Towards 2020: Taking Care to the Patient - Improving Access Improving Care Improving Outcomes - Aspen People
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Towards 2020: Taking Care to the Patient Improving Access Improving Care Improving Outcomes
Contents PAGE 36
Delivering
the Vision
5 YEAR PLAN
PAGE 12
Building on
Successful
Partnerships and
Collaborations
PAGE 5 PAGE 33
Introduction Our People
DEVELOPING OUR
FOREWORD FROM
WORKFORCE
THE CHAIR AND
FOR THE FUTURE
CHIEF EXECUTIVE
ABOUT US
PAGE 20 PAGE 38
OUR VISION FOR 2020 Resourcing
Towards 2020 our Plans
OUR VISION AND
ASPIRATIONS
PAGE 8 PAGE 24
Our Story so Far Delivering Improved
WORKING TOGETHER
Outcomes
FOR BETTER PATIENT CARE OUR CLINICAL MODEL
PAGE 39
Glossary
2 A Strategic Framework for 2015-2020 Scottish Ambulance Service 3
Introduction
Foreword from our
Chair and Chief Executive
The Scottish Ambulance Service recognises that Delivering the ‘2020 Vision’ requires
it has a significant contribution to make to the whole system transformation and as a Service
effective delivery of this strategy as a frontline we recognise the need to work differently to
service providing emergency, unscheduled and deliver emergency, unscheduled and scheduled
scheduled care 24/7. This five year strategic care in this context. We cannot deliver in
framework describes how we plan to do that in a isolation and will need to work effectively in
way that supports the national quality ambitions partnership with NHS Boards, Health and Social
for person-centred, safe, and effective care. Care partnerships, patients, communities, and
other public and voluntary agencies to deliver
By 2020 we aim to: this vision.
improve access to healthcare; We are committed to continuing to provide a
Scottish Ambulance Service that is flexible and
improve outcomes for patients – specifically responsive, innovative and open to learning,
cardiac, trauma, stroke, mental health, respiratory, skilled and resourced to respond to clinical
frailty and falls; need, and one that can effectively support an
The Scottish evidence a shift in the balance of care by
integrated health and social care system.
Government vision: taking more care to the patient; ‘2020’ is based on the fundamental principle
that care should be appropriate to need
“By 2020, everyone is able to live longer, healthier enhance our clinical skills as a key and
and where that care is delivered should be
lives at home or in a homely setting. We will have integral partner working with primary and
appropriate, which may not be in a hospital
a healthcare system where we have integrated secondary care;
setting. The Scottish Ambulance Service has a
health and social care, a focus on prevention, key contribution to make in terms of taking care
develop our Service as a key partner with
anticipation and supported self-management. to the patient. Our ability as a 24/7 healthcare
newly formed Integration Boards;
When hospital treatment is required, and cannot provider to provide face-to-face assessment and
be provided in a community setting, day case collaborate with other partners including diagnostics, to determine need and to treat, route
treatment will be the norm. Whatever the setting, the voluntary sector and the other blue light and/or refer patients to anticipatory or definitive
care will be provided to the highest standards emergency services as part of a contribution care more effectively is critical in supporting this
of quality and safety, with the person at the to shared services and public service reform; approach.
centre of all decisions. There will be a focus on
ensuring that people get back into their home or build and strengthen community resilience; This strategic framework “Towards 2020:
community environment as soon as appropriate Taking Care to the Patient” outlines our
with minimal risk of re-admission.” expand our diagnostic capability and use approach to delivering clinically focused,
of technology to improve patient care; and high quality care for patients, and developing
our future workforce to meet the changing and
develop a more flexible, responsive and integrated complex landscape of health and social care
scheduled Patient Transport Service. for Scotland.
