneedtobedippinginandoutonafairlyfrequentbasisfromthestandardambulanceworktobeabletomaintainthoseskillsandconfidenceandjustbeabletowalkinondayone,getonwithdoingtelephonetriageortobeabletogointoprimarycareoranacutesector,sothatyouarenothavingthatskilland

18

knowledgedegradationwhenyouarenotthere,ifthatmakessense.WhatthatoptimalmodelisandhowyoumakethatworkIthinkisprobablygoingtobethebiggestchallenge”.

Lengthofrotationcanbetailoredtolocalneeds,theservicespecificationsbeingofferedandthe

poolofstaffavailabletorotate.Eachrotationalmodelhashadadvantages,whetheritbeprovidinga

longenoughperiodtoestablishSPworkinginanewenvironmentorshiftbasedrotationatshort

intervalstosupportworkingthroughmultiplecomponentsonaregularbasis.Inthelongerterma

hybridmaybeneededwherealongerinitialperiodisneededtoconsolidatenewskillsinprimary

careorMDTbutsubsequentrotationscouldbeshorter.PeriodsmayalsobeinfluencedbyThere

arealsopotentialdisadvantagestobothmodelsbutthepilotschemeswhereplannedrotational

havemostlikelynotbeenoperatingforlongenoughforthesetobecomeapparent.Thisis

particularlytrueoftheschemeswhereSPshavebeendedicatedtoasinglecomponentanditwould

beinterestingtore-visittheschemesaftertheyhavebeenoperatingfor12-18monthstoseewhat

featuresemergewhencomparingmodelswithlongandshortrotationalelements.

ImportantfactorsforconsiderationwhensettinguparotationalmodelarehighlightedinFigure3.

Figure3:Factorsrelevanttoestablishingarotationalparamedicmodel

• Flexibilityindevelopmentofrotationalelements

• Whenlimitedresourcesornumbersofstaffconcentrateeffortsondeveloping

singleelementswellratherthantryingtodevelopallrotationalelementsatonce

• SomeblendingofPrimarycareandMDTcanbemoreefficientwherethereis

mixedteamsandpotentialforacrossserviceworking

• EOCmayneedtobecombinedwithfrontlineresponseasanambulance

componentratherthanjustEOC

• Primarycareworkingoutofplanandprotectedfrom999responsemaybebetter

withstaffoutofuniform

• Useofleasecarsmaybemorecosteffectiveforoutofplanprimarycareresponse

• Rotationalcomponentsthatincludesomeambulanceresponseworkwillneed

stafftobeinuniformandusingambulancevehicles

• Rotadecisionsneedtobeflexedtosupporttheworkloadofeachcomponent.This

maymeandifferentperiodswithindifferentelements

• Where7dayworkingisrequiredconsiderationandplanningneedstobegivento

ensuringSPsareusedefficientlyoutofhours(nightsandweekends)eitherby

frequencyofrotationthroughservicesthatoperate24/7orexploringdirect

referralpathwaysfromsourcesotherthan999tobestutiliseSPurgentcareskills

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4.2 Factorsandpracticalconsiderationsrelatedtoimplementation

Weidentifiedasetofkeythemesandsubthemesrelatedtothedevelopmentandpractical

implementationoftherotationalparamedicpilotschemes.Thesearesummarisedintables2and3.

Forsimplicitywehavereportedgeneralfindingswheretherewasconsensusacrossthepilotsites

andsupplementedthesewithexperiencesfromindividualsiteswhereappropriate.

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Table2:Keythemesonrecruitmentandstaff

Challenges Solutions Benefits Risks

Recruitment Allservicesreporteda

significantlossofexisting

specialistandadvanced

practitionerstoother

sectors.

Retainingexistingstaff

beforetheyleave.Attracting

newstafforthosethathad

leftwithabetterofferthan

hadpreviouslybeen

available.

IndividualSPandAPstaff

reportedthattheyfelttheir

skillswerenotbeing

properlyutilisedwhich

causedthemfrustrationand

demotivatedthem.They

sawthisasawaytochange

thissotheycouldbetter

practicetheirurgentcare

skills.

Lossofincomefromshift

allowancesanddaytime

onlyfixedshiftswasa

concernforsomestaff.

IncreasingSPtrainingposts.

Includingadvanced

practitionernurses.

Creatingattractivejob

descriptionsthatenabled

realportfolioworkingand

opportunitiestofurther

advanceurgentcareskills.

Re-bandingposts–Primarily

band7forAPsandband6

forSPsastrainees.

Rotasthatinclude12hour

shiftsandweekendworking

wherefeasible.

Nopilotschemesreported

difficultiesinrecruitment.

Allofthemreportedan

increaseinenquiriesfrom

SPandAPstaffwhohadleft.

Therotationalscheme

appearstofillagapthatwas

unavailabletoformerstaff

andprovidesthe

opportunitiesandscopeof

practicetheypreviouslyfelt

wasmissing.

Formorerecentlyqualified

staffprovidesapathwayto

specialistcareer

developmentwhichmayin

thelongertermenable

themtostaywithinthe

ambulanceservicebut

practicetheirspecialist

skills.

Fewriskswereidentified.

Themainonewasthat

PrimaryCaremaystill

recruitstafftowork

exclusivelyintheir

organisationswithcontracts

ataband8.

Whereweekendandoutof

hoursworkingisincludedin

rotastherehastobe

sufficientworkloadtojustify

theSPpostanditneedsto

befinanciallyviable.

21

Staffskillsandtraining Therewasveryclear

consensusacrossthepilots

abouttheskilllevels

requiredandtheneedto

provideaccreditedtraining,

Thereweresomeconcerns

aboutthecapacityof

PrimaryCaretoprovide

sufficientplacementsand

mentorshiptoprovide

trainingplacesasSPswillbe

competingwithotherHCPs

andGPtrainees.

Schemeswereusing

nationalorlocallybased

Universityledprogrammes

toprovidepostgraduate

programmesusingthe

CollegeofParamedics

framework(PGCert/PG

DiplomaandMSc).

Processeshavebeen

negotiatedwithmultipleGP

Practicestoprovide

placementsandongoing

supervisiontoacontrolled

smallnumbercurrentlyin

traiing.

Providesaclearand

rigoroustraining

programme.

Providesaclinicalcareer

pathwayforthose

paramedicsthatwantto

progress.

Allowsdevelopmentofa

rangeofextendedclinical

skills.

Increasingthespecialist

paramedicworkforcewill

putpressureontraining

placementswheretherewill

becompetitionwithother

HCPgroups.

Thiswillincreaseifurgent

carebecomesabiggerfocus

inundergraduateparamedic

training.

Therewererelated

divergingviewsaround

providingnewlyqualified

paramedicswithmore

urgentcareskillstosupport

seeandtreat.Somethought

thiscouldbewithinscope

whereasotherssawthisas

verymuchwithinthe

domainofspecialist

practice.

Somerotationalparamedics

willstillwanttoretaintheir

emergencyworkskillsand

thisneedstobeconsidered

andincorporatedintorotas

ifneeded.

Notallspecialistparamedics

willwanttorotateandso

carefulrecruitmentofthose

22

motivatedfortheroleis

needed.

Table3:Keythemesonclinicalgovernance,contractingandfinance

Challenges Solutions Benefits Risks

Clinicalgovernance Clarityaround

responsibilitiesforclinical

governanceacrossdifferent

services.

Clarityaroundscopeof

practiceindifferentsettings.

Allserviceshadfoundthat

havingasingleambulance

serviceemployerhadmade

managingtheclinical

governanceprocesseasier.

Forprimarycare/MDT

rotationstheambulance

serviceremainsthe

employerwithservices

contractedout.WhereSPs

arebasedwithGPpractices

thepracticesprovideclinical

oversight.Allmanagersand

SPswereveryclearthatthe

rotationalparamedicsonly

workwithintheirscopeof

practiceandagreed

protocolsandPGDsordrugs

Thishadmadeclearthe

workingboundaries.

Avoidshavingmultiple

governancearrangements

andresponsibilitiesfor

differentcomponentswith

consequentriskthisisnot

adequatelyaddressedand

managed.

ClearboundariesforSPson

theirscopeofpracticein

differentsettings.

ClinicaloversightinGP

practiceswasseenasareal

advantagebySPsasbotha

learningopportunityand

maintainingconfidencein

clinicalskills.Debrief

sessionsafterpatient

contactswascommonly

citedasveryimportant.

Nosignificantrisksrelating

toclinicalgovernancewere

identified.

Contracting Developmentofcontracts

thatclarifyarrangements

aboutscopeandduties,

activity,employment

contracts,indemnityand

Varioussolutionshavebeen

employedincluding

memorandumof

understandingandtemplate

contracts(forexample

Timeconsumingtosetup

buttemplateapproaches

meansubsequent

contractingprocessesare

muchquicker.

Insufficientconsiderationof

contractingarrangements

exposesallorganisations

andindividualpractitioners

torisk.

23

insurance,VAT,

partnerships.

betweenambulanceservice

andGPpractices.

Contractsneedtobe

adapteddependingon

whetherisindividual

practicesofCCGstocover

multiplepractices.

Appropriaterisk

assessmentsandadvice

takenfromNHSResolutions.

Wherepossiblebuildon

existingcontracts.

Tieintoexisting

arrangementsiscostsaving

(forexampleinNewcastle

theexistingindemnityand

insurancearrangementsfor

providingtheoutofhours

serviceweresufficientto

covertherotationalmodel)

Lackofclarityonwhatwill

beprovidedandhowmuch

risksincreasingand

unsustainableworkloads.

Lackofboundariesonscope

ofpracticeputsSPsatriskof

beingaskedtodowork

outsidetheirscopeof

practice.

Financing Themainchallengeshave

beenaroundestablishing

whowillpayforthe

differentelementsofthe

rotationalmodelincluding;

Lossofstafffromthemain

ambulanceworkforceifthey

willnotberespondingto

core999work

Educationandtrainingof

SPs–boththeacademic

componentandclinical

placements

Provisionofstaffinnon-

ambulanceservices(Primary

CareandMDT)

Ofthe4pilotstheSouth

EastHampshiremodelisthe

onlyonethat,fromthe

outset,hascreateda

financialmodelwhereGP

practicespayforthe

rotationalparamedicswhile

theyarewithinthepractice.

Itisalsotheonlyone

currentlywheretheprimary

carerotationalelementis

forasubstantialblockof

time.Thischarging

mechanismisallowingitto

continuetoexpand.

Allotherpilotshave

absorbedcostsusingthe

HEEpilotmoneybutthis

createsuncertaintyabout

continuationinthefuture.

TheSouthEastHampshire

modelhasclearadvantages

inthatchargingforSP

servicesinprimarycare

offsetsthecostsofreplacing

theminthegeneral999

pool.

Considerationofwhatneeds

tobeprovidedcanproduce

costssavings.Inthe

Newcastleschemeusing

basicleasecarsand

equipmentratherthan

expensiveambulance

responsevehiclesforGP

homevisitinghasprovedan

effectivewayofreducing

costs.

Schemessofarhave

progressedbecausethere

hasbeennoorminimalcost

toexternalservices.The

truecostofservicesneeds

tobedeterminedand

presentedtoPrimarycare

andMDTservices(orCCGs)

inawaythatdemonstrates

valueformoneyand

persuadesthemtheyare

worthinvestingin.

Uncertaintyandshortterm

arrangementswillthwart

thecontinuationofsome

schemesandmayseethem

stopaltogether.

Itmaywellbethatcost

savingsoccurelsewherein

24

Overtime,ifsomeofthe

potentialbenefitsare

realisedforambulance

services–fewerprimary

carerequestsfor999

ambulances,morecalls

managedbysingleresponse

SPsorresolvedthrough

telephoneclinical

assessmentthensomecosts

mayberecoupedbutthis

wouldneedtobeatscale.

thesystem–forexampleby

reducingunplannedhospital

admissions.Thisneedstobe

betterunderstoodto

accuratelymapcostswhich

whenunderstoodcould

justifyadditionalambulance

serviceinvestmentto

supporttherotational

model.

25

KeylearningpointsAlloftherotationalparamedicschemeshavefacedchallengesingettingtheirfirstrotationalelementsupandrunningbuttheyhavefoundsolutions.

