From exile to Main Street

The blueprint for regional emergency care networks could finally see ambulance services rescued from isolation, says Mary-Louise Harding

The world of emergency care is changing. After too long in 'a forgotten corner of the NHS', in the words of one chief executive, ambulance trusts are increasingly seen as the vital cog in a more integrated approach to the emergency service.

Many are working closely with acute accident and emergency departments, primary care trusts and social care providers to better manage demand, improve patient care and use resources more efficiently.

Planning for out-of-hours cover, when the new GP contract takes effect in April, is one major driver. Others play a part, including tough targets on four-hour A&E waits and response times; a greater recognition of how social care of older people affects demand; and how job redesign and working closer with GPs can mean more emergency work is done outside an acute setting.

The blueprint for regional emergency care networks is being championed by emergency access czar Professor Sir George Alberti, and has been embraced by many trusts in England and Wales. Such networks would usually involve a board with representation from A&E operation directors; PCT commissioners and planning leads; GPs; and ambulance operations and planning leads. They are looking to design better processes and more appropriate responses, for instance systems meaning that mentally ill patients calling 999 will receive specialist emergency mental health support rather than a paramedic crew.

Covering often vast areas, England's 32 ambulance trusts' catchments sweep across PCT and sometimes strategic health authority boundaries (East Anglian Ambulance trust has 17 PCTs on its 'patch', while North East Ambulance Service trust has two SHAs).As a result, most ECNs are chaired by ambulance chief executives and are administered from their headquarters.

As ECNs are currently unfunded and informal, a one-size-fits-all approach has been avoided in favour of partnership working, which suits local demand. For example, Mersey Regional Ambulance Service trust has an emergency service access team, which secured funding from local PCTs for an unplanned-care direct hotline, complete with call centre. GPs use the line, rather than 999, for less urgent cases. Trust clinical director Mike Jackson says 40 per cent of GPs succeed in finding 'an alternative care pathway for a patient other than hospital' through the specialist directory service.

Reducing unnecessary hospital admissions is the holy grail for all ECN members - not only with ambulance trusts and A&E in terms of response and treatment targets respectively, but also for acute trusts and PCTs in terms of tackling delayed discharge levels.

A high percentage of so-called inappropriate calls are generated by falls among elderly people. Surrey Ambulance Service trust has set up a 24-hour hotline to intermediate-care community medical teams to divert some of its falls calls away from hospital, when it is clear a hospital visit is unnecessary. 'Twenty per cent of emergency calls received by Surrey Ambulance Service trust involve calls from the elderly.We now have a system where we can call in the local district nurse after we have ensured the person is stable, who will set processes in motion that perhaps mean the house will be equipped to prevent the likelihood of a fall happening again, ' says operations director Gary Butson. 'This avoids the whole chain of events that is started by taking a person to A&E, and often leads to a bed-block situation.'

The bottom line for ambulance trusts is improving response times, particularly responding to 75 per cent ofcategory-A (urgent or life-threatening) emergency calls within eight minutes.

'We are particularly anxious to see ECNs developed further, ' says Ambulance Service Association chief executive Richard Diment.

'Taking fewer people to hospital and providing the appropriate treatment or referral to patients means everyone is a winner.'

Last autumn saw the launch of the much-heralded£1m Improvement Partnership for Ambulance Services initiative. Associate director Julia Taylor says a package of leadership and learning initiatives are set to run throughout the year - some of which will be open to more 'challenged' trusts, and some to the service as a whole. 'There hasn't been sufficient support for ambulance services in the past. The big challenge is working towards more wholesystems thinking in local health economies.

'One of the important priorities for 2004 is for all stakeholders to recognise that there has been an increase in demand, and the reasons need to be fully understood, ' she adds.

Part of the work being done by ECNs has been around thinking about the workforce and re-designing competencies to deal with more emergency care in the home and community. The first wave of 300 emergency care practitioner graduates from 15 pilots across England and Wales will flow into practice in April, as the new GP contract comes online.Most trusts have been concentrating on training lay responders in communities to provide mainly emergency cardio support using automatic defibrillators (see pen portrait, opposite).