4 A Strategic Framework for 2015-2020 Scottish Ambulance Service 5
Introduction
Our Vision: “Towards 2020: Taking care to the Patient”
Our Mission To deliver the best ambulance services for every person, every time
Our NHS Values Care and Compassion, Equality, Dignity and Respect,
Openness, Honesty and Responsibility, Quality and Teamwork
Our Goals To ensure our patients, Expand our diagnostic Continue to develop Evidence a shift in To reduce Develop a model
staff, and the people capability and the a workforce with the the balance of care unnecessary variation that is financially
who use our services use of technology to necessary enhanced through access in service and tackle sustainable and fit
have a voice and can enhance local decision and extended skills to alternative care inequalities delivering for purpose in 2020.
contribute to future making to enable more by 2020 to deliver the pathways that are some services “Once
service design, with care to be delivered highest level of quality integrated with for Scotland” where
people at the heart of at home in a safe and and improve patient communities and with appropriate.
everything we do. effective manner. outcomes. the wider health and
social care service.
Our SAS Way Person-centred Safe & Effective Quality and Collaborative Fair and Equitable Value driven
Outcome Focused
About us
The Scottish Ambulance Service Our air ambulance service We employ over 4,300 highly
responds to around 1.8 million undertakes around 3,500 skilled staff and operate across
calls for emergency and non- missions and we co-ordinate the whole of mainland Scotland
emergency assistance each delivery of the ScotSTAR and its island communities,
year and attends nearly 700,000 Specialist Transport and supporting 14 territorial Health
emergency and unscheduled Retrieval Service for Scotland Boards. We are helped by over
incidents. Of these over 500,000 which transfers 2,300 of the 1,200 volunteers working in
are emergencies. We transfer most seriously ill patients to roles such as community first
around 90,000 patients between specialised treatment. Our responders and volunteer car
hospitals each year and Patient Transport Service takes drivers.
respond to over 150,000 urgent over 1.1 million patients to
requests for admission, transfer and from scheduled hospital
and discharge from GPs and appointments each year.
hospitals.
6 A Strategic Framework for 2015-2020 Scottish Ambulance Service 7
Our Story so Far
“Working together
for Better Patient Care”
In 2010, the Scottish Ambulance Service Emergency and Unscheduled Care frail and elderly patients who have fallen along In April 2014, ScotSTAR, (The Specialist
published “Working Together for Better Patient with the publication of a guidance booklet and Transport and Retrieval Service for Scotland)
Care” a five year strategic framework which was A range of improvements in Pre-Hospital resource tool “Making the Right Call for a Fall” was launched, bringing together neonatal,
fully aligned to the national NHS Scotland Quality Cardiac Care have been achieved. By supporting has improved care for many non-injured elderly paediatric, and Emergency Medical Retrieval
Strategy. We have made significant progress in the development and implementation of national fallers and enabled referral into local health and Service (EMRS) teams under the co-ordination
delivering the commitments made within this pathways for Optimal Reperfusion, clinical social care systems with access to assessment, of the Scottish Ambulance Service. This provides
strategy and in redesigning the way we deliver outcomes for patients suffering myocardial prevention and ongoing care packages. Overall, a vital road and air service for critically ill
care. The Scottish Government’s 2020 Vision infarction have improved significantly. In addition, the percentage of patients over the age of 65 patients, taking the skills of specialist clinicians
builds on the framework set out in the NHS our work in partnership with NHS Lothian taken to hospital across the whole of Scotland directly to patients to enhance their treatment
Quality Strategy. to improve clinical intervention through the as a result of a non-injured fall has reduced and ensure patients reach specialist centres
development of the 3RU model (Rapid Response from around 80% in April 2012 to around 66% of excellence first time. Closely linked to this
This next iteration of our strategy, “Towards 2020: Resuscitation) has enhanced the treatment of Out in April 2014. We have had notable success we have been working with regional and national
Taking Care to the Patient”, continues to reflect of Hospital Cardiac Arrest (OHCA), contributing in Argyll, Edinburgh City, and Lanarkshire where planning to develop a major trauma network
those aspirations and positions the Scottish to an improved survival rate in adults. The rate our staff have worked alongside community across Scotland.
