What is the challenge your project is going to address and how does it connect to the theme of 'How can improvement be used to reduce delays accessing health and care services'?

The urgent and emergency care system is experiencing sustained pressure, hospitals operate at capacity and discharge delays impedes system flow. ‘Handover delays’ result when ambulance clinicians and vehicles are waiting to hand over patients to emergency departments (ED). Approximately 44,000 patients experienced potential harm due to handover delays in October ’22 (AACE, 2022) but patient safety risk is highest for individuals in the community waiting for an ambulance (HSIB, 2022). Call volumes and response times have significantly increased, category 3 ‘urgent calls’ waiting over 3 hours nationally (NHSE, 2023).

Additional funding can support recovery (NHSE, 2023) but it is the redesign of services, recommended in The NHS Long Term Plan (NHSE, 2019) that will manage growing demand and provide right care, right place, first time. The challenge for ambulance services is to how to respond differently, better equip their workforce, integrate and collaborate to provide definitive care in the community.

What does your project aim to achieve?

Aiming to provide an enhanced response to individuals calling 999 with urgent care needs, the London Ambulance Service NHS Trust collaborated with community providers in South West London in September 2022. A co-designed service combined the skills and expertise of paramedics, community nurses and therapists, working together on an urgent community response (UCR) car. The service sought to streamline access to UCR services, providing care in the community, preventing unnecessary ED conveyance and potential harm from admission; predominately aimed at older individuals experiencing decompensation of frailty, falls and those needing wound, catheter or end of life care.

Initial data suggests that for patients who had fallen, only 30% were conveyed to EDs, in contrast to 70% when a standard ambulance response is provided. The UCR has a shorter response time, resulting in a reduced wait for these vulnerable patients and it is estimated that 28 ambulances are saved a week.

How will the project be delivered?

The pilot has demonstrated initial benefit and partnerships expanded to three ICB areas, comprehensive evaluation is now required to determine value and evolution of the service. Does the UCR car utilise the time and skills of community nurses and therapists to best effect or could an extended scope of practice for paramedics provide similar benefit?

This project should evaluate:

·         Response metrics

·         Service user experience

·         Patient safety, re-contact rates and outcomes

·         Value for money, realised benefits and staffing model

·         Impact on wider system and effect on community and ambulance service provision

·         Health inequality data to influence UCR car utilisation

·         Influence on workforce, professional/personal development

Funding is sought to employ the specialist skills of an evaluation lead for 6 months, to deliver an evaluation of the UCR service, cultivating utilisation of improvement methodologies. Funding will support dissemination of findings, an event and establish data metrics, allowing for sustained monitoring and service development.

How is your project going to share learning?

Formative learning from the evaluation will inform iterative enhancement and governance of the service and be shared internally to inform ongoing ambulance and community service strategy.

Summative evaluation will be disseminated widely; to the Q community, to service users via Trust websites, across service providers, encompassing stakeholders from clinician to executive level. Reaching ICBs and wider audiences via open access publication, conferences and webinars, presentations will extend across Integrated Urgent and Emergency Care and Association of Ambulance Chief Executives networks. Such an expansive approach will not only enable knowledge transfer but will allow for critical review and for community and ambulance services nationally to consider transferability and adaption for their Trusts.

Evaluation of this project has the potential to inform research studies on alternative response models and will contribute to evidence and debate regarding the paramedic’s role in the wider health system and nurses working in emergency medical services.