ContractingandclinicalgovernancearrangementsAcommonthemeintheinterviewswastheshorttimescalesneededtoresolveimportantissueslikecontractingandclinicalgovernancearrangementsandthisdidleadtosomedelaysbutworkingthroughtheseprocesseshasledtosolutionsthatwillmakesubsequentarrangementsquickerandmorestreamlined.Ithasalsobeenimportanttounderstandandexploreexactlywhatservicesareneededthattherotationalschemecansupport.

“So,ifwegettheworkingpracticesactuallyestablishedwithsomewherethat’sworkingwell,thenwecantakeourservicestotheothersurgeriesratherthansortofdisruptingallthreeofthem,wecanjusthoneoursortofworkingpracticesinoneandthenmovethatasapackagetotheothertwo.""Ithinkthat’sonethingthatIwantedtogetawayfromintermsofIdidn’twanttobetoodidacticwhenIwenttothoseorganisations;Iwentinwith‘Whatdoyouwant?Whatareyoulookingfor,andisthatsomethingwecanadaptorchange?’sothat’sthemodelI’vetakenorapproachI’vetaken.I’venotgonein,I’vesaid‘We’reheretodocollaborativeworking’butIhaven’tsaidanythingmorethanthat.I’vegoneinandsaid‘Okay,whatareyoulookingfor?Whatdoyouwant?What’syourbiggestproblem?Isityourhomevisits,orisityourtelephonetriage,orisityourface-to-faceconsultationsandhavingthat,needingsomebodyto…?Orisityourrespiratoryclinic,youhaven’tgotanyonethatcandothatoryourchronicillnessclinicmanagement?’So,Iguessthat’sthethingthatmightbedifferentisI’mhavingthatconversationwiththepracticemanagersortheseniorpartnersandsaying‘Whatisityouwant?What’syourgap?’andthenI’msaying‘Okay,wecandeliverthat’or‘Actually,wecandeliverthatbutweneedabitofsupportfromyou,X,Y,Z’."

ItwasalsoemphasisedthatintheearlystagescollaboratingwithwellperformingGPpracticeswasimportantasthishelpedtheSPslearnmoreandgettherightlevelofmentorship.Therewasaclearmessagethatsupportforstrugglingpracticesshouldcomeonceexperienceandgoodprocessesareinplace.Theneedtomakerolesandscopeofpracticeclearfromtheoutsetwasalsoemphasised.

"thecontactthattheparamedicshavewithGPsintermsofpriortogoingoutandadebriefwhentheycomebackismostvaluable.AndIknowthatthereareothermodelsouttherewheretheyworkabitmoreremotelyandaregivenavisitlistandveryoccasionallywillliaisewiththeGP.JustinmypersonalopinionIdon’tthinkthatenhanceslearningortheMDTworking”."TheseGPsaresodifferent,they'resopositive,theyarestillmotivatedabouttheirjobs.They

26

knowtheirpatientsandtheyareagoodexampleofreallygoodGPs.AndIknowtheideaisthateventuallywewillbe-Ithinktheideaisthatyoufocusisinpoorly-performingGPsurgeries,wherewecouldprobablymakethemostdifference.Butit'sgoodtogetintoseehowthingsshouldbedone,andcanbedone,tothenbeabletoidentify…Becausethereare…practices,Ithinkthereissomefluctuationbetweenperformance,andweareinthebest-performingone.Andtheideaiswewillthenmoveontotheothers,andseeifwecanmakeadifferenceinthoseone."SP“There'sgottobetheinitialsupportfromtheGPs,basically.Andthattimeatthebeginningto-forthemtoassessyou,andforyoutoaskquestionsabouttheirrole,andseewhereyoufitin.Andfromthenon,ifyou'reringingupaGP,say,andI'mseeingthis,thisandthis,theyknowyou,theyknowwhatyou'recapableofandthereisn'tjustthatriskofbeingputintoasurgeryandusedstraightawayforeverything,andanything,andbeingaskedtodothingsoutsideyourscope.Soit'sgottohavethatsupportatthebeginning,really,ofthemseeingexactlywhereyouare,Ithink,"

StaffrecruitmentAverypositivefindingwastheamountofinterestintherotationalpostsfrombothexistingambulancestaffand,reportedly,thosewhohadleftindicatingthat,fromaparamedicperspective,thisisseenasamuchneededstepforwardasaclinicalcareerpathway.

“…thereasonwhyweputthisbusinesstogetherwasabouttheportfolioworking.Ithinkpersonallygonearethedayswhereyoujoinedtheambulanceservice,youstayedintheambulanceserviceuntil,youknow,yougotthebadback,mentalhealthissuesorwhatever,gonearethosedays.Butwhatwe’renowseeingispeoplejumpingship,butifwecankeepthosestaff,keepthosestaffengaged,dotheportfolioworking,allowthatrotationtowork,wewillengageandkeepthosestaff,whichwillagainbenefiteverybodybecausewe’resharingaworkforcebutthey’restillstayingwithintheambulanceservice,sowe’renottrainingthemupandthenlosingourexperienced,mostqualifiedstaff,westillkeepthem.Sothat’sgottobeabenefitagainintermsofthewholeambulanceserviceandintermsofeducationandsupportandsystemsandclinicalandpatientcareandoutcome”.“We'veactually-weranarecruitmentcampaignbackinNovemberforatraineespecialist,andwe'rethensendingthemontheirtraining,whichisactuallyintheirowntime,butweprovidetheplacements.Yeah,andthesupportofthesupport,obviously.Andthathadareallygoodresponse,andwehadamixtureofinternalandexternalapplicants.Andthenwe'veactuallyjustgoneouttoadvertagain,sowe'veslightlyrevampedandrevisedtheroletofitinwithourproject,andtheenhancedrequirementforrotationofworking.Sothejobdescriptionandpersonnelspecreviewed,andit'sbeenre-bandedasaseven.Sowe'vejustgoneoutagainwithtwoadverts:one,lookingforaqualifiedBand7staff,hopingthatwemightattractback,andattractsomenewqualifiedstaff.Andthenwe'vegoneoutwithanothertraineeadvertaswell,andIthinkbothofthemhavehadaprettygoodresponsesofar”.

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"Sowe’vealsohadECPswhohaveleftwhoarenowstartingtoknockonourdoortosay‘Wearehearingitisnowrunning,pleasewouldyoukeepusabreastbecauseactuallyiftheorganisationisseriousaboutthisroleagainwewouldactuallyliketocomeback.’Andthesearepeoplewewouldwelcomebackwithopenarmsthatweshouldneverhavelostinthefirstplace."

Theissueofwhatpaybandspecialistandadvancedparamedicsareemployedaswasmentionedfrequently.Withinthepilotschemestheearlycohortshavebeenband6specialistparamedicsandband7advancedparamedicsbuttherewasrecognitionthatthereisworktobedoneinproperlybandingposts,particularlyiftheretentionaspectistobeaddressed.Thisisacomplexareabuttherewasconsensusthat,asanoverallstrategy,band6specialistsareconsideredtrainingpostswithsupervisionandmentorshipfromband7sandstudyingfororholdingpostregistrationcertificateordiplomalevelqualifications.Band7aretheadvancedparamedicpractitionersstudyingfororqualifiedtopostgraduateMasterslevelalthoughtherewassomevariabilityinexpectedpostregistrationqualificationateachband.AcommonthemeacrossallschemeswastheavailabilityofexistingpostregistrationcourseswithintheirlocalitiesandamovementtowardstheadoptionoftheCollegeofParamedicsDiplomainPrimaryandUrgentCare.ThisiscurrentlyindevelopmentwithanexpectationthatitwillbevalidatedbytheRCGP.Lookingforward,twoissueswereraised.Firstlythatsomeconsiderationneedstobegiventoprovidingsomescopeforfurthercareerdevelopmentandcreatingrotatingpostsatthehigherband8iftheambulanceserviceistoremaincompetitivewithprimarycare.

“Idon’tknowit’stryingtoachieve,becausewhatyou’redoingisupskillingBand7swhoarelookingforBand8jobs,youupskillthemandgivethemclinicalskills,diagnosticskills,examinationskills,theyaregoingtomoveonandunlessEMASandunlesstheambulanceservicepaysthemaBand8they’rejustgoingtomoveonandthey’regoingtogetjobsinGPpractices”“IthinkobviouslypotentiallythebandingandthepayrewardneedstoreflectthatasacareerprogressionIthink.Andagainthatcomesbackthentothewholefundingmodeldoesn’titIthinkessentially.SoIthinkthewholecareerframeworkandsupervisionandthementorshipwouldthenallkindoffittogether.SoIthinkinmyeyesIseetheparamedicsareBand6now,movingforwardentrytopractitionerlevelwork,whetheritbeinprimaryorcriticalcareisaPGDip,PGCertlevelwhichmarriesthatoftheCollegeofParamedicscareerframework.AsaspecialistpractitioneratBand7potentially,youwillhaveyourPGDiporPGCertandthenpotentiallymovingforwardthosethatwanttoprogressontofullMasterslevel,attaintheirfullMasters,classedasanadvancedpractitionerthenatfullMasterslevel.Thatequallythenattractsahigherbandingat8Aandprovidesthatincentivetogoontobeanadvancedpractitionerandequallythenasyouhaveyouradvancedpractitionersthatprovidesyourmentorshipandsupportstructureforthosespecialistpractitionersat7aswell,sothenitallkindoffiltersdownthechainIthinkintermsofpreparationmovingforward.Doesthatmakesense?”

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Secondlyamuchbroaderissueofprovidingrotationalopportunitiesforstudentandnewlyqualifiedstaff,notsotheyoperateasspecialistrotatingparamedicsbutasawayofdevelopingapipelineofstaffwhohavehadplacementsandsomeexperienceofotherworksectorssuchasprimarycareandEOCwhichmaythenencouragethemtotakeupspecialisttrainingandstaywithintheambulanceserviceasmorecareerpathwaysbecomeavailabletothem.

FinanceandfundingThemostcomplexissueandtheonethatposesmostrisktothecontinueddevelopmentofthemodelsisthatoffindingsustainablewaystofundarotationalparamedicprogramme.Intheshorttermthereisasensethat,atleastinsomeschemes,untileitheralongerperiodoffundingismadeavailablefromHEEoranothersourcetosupportcontinueddevelopmentandoperation,theschemeswillatleastpausewhilefinancialsolutionsarefoundandifthiscannotbeovercomemaystop.

"We’vegotthefunding…sowe’vegotfundingforanothermonthbutthatleavesmewithabitofaproblemwherebyIcan’t…becausewhatIwouldliketodoisbecausethenumbersthelastcoupleofweekshavestartedtodropalittlebecausewearecomingoutofwinter,Iwouldliketogowithconfidence,we’vegotfundingforXamountoftime,canwetakeanothercoupleofpracticesonintheshortterm.ButwhatIneedtounderstandis…forapracticeit’sadifficultsellformetosay‘Actuallywouldyouwanttodothisschemeorthispilotforthreetofourweeks?”…………………”Ijustcan’trecruitthembecausethey’rejustgoingtoturnroundandsaywellthat’salotofchangesinpathwaysandworkingprocesses,alotofeffortforthreeweeks’worthofwork,sothatistheissueI’vegotatthemoment."

Financialstabilityisneedednotonlytosupporttheexistingmodelsbutalsotofurtherdevelopandexpandthem.Itisdifficulttoarrangepartnershipswithotherservicesforshortperiodsofafewweekswithnoguaranteearotationwillcontinuebeyondthat.TheSouthCentralmodelhasovercomethisbymakingthePrimaryCarerotationalcomponentaservicethathastobepaidforfromtheoutset.Thishasentailedundertakingdetailedcostingsofallelementsoftheservice.

“Yeah,exactly.Yeah,fundingisthebiggestissueandweareona,asIsay,it’sthechickenandtheegganditisintermsofmakingthissustainable.Andthat’sthereasonwhywe’recharging,andsomepeopleI’vegiventhemthechargesandthey’vesaid‘Ican’tpaythat.Icangetalocumforthat’andIgetthat,butit’sabouteconomyofscale,it’sabouthowwedothatandhowwecantweakourprices,whatsupportandfundingisthere,youknow,inthewidereconomy.ButIguessthesellingpointforussayingthatthiscostdoesincludeyourfirst-linemanagement,yourprofessionalmanagement,yourindemnity,yourinsurance,yourcompetenciestoensurethatthey’reuptodate,yourDBSchecks,yournationalinsurancecontributions,yourpensioncontributions……….equipment,yourinsurance,exactly,yourfuel,allofthisstuff.So,when,IguesswhatI’mtryingtosayisthoseschemesthathavegoneonboardarethosepracticemanagersI’vebeenabletohavethatconversationwithandsay‘Okay,justgoaway,lookatwhatitwouldcostyouforallofthisandthencomebackandcomparewhatwe’recharging’.