Ambulance Service as a key enabler in shifting for patients arriving at hospital with a pulse based teams to support management of these
the balance of care away from acute hospitals following resuscitation from cardiac arrest in patients at home and identify and refer to the As a key objective from “Working Together
into local communities and improving patients’ Edinburgh is 29% this year against a national appropriate services to put solutions in place for Better Patient Care”, we have invested
experience of healthcare. Scotland average of 18%; this is world class to prevent future falls. This work in partnership in significant development across our three
performance. with local community based teams has led to Ambulance Control Centres (ACCs), including
In “Working Together for Better Patient Care”, minimal number of patients finding the need the introduction of 24/7 clinical advisor support
we set out a vision to deliver the best patient Improving the triage and deployment of for further 999 calls. and establishing a dedicated specialist services
care for people in Scotland, when they need us, appropriately skilled staff and vehicles to ensure and trauma coordination desk improving the
where they need us. Underpinning this aim was patients suffering hyper-acute stroke get to In 2013/14, we tested new care pathways for response to major incidents and major trauma.
to: improve patient access and referral to the definitive care first time within 60 minutes has patients with Chronic Obstructive Pulmonary These developments have dramatically improved
most appropriate care; deliver the best services also been a key priority and we have made Disease (COPD) and Mental Health across telephone answering standards and the
for patients; and engage with our partners and good progress in achieving this outcome. We Edinburgh City with evidence of positive effectiveness of our dispatching of ambulances.
communities to deliver improved healthcare. have secured funding to enable us to engage outcomes for patients, reducing avoidable
Since the publication in 2010, we have made more effectively with local Stroke Managed Care attendances at A&E and managing treatment of
significant progress and have successfully Networks, streamlining and improving access to the existing condition at home with paramedics
delivered a number of key improvements under specialist care for stroke patients. operating as part of an integrated healthcare
the direction of the following five strategic team. We also continued to develop our
programme boards. We continued to work in partnership with capability to offer safe and more effective care
NHS Boards through Community Healthcare to patients who suffer from dementia. A
Partnerships (CHCPs) in 2013/14 to further number of staff have now completed Alzheimer
embed the national framework for frail and elderly Scotland’s dementia champions training
patients who have fallen, which was developed programme and this was recognised at the
in partnership with the Long-Term Conditions Alzheimer Scotland National Award Ceremony
Collaborative in 2012/13. The development of a in September 2013. Training for all staff in
good practice guidance for the management of dementia will continue during 2015/16.
8 A Strategic Framework for 2015-2020 Scottish Ambulance Service 9
Our Story so Far
Scheduled Care Engaging with Communities e-health
Within Scheduled Care we undertook a national As part of our Community Resilience strategy We set out some ambitious aspirations to enhance our use of
redesign and reconfiguration of our Patient we introduced new and innovative models technology, and in terms of tele-health and diagnostic capability,
Transport Service, establishing a new direct of care in partnership with communities to to be operating at the leading edge.
patient booking line and investing in mobile enhance resilience, for example, the Emergency
technology across our fleet. We enhanced our Responder Model in West Ardnamurchan Over the past five years we have succeeded in:
systems and processes to better understand and the Retained Service model in Lerwick.
