South Central Ambulance Service NHS 111

Updated 19 September 2018

South Central Ambulance NHS Foundation Trust NHS 111 service is contracted by two clinical commissioning groups and provides a service to a population of 7 million people in the Thames Valley and Hampshire areas. NHS 111 provider operates 24 hours a day, 365 days a year. It is a telephone based service where people are assessed, given advice and directed to a local service that most appropriately meets their needs.

This is achieved following initial triage using NHS Pathways, where patients are signposted to the most appropriate professional through the use of a directory of services (DoS) that includes all services provided in the area and all services nationally available. The service handles on average 1.2 million calls per year.

Further information can be found on the provider’s website at http://www.scas.nhs.uk/

The service is provided from two locations. We visited both as part of this inspection:

Trust HQ

Unit 7-8 Talisman Business Centre

Talisman Road

Oxfordshire

OX26 6HR

and

Southern House

Sparrowgrove

Winchester

SO21 2RU

Updated 19 September 2018

This NHS 111 service is rated as good overall. (Previous inspection May 2016 – Good overall with requires improvement in the effective domain)

The key questions are now rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We inspected this NHS 111 service as part of our inspection programme. This was a planned comprehensive inspection which looked at breaches in regulations identified at the inspection in May 2016 and looked at what action the provider had taken in relation to concerns regarding staffing recruitment.

We carried out an inspection of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• The NHS 111 service provided a safe, caring, responsive and well-led service to a diverse population spread across central and south England.
• The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
• Governance systems and processes were embedded and established.
• The provider recognised where risks were identified and were proactive in mitigating and reducing these risks. For example, low staff recruitment and retention had triggered the successful implementation of a demand and recovery plan.
• The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence- based guidelines.
• The provider worked with outside agencies and charities to secure improvements to services.
• Staff involved and treated people with compassion, kindness, dignity and respect.
• Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
• Staff had been trained and were monitored to ensure they used NHS pathways safely and effectively. (NHS pathways is a licensed computer based operating system that provides a suite of clinical assessments for triaging telephone calls from patients based on the symptoms they report when they call).
• The provider continued to be used as an approved national testing site for new NHS pathways being introduced.
• The provider was responsive and acted on patient complaints and feedback. Feedback from patients was welcomed by the provider and used to improve the service.
• The service were also involved in many projects, joint working and displayed evidence of innovation. For example, being appointed to lead a project for urgent and emergency care and in the provision of new services.
• The provider was testing a new training programme to help training in the workplace. The equipment allowed non clinical staff to experience a range of medical conditions they would not otherwise see and assist in the telephone triage.
• There was visible leadership, with an emphasis on continuous improvement and development of the service. For example, expansion of the service and integration with other stakeholders and urgent care providers.
• The provider was creative and proactive in looking at ways to solve staffing issues. For example, the use of home workers, joint working and change in working patterns to attract more staff. Staffing gaps had been met to provide patient safety. This was maintained through use of external call centre providers and offering overtime shifts.
• Staff said the NHS 111 service was a good place to work, although acknowledged this had been stressful recently due to issues with staff recruitment.
• The provider cared about the wellbeing of the staff and had invested in wellbeing officers who provided pastoral and operational support for staff. This had contributed to a reduction in staff sickness levels.

The areas where the provider should make improvements are:

• Continue with the implementation and monitoring of the recruitment programme.
• Ensure systems are in place to enable staff to keep abreast of changes, updates and new policies.
• Continue to review call handling responses to ensure agreed targets are achieved.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Updated 13 January 2015

Patient transport services (PTS) provided non-emergency transport for patients who, for example, attended hospital outpatient clinics or day hospitals, or were discharged from hospital. Commissioners had identified eligibility criteria for the service and the trust was working with 12 clinical commissioning groups to monitor performance and compliance. Staff followed the eligibility criteria and were also working to improve the signposting of people to other services if they did not meet the criteria. Procedures to ensure the safety of services needed to improve, specifically around incident reporting, equipment checks and safeguarding procedures. ‘Do not attempt cardio-pulmonary resuscitation’ (DNA CPR) orders were understood and used appropriately, but staff had limited awareness of the Mental Capacity Act 2005. Most vehicles were visibly clean. There were staffing vacancies and staff felt stretched, particularly in the dispatch team where this had an impact on the planning and scheduling of transport. The trust was using volunteers and private providers to cover driving shifts. There needed to be better governance arrangements for private providers and driving and employment checks for volunteers. Anticipated resource and capacity risks needed to be better managed. For example, problems with the new IT system had caused a serious disruption to the transport arrangements for patients during our inspection.

Dispatch staff did not always have appropriate assessment information, from hospitals or patients or from their own records. As a result patients sometimes did not have an appropriate vehicle or equipment, and transport sometimes had to be reorganised. The system to plan journeys was manual and often reactive based on a lack of timely and coordinated information and this had caused delays to patient transport. Computer aided dispatch was being developed.

The trust was not meeting performance targets and this was having an impact on patients’ care and treatment. Patients were experiencing delayed and missed appointments for outpatient consultations and diagnostic scans, and renal dialysis, and some were choosing to curtail their treatment in order not to risk missing their transport home for fears of excessive delay. There were good examples of multi-disciplinary working with GPs and health professionals in hospitals. Trust had been working with other providers to improve the coordination of care and some progress had been made.