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Andactually,onreflectionit’smuchthesame,it’sjustcertainlyGPsseethebottomfigureandtheysay‘Icangetalocumforthat’or‘Icanemployaparamedicdirectly’andbyallmeans,yeah,theycan,butintermsofthatlinemanagement,intermsoftakingoutannualleave,intermsofallofthatstuff,theydon’torhaven’tconsidered,isabig,bigthing."

Theyseemtohavenoshortageof“customers”forthisservicealthoughitisalsotruethatsomehavebeenlostwhenitbecamecleartheservicewasnotfree."Well,we'vetriedinvolvingcommissioners,we'vetriedgoingtoGPsurgeriesindividually.Someofthemhaveexpressedinterest,butthenwe'vegotacostframeworksetup,andoncethey'veseenourframework,haven'tbeeninterestedinproceeding.Sothat'sbeenquiteachallenge”.OtherschemesareunsureiftheirprimarycarepartnerswillbewillingtopayforhomevisitingoncethecurrentservicefundedbyHEEpilotsitemoneyends.Theyarehoweverquiteclearthatthetruecostsofprovidingaserviceneedtobewellthoughtoutsothatthereisastrongnegotiatingtoolwhichshowspotentialprimarycarepartnerstheactualcostsofaserviceoverandabovesimple“employingalocum”.Someparticipantssuggestedthatthereneedstobeapracticalandculturalshiftinperceptionsoffundingandthatnewwaysoffundingneedtobedevelopedalongsidethesenewwaysofworking.

"theskillsetisrightwithsomeminortweakingandsomeminoreducation,butthat’snotinsurmountable.ButcertainlythebottomlineiswhoispayingforitIthinkandhowyoudevelopthatfundingmodelsothatyoucanhavepeoplesatunderoneNHSproviderbuthaveaportfoliocareerandthemoneyhasgottoflowsomehowtothatoneNHSprovidersothattheycanprovidethoseservicestootherproviders.Becauseuntilthefinancesinplaceitwon’tworkIdon’tthink.Thefinancehastoworksomehowtomakeitrun.AsmuchasIdon’tlikeitbeingaboutmoneyitis."“TheCCG,the….CCGwhoIworkfor,areagainverypositiveandsupportiveofthis.ButIthinkthatwe-again,toaddmomentum,toaddsomeclarityandalmostcredib-…notcredibility,becauseitdoesn'tneedthat,butfiscalsortofcredibility,ifyoulike,toit.Weneedto-thecommissionersneedtocommissioninadifferentway.I'mnotsurewhatthatis,buttheyneedtocommissionthisrole,orthisarrangementsomehowtointegratethatthefundingdoescomefromprimarycareandambulance…….Theyneedtostartlookinginthenextroundofcommissioning,howarewegoingtodothis?AndIknowit'sinitsinfancy,butthatcan'twaitbecauseitwillgivepeopletheabilitytosaywecan'taffordthis,we'repayingforthis.Itmaybeworking,butwe'repayingforthis,sothatreallyneedssettlingdown.Sotheyneedtocommissionambulanceservicesinadifferentway.I'mnotsurewhattheyareatthemoment,tobehonest,buttheyneedtocommissionitinadifferentway”.

Thereremaintensionsbetweenambulanceservicesandtheirwillingnesstofundstaffwhoareoutsidethefrontlineworkforcerespondingto999calls.

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"Soweneedtoholdournerveandsay,right,thesefourpeople,orthesetenpeople-takingthemout-nothingtodowiththeambulanceservice.We'regoingtotrainthem,we'regoingtosupportthem,we'regoingtoleadthemandwe'llreaptherewards.Oryoucansaywe'lltakethesetenpeopleoutoftheequation,demandgetshighandwe'resayingwe'resorry,we'regoingtoputyoubackinthestack,soyoujustloseyourmojo,Isuppose."

TherearealsoquestionsparticularlyaroundtheprimarycareelementasGPsarealreadyresourcedtoprovideprimarycareservices.WherethisissupplementedbyparamedicsonrotationthereisuncertaintyabouthowmuchCCGswillwantcontribute–itmaybeeconomicallysensibleifitachievesintendedbenefitssuchasreducinghospitaladmissionsbutthereisalsoanargumentthatprimarycareispotentiallybeingpaidtwicetoprovideoneservice.

"FormethereisalotofinterestbeinggeneratedbythisalreadyandIthinknewsisspreadingfast.IhavealreadystartedtotalktoandI’mpresentingtotwoA&Edeliveryboardsaroundtheconceptandearlyfindingsofthemodel,andwhatIwanttodoisI’mnotsuggestingthatthisisapanacea,butwhatI’msuggestingisthatthisisanoptionthatwemightwishtoconsidergoingintonextwinterandwherethecommissionersmightwishtolookat,wheretheirareasofgreatestneedare,becausewe’vebeenveryclearwiththepracticethisisnottodotheirwork,thisistopickupunmetneed.Andtheyareveryclearonthatbecausetheyarealsotalkingtothecommissionersaboutwhatthispilotisandisnotdoingforthem,becausetheywerenervousthatsomebodywouldcometothemandsayyouareactuallyusingsomebodyelsetodoyourcorebusiness.Sowe’rebothveryclearonthatandIthinkwe’vebeenreallyuseful."

Withoutresolutionoftheseissuestherewillbeaseriousriskthatrotationalmodelswillnotoperateforlongenoughperiodstodevelop,matureandgrowtoalevelwheretangiblebenefitscanberealised.Thequalitativedataandfeedbackatrotationalparamedicpilotworkshopsprovidedarichsourceofinformationintermsoflessonslearnedonthepracticalimplementation.AsummaryofpracticalissuesisprovidedinFigures4and5.

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Figure4:Practicalissuesrelatedtoimplementation

Figure5:Practicalissuesrelatedtorecruitment

• Singleemployermakesoverallmanagementofclinicalgovernanceeasier• Fortheprimarycare/MDTcomponentGPoversightisimportant• Contractsneedtoclarifyclearboundariesonscopeofpractice,activitiesandworkload• Explorewhatservicesareneededandwheretherearegapsinprovisionlocallysoa

rotationalsolutioncanbetailored• Templatecontractsandmemorandumofunderstandingimproveprocessesandmake

newcontractingsimplerasschemesexpand• Wherepossiblebuildonexistingcontractstosimplifyprocesses• ConductrigorousriskassessmentusingexistingsupportsystemssuchasNHS

Resolutions• Considertheimpactoflossofworkforceoncore999workiftakenoutofplan• Buildbusinesscasesthatjustifyinvestmentintrainingandemploymentofstaffoutside

the999workforce• Makeprovisionforongoingstafftrainingandeducationalconsolidationincontracts• ConsiderusingleasecarsandequipmentrequirementforSPsworkingoutof999plan• Establishfromoutsetwhichelementsoftherotationalmodelneedtobepaidforas

additionaltoexistingAmbulanceServicecontract• Inthelongertermmoreworkisneededtounderstandcostsandtheshiftsincosts

acrosstheurgentcaresystemasthesemaynotalwaysbevisible(e.g.ifsavingsareinhospitalfromreducedunplannedadmissions)

• Considercapacitywithinprimarycaretoprovideclinicalsupervisionandplacementsforspecialisttraining

• Buildintrainingandsupervisiontime• Setoutthecaseforportfolioworking,careerdevelopmentandexpansionofskillsnot

justarotationalpostjobtoattractexistingstaffandpotentialreturners• Reviewscopeandexpectationsofpostsandbandappropriately• Rotasmayneedtobeflexibleandtailoreddependingonrotationalcomponentand

individualpreferencesfor5dayor7dayworkandshiftpatterns• Rotationalelementsmayneedtobeflexibleiftherearecomponentsstaffdonotwant

todo• Provideinternalsupportnetworksfornewcohortsorteamsofrotationalparamedicsas

theymovetonewwaysofworking

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4.3Broadissuesidentifiedbykeystakeholders

Thedetailedinterviewsrevealedanumberofbroaderissuesrelatedtotheexperiencesresultingfromimplementingthefirststagesofarotationalmodelwhichreflectbenefitsandpotentialfurtherchallengesandsolutions.

PartnershipsbetweenambulanceserviceandMDTTheexperiencesrecountedwereoverwhelminglypositive.Intervieweesfeltrealstrideshadbeenmadeinunderstandingeachother’swork.ParamedicsunderstandbetterwhatprimarycareandmultidisciplinaryteamsdoandprimarycareandMDTbetterunderstoodtheskillsetsandscopeofpracticeoftheSPsandhadbecomeconfidentintheirabilitieswhichinturnimprovedSPsconfidence.

“It'sincreasedmyclinicalknowledge.It'sincreasedmyknowledgeoftheoperationalday-to-daysofaGPsurgery.It'sincreasedmyunderstandingofthepressuresonaGP,asanindividual,andthepressuresonaGPsurgery,asagroup.AndIthinkithas-it'sincreasedmyunderstandingofthewholeNHS,andwemoanaboutthefactthatwhyisittakingsolongformetogetthisreferraltocomethrough?Butyoudon'tunderstandsomeofthelinksthatthesehavetogothroughtogettowheretheygetto.Commissioning,forexample,anddoesaGPhavetojustifythatreferral?[….]IfI'mapplyingforthatformypatient,I'vegottopayforit.Wedon'tunderstandthat-well,Ineverdidanyway.Soitdoes-anythingthatincreasesunderstandingbetweenpartsoftheNHS,hasgottobeagoodthing.Wedon'trealisethedemandsonotherpartsoftheNHS.”

“Imeanit’sopenedtheireyesto………andtheambulanceservice,letalonethesortofclinicalskillsthatweactuallyhave,howtobestutilisetheambulanceserviceinfuturetogetthebestoutoftheambulanceserviceforwhattheyneed.Attimesthey’vethoughtthatdialling999isthebestwasforwardforthemandactuallyit’snotbecausethey’rethengradedontheARPsystemwhereasifit’saclinician-to-cliniciancallit’satotallybetterresult”.“Fromawiderthinkingtheadvancedparamedichasaddedvaluetothatteam,ithasaddedvaluetoprimarycareinthatparticulararea.Sofrommypointofview,doIseeafutureroleoftheadvancedpractitionerintheMDT?Withoutashadowofadoubt.AndIthinkit’scompletelychangedthethinkingoftheCCGs.TheCCGsbeforethismodelwereallaboutadvancednursepractitioners,nowwe’veactuallybroughttheskillstothetableoftheAPaswellwhowillhaveadifferentwayofworking,adifferentwayofthinking.Soyeah,it’scertainlybroughttothetableinthestrategicthinkingaboutthaturgentcarewithinthecommunity,theroleofwhattheAPhasgottogive”.

TheSPswereseenasrealassettotheprimarycareandMDTsettingsandinoneschemetheyhadaddedvaluebyprovidingBLS/ALStrainingandreviewingemergencyequipment.Bothpartiesfelttheyhadlearnedfromeachother.IntheSouthHardwickpilottheMDTteamhadbeguntoutilisetheSPsforadviceandtosharevisits.Thereweresomechallengesidentifiedpredominantlythattheexperienceshadbeensopositivethereisadangerthatthemodelcanbecomea“victimofitsown

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success”andcreatedemandthatcan’tbefulfilledorisusedinappropriatelytofillgapsinotherservices.

“TheMDTandtheprimarycare,again,isanimportantpart,butoneareathatIwouldliketoseeisgreaterclarityandpurposeforthatareaofrotation,youknow,becauseI’mmindfulthatsomeareasmayhaveseen…thatit,effectively,hasaddedjustabitmoreextracapacitytoprimarycareratherthan,Isuppose,fillinginthetruegapinpatientneedandIthinkwejustneedtounderstandwhattheprimarycareelementofrotationwouldgiveandwhether…whetheritisaparamedicthatisofferingsomethingtothecarepathway,orwhetherit’s,Isuppose,youknow,fillingagapthatweneedtofillinanotherway.Becauseoneofthethingsthatisevidenceisthatwhenourcliniciansdorotateintoprimarycare,theyneedgoodsupportandmentorshipfromtheGPs,andfromthepractices,to,Isuppose,improvetheirconfidenceandcapabilities.So,ifyouaresimplyfillingagap,thenyou’renotnecessarilygoingtogetthatsupport”.