and respond to patient needs, and continued to In partnership with British Heart Foundation, successfully developing and testing an electronic patient record
work with our partners in health and social care dedicated Community Resuscitation Development interface to transfer patient records to GP practices;
and beyond to improve planning and access Officers have been established in each of our
to alternatives where an ambulance is not operational management divisions to support developing and testing the concept of near-patient testing for
required. We have steadily improved the quality, the extended use and awareness of community cardiac patients in NHS Borders and remote diagnostics for
performance and efficiency of this service over public access defibrillators and to continue suspected Sepsis in NHS Forth Valley;
the past five years and our patient feedback to grow and develop the Community First
indicates a very high level of satisfaction with the Responder Schemes and volunteers across successfully updating the technology within our Ambulance Control
service provided. There is, however, more to be Scotland. Our Community First Responder Centres to enable our three geographically based control centres
done and we will continue to work with patients Schemes across Scotland have grown from 82 to operate as one virtual centre;
and partners to build on these improvements, to 127 over the past 5 years with over 1,200
particularly supporting discharge planning, active volunteers and partners such as RAF investing in technology to significantly improve the business
greater integration of alternative transport and Scottish Fire and Rescue Service operating continuity arrangements within our control centres;
solutions and continuing to improve patient these schemes. We have worked with British Red
experience. Cross and British Heart Foundation to develop introducing new state of the art technology in all of our
training and support for these volunteers. ambulances and invested in scheduling software to improve
productivity and efficiency and ultimately provide more responsive,
Whilst we respond to an emergency almost every punctual services to patients within our scheduled care service;
minute of every day and many simultaneously, and
Doing the Right Thing – Our Organisational occasionally a more disastrous, complex or
Development Programme hazardous incident occurs, often involving working in partnership with the Digital Health Institute to develop
multiple patients, which requires a greater our future mobile tele-health platform.
Delivering the commitments of “Working degree of specialised response and co-ordination
Together for Better Patient Care” could not have with other emergency organisations. This can
happened without significant development of include a wide variety of circumstances for which Whilst we have made considerable progress, we recognise
our workforce. In 2011, the Service moved its the ambulance service must be prepared, such the scale of transformation required to deliver the ‘2020 Vision’
training facility to an Academy within Glasgow as major transport accidents, firearms incidents, and acknowledge that we cannot achieve this in isolation. 2020
Caledonian University and developed the BSc in chemical and biological releases, explosions, requires whole system change and we have a vital role to play
Paramedic Practice and Specialist Practitioner public disorder situations, pandemic outbreaks, in supporting that change in partnership with NHS Boards,
Critical Care role initially to support the work of industrial accidents, incidents at crowded other care providers, patients and communities. In this strategy,
the Air Ambulance and Retrieval Team. Creating locations, extreme weather, acts of terrorism and “Towards 2020: Taking Care to the Patient”, we are aiming to
a culture of Continuous Quality Improvement many more. Specialist paramedics and support build on the achievements made so far and to work within an
and Safety has been a key priority and, as a staff from the Special Operations Response integrated health and social care system to see and treat more
partner in the Scottish Patient Safety Programme, Teams (SORT) have been active at many major patients safely and effectively at home where appropriate to do
we made improvements in the recognition and incidents, working together in partnership so, and where this is not the most appropriate outcome, to work
management of deteriorating patients, including with other emergency services and providing with others to develop and access appropriate care pathways
the use of early warning scores and screening care within hazardous environments such as to ensure patients get access to the right care in the right place
for Sepsis. We also led the development of collapsed buildings and structures, accessing first time, every time.
a Paediatric Early Warning Score supported patients in severe weather including snow and
nationally by Scottish Patient Safety Programme flooding, and undertaking the movement of
Clinical Fellows. patients with suspected infectious diseases such
as viral haemorrhagic fever.
10 A Strategic Framework for 2015-2020 Scottish Ambulance Service 11
Building
on Successful
Partnerships and “I am delighted with the service
Collaborations provided by the ASSET team. Being
an older lady I am very reluctant
to go into hospital so was relieved
when my GP informed me of this new Developing an face-to-face assessment with
patients, participating in a
service. All involved from the initial GP ASSET based ‘virtual’ ward, referring patients
phone call to the Paramedics, nurses,
physiotherapist and consultant were approach directly to the team where a trip
Taking more care to the patient to hospital is not appropriate,
attentive and caring. Being cared for in
by 2020 will require Scottish and treating and monitoring
the comfort of my own home without a The Scottish Ambulance
Ambulance Service to continue to patients in their home. Already
doubt helped my recovery. My family Service has been working with
strengthen existing partnerships the ASSET pilot is demonstrating
and I were most impressed by the NHS Lanarkshire to support
and to collaborate effectively as real benefits for patients and
service which felt like a virtual hospital the development of their Age
part of an integrated health and improved multi-disciplinary team
ward in my own home. I am extremely Specific Service Emergency
social care system to design new working.
