By Audrey Fraizer
The consolidation of England’s 33 National Health Service (NHS) ambulance services in 2006 wasn’t so much of a shock, as much as it was a realization that any combination of circumstances could result in making contact with a hydroelectric powered oscillating air current distribution device.
That didn’t happen, at least on the larger scale, although it certainly took a herculean effort to keep any of the million steps involved from bearing off in the wrong direction.
“There was a lot of work ahead of us,” said Lisa Gibbons, acting Emergency Operations Centre (EOC) Business Support manager of the consolidated North West Ambulance Service (NWAS) NHS Trust, one of 13 trusts resulting from the mergers. “Everyone knew it was coming, but that didn’t make it any easier.”
The understatement is no more indubitable than the trust’s current drive to become the world’s largest ACE by the time UK NAVIGATOR 2014 rolls around or IAED™ Accreditation Officer Beverley Logan’s complete confidence that NWAS will pull off the ACE with the clock still running.
“They certainly have had a lot in front of them,” Logan said. “But the hard work will all be worth it when their names are attached to the ACE status of the trust. I truly believe that and keep convincing them of it.”
Optimism remains the mantra during the seven years since consolidation efforts formally got under way in July 2006. NWAS is the outcome of four former independent ambulance services rolled into a singular oversight.
The four EOCs in the merger make NWAS the world’s largest ambulance service; in terms of population served, NWAS surpasses the London Ambulance Service (LAS), the former frontrunner. Headquarters for the entire NWAS Trust is in Bolton.
By the numbers, the almost seven million residents within the NWAS boundaries of the 5,500 square mile trust (roughly 1/10th of England’s total area) rely on services provided by 114 ambulance stations and 4,700 employees. There are 222 calltakers.
The impact on 9-9-9 operations cannot be understated.
The three EOCs —located in Liverpool, Preston, and Manchester—are dedicated to 9-9-9 calls, while a former center in Cumbria handles all technical and administrative issues arising within the NWAS Trust. Each control center consists of a calltaking suite and a dispatch center.
Control center staff was under immense pressure to merge operations and meet performance standards for 9-9-9 calls the trust divides into two categories: red or green calls. Seventy-five percent of all red calls must have response on scene within eight minutes from time of first ring. Green calls have locally agreed performance standards.
To get an idea of how saturated the lines can get, NWAS received 2,265 calls from midnight on New Year’s Eve until 7 a.m. on New Year’s Day 2013, of which 546 calls represented serious and immediately life-threatening incidents. On an annual basis, call volume peaks near one million. The most recent figures, from 2011, show 426,365 emergency 9-9-9 calls and 618,312 non-emergency patient transports.
Kevin Mulcahy, sector manager at the Cheshire and Merseyside EOC in Liverpool, said the call numbers are climbing, as was expected. Population growth will do that, along with public reaction to a change in emergency services. The transition of the Cumbria control center into a NWAS troubleshooting hub, for example, put people on edge until they realized that the 9-9-9 system was actually more efficient.
Consolidation was also in line with fiscal demands.
Similar to economic pressures in other parts of the world, healthcare expenses in the U.K. are increasing, requiring permanent fiscal tightening to help minimize future debt. According to the trust’s integrated business plan (2011-2016), NWAS was determined to deliver a 5% savings in 2013-2014, 5% in 2014-2015, and 4.2% in later years.
“A single, unified, integrated system could improve the quality of services and reduce costs,” Mulcahy said. “That made sense.”
And in the case of the U.K. ambulance service, at least this far into the merger, the success of fiscal consolidation and subsequent improvements to infrastructure and framework have gone hand in hand with reaching performance goals without jeopardizing patient care.
“It’s all been for the better, and we’re doing extremely well,” Mulcahy said. “Being performance driven, we hit all performance levels required. We’ve seen a huge improvement.”
It all adds up to the real reason behind the push to succeed, he said.
“It’s for the benefit of the patient,” Mulcahy said. “That’s why we do things.”
Logan calls Gibbons “the driver” behind the multiple processes always going on simultaneously.
“She is very much involved with each center and approaches them with a team mindset,” said Logan, who is, much to her delight, welcomed as part of the team. “She involves as many people as possible, and once they recognize the need and see something as a priority, the drive is set in motion.”
Gibbons regularly visits each emergency control center because best practices takes focusing on the project at hand and relevant staff.
“It’s been a team effort,” Gibbons said. “We had to build buy-in. That was probably the most important factor in this entire process.”
The consolidation, of course, has meant considerably more than shifts in boundaries and buildings.