Therewasalsoawarenessthatshiftingdemandcreatesextraworkinsomeareasandthisneedstofactoredintoplanning.Forexample,theroutingofGPurgenthomevisitsthroughtheMDTsinglepointofaccesssystemcreatesextracallsthathavetobemanagedbytheexistingtelephonetriageresources.AsthepilotisstillsmallscalethishadbeenabsorbedbutifthenumbersofSPsandGPpracticesincreasesextratelephonehandlingresourcesmayneedconsideration.

EmergencyOperationsCentre(EOC)Overall,theEOCcomponentseemstobethemostproblematicpartandtherewaslessenthusiasmforthiscomponentamongsttheSPs.TheyunderstandvalueofidentifyingpotentialhearandtreatandseeandtreatcallsandsupportingEOCandcrews.

“TheareathatIseereallymixedviewsaboutistheEOC,thecontrolroomelement.Again,withinEMAS,wehadawell-establishedclinicalassessmentteam,sotheywerefocusingonthe‘hearandtreat’ofpatients,andweperformedreallywell.So,itwasquitedifficulttoquantifywhatbenefitsthattherotationpilotwouldbringtoEOC.Woulditfurtherenhancethatcapability?Orwoulditcauseaconfusedandmixedidentity?So,IpersonallyfeelthattheEOCrotationisvaluable,but,again,weneedtobeabsolutelyclearonwhattheobjectivesofthatare.Ithinkifit’spartofarotationpackage,itwouldworkreallywell,butIthinkwhatwefound,insuchashortperiodoftime,wasthatitishardtoquantifyorclarifywhatbenefitsitbrings……forme,that’swhyIwouldwantanabsoluteclearsenseofpurpose,astowhatitisaimingtoachieve.”

“No,Iwouldn’twalkawayfromthewaythatthejobisactuallyworking,becauseforyearsoncethetargetsforambulanceresponsecameinIdidbelievethatanambulanceoneverycornerwastheonlywayforward.Butnowit’sactuallyfrustratingtoseethechangeinthenatureofcallsandthey’retotallyinappropriateforambulancecalls.So,tobeabletodosomethingaboutthatfortwothirdsoftherotationandactuallyputupwithEOC,thenIprobablywould.AndIdofeelaswellthatonceEOCisupandrunningproperly,ifwegotmoreECPsto

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actuallylookforjobsanddispatchandwegetmoreinvolvementwiththehear-and-treatsideofthings,becauseIwasalittlebitwaryaboutdoingthatandsaying‘Youdon’tneedanambulance’notknowingwhatparametersIwasworkingwithin.So,IthinkonceitactuallybecomesestablishedasthefullEOCrotation,thenitmightbedifferent.Ithinkyou’regoingtobeverybusyandalsoveryuseful.Butforwhatwewereactuallydoing,itwasnotsomethingIreallysortofenjoyed."

HowevertheprospectoflongblocksoftimespentonlyinEOCwasnotpopular.Someexpressedtheviewthattheywouldtolerateit–particularlyifitwasmixedwithsomefrontlinerespondingtoSPappropriatecallsbutinoneortwocasesalongperiodinEOCwouldbeenoughtostopthemconsideringarotationalpost.

“Ithinkonatimescalething,ifyoudidthreemonthsontheroad,andthreemonthsinoneofthesekindoffacilities[GPsurgery/MDT],butIdon'tthinkyou'dwanttodothreemonthsinanEOC.Thatyou'dwantamuchshortertimeframe,becauseit'sjustsodemandingandstressful”.

ThevalueoftheEOCcomponentmayalsobedependentontheexistingclinicalcapacity.OneviewexpressedthatinEOCswheretherearelargeclinicalassessmentteamsofclinicianstheneffortwouldbebetterspentsupportingexistingclinicalstafftobetteridentifySPsuitablecalls.TherewerealsosomeapparenttensionswithexistingEOCstaffandanamountofencroachingonterritories.HoweverthiswasnotuniversalandanotherviewwasthatSPtimeinEOChadbuiltrelationships,betterunderstandingandbettermatchingofcallstoSPskillswhichisalreadyseeingbenefits.

"ButintermsoftheconversationsthatwehadinEOCandtheunderstandingthatweactuallybuiltupandtherapportwiththestaff,IthinkinthatrespectitwasveryusefultochangetheEOCsortofprocessofjob,send.Therewereactually,obviouslyARPsmadeadifferencetothis,buttheywereactuallynowabletodiscusswithusandsay‘Well,yeah,sendanECP’,Icanseeit’sgoingtosaveacrewandifit’sanappropriatejobit’ssavingacrewandanECP.So,yeah,theworkingrelationshipwebuiltup,itwasdefinitelyworthwhilehavingthatcontactwithEOC.Andtheclinicalsideofourexperience,thattheywereactuallyaskingquestionsandusingourknowledgetofurtherwhattheyweredoing.So,inthatrespect,yes,itwasveryuseful."(SP)

TheseareasmallnumberofopinionssowecannotgeneralisebuttheywereveryconsistentanditdoeshighlightthatwhenplanningandmovingforwardtheEOCelementneedscarefulconsiderationbothintermsoflengthofrotationaltimeandhowthismightbemixedwithpatientcontactwork.IntheNewcastleschemethereisalreadyrotationthroughEOCandastheseareshortperiodssharedamongstthecurrentcohortofstaffandwerealreadyquitewellembeddedwereseenaslessdifficult.TheEastLincolnshiresitehasalsobeenrotatingSPsthroughEOCbutforshortrosteredperiods.InonesitewithasmallnumberofrotationalparamedicsbasedinMDTtherewasarecognitionthatsometaskingtourgent(category3and4)callshadnothappenedbecausethelinkstoEOCwerepoorbuttherewasnotasufficientnumberofSPstoincludeanEOCelementandthatthiscouldimprovewhencapacityincreasestosupportEOCSPworking.

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"NowwhatIwouldsayisthatifyouhadalinkintheEOC,somebodywhowastakingthosejobsoffthepileorofftheworkloadthenwecouldmakebetteruseofthatresourceinthecommunity,andIthinkthatwouldbesomethingwhereby…IknowthatEMAShavegotaclinicalnavigatorwhichisn’tpartofthisprojectworkinginthere.Ithinkthere’sarealopportunitytherebecauseIthinkthere’sareallinkthere.Sointermsofanurgentcareneed,intermsofreducingnon-electiveadmissions,reducingaconveyanceofanambulance,wecanonlystopthoseconveyanceofambulancesifwecancrackthatEOCandIdon’tthinkwe’vedonethatyetwiththismodel”.

InonesitetherewasalsorecognitionthatbettercommunicationmighthaveimprovedtheEOCexperienceforboththeSPsandotherEOCstaff.

“AndIthinkthat’sthebit,whenIreflectbackbecauselookingbackwardsintoPhase1,didwereallysetoutveryclearlywhatitwasweweredoing,bothtotheECPsandtotherestoftheorganisation?Becauseyouthengetintothatpicture,particularlyinEOCofanECPgoinginandthensaying‘Wellwhatareyoudoinghere?’andit’sthatlevelofeducation.AndIthinkhadweofdonealittlebitmoreintermsofactuallypublicisinginternallywhatweweretryingtodoIsuspectthatthelevelofsupport…wellthelevelofunderstandingwouldhavebeengreaterandthereforethelevelofsupportwouldhavebeenbetter."

SpecialistandadvancedparamedicsworkinginEOCisnotanewinnovationandanumberofambulanceserviceshavebeenutilisingspecialiststaffinthisroleformanyyears.YorkshireAmbulanceService(YAS)areoneoftheHEEfundedpilotsitesandalthoughtherotationalmodelshavenotyetstarted,thisisaservicethathasemployedasubstantialnumberspecialistparamedicswithinanoperatingmodelofSPsworkinginEOCaspartofastandardisedrota.Their10yearsofexperiencehavehelpedidentifyanumberofstrategiesthatcanhelpsupportdevelopingtheEOCcomponent.KeyprinciplesareempoweringtheEOCSPtomanagetheSPworkforceandensuringavarietyoftaskscanbeutilisedsothatbestuseismadeoftheEOCSP.ThisisparticularlyimportantwherenumbersofSPsinapoolorlocalitywhoarebeingtaskedtourgentcallsissmallasthecorrespondingworkloadisalsosmall.AttheotherendofthescaleYAShavealsorecognisedandstartedtoplanaheadforthelikelychangesandincreaseinworkloadthatwillariseastherotationalschemesexpandandnewstaffwillrotateintoEOC.Theyhavealsorecognised,ashasbeenapparentinthepilotsites,thattherecanremaintensionsbetweendifferentgroupsofEOCstaffwhichmaynotalwaysberesolvedandthattheremaybesomerotationalSPsthatdonotwanttoworkinEOCandthiswillneedtobetakenintoconsiderationwhendesigningrotationalelementsforsomeindividuals.NeverthelesstheyhaveidentifiedanumberofstrategiesthatmightprovehelpfulindevelopinganEOCcomponent.ThesearesummarisedinFigure6.

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Figure6:StrategiesthatcansupportdevelopmentofanEOCcomponentThismaybethecomponentthatwillbemostdifficultonetogetrightandwillneedsomecreativethinkingandflexibilitybutthereareestablishedstrategiesthatcanhelpwithdevelopment.

SpecialistandadvancedparamedicsexperiencesTherewasuniversalconsensusfromtheSPsaboutthevalueoftheprimarycareandMDTcomponents.Theyfelttheywereusingskillsmoreappropriately,skillswereimprovingandtheywerecontinuingtolearn–thelatterbeinganimportantfactorwhenconsideringwhethertostaywithinanambulanceserviceornot.

“Ithinkthepilotwe'verun,thedoctorshavebeenvery,very,verysupportive,andthey'vetakentimeonthephonetogothroughthingswithus,explaineddifferentconditionsandtheirredflagmarkers,andgonethroughthosewithus.Andtheyhavebeenvery,verygood,butIthinkifyouhaven'tgotthatandyouwerejustringingup,andyouwerejustgettingthebareminimum,Ithinkitwouldbenicetohavesomesortofsupervision.Ithinkit'snotreallycausedusaproblemhere,becausethey'vebeensogood”.“Yeah,fantastic.Thesurgeryisabsolutelybrilliant.They’vewelcomedus,they’reareallywell-performingsurgery,whichisreallyslickinhowtheyoperate.AndnottoknowagreatdealaboutGPsurgeries,butthat’stheinstantimpressionthatyouget.So,it’sanabsolutelypleasuretoworkthere."

“Ifnothingelse,ifit’snotwhatyou’reactuallylearningintheGPsurgeryit’stheconfidencethatIfeelthatI’mnowgettingbackinbeingabletomanagepatientsinabetterway.It’salmostafeelinglikeI’vegotsomeclinicalsupport,especiallyifit’swithinthesurgery

• RostertimetomatchSPshifts• Dedicateddeskwithdedicatedtelephonenumber(notinacorneratthebackofthe

room)• Empowertomanageownclinicalteam• Specifytaskstoprovidevariety,useofclinicalexpertiseandprovidesufficientwork.

Thesecaninclude:o TaskingSPso Hearandtreat(tofitwithotherclinicalhubexpertise)o ProvidingspecialistadvicetodirectcallsfromnursinghomesandGPswhocan

calltheSPdesko Providingclinicaladviceandsupporttofrontlinecrewswhoneedreassurance

fornon-conveyancedecisionso Attimesofpeakdemandscanningcallstacksforcallbacksandclinicaladvice

• SupportiveinformationandcommunicationwithotherEOCstafftoclarifyrole• Asdemandincreasesidentifycalltypeswithhighnon-conveyanceanddevelopclinical

criteriafordispatcherstoflagsuitablecallsforSPallocation• AsschemesexpandconsiderareadeskstomanagesectorsandpoolsofSPs

37

hours,I’vegotsomeclinicalsupporttherethatisathand,youhadthatbeforeontheroadbutperhapsinalittlebitmoreimpersonalway.ItwasacaseofphonetheGPandthenyouwerehavingtoactuallyestablisharapportwiththatGP,whereasthatisactuallyinplaceandyoujustphoneupandsay‘Hi,it’s….,right,whathaveyougot?’theyknowwhoyouare,howyouwork,andtheyprobablyknowthepatientsanyway.Soactuallyyeah,itisatwo-waything”

TheRotationalmodelisveryappealingandthosecurrentlyinvolvedwerereallyenthusiasticandseeitasapositivestepandonewhichwillencouragethemtostaywithintheambulanceserviceasitgivesthemaclearlydefinedcareerpathwayinclinicalpracticewhichallowsthemtogrowanddevelop.Forsomeithasbeenawayofreturningtowhattheyhavebeentrainedtodo.