grateful for this and thank ALL the Team (ASSET) model for frail
innovative models of care designed
NHS staff involved. I am sure others and elderly patients (over 75s)
around patient needs. The learning Our aim by 2020 is that our
will find this service beneficial also.” in North Lanarkshire.
from recent pilot projects and Paramedic Practitioners are able
collaborative work across Scotland to work as a key component
The ASSET team aims to
will continue to be tested, and of integrated multidisciplinary
manage patients care at
evaluated. Where there is evidence teams, but also as autonomous
home and avoid unnecessary
of success and improved outcomes practitioners where appropriate,
admissions to hospital. This is
for patients, plans will be developed supporting care in local
done by a team of practitioners,
to spread this good practice across communities. They will be
including Paramedic
Scotland where safe and appropriate experienced in Care of the
Practitioners, with consultant
to do so. Elderly and will be educated
support. The team accepts
and trained in areas of minor
referrals directly from GPs
The following examples highlight ailment and minor injury.
and from Scottish Ambulance
some recent joint initiatives that are They will be able to carry an
Service following a 999
already beginning to demonstrate extended range of medications
response. Thereafter patients
the effectiveness of new ways of including antibiotics, painkillers
are assessed at home, treated
working in partnership with others in the appropriate circumstance
and monitored where it is safe
and support our vision for 2020 to prescribe, avoiding many
and clinically appropriate to
take more care to the patient. unnecessary journeys to
do so. ASSET will also review
hospital. They will also provide
patients admitted to hospital
internal professional-to-
to identify those that can be
professional decision support
treated appropriately at home
for other ambulance clinicians
managing their early discharge
supporting staff to see and treat
and follow up care. Scottish
more patients presenting with
Ambulance Service has two
minor injuries and illnesses.
Specialist Paramedics working
as part of the ASSET team,
undertaking
Mrs Rose Gillespie (centre)
12 A Strategic Framework for 2015-2020 Scottish Ambulance Service 13
Building on Successful Partnerships and Collaborations
Making the Right most frequent single ‘diagnosis’
presenting to the Service for
Call for a Fall this group of patients, and,
typically, we take 80% of them
The needs of patients across to hospital due to a lack of
Scotland are changing, with easily accessible alternative
the population of over 75 year pathways. Over the last three
olds in Scotland due to increase years we have been working
by approximately 25% over in conjunction with Health and
the next 10 years, and the Social Care services to develop
number of people with multiple integrated pre-hospital pathways
and complex conditions also to make sure frail and elderly
continues to grow. Many elderly patients are provided with We aim to build on this
patients have a combination the right care at the right time collaborative approach
of physical, cognitive and following a fall. and to develop better
functional impairments that access to more local care
increase their risk of a fall. The introduction of a number pathways and services for
This situation can be caused of specialist falls teams across those frail elderly living at
by common and reversible Scotland means we are now home with multiple and
problems such as a chest or able to refer patients into more complex long term
urine infection, side effects alternative pathways either at conditions.
from medicines, or by a flare the point of taking the call or
up of another condition. Whilst following ambulance attendance “Over the last six months I have
some of these issues may and help them get the care fallen three times. The ambulance
require prompt assessment they need. All of this has been was called to attend as I was unable
and treatment, often this can supported by an increase in to get up myself. My experience
be done quickly by integrated the amount of intermediate has been that I received excellent
teams visiting patients in their care services across Scotland. attention from the ambulance staff
own home rather than a patient Ambulance Clinicians can now that checked me over for injuries
having to attend an acute access alternative pathways to before lifting me up using an air
hospital. community health and social cushion device. After this they
care services in many localities, referred me to the local community
We have recognised that we with those services covering based falls team to reassess my
play a key role in making sure both immediate interventions needs, help manage my diabetes
that when providing high quality and follow up assessment. This and support me to stay at home.”
clinical care to elderly patients approach clearly demonstrates
Mr Harold Gillespie
who have fallen, we help them the benefits of an integrated
to access the care they require. health and social care response.