The staff were caring, compassionate and dedicated to improving the service. Training was available but many staff had not undertaken this training to support them in undertaking their roles. Patient surveys were regularly undertaken; these were positive but identified delays. Patients we spoke with were similarly positive about the staff. However, they were concerned that the service was not effective and that they were not given enough information about delays, missed appointments and the eligibility criteria. Call handlers were overwhelmed with calls about service delays and only half of all calls were answered.

Many patients told us they had been distressed and anxious waiting for transport, but did not know whom to contact within the service. There was good support for vulnerable patients (for example, those with dementia or a learning disability), and carers and escorts could travel in the ambulances too. A policy for the transport of children was under development. The trust had a clear strategy for the development of PTS to support safe non-emergency travel between people’s homes and healthcare settings, but most staff were unaware of this strategy. Governance arrangements needed to improve in order to assess and manage risks. Although staff worked effectively in teams, many wanted the management and leadership of the service to improve and for the trust to prioritise PTS  alongside the emergency 999 service. Patient feedback was gained through regular surveys and there were good examples of changes to improve the service as a result, but staff did not always receive the feedback from the surveys. There had been a number of innovation and improvement projects within the service.

Updated 13 January 2015

Front-line 999 services provided an emergency response to people with life threatening emergency or urgent conditions. Overall, the trust was meeting national emergency response times to respond within 8 minutes to 75% of patients who had had a cardiac arrest, had stopped breathing or had other life threatening emergencies, and to have a vehicle that could convey the patient to hospital arrive at the scene within 19 minutes. The trust had the highest percentage of for ‘see and treat’ in the country (that is, managing patients at the scene without the need for ambulance transfer to hospital). The re-contact rate within 24 hours of this treatment was higher than the national average in 2013-14 but was decreasing.

The trust used a Resource Escalation Action Plan (REAP) as a way of forecasting performance and service delivery. There was moderate to high pressure on the service during our inspection and the trust was communicating effectively with hospitals to align conveyancing decisions against waiting times and the capacity to receive patients. This included having hospital ambulance liaison officers (HALOs) to support the timely handover and safety of patients in A&E departments, and to monitor and respond to situations, particularly at times of increased demand for services. The trust was monitoring long waiting times and had introduced measures to ensure that people were monitored while waiting and that high-priority calls took precedence. There was an impact however on people who may be in a healthcare setting but awaiting transfer to another hospital for acute care and for people at a distance from a resource centre. The trust was taking action to reduce long waiting times and projects were planned in different areas. There was effective planning and preparation for major incidents and the trust had worked effectively with partner organisations.

The service followed safety procedures overall, but needed to improve infection control practice and the management of medicines. Staff had a good understanding of the Mental Capacity Act 2005 and of safeguarding procedures although the timeliness of reporting concerns and referrals needed to improve. The performance of the external contractor to ‘make ready’ ambulances was monitored but the quality of their work required better supervision and monitoring. Ambulance crews had allocated time to check vehicles but told us they spent more time rechecking vehicles to ensure they were ready for use. The trust was affected by the national shortage of paramedics and there were a high number of vacancies. The allocation and skill mix of staff were appropriate but staff worked long hours and some reported stress and fatigue.

The trust was affected by the national shortage of paramedics and there were a high number of vacancies. The allocation and skill mix of staff were appropriate but staff worked long hours and some reported stress and fatigue. There was a rising demand for services that was above predicted levels. The trust had introduced shift changes to help manage resources to meet demand in emergency services and new rotas were being introduced to further improve the work life balance of staff. The trust used private providers to ensure service cover and these providers were appropriately monitored. Staff spoke positively about the quality of care they provided for patients and said they were proud to work for the trust. There had been a good level of communication on issues and they understood the need to match resources and demand and requested further ongoing dialogue around these issues.

National evidence-based guidelines were used to assess and treat patients. Patients experiencing a heart attack did receive pain relief although this was not always the pain relief that was nationally recommended. Patients experiencing a heart attack were transported quickly to hospital. Patients that had had a stroke had appropriate care but there could be delays in their transport to hospital. Some hospital staff identified the need for better pain relief for children in certain circumstances. The coordination of emergency care with hospitals and GPs was good overall, but needed to improve for heart and stroke care in Buckinghamshire and for mental health patients in crisis across the four counties. The trust was working with its partners and had action plans to improve care in these areas. The trust had good outcomes overall for the survival of patients who had had a cardiac arrest. The trust had improved the effectiveness of action taken when staff witnessed a cardiac arrest and was fourth best in the country this year (April to August 2014) a change from eighth best in 2013-14.

Staff were caring and compassionate. They explained treatment options to patients in a way that they, or their relatives, could understand. Patients, and relatives or carers, received good emotional support if they were in distress. There was support for vulnerable patients (such as those with a learning disability), bariatric patients and people whose first language was not English.

The trust had a clear vision and strategy for the service to provide mobile healthcare and to coordinate care in hospital, the community and people’s homes. Staff were supportive of the strategy and told us they worked well together in teams and with their managers. There were good governance arrangements to monitor performance and quality and to manage risks although more action was needed on ongoing risks. The performance of the external contractor to ‘make ready’ ambulances was monitored but the quality of their work required better supervision and monitoring. Patient engagement was well developed through a variety of channels, such as social media, surveys, newsletters and liaison work. There were many examples of innovation and improvement.