"SoI'vebeengettingfrustratedforawhileaboutthisgoingouttopatients,andtakingthemtohospitalandthentryingtosortofgetpeopletoseethingsinotherways:youcanimprovepatientcarekeepingthemathome.Sothenthispilotcameupanditwasjustlikeitwaswrittenformetogoanddo,soIappliedforit…”

Oneissuethatdidarisewasthespeedwithwhichthepilotsiteshadbeensetupandimplemented.RespondentsrecognisedwhythishadhappenedbutSPsandprimarycarerespondentsdidcommentthat,forfuturecohortsasschemesbuilditwouldbehelpfultohavesomemoretimetofamiliarisethemselveswiththeirnewworkingenvironmentandgettoknowtheteamstheywouldbeworkingwith.

“No,itwaslikehere'stheparamedics,they'restartingonMonday.Okay,whataretheydoing?Ithink,myself,it'dbepreparingtheteamsbeforetheycome.Introducingthemalittlebitmore,andsayingwhattheirroleisgoingtobe.Sothatstaffknow,andtheyknowandthentheycandevelopinthatway,andalljoinforces.Soit's,howshallIsay?Soeverybody'ssingingfromthesamehymnsheet.ButIthink,yeah,itneedstobeplannedalittlebitmorethanjustFridaycoming,oh,they'restartingMonday.Okay,whataretheydoing?Andwedidn'tknowhowlongtheyweregoingtobestopping”.“Ithinkyouneed,beforeyoustart,tospendabitoftimeshadowingeachoneofthemultidisciplinaryprofessionals,justtospendadaywiththemjusttoseewhattheycanactuallydoandwhatthescopeis,we’vekindoflearntthataswe’vegonealong….”.

TheyfeltthatworkingintheprimarycareorMDTsettinghadforgedvaluablelinksandrelationshipswhichtheywouldcontinuetoutilisewhenworkinginanambulanceresponsesettingasthesewouldhelpthemincreaseseeandtreatandhearandtreatbybuildingcommunitypathwaysandreferrallinks.ThisalsohasthebenefitofSPsbeingabletoprovidesupporttonon-specialistcrewswhentheyaremakingdecisionsaboutwhethertotransportpatientsorrequestSPassessment.Thiswillbeanimportantbenefitasthemajorurgentcarepolicyagendaistomanagemorepatientsoutsidehospitalbutresearchhasshownthedecisionmakingprocessforparamedicsaroundwhetherornottotakeapatienttohospitalhassignificantrisk6.Seniorcliniciansupportwillhelpfrontlineambulancecrewsmakebetterconveyancedecisions.

38

“Yeah,sowhenIcomebackonthefrontline,IkindofthinkofnotwhetherIshouldreferthistoaGP,butwhetherIshouldreferthistoaGPandwhataretheygoingtodo,andwhatamIexpectingtheGPtodo.Soit'sthefurthermanagementofit,atalmostapointthatyoucouldn'trec-…becausesometimesaGPwouldturnaroundandgo,well,whatdoyouwantmetodowiththis?Justifit'sadifficultsituation,andit'salsoyoucanthenpre-emptthatandsay,well,actually,canwenotdothis,thisandthis?Anditmaywork,itmaynotwork,andsomeGPsareoffended,butsomehavequiteopenarmsandthink,actually,that'sagoodidea."

"thoseGPpatientswithinthat-thecohortofpatients-naturallyI'mgoingtoseethosepatientswhileI'mintheambulanceservice.AndnowIfeel-andcertainlyaswecarryontheGProtation,ishavethatconfidencetospeaktoGPsandsayit's…,andI'vedonex,yandz,andIwanttodox,yandz,willyousupportmewiththat,oristhereanythingyouwantmetododifferently?I'vegotthatconfidencetodothat,andIprobably-itprobablywouldgivemetheconfidencenowtospeaktootherGPs.WhereasbeforeI'mveryrespectful,andIwouldringupandbowdowntotheirbetterknowledgeallthetime.ButthereareGPsouttherethatarequiteresistant,so,yeah,itwouldgivemesomefoundationstobuildonwithregardstotalkingtootherGPs."

“Soit's-butit'saboutoneofthekeyrolesforAPs,whenthey'rebackintheambulance,andnotjustwhenthey'rebackintheambulance,butpredominantlywhenthey'rebackintheambulanceenvironment,isgivingotherambulancestaff,technicians,paramedics,tome,givingthemdirectaccesstothem.AlmostasifyouwereaskingforadvicefromaGP,toavoidthis,let'sjustloadthemupandgo,andthat'sstillgoing,thatstillgoeson”.

TheyalsosawtheirincreasedcapabilitytoarrangedirectadmissionsasavaluablewayofdivertingpatientsawayfromED.TheyarealreadyseeingscopeforfurtherexpansionandcontributionforexamplebycreatingdirectreferralstoSPsfromnursinghomesratherthanusing999,andalsoaSPreferraldispositionfrom111(ratherthanambulance).ThiswasseenasonewaytoincreaseweekendandoutofhoursworkwhenGPhomevisitingdecreasesandwhichwouldmake7dayserviceworkingmoreviable.

ParamedicprescribingThereweremixedviewsaboutthelikelyimpactofintroducingparamedicprescribing.SomeparticipantsthoughtthiswouldfurtherenhancetheirscopeofpracticeandincreaseefficiencyasitwouldreducethenumberofcasestheyhadtorefertoanotherHCPorGPforprescribing.Othersthoughtitwouldn’tmakeahugedifferenceasthenumberofrelevantadditionaldrugswasunlikelytoexpandmuchbeyondcurrentpracticeandthiscouldbecoveredthroughPGDs.OneriskthatwasidentifiedisthatsomeservicesarealreadygettingenquiriesfromGPsaboutAdvancedPractitionerswithindependentprescribingskillswhichmayresultinmorespecialistsleavingtheambulanceserviceforprimarycareifalternativecareeroptionsarenotavailabletothem.

39

StrategyandfitwithstrategicplansSeniorambulancemanagersrevealedsomeinterestingviewsonhowtheyhadhadtobuildtheircasesforsupportandinvestmentintherotationalparamedicmodel.Thereisacomplexhistoryattachedtothedevelopmentofadvancedparamedicpracticeandvariationinhowthishasbeenembracedatanorganisationallevel.Someambulanceserviceshadheavilyinvestedindevelopingadvancedpracticeatthetimethisbegantoevolveintheearlyandmid2000s(theEmergencyCarePractitioner–ECPschemes)butatthattimetherewasnoclearcareerframeworkandinmanycasesECPshadeithernotbeenproperlyutilisedor,asdemandandpressureshaveincreased,hadbecomeabsorbedintogeneral999responsework.Muchofambulanceoperationsandstrategicprioritieshaveremaineddrivenbyresponsetimetargets.Thiscreatedtheenvironmentthathasledtomanyspecialistpractitionersleavingtheambulanceserviceandithasthereforebeendifficulttopersuadeservicestofurtherinvestinaspecialistworkforcewhereanothersector,particularlyprimarycare,canreapthebenefitsatnocost.Thepersuasiveargumentshavecentredona)withasupportivecareerpathwaysuchastherotationalmodelthenitismuchmorelikelythesespecialistswillstayintheambulanceserviceb)theywillsupportbetteralignmentoftherightresponsetotherevisedcallcategoriesintroducedaspartoftheambulanceresponseprogrammeandc)thereisincreasingfocusfrombothNHSEnglandandlocalsystems(eitherthroughCCGs,STPsorACOs)onincreasinghearandtreatandseeandtreatandthiswillinfluencecommissioningandfundingdecisions.

"So,subsequentlythenthere’sbeennorealhardandfastruleaboutwhataspecialistshoulddoandwhattheyshoulddevelop.So,thoughtabouthowwe,howIcouldmaybeconvincetheTrustandtheorganisationtochangedirectionandreinvestinthat,andtheonlywayreallywasaboutifitwasfinanciallyviableandtherewasn’talosslikethey’dhadbeforeintermsoftheoutset.Sopreviouslyitwasagreedthattheywouldpayforbackfill,theywouldpayfortheirtimeatuniversity,allofthesethings,theywouldpayfortheirplacementsandplusthecostofthecourse.So,itwasamassivecostandItotallyunderstandwhytheTrustmadethatdecisionnottospendanymoremoney.So,Iputaproposaltotheboard,itinprinciplewasagreedbuttheywantedtolookatthefigures,wasn’tsurethatitwouldovertlywork,butwerelookingatsomethingnewanddifferentifitdidwork.So,wewentaway,lookedatfiguresagainandhowthiswouldwork,andjustfinalisedit,didabitofscoping,lookedatwhatinteresttherewasoutthereandtookthatbacktotheboardandtheboardapprovedthisprojecttogoahead”."Iknowtheambulanceserviceneedstodothingsdifferently,Iknow,attimes,it’sabigleapoffaith,butwealsoneed,youknow,thestakeholders,commissioners,peopletobuyintotheconcept,aswell.Because,youknow,we’veonlygotafiniteamountofresourcesacrossthesystem,butwe’vegotprobablyagrowingnumberofpatients,andweneedtobestmeettheirneeds,inthebestpossibleway.So,Ithinkjustbybeingalittlebitcreative,anddoingthingsdifferently,youknow,wecangetalotofgoodresults.Butwejustneedto,likeIsay,takestockofthefactthatit’sbeenaveryshortpilot,wehaven’tgoteverythingright,wemightneedtodothingsalittlebitdifferently,youknow,ifwecontinue,orifwescaleitup,butactually,it’sareallycompellingargumenttopeople.It’sreallyhardnotto…notto,Isuppose,thinkthatthisistherightdirectionthatwe’reheadingin."

40

Forthemostpartengagementwiththebroadersystemorganisationshasbeenavaluablepartoftheprocessasithashelpedidentifypotentialbenefitsacrosstheurgentcaresystem.ThishasbeenpersuasiveinbothdevelopingbusinesscasesandhelpingidentifyfundingastheentireburdenoftrainingandprovisionofSPsandAPscannotliewithambulanceservicesaloneoratleastwithintheirexistingbudgets.InterestinglyonepilotschemehastakenadifferentstanceandhasdevelopedamodelthatisentirelydeterminedbytheambulanceserviceandnotCCGs.Theyhavedonethissothattheyretaincontrolofexactlywhatactivitiestheycanandcan’tprovideastheyseeariskincontractingaserviceataCCGlevelasoperatingareasbecometoobigandtheservicebecomeslessefficientifSPshavetocoverlongdistances(i.e.eachSPthenseessubstantiallyfewercases).TheirpreferenceistocontractwithindividualGPpracticesorGPfederationsandtocontractforaveryspecificamountofactivity.Othersaretakingtheviewthat,inthelongertermasschemesexpandamovetopoolsofstaffworkingacrossanumberofGPpracticesmaybeabetterwayofmanagingtheprimarycareandMDTcomponentssothatthereisbetterresilienceforcoveringannualleave,sicknessandstafftrainingalthoughthisconflictswiththedesireofprimarycaretomaintainindividualrelationshipsandknowingpeopleWhicheverviewistakenthereisaclearmessageaboutorganisingatlocalityleveltokeepmodelsbigenoughthattheyaresustainableandeffectivebutsmallenoughtokeepstrongandtrustedrelationships.TherewasalsoaclearviewthattherotationalparamedicmodelshouldavoidjustbeingasolutiontoprovideextracapacityforfailingservicesasSPswon’tgetthesupporttheyneed.Howeveritwasrecognisedthereisscopeforselectivetargetingofpracticeswherethemodelmayhavemostimpact,forexample,thosewithhigh999urgentrequests.Therewerealsosomeinnovativeforwardthinkingideasabouthow,inthefuturewithlargercohortsofSPsthereishugescopetoimprovedirectworkingbetweenSPsbasedinMDTsorcommunitybasedservicesandwiderintegratedcareteamssupportingprimarycarenursinghomes.