Focus groups were organized to analyze and develop the implementation plan. The broader team created teams within each center to pull their people into the process and encourage “buy-in.” They merged policies and procedures from four centers into single plans to uniformly cover the entire trust, and, once that was done, set about the job of incorporating local control policies. Staff traded places temporarily to become more familiar with areas added to their circuit.
They rewrote job descriptions to match across the centers, corrected policies and procedures for the quality assurance process, and organized the regional team dedicated to auditing calls from the three centers; once the program is fully in place, all audits will go to Gibbons for final review. Her position as trust Business Support manager discourages favoritism and encourages transparency. The principal work remaining involves meshing local policies.
“It’s been a lot of work, a lot of pain, but as a whole, we’re doing well in the process,” Gibbons said.
Elbow grease required
Consolidation and recent efforts to organize a single QA/QI process place Gibbons in a constant travel mode to maintain contact with managers, supervisors, team leaders, and ED-Qs at each of the control centers. Although the list is long, they include Peter Ballan (Cumbria & Lancashire EOC, in Preston), Mulcahy and John Kilroe (Cheshire & Merseyside EOC, in Liverpool), and Vicky Worral and Nick Sutton (Greater Manchester EOC, in Manchester).
Cumbria and Lancashire
Ballan, sector manager for the consolidated Cumbria and Lancashire ECC, has felt the pain in a journey he said has been everything but easy.
“Changes like this take a long, long time and, at the very least, you can say it has been interesting, full of challenges,” he said.
Ballan transferred to the Lancashire Control Room in 2001 following 10 years as a paramedic for the same ambulance service. He was a supervisor at the official start of the consolidation in 2006 and has since been promoted to sector manager; he oversees operations at the control center in Preston and the support calls managed by calltakers in Cumbria. Requests for North West Air Ambulance services are also managed from the Preston center.
While the transition affected everyone on staff, the Cumbria team probably underwent the greatest impact. The center was slated for closure. The trust offered transfer options; however, the 80-mile distance between the two buildings and their familiarity with Cumbria limited the number of volunteers.
“There were no takers,” Mulcahy said.
Mulcahy was basically “on loan” to Cumbria/Lancashire, while, at the same time, accountable for Cheshire/Merseyside operations. The dual role was pragmatic: Mulcahy was involved in the 1991 merger of Cheshire and Merseyside, the first regional ambulance center in the U.K.; his responsibilities included moving former Cheshire staff to the control center in Liverpool (the Cheshire/Mersey EOC).
From that experience, he understood the impact the merger could have on staff, coupled with the empathy he felt for staff trying to secure alternative employment in the largely rural Cumbria.
“We needed to look after the entire trust and find a solution for them,” he said. “We didn’t want anyone losing a job.”
The solution kept Cumbria’s doors open and rerouted staff responsibilities. Cumbria no longer answers 9-9-9 calls; rather, the call-takers resolve non-patient issues such as vehicle defects, radio faults, and sick leave for the entire NWAS Trust. They also refer suspected cases of domestic violence and child abuse to the proper authorities. Their jobs are guaranteed.
The switch to channel all 9-9-9 calls to the EOC in Preston, Lancashire, was made in one fell swoop.
“We went live in covering both areas at the same time,” Mulcahy said.
To assist Lancashire staff in taking over Cumbria’s emergency calls, Mulcahy invited Cumbria staff to work alongside staff in Lancashire, and also sent Lancashire staff into the Cumbria community. The introduction acquainted staff with Cumbria’s distinctive geography (to expedite response) and quelled public unease over losing their local 9-9-9 control center.
Ballan said Cumbria staff initially took the transition hard.
“[The profession] takes a special breed of people,” he said. “They like making a difference in someone’s life and to lose the 9-9-9 calls was difficult. Fortunately, their responsibilities are increasing and that’s making it better for them.”
Cheshire & Merseyside
Kilroe, EOC Training and Development manager, was well familiar with the consolidation drill. He was emergency medical duty control (EMDC) manager for Merseyside Regional Ambulance Service prior to its merger with Cheshire and held that position under that combined trust until transitioning to his current position in 2005. He works under the direction of Mulcahy.
“It [the earlier merger] wasn’t too bad, in comparison,” said Kilroe, who started his career in 1985 as the leading ambulance man at Mersey Metropolitan Ambulance Service. “Merging into three centers for the larger trust was a lot more difficult.”