We respond to around 45,000
calls each year where people
aged 65 years or older have
fallen. This represented the
14 A Strategic Framework for 2015-2020 Scottish Ambulance Service 15
Building on Successful Partnerships and Collaborations
Supporting NHS
Lothian’s Discharge Hub
In 2011, during the early stages of implementing
the Scheduled Care Programme, we embarked on
a collaborative programme of work to support NHS
Lothian with the development of a Transport Hub to
coordinate all ambulance transport services across
NHS Lothian hospital sites for patients returning back
to a homely setting, following discharge from hospital,
or being transferred to other hospital sites for ongoing
care. This collaboration has provided a mutual benefit
for Scottish Ambulance Service and NHS Lothian. It
has supported us to improve the effectiveness of our
scheduled care service in delivering a high quality
and patient-centred service to those patients with a
clinical and medical need for ambulance transport, “We aim to grow this
and has supported NHS Lothian to improve the flow model by 2020 to support
of patients through their hospital sites. unscheduled care in the
community particularly in
the out of hours period.”
Specialist Paramedic Model
Scottish Ambulance Service has been working with NHS
Western Isles for a number of years developing the
Specialist Paramedic model. Specialist Paramedics are able
to see and treat patients both as part of the out of hours
community team and working within the minor injuries unit
“We aim to continue at the local hospital. The enhanced skills of the Specialist
to support this model Paramedics means they can operate more autonomously
in NHS Lothian and and are able to access alternative care pathways directly.
across Scotland to Because they carry an extended range of medicines,
ensure we are able to they are able to offer a greater range of treatment and
support the effective interventions directly for patients, resulting in fewer
flow of patients in and avoidable A&E attendances. These Specialist Paramedics
out of acute hospitals.” are engaged with the GP community, are able to access
decision support from GPs and request follow up visits to
the patient from the GP. There are clear benefits to patients
with this model, increasing likelihood of being treated safely
at home but additionally, freeing up hospital resources and
enhancing the skills of paramedic staff.
16 A Strategic Framework for 2015-2020 Scottish Ambulance Service 17
Building on Successful Partnerships and Collaborations
The Ambulance of 2020 The future of Ambulance Technology
ePRF On-board Mobile Broadband
Communications Hub Communications
Modern, app-based, electronic
Patient Reporting Form. Hosted Provides all routing for data to Array of antennae providing
A mobile Health Facility on the on-board tablets, with
automatic data input from
and from the ambulance. Acts
as a wi-fi router for peripheral
2G, 3G and 4G mobile and
wi-fi signals. Provides fast
medical devices through the devices and aggregates cellular mobile communications to
Communications Hub. Capable signals to provide increased ACC and other healthcare
of being shared at a multi-crew bandwidth. facilities, enabling video
The ambulance of the future Our aim is to evaluate the incident. streaming and web access.
aims to give our staff access electronic transfer of patient Physically connected to the
to: key patient information records to acute and primary Communications Hub.
(such as the Key Information care services and to work with
Summary, Anticipatory Care Health Boards across Scotland
Plans, Palliative Care Plans etc.); to roll this out.
clinical guidelines; integrated
diagnostic devices; and the This facility will be beneficial
capability to exploit advances in transferring clinical
in decision support which information for those patients
rely on technology, (e.g. video requiring urgent care on arrival
conferencing, electronic access at hospital, such as stroke,
to patient records). cardiac arrest or major trauma,
but also in communicating with
These developments will GPs where patients with multiple
enable us to work together long term conditions have been
with health, social care and seen and effectively treated in
emergency service partners to their home by our paramedic
deliver the best outcomes for practitioners.