CodesetsforidentifyingSPrelevanturgent999callsAkeyactivityidentifiedintheHEEdocumentsondevelopingarotationalschemeistheidentificationofsuitabletriagecodesfortargetingSPsrespondingtourgent999calls.Howevertherewaslittlediscussionintheinterviewsaboutthisaspect.ThismaybebecausetheEOCcomponentistheleastdevelopedcomponent.Wherethishasbeeninplaceworkalreadydonethishasimproved–notjustforrotatingSPsbutalsootherSPsdoing999responseasnotallSPswillberotating.TheSouthHardwickpilothadidentified999Category4fallsassuitableforresponseinhoursand999Category3and4callsatweekendsbutveryfewreferralshadbeenmadetotheSPs.Howevertherewereonly2SPsandnoneasyetinEOCsotherehasbeennoopportunityforanEOCrotationalparamedictoinfluencethis.IdentificationofsuitableSPcallsisdiscussedinmoredetailinthenextsection.

InformationsystemsThereweresomediscussionsaboutinformationsystemsparticularlywhereamixofambulanceserviceandprimarycarerecordsareusedastherearecumbersomeprocessesinlinkingtheseuportransferringbetweensystems.Thisalsohasabearingonrotationalpatternsasthereisanelementofgainingexperienceandconfidenceinusingdifferentinformationsystems.

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“Ithinksomeofthethingsthatdon'tworksowell,forme,becauseI'monlyinthereonceaweek,isthesystems,learningthesystemstobeabletocomebackandyoucomebackin,andyou'vegottofindaroom,you'vegottofindacomputer.You'vegottorememberhowthatsystemworkswhenyouhaven'tuseditfortendays.It'ssomethingthatyou'veneverhad-physiotherapyreferral,ah,IknowIcandoone,butIcan'trememberhow.It'sthosetypesofthingsthatifweputourpeopleintherefull-timeormaybethreedaysaweek,theywillgettoknowtheirsystemsbetter.Andwe'reonly-Ionlyworkbetweentwosurgeries,andthosetwosurgerieshavetwodifferentsystems.Soit's-andthenit'sadifferentsystemhere,soyou'relogging…ohright,what'smylogonforthisone?Oh,butwhat'smylogonforthatone?Okay,oh,thatonedoesn'tdothis,thatonedoes.Soit'ssystems.ItwouldbelovelyifallGPsurgeriesusedthesamesystem.Ithinkthatwouldmakelifeeasier.Ithinkitjustmeansthatmorepeoplecangetseen,morepatientsgetmoretimefrom,hopefully,themostrelevantclinician”.

Futuresolutionswillbeneededtostreamlinetheseprocessesandimproveaccessibilitytodifferentsystems.Therewerealsodifficultiesinrecordingandgeneratingthesysteminformationneededtomeasureimpactandoutcomesalthoughthepilotschemeshavebeenproactiveinadoptingastandardisedsimplesmartsheetdatacaptureprocesstoenablethemrecordandanalysetheirworkload,casemixandpatientmanagementdecisions.SomehavestartedtogofurtherandexaminetherotationalSPworkinthecontextthecontributiontothelargeroverall999workloadintheirlocalities.OthershavestartedtolookinmoredetailatlocalitydemandprofilestoseewhereSPscanmakethemostdifference.Datacapturefromdifferentcomponentsourceswillneedtobeakeyconsiderationforfutureplanningandmeasurementofimpactandbenefits.

Overall,theexperiencesofthe4pilotschemeshavebeenextremelypositive.Thereisnodoubtthatverysignificantamountsofworkhavebeendonetomoveeachschemefromaplantoanoperationalservice.Theyhaveovercomepracticalproblemsbutitisimportanttoalsohighlightthewiderissuesthathavecometolightwhichhavebothcontributedtosuccessfulimplementationandwhichmayrequirecarefulmanagementinthefuture.Amajorvaluethatisevidentfromthequalitativedataistheclearbenefittheprocessofsettingupandimplementingthesepilotschemeshashadongeneratingpositiverelationshipsacrossthedifferentsectors.Thesebenefitnotonlythepilotschemesoperationsbutarearealstepforwardinbeginningtofostermuchbetterunderstandingandcollaborativerelationshipsacrossorganisationsthathavepredominantlyworkedindependentlyofeachotherinthepastandhasthepotentialtoinfluenceurgentcaresystemdevelopmentatamuchbroaderlevelthantherotatingparamedicprogramme.

.“Iguessbenefits{forambulanceservice}isaboutthatcollaborativeworking,it’sabouttheunderstanding,it’saboutthenetworking,it’saboutbuildingupthatrapport,it’saboutmaintainingstaff,soit’saboutretention,retentionisabigthing.It’saboutportfolioworking,it’saboutgivingstaff,clinicianstheopportunitytolearnanddevelopaspartofanMDT.Butequally,thoseskillstheyhavelearntinprimarycare,transferringthembacktotheoperationalfrontlineservice.So,Ithinkagainit’satwo-waythingintermsoflearning,Ithinkit’sbeenreallyvaluableforallofthosethings,asIsay,forsharedlearning,forsharedtreatment,forsharedprotocols,forunderstandingreferralpathways,forconfidencegaining.Generally,Ithinkthebiggestthingthat’shelpedisthatrapport,isthatunderstandingwhataGPdoesandcandoandequallythemunderstandingwhatwecandoandwhatourstrengths

42

andweaknessesareandbuildingupthatreallygoodrapportwiththem.Ithinkthat’sinvaluableintermsofthatsideofthings”

“Yes.It’sinterestingthat,ourleadcommissionerforthe…..is….CCG,and….arealsotheareathatwe’reworkingin,sowe’vekindofgotsomerealgoodGPadvocates,whokindofwanttoworkwiththeambulanceservice,wanttoworkwith….,inadifferentway.So,it’sbeenreallypositivefromthecommissioners,andIthink,youknow,that…that’shelpedbuildsomegoodrelationships,aswell,thatIthinkwilltakeusbeyondjustdoingthispilot,itwillkindofbeanenablerforotherstuffwithintheurgentandemergencycareagenda”.

“Andthere'ssomefabulousstuffoutthere,therereallyisandIjusthopenationallyorlocally,orwhatever,wedon'tmissatrickonthisone.Becauseoutof36years,and,obviously,thefirst15/20yearsofthosewewerebasicambulancemenbeforeparamedictrainingcamein.ButIhaveneverknownitsoclosetosomethingquiteinnovative,butalso…AndI'mbiased,becausesomeoftheprimarycarecolleaguesIworkedwithwhenIwasincommissioning,etcetera,andwe'vegotgoodrelationshipswiththeGPs.ButI'veneverknownsuchapositiveandproductive,andfertilerelationshipbetweenourselvesandprimarycare.Andit'llonlyspread,Ithink.Andmyrealworryisthatbecausewe'vegotthatengagementnow,ifwedon'tcarrythison,I'mfrightenedwe'lllosethat.Notjusttheengagementbutalittlebitofrespect”.

"Ijustthinkit'sagreatopportunity.Ithinkwhatenthusesme,isthatI'veseenlikeaglimpseofwhatcouldbedonebeforeandthisisfarbetter-therotationis,it'sideal.Ithinkweknowwherethechallengesaregoingtobe,andtheydon'tworrymeaslongaswe'vegotthedatathatprovesit.Isupposethethingthatworriesmeisit'sarelativelysmall,shortpilot,andthat'llbeeasierforthenaysayerstopourdoubtonit.ButIsupposegoingbackto,well,attheendwhathappens,I'dliketobeinapositionwherewecansay,look,thishasworked,let'skeeptheseguysdoingwhatthey'redoing,evenifit'sjustfourorfiveofthem.Andthenwecanworkoutwhatistheworkforcedevelopment,goingforward."

"IsupposewhereI’dliketosaywiththecontext,Ithinkthereneedstobearecognitionofthetimescales,ofwherewe’vecomefrom.I’mveryproudoftheteamofwherewe’veturnedthisroundfrom…well,theendofDecembertogettingsomethingupandrunningbytheendofJanuary…”.

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5. Pilotschemesactivityandprocesses

5.1PotentialcallpopulationPriortobeginningtherotationalparamedicpilotmodelsHEEcollectedbasiccalltypebyvolumedatafromallservicesacrosstheUK.Eachserviceprovidednumbersofcallsforthe10mostfrequentlyoccurringcalltypes.Thiswastoillustratethepotentialforincreasingthenumberofcallsmanagedclosertohomeandreducing999demandifthereisastableandreliablespecialistandadvancedparamedicworkforceacrosstheurgentcaresystem.ToprovidecontextthemostcommoncalltypesbyvolumearepresentedinTables5and6.Twocalltriagesystemsforassessing999callsarecurrentlyusedacrosstheUK–NHSPathwaysandtheAdvancedMedicalPriorityDispatchSystem(AMPDS).Eachsystemvariesinthedescriptionofcalltypessotheresultsarepresentedseparatelyforeachsystem.OnlyresultsforEnglandarepresentedastotalcallvolumeswererequiredtocalculatetheproportionofallcallsforeachcalltypeandthisinformationisavailablefromtheNHSEnglandAmbulanceQualityIndicators.Onlyservicesreturningcompletedataarereported.ForallservicesthelargestcalltypeasaproportionofallcallswerereferralsfromNHS111(range10.3%-22.4%).Thesecallshavealreadybeentriagedasrequiringanambulanceresponseandarenotrecordedbyproblemtype.Wehaveexcludedtheseandshownthe9mostcommoncalltypesbynumberofcallandproportionofallcalls.Forproportionswehaveshowncalltypesintermsofrankbycolour-the3mostcommontypesred;largestcategoriesranked4-6orangeandlargestcategoriesranked7-9ingreen.

Table5:NinemostfrequentlyusedcalltypesNHSPathwaysservices

Calltype

Totalcalls2016/17

%oftotalcallvolume

Totalcalls2016/17

%oftotalcallvolume

SECAMB WMAS Trauma 100032 17.9% 115616 14.5%999HCP 60433 10.8% 45982 5.8%Medical 58414 10.4% 34498 4.3%PREALERT 43737 7.8% Generallyunwell 43123 7.7% Falls<12ft 41061 7.3% 45120 5.7%Chestpain/cardiacproblem 36406 6.5% 92490 11.6%NHS111(Manualentry) 32632 5.8% Stroke/neurological 32187 5.8% 31379 3.9%Breathingproblems 87909 11.0%Abdominalpain 39784 5.0%Medicalminor 70683 8.9%Unconscious 35742 4.5%

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Table6:NinemostfrequentlyusedcalltypesAMPDSservices

Totalcalls2016/17

%oftotalcallvolume

Totalcalls2016/171

%oftotalcallvolume

Totalcalls2016/17

%oftotalcallvolume

Totalcalls2016/17

%oftotalcallvolume

Totalcalls2016/17

%oftotalcallvolume

NWAS SWAST EEAST LAS YAS 999HCP 78929 8.8% 6623 17.2% 110796 18.7% 106625 9.6% 82215 16.0%Falls 72451 8.1% 5318 13.8% 115921 19.6% 123407 11.1% 96901 18.8%Breathingproblems 51752 5.8% 3345 8.7% 66538 11.2% 111772 10.1% 59574 11.6%Top3total 22.7% 39.7% 49.5% 30.8% 46.4%Chestpain 46015 5.1% 3151 8.2% 63273 10.7% 93806 8.4% 58655 11.4%Unconscious/fainting 41304 4.6% 2775 7.2% 41789 7.1% 93325 8.4% 40119 7.8%Sickperson 37164 4.1% 1870 4.8% 39575 6.7% 61870 5.6% 43656 8.5%Psychiatric/suicideattempt 27732 3.1% 20337 4.0%Convulsions/fitting 26665 3.0% 1513 3.9% 28936 4.9% 39983 3.6% 25995 5.1%Overdose/poisoning 20520 2.3% Notrecorded/unknown 2688 7.0% 96156 8.7% Haemorrhage/lacerations 1280 3.3% 22233 3.8% 32750 2.9% Stroke 21859 3.7% Traumaticinjuries 19849 3.9%14weeksonlyNov-Dec2016

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Therearesomedifferencesbetweenthetwosystemsreflectingdifferencesinhowcallsare

describedandrecorded.Datawasavailableforonly2NHSpathwaysservicesandthereisalarger

numberofcalltypedescriptionssoitisdifficulttomakecomparisonsandidentifycommonthemes.