Kilroe points to the complexity of merging the unique qualification of each region into the one-size-fits-all policies and procedures manual. Similar to QA/QI, the trust is also considering a merger of training into one dedicated team.
“It’s more about formalizing what I already do now,” he said.
Technical demands in changing and upgrading the computer-aided dispatch (CAD) system across the trust were mind-boggling. But NWAS IT was certainly up for the task.
The first challenge was to review existing CAD systems and develop it into one system that could deliver high performance and increasing demand capacity. Failure to do so could cost lives.
“Downtime was not an option,” Kilroe said.
Each center had a different CAD system and its own records management system (RMS). The single CAD system had to be capable of transferring all data to the single RMS, and the virtual PSAP envisioned meant that the systems must operate remotely without loss of functionality.
In this virtual world, each center acts as a backup facility to take over phones and dispatching during overflow situations and has the capability to transmit on any of the other transmitters. The overflow call still appears on the CAD screen of original destination no matter which center picks it up.
“We’ve done a lot of good work and continue to do so,” Kilroe said. “But it does make for a few sleepless nights.”
Kilroe harbors no illusions for an end to changes in 9-9-9.
“Give it another 10 years and something else major will happen,” he said. “Nothing ever stands still.”
Sutton is the training manager at the Greater Manchester EOC. His list of credentials includes securing an ACE reaccreditation prior to consolidation and he has been determinedly active in coordinating technology and training components over the past seven years. For example, he developed a user-interfaced system to provide key performance indicators for control room staff and was a member of the project team implementing the new CAD system across the three control centers. He took a lead role in relocating the Manchester EOC to a new facility.
There’s no doubt he’s sincere in his claim to thrive under pressure.
“I particularly enjoy dealing with spontaneous situations requiring quick thinking and problem solving skills,” quotes his online professional vita. “I am highly motivated to succeed.”
Where it all started
Similar to the U.S., the U.K. structure of emergency response is decentralized and maintained at the local level, contrary to what the term consolidation might imply on both sides of the Atlantic. Central government gives collaborative support, and increasingly so—again similar to the role of federal government in the U.S. when requiring collective action for the states—but the emphasis lies in local efficiency in managing response.
The proposal to reduce the number of ambulance services came to a head in the June 2005 report “Taking healthcare to the Patient” by Peter Bradley, former chief executive director of the London Ambulance Service NHS Trust.
“It had been talked about for quite a long time,” Mulcahy said. “So, it was no great surprise when it actually happened. But as happens with change, everyone was wary.”
The “Bradley” report recommended reducing the number of local ambulance services by at least 50% “to ensure they have the capacity, leadership, and resources available for the delivery of effective patient care.” Clock time for response was set from the time the call connected to the control room and answered within five seconds at least 95% of the time.
A list of suggested consolidations—or, as also called, reconfigurations—released within the same year represented more of a total 66% reduction, and it was accompanied with a plan for rapid implementation of the new trust boundaries.
Aside from administrative, technological, and demographic challenges, there were also the very real piques of human nature. How do you explain to dedicated and hard working EMDs that they’re good but not quite good enough?
“This blinkered images of believing their center was the best,” Logan said. “It took a lot for the barriers to come down and work together. The larger the center, the more difficult it is because of the number of people involved.”
The challenges are far from over.
The U.K. celebrated its 75th anniversary of the 9-9-9 emergency telephone number in 2012, and you can be sure that BT Wholesale, which contracts 9-9-9 services for the U.K., will be closely monitoring the U.S. in its development of Next Generation 9-1-1 (NG9-1-1). NHS is also developing a single point of access and a single number for urgent care to use alongside 9-9-9.
The recently introduced NHS Trust Development Authority advocates locally-focused delivery and development tools for all trusts, which might seem contrary to the consolidation process.
There are also the same concerns facing emergency services internationally—changing demographics (e.g., an aging population), financial strain, and the constant pressure of a performance-driven service.
Gibbons is optimistic, even with the prospect of not quite knowing the direction healthcare delivery will take next.
“We’ve been able to get our people onboard, and that’s the most important factor in all of this,” she said. “With that in place, we can achieve whatever is in front of us.”
Logan said she keeps her eye on the receiving end.
“That’s why we do this,” she said. “It’s not about consolidation; it’s not about accreditation. It’s really lovely when you can achieve all of this but, in the end, we’re here for one reason, the ultimate receiver. Whoever rings for service, no matter where they are, will receive the best service possible.”
Taking Healthcare to the Patient, Transforming NHS Ambulance Services: http://www.solihull.gov.uk/akssolihull/images/att5718.pdf