Many more are needed. 'There is and will be big issues with the workforce, ' says East Anglian Ambulance trust chief executive Chris Carney. 'We are still going to be very dependent on GPs in the first few years of the new contracts, because we simply haven't got coachloads of people trained to support GPs; the transition to new ways of working to cover out-of-hours unplanned calls; and reducing inappropriate hospital admissions.'

Most people concerned with improving performance in ambulance trusts and promoting ECNs agree that more resources must go into training and workforce expansion. Some also believe that partnership working depends on ambulance and acute trusts making sure their targets, and the commissioning process behind them, complement each other rather than conflict.

Some in emergency care are arguing for individual ambulance and A&E targets to be abolished, and replaced by joint targets that set the length of time between a 999 call and a treatment decision - be that referral to a mental health helpline or transportation to a hospital bed.

However, this does raise questions of who is accountable, who holds the funding and whether it calls for standalone emergency care trusts.

Professor Sir George Alberti has talked openly about the need to give purchasing power to the networks, but It is hard to tell if his words will be translated into action this year.

Though new money will not become available for a couple of years, Mr Carney says significant sums could be moved around the system to massive effect - such as using acute money for expanding mental health emergency support. This would, in theory, mean the cost savings would follow as less beds would be allocated unnecessarily.

'The NHS is very good at finding structural solutions to problems of life - there is a danger of just rearranging deckchairs, ' says Mr Carney. 'Emergency care does cross health and social boundaries all the time, and if commissioning doesn't start to happen across organisations to reflect the true pathway that patients take, then changes will not happen - because if a PCT funds an A&E initiative but the corresponding ambulance trust fails to find extra funding, then it just will not happen.

At this year's National Institute for Clinical Excellence annual conference, Sir George highlighted the benefits of ECNs, starting with the needs of the patients rather than institutions, thereby removing the fighting between secondary and primary care over funding.He said: 'I think this is working. I think there should be funding, or at least they should be given an allocation to advise how emergency money should be spent for local populations.'

Ambulance trusts are seen as fairly neutral organisations, partly because their management teams have operated largely under the political radar for so long and therefore are not seen to be motivated by anything other than rapid emergency response.

They are therefore seen as the ideal leaders on networks by SHAs.

However, they are relatively small organisations that are already stretched.

North East Ambulance Service trust chief executive Simon Featherstone says that if the networks start to do their jobs properly, then the pressure should be relieved.

'A blue light and siren is an inappropriate response in a great deal of cases, but It is what people turn to.We need to establish ways that calls coming into 999 will be assessed, and passed onto the relevant available mental health, primary, intermediary, social or, of course, emergency care.'

PEN PICTURES ANDY REDGRAVE

Andy Redgrave was a busy paramedic operation trainer when he visited a local Heart Start community group, in the Eccles area of Greater Manchester.

The group was meeting to discuss health action zone funding for community-based basic life support training, and had purchased four automatic defibrillators to that end.

Fast forward 18 months, and Mr Redgrave is now first responder operational manager, managing 450 community responders on 38 schemes.These are based in residential areas, as well as Department of Healthfunded 'commercial sites'at railway stations, the airport and some shopping centres in the Greater Manchester area.

Much of his time is spent with local primary care trusts, training volunteers in basic first aid and use of the 'defibs'.But Mr Redgrave also chairs the national first responder development forum, where trusts from around the country share best practice and ideas to involve lay help.

The first responder community recently celebrated a£5.7m British Heart Foundation fund to train at least one defibrillator operator officer in each of the 32 ambulance trusts.

'We now have cover for most of Greater Manchester.But we need more equipment - every GP practice and shopping centre should have one. I would like to see the day when every time you see a fire extinguisher, you'll see a defib next to it.

'We also need to work with communities to encourage more volunteers to come forward - to dispel the myth created by Casualty and ER that it involves big machines making patients jump five feet in the air.'

Visit www. asa. uk. net for more information on first responders.