TheSECAMBdataincludescallsbyoperationalfactors(Pre-alertandsomeNHS111callswhichdon’t

reflectproblemtype.However,consideringthesearethemostcommoncalltypestherearegroups

ofcallsthatappearwithinthehighestcallvolumesinbothservices–trauma;HCP999calls;medical

problems;fallsandchestpain.

TheAMPDSservicesprovideabetterillustrationofcommoncalltypesasthereisamorestructured

andconsistentprocessforrecordingcalltypes.Thetableshowsthereisremarkableconsistencyin

the3mostfrequenttypesofcalls–HCP999calls,fallsandbreathingproblems.These3calltypes

aloneaccountforbetween23%and50%ofall999activityandthesearecalltypeswherespecialist

andadvancedparamedicskillscouldbeusedtoprovideappropriatecarewithouttheneedfora

hospitalattendanceforsomecalls.Ofcoursetherearesomecalltypeswhereanemergency

responseandlikelytransporttohospitalwillbeneededandthesefeatureinthe9mostcommoncall

types,particularlychestpainandunconsciousness.Howeverothercalltypessuchas“sickperson”

alsofeatureinallservicesmostcommoncalltypesandthesemayberichincaseswherespecialist

skillsmaybeofvalue.DatafromWales,ScotlandandNorthernIslandalsoshowedthatHCP999

callsandfallswerethetwolargestgroupsofcallsfollowedbybreathingproblemsorsickperson.

Thepurposeofreviewingthemostcommoncalltypeswastoprovidesomecontextforthepotential

withinthe999callworkloadtomanagesomecallsdifferentlyandthereareclearlysomehigh

volumegroupsofcallswherethisispossible.However,itisimportantnottoover-interpretthis

potential.Withineachgroup,forexamplefallsorbreathingproblems,therewillbearangeof

acuitiesandsomepatientswillstillneedemergencycareandhospitalcare.Otherscouldbeideal

candidatesforSPandAPcareandmanagementinthecommunity.Similarly,HCP999callsaccount

foranaverage12.4%of999activity(range5.8%-18.7%).Oneperceivedbenefitoftherotating

paramedicmodelisthatbyincreasingcapacitywithinprimarycaresomeofthesecallscanbe

divertedawayfrom999.Whatisunclearatthemomentiswhatproportionthisislikelytoapplyto

assomewillneedanambulanceresponse.Inlookingatreducingdemandthecapacitytoachieve

thisalsoneedstobetakenintoaccount–thecallvolumespresentedinthetableareoftheorderof

10’softhousandsso,asmallnumberofspecialistpractitionersinpilotschemeswillmakeno

discernibleimpactonthesenumbersatanambulanceserviceorregionallevelbuttheremaybe

morevalueinexaminingthisinlocalitiesservedbySProtationalschemes.Benefitwillonlybe

measurablewhenthereisabetterunderstandingoftheproportionofcallsthatarethetarget

populationandtosomeextentthiswillonlybecomeapparentaspilotschemesoperateovertimeso

thatthesefactorscanbemeasuredmoreaccurately.

5.2PilotschemeactivityTosupportthedescriptionofhowthepilotschemeshavebeenoperatingduringtheinitialfew

weekswehavereportedasummaryofearlyactivityusingaggregateddatasuppliedbythe4pilot

models.Thisisprimarilyprocessdataofactivityvolumesandpatientmanagementprocesses.

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SouthCentralTheSouthCentralpilotteamprovidedsummarydatafor200patientcontactsatoneGPsurgeryfor

theperiod12/12/17–25/4/18althoughtherewere49daysdatamissingwhichmaybeupto250

patients.Thisprovidesasnapshotofactivityanddispositionsinaprimarycarerotationcomponent

(Table7,Figure7).

Table7:SummaryofactivityandcasetypeinoneGPpractice

Number(%)

ContacttypeHomevisit

GPsurgery

Missing

174(87%)

18(9%)

8(4%)

PatientcharacteristicsFemale

Male

Missing

AgeGroup(years)1-5

6-60

>60

Missing

125(62.5%)

70(35%)

5(2.8%)

8(4%)

20(10%)

164(82%)

8(4%)

DispositionA&E–emergencyambulance

A&E–madeownway

A&E–non-emergencyambulance

Directhospitalreferral

Dischargedonscene–GPreferral

Dischargedonscene–MDTreferral

Dischargedonscene–noreferralrequired

Missing

1(0.5%)

2(1%)

1(0.5%)

10(5%)

4(2%)

9(4.5%)

151(75.5%)

22(11%)

Themajorityoftheworkloadwashomevisits.Patientswerepredominantlyfemaleandover80%

wereagedover60years.Injustoverhalfofpatients(107)nodrugsweregivenandfor75casesa

prescriptionfromanotherHPCorGPwasneeded.Only2%ofpatientsweredirectedtoEDandhalf

ofthesemadetheirownwaywith5%requiringadirecthospitalreferral.Overall,ofcaseswhere

dispositionwasrecorded,93.3%didnotrequireatransferbyambulance.

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Figure7:ProportionsofcallswitheachdispositiontypeSouthCentral

EastLincolnshire

TheEastLincolnshirepilothasprovidedapictureoftheeffectsofrotatingaSPthroughEOConhear

andtreatandseeandtreatratesforemergencyandurgentcalls.Thepilothasonlybeenrunningfor

asmallnumberofweeksandthesecrudechangesagainsttheprecedingyearhavenotbeen

adjustedforotherfactorsthatmayaffectdispositiontypebuttheydoprovideanindicationofthe

directionoftravel.Allcallvolumesarefortheoperationalareaofthepilotservice.(Tables8&9).

Table8:Changeinactivitybydispositionfor999/111/HCPcalls

Precedingyear23.07.16-13.04.17

Pilotyear23.07.17-13.04.18

Difference

DisposalType Numberofcalls

%oftotalcalls

Numberofcalls

%oftotalcalls

Hear&Treat 1654 14.5% 1982 14.4% ↓0.1%

See&Treat 1876 16.5% 2336 17.0% ↑0.5%

H&T/S&Tcombined

3530 31.0% 4318 31.4% ↑0.4%

See,Treat&Convey

6108 53.7% 6775 49.3% ↓4.4%

Total 11379 13737

-1% 1%

-1%

5%

2% 5%

76%

11%

DispositiontypesA&E- emergencyambulance

A&E- madeownway

A&E- non-emergencyvehicle

Directhospitalreferral-

Medics,Surgeons,other

Dischargedonscene- GP

referral

Dischargedonscene- MDT

referral

Dischargedonscene- no

referralrequired

48

Table9:Changeinactivitybydispositionforallcalls

Precedingyear23.07.16-13.04.17

Pilotyear23.07.17-13.04.18

Difference

DisposalType Numberofcalls

%oftotalcalls

Numberofcalls

%oftotalcalls

Hear&Treat 2332 13.3% 2633 14.0% ↑0.7%

See&Treat 3080 17.5% 3314 17.6% ↑0.1%

H&T/S&Tcombined

5412 30.8% 5947 31.5% ↑0.8%

See,Treat&Convey

9509 54.1% 9340 49.5% ↓4.6%

Total 17578 18859

Theresultsindicatethat,evenoverashorttime,therehasbeenareductionintheproportionof

callsconveyedtohospital.Ofcourseitisnotpossibletodirectlyattributethistotherotational

paramedicschemeoversuchashortperiodasotherinfluencesmaybeaffectingthisbuta4%

changeinthecalldispositiontypeinthecorrespondingoperationalareaindicatesapotentialshiftin

therightdirection.

EastLincolnshirehavealsoprovidedsummarydataoftheSPambulancerotationalperiod23/1/18

to08/04/18for223cases.Thisincludes201patientsseenathomeand22casesmanagedwithin

EOC.Ofthese223casestheaverageagewas69years(range1-19years).Figure8showstheoverall

dispositionofpatientsattendedbytherotationalSPs.57%ofcasesweredischargedatsceneand

17%directedtoEDorawalkincentre(WIC)orurgentcarecentrebynon-emergencyambulanceor

patientsmadetheirownway.25%requiredtransporttoEDbyemergencyambulance.

49

Figure8:PatientdispositionforpatientsattendedbyEastLincolnshireSPambulancerotation

MorerecentlytheEastLinconshirepilotsitehasimplementedaprimarycarerotationalcomponent.

Duringthefirst4weekperiodfor1SPbasedinprimarycare(13dayshifts)theSPmanged43cases

withanaverageageof62years(range10-95years).Figure9showsthetypeofcallsmanagedwith

themajoritybeingbreathingproblems(28%).35patients(81%)weredischargedwithoutreferral,3

(7%)weredischargedwithreferraltoaGPorMDTand5cases(12%)weresenttoEDbyemergency

ambulance.

Figure9:EastLincolnshire-DispositionofcallsmanagedbyoneSPduringonemonthprimarycare

rotation

26%

17% 46%

11%

Dispositiontype

A&EorWICEmergency

ambulance

A&EorWICnon-

emergencyvehiclemade

ownway

Dischargedatsceneno

referral

5%

28%

7%

5% 2% 2%

18%

12%

21%

Proportionofcallsbytype

AbdominalPain

BreathingProblems

ChestPain

Convulsions/fitting

Immobility

MentalHealth

MinorIllness

MinorInjury

Other(detailinnotes)

50

Newcastle

TheNewcastlepilotsiteprovideddataonactivityfortheperiod20/2/18–19/4/18althoughsome

recordshadyettobeentered.Therewasdataavailablefor515casesmanagedbytherotational

paramedics.Theaverageagewas51years(range4weeksto95years)excluding29caseswithan

ageoflessthan1year.55%werefemaleand45%male.Thissitehasrapidrotationthrougheach

componentwithacontrolledallocationofGPurgentcarehomevisits5daysperweek.Thisis

reflectedintheactivitywith27casesrecordedasprimarycare(GPhomevisits),484(94%)asurgent

care(theMDToutofhourscomponent)and4casesasambulanceserviceEOCcases.Thehigh

proportionofurgentcarecallsreflectstherosteringsystemwhereoutofhours(eveningsand

weekends)isincorporatedaroundtheMondaytoFridayGPhomevisits.

Figure10showstheproportionsofcallsmanagedbyeachtypeofdispositionandFigure11the

proportionofcallsmanagedbycalltype.

Figure10:Newcastle–DispositionofcallsmanagedbyrotationalSPs

27%

17%

17%

6% 3%

6% 0% 0%

24%

Dischargedonscene- no

referralrequired

Dischargedonscene- GP

referral

Dischargedonscene- MDT

referral

A&E- emergencyambulance

A&E- non-emergencyvehicle

A&E- madeownway

Urgentcare/WIC- emegency

ambulance

Urgentcare/WIC- non

emergencyvehicle

51

Figure11:Newcastle–Callsbytype

Themajorityofcasesweremanagedbydischargingatscene(61%)orreferraltoawalkincentreor

urgentcarecentre(24%).Only15%ofpatientswerereferredtoEDand6%requiredemergency

ambulancetransport.Themaincalltypewasminorillnesswhichmayreflectthedifferentcallorigin

withahigherproportioncomingfromtheoutofhoursservice.Table10providesasummaryofthe

dispositiontypesforeachpilotscheme

Table10:Summaryofthedispositiontypesforfourpilotschemes

EastLincs Newcastle Hardwick SouthCentral

Patientdisposition No.ofcases Dischargedonscene-noreferral

required

100 118 43 151

Dischargedonscene-GPreferral 13 77 37 4

Dischargedonscene-MDTreferral 11 81 16 9

A&E-emergencyambulance 54 27 27 1

A&E-non-emergencyvehicle 3 15 4 1

A&E-madeownway 21 27 1 2

Urgentcare/WIC-emergency

ambulance

3 0

Urgentcare/WIC-nonemergency

vehicle

4 1

Urgentcare/WIC-madeownway 9 118

Directhospitalreferral 10

Non-conveyancerate 70.6% 91% 76% 93.3%

Missing 8 9 6 22

Total 226 473 134 200

0

50

100

150

200

250

52

5.3SummaryofquantitativefindingsTheresultsshowthatthereissomevarianceinthenon-conveyancerateacrossthe4sitesbutthey

allhavearateofatleast70%.Thevarianceislikelytobeduetodifferencesincase-mix.Thehighest

rateisintheSouthCentralsitewhichisprimarycarebasedandthecaseloadmaybeofloweracuity

thanthoseusing999.TheNewcastlepilotalsohasanon-conveyancerateofover90%andthisisa

moremixedpopulationofprimarycare,outofhoursurgentand999urgent.Thelowestrateisin

EastLincolnshirebutthisserviceismanagingcallscomingviatheambulanceservicenotfrom

primarycaresotheacuityislikelytobehigherandtheremaybemorecaseswhichdoneed

emergencyoratleasthospitalcare.TheSouthHardwicksiteisprimarilyprimarycarefocussedbut

requestsaremadebyGPsremotelyandtheremaybesomesubtledifferencesinthattheserequests

maybemorelikelytobecallsthatpreviouslywouldhavegeneratedanemergencyambulance

request.Moredetaileddataovertimewillhelpunderstandcase-mixdifferencesbetter.

Thesequantitativedescriptionsofactivityandprocessescannotdemonstrateimpactorbenefitasto

dothiscomparativedataisneededtoshowchangesovertime.Thistypeofcontrolledtimesseries

analysiswillbeessentialinalongtermevaluationtoassessimpactoverarealisticoperational

period.Whattheydoshowisthat,withtherightpatientcohort,averyhighproportionofcasescan

bemanagedbyspecialistparamedicswithouttheneedforhospitalreferralwhichfitstheintended

objectivesofmanagingurgentcareproblemswithcareclosertohome.Thesefindingsalsomirror

thoseinalongerrunningandmoreestablishedprogrammedevelopedinWaleswherespecialist

practitionersrotatethroughEOCandurgentcare999responsetargetedtospecificurgentcalltypes

withanon-conveyancerateof70%.

53

6. Summaryandconclusions

Wehavedescribedtheearlyexperiencesofdesigningandimplementingarotationalparamedic

modelinfourpilotsitesandcomparedprogressinrelationtotheHEEprogrammemodel.The4pilot

siteshaveeachadaptedthebasicframeworkandcreatedafeasiblemodelthathasallowedthemto

moveforwardfromaplantoimplementationinaveryshortspaceoftime.Therotationalmodel

representsasubstantialchangeofserviceprovisionbothintermsofscopeandcomplexity.Thepilot

siteshaveonlybeenoperatingforaveryshortperiodoftimesoitisthereforeunrealistictodraw

anyconclusionsaboutanoptimalrotationalmodelbutwhatisclearisthatbytakingtheprinciples

ofthe3componentmodelsuggestedbyHEEbuthavingthefreedomtobecreativeandflexiblein

howeachpilotasdevelopedhasprobablybeenacornerstoneofmakingthedifficulttransitionfrom

planningaservicetomakingitoperationalintherealworld.Differentapproacheshavebeentaken,

insomecasesbuildingthecomponentsinasimilarwaytotheHEEmodel,soforexamplecreatinga

primarycareorMDTrotationalcomponentbutthisdoesmeanthatonlyoneelementisinplace.

Howeveritisclearthatconcentratingeffortandworkingthroughthecomplexitiesofestablishing

partnerships,contractsandtraininghasbeenkeytosuccessfulstartup.Thesameeffortwillbe

neededforthenextcomponents.Othershavetakenadifferentapproachandalreadyincorporated

someformofrotationthroughatleasttwocomponentsbutthisdoesmeantherotationaltimesin

eachcomponentareshorter.Itwilltakeamuchlongerperiodofassessmentoveratimeperiodthat

encompassesallcomponentstoestablishwhetherthereisanoptimummodelbut,sofar,adapting

themodeldoesnotappeartohavehinderedprogressandindeeditisnotrigidlystickingtoan

expectedplanthathasallowedsuchswiftprogresstobemade.Itisentirelypossiblethatthereisno

single“ideal”modelonlythebestonethatfitslocalneedsthatallowsittooperateefficientlyand

sustainablyaccordingtoalocalplanandservicespecification.Thepilotsiteshavealso

acknowledgedthesupportprovidedbytheHEEprogrammeteaminfacilitatingthisprocessand

providingencouragementtotestandrevisetheirmodelsonanongoingbasisandtheopportunityto

sharelearningthroughtheregularmeetingsandworkshopsthathavebeenanintegralpartofthe

process.

Somekeypositivemessagesandlessonshaveemergedfromthepilotsiteexperiences.Insummary

theseare:

• Theyhavesensiblyconcentratedeffortsonmakingsureeachstartingpointhasbeenwell

developedandthoughtthroughtomaximisethechancesofsuccessfulimplementation

ratherthantryingtooperationalisethewholerotationalschemeatascalethatcannotbe

putintopractice.Thiscanbeeitherdevelopingarotationalcomponentindetailor

implementingarotationalschemethatisatasmallenoughscaleitcanbewellmanaged.

• Itisfeasibletobegintosetuparotatingparamedicmodelbutadaptabilityisneededto

ensureitmovesfromaplantoparamedicsactuallyworkingrotationally.Thisispreferableto

tryingtogeteverythinginplacebeforestartingwhichmaypreventitevergettingoffthe

ground

54

• Planningisimportantandconsiderableeffortisneededtodevelopthestrategiccasefor

investmentandsupport.Workingwiththewiderurgentcaresystemorganisationscanhelp

withthis

• Attentiontodetailindevelopingclinicalgovernanceprocesses,contractsandfinancial

arrangementsisneededtoprotectorganisationsandstaff.Clearboundariesshouldbeset

outaboutscopeofpractice,activitiesandworkload

• Lengthofrotationineachcomponentisnotstraightforward.Longerrotations,particularlyin

primarycaresupportlearningandrelationshipbuildingbutshorterrotationsincrease

varietyandbettersupportshiftrotapatterns–thereislesslikelihoodofperiodsoflow

activity–andmaybettersupporttheEOCcomponent.ForsomeSPsitwasimportantto

retainatleastsomefrontlineemergencyexperience,bothtokeepuptheirskillsand

becausetheystillwanttodosomeofthatwork.Asmodelsmaturetheremaybemore

scopetotailorrotationalpatternstoindividualsifthiswillhelpretention.

• Thereisarealappetiteamongstspecialistparamedicsforarotationalprogrammeasit

allowsthemtobetteruseandfurtherdeveloptheirskillsandgivesthemaclearlydefined

clinicalcareerpathway.Earlyevidencesuggeststhiswillhelpretaincurrentstaffandmay

encouragestaffwhohaveleftforothersectorstoreturntotheambulanceservice

• ExperiencessofarhavebeenoverwhelminglypositivefortheprimarycareandMDT

components.Thecollaborativearrangementshaveenhancedunderstandingandtrust

betweendifferentprofessionalgroups.Thisisalsoreflectedinbetterworkingrelationships

withotherorganisationssuchasCCGswhichishelpingdevelopmorecoherenturgentcare

pathways.ThereismoreworktodomanagingtheEOCcomponentasthisistheleast

developedandleastpopularoptionamongstSPs

• EarlydatashowsSPpatientmanagementresultsinahighproportionofpatientsreceiving

assessmentandcareinlocalcommunitiesratherthanacutehospitals.

Recommendationsfornextsteps• Thecurrentpilotsitesareintheirinfancyandsmallinscale.Therearealargenumberof

expectedbenefits-reducingEDattendancesandunplannedadmissions,reducingHCP999

demand,reducingresourceallocationfor999callsandhandoverdelaysathospital–aswell

asimprovingpatientoutcomesandstaffrecruitment,retentionandsatisfaction.However

thesearedifficultthingstomeasureintermsoftangibleimpactwhenSPnumbersaresmall

–twospecialistsseeing10patientsadaywillnotmakeadetectabledifferenceto999call

volumes.Todetectthesetypesofchangesmodelswilla)needtomature,expandandrun

forseveralrotationalcyclesandb)beallowedtorunforlongenoughthatchangesovertime

canbemeasured.Thereisarealdangerthatifneitheroftheseconditionsisfulfilledand

benefitsarenotapparentintheshorttermthenthemodelswillbejudgedtohave“failed”

wheninrealitytheymaynothavebeengivensufficienttimetosucceed.

55

• Someofthiscanbemitigatedbybeingverycarefulinchoosingthedenominatorforany

ongoingevaluation.Inparticulartheoperatingcontextwillbecrucialandmeasurement

shouldbeconfinedtothepopulationswithinoperatingareasnotthegeneralpopulationof,

forexample,aregionalambulanceservice.Therealsoneedstobebetterassessmentofthe

baselineactivityandproblemssothatthescaleofpotentialeffectcanbeproperlyassessed.

Oneexampleisthatifanexpectedbenefitisareductionof999GPcallsthenthetrue

proportionofthosecallsthataresuitableforalternativemanagementneedstobe

establishedasitisonlytheoutcomeofthesecallsthatcanbechanged.Somemodellingof

localityurgentcaredemandmayhelpdefinethescopeofpotentialchangeandprovidea

baselineformeasuringimpact.

• Thereisaclearcaseforcontinuedsupportsothatmodelscanberunforlongenoughto

generatetheevidencetoestablishtheirvalue.Atalocallevelthismaybeachievedwithina

yearifcarefullyassessedinrelationtoalocalsystemandpopulationandcansupport

decisionsaboutcontinuedsupport.Realisticallytherewillneedtobeamuchlongerperiod

toassesstheimpactonhighlevelobjectivessuchasreducingEDattendancesand

unplannedadmissionsandchangingrecruitmentandretentionpatternsasthiswillrequire

timeseriesanalysesandschemesofsufficientscaletodemonstratemeasurablebenefits.

Thiswillneed2or3yearsgiventhisisasignificantchangeinservicedelivery-andthis

meanstheywillneedastableandcontinuoussourceoffunding.Thisisevidentlynotthe

caseatthemomentandthereisconsiderableuncertaintyaboutthecontinuationofthe

existingpilotsitesevenbeyondthefirstfewmonthsofoperation.Withoutproperfinancial

commitmenttoalongtermtrialthereisaseriousriskthatmodelswillceasetofunctionor

willbecomeindividualcomponentservicesratherthantrulyrotational.Theopportunitywill

thenbelosttoseriouslychangethecareerpathwayforspecialistpractitionersinambulance

servicesandretainthem.Themarketfortheirskillsoutsidetheambulanceservicewillnot

diminish.Itwillalsoimpedethepolicyobjectivesofprovidingmorecareclosertohomeand

rightcarefirsttime.

• Ifthemodelistobesustainableandexpandtherewillneedtobeaplantomaintainan

ongoingpipelineofSPrecruitmentandtrainingsoconsiderationwillbeneededonhowthis

canbefunded.

Therotationalmodelhasthepotentialtoreversesomeofthefailingsofthepastwhenspecialist

practitionersintheambulanceservicewerenotusedtotheirfullpotentialresultingindepletionofa

paramedicworkforcethatisalreadyinshortsupply.Italsohaspotentialtoimprovetheclinicalcare

ofpatientsbyprovidingthemwithhighqualityurgentcareappropriatetotheirneedsintheright

setting.Thereisahugeamountofenthusiasmfortherotationalmodelbothfromthepilotsitesand

otherambulanceserviceswhoarealreadylookingtodevelopthistypeofmodel.Thepilotsiteshave

madewhatisthemostdifficulttransitionfromplantoactionbutinsuchashorttimecannotprovide

theevidenceneededtoestablishwhethersuchafundamentalchangewillhavethedesiredeffects

atawholesystemlevel.Todothatamuchlongerperiodofsupportandconsolidationisneededto

buildontheprogressmadesofaranexploitittoitsfullpotential.

56

LimitationsClearlythepilotsiteshaveonlybeenfunctioningforashortperiodoftimeandtherefore,the

currentevaluationisunabletoassessinwholewhetherthemodelsachievedtheirintended

benefits.Onlywhenthenewservicemodelshavehadtimematureandoperatedforsometimeata

sufficientscalecantheireffectsbereliablymeasured.Thisevaluationhasproducedrelevant,

interestingdatabutsomecautionneedstobeappliedtothefindingsasitisanearlyevaluationand

necessarilydescriptiveinnature.

Currentlytherearefewparamedicsemployedintheseroles,thustherehasbeenlimitedexperience

ofactuallyrotatingparamedicsthroughallareaswhichlimitswhatcanbedrawnfromthefindings

as,atthetimeoftheevaluation,amajorityofefforthadgoneintotheinitialsetupandpreparation

ofstaffforworkingwithGPsinparticular.

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