patients in terms of improved
care and safety. Our aim is also to explore and
exploit remote diagnostics,
During 2014 we tested the near patient testing and the
transfer of the electronic Patient use of tele-health within our
Report Form (ePRF) from the ambulances. Recent testing of
ambulance to GP practices troponin levels in patients with
in NHS Greater Glasgow and suspected myocardial infarction
Clyde. We also trialled the within NHS Borders will be
process of transferring the evaluated and a range of other
record from the ambulance diagnostic equipment such as
to the receiving Accident and ultrasound will be assessed for Rear Tablet Medical Devices Front Tablet
Emergency department as a use in a mobile environment
Used by crew to access Situated in the rear of the cab, Primarily used for satellite
pre-alert prior to the arrival of as part of an integrated model
incident information, ePRF, providing analysis tools for navigation and providing
the patient. supported by senior decision
web, ECS/KIS and back office Clinicians. Linked to ePRF via incident information for
support.
systems (Intranet, workforce the Communications Hub so allocation and mobilisation of
planning, incident reporting). that data from the device will the vehicle. Also allows crew
Linked to medical devices auto-populate the ePRF. to update the CAD using status
via the Communications Hub. messages and access a range
Integrated SIM providing data of other software.
communications when out of
wi-fi range.
18 A Strategic Framework for 2015-2020 Scottish Ambulance Service 19Towards 2020
Our Vision and Aspirations
The Scottish Ambulance Service recognises the key role it has Achieving these aims will require investment in developing the capability and skills within
to play as a frontline service, in supporting the effective delivery our staff, in new technologies and innovation to our workforce, fit for the future role of the
of the Scottish Government’s 2020 Strategy. realise our ambitious aspirations, including: Service within an integrated approach, flexible
and sustainable and with the right leadership to
This strategic framework aims to set out our vision for the working with our partners across health and drive a culture of innovation, co-production and
development of our service as we move towards 2020 and social care to develop alternative care pathways improvement;
describes the key actions required to deliver that vision. There are which reflect Scotland’s commitment to shifting
some core over-arching principles which underpin all our work. the balance of care towards communities. The continuing to develop our scheduled care service
overarching principle is to improve outcomes and in partnership, recognising the expectation on
In summary we aim to: patient experience ensuring those pathways direct NHS Boards to transform the delivery of outpatient
patients towards the most appropriate definitive services, support effective discharge and transfer
enable a tangible shift in the balance of care away from acute care first time and prevent avoidable hospital of patients, to support patient flow across the
hospitals by equipping the Service to deliver more care at home attendances and admissions; whole healthcare system, and deliver a better
or in a community setting where safe and appropriate to do so; experience for patients.
aiming to use our status as a 24/7 mobile
deliver care that ensures high quality outcomes for patients, healthcare provider to enhance our contribution building on our strengths as a national
is person-centred, safe, and improves experience; to wider NHS as part of an integrated health and organisation to offer “Once for Scotland”
social care service, delivering the highest quality solutions to particular challenges such as
enhance decision support further to ensure effective, safe decision of emergency, unscheduled and scheduled care demand management, resource deployment
making at all stages of the patient journey; for patients; and primary care; and
develop a workforce educated, trained and enabled to deliver the striving to improve safety and effectiveness adopting an integrated approach to transport
service model; and to support our staff with clinical assessment to healthcare ensuring that patients with a clinical
and decision making skills appropriate to meet need are able to access ambulance transport
work in partnership to achieve a service model that is integrated the needs of those patients with complex long to hospital. However, it is vital that patients who
with communities and with the wider health and social care service; term conditions and multi-morbidities, supported do not require our help are still able to access
by access to enhanced senior clinical decision- appropriate alternative transport provision. We
fully engage our staff, our partners and the people who use our recognise that we have a role to play in ensuring
support and technology solutions to make safer
services to design models of care that meet the needs of the people that access is as seamless and straightforward for
decisions with and for patients;
of Scotland and reduce health inequalities; and patients as possible. We will continue to work with
embracing the shared values of the NHS in our partners in NHS Boards, Regional Transport
develop a model that is sustainable and fit for purpose in 2020.
Scotland in everything that we do to ensure Partnerships, and others to support the improved
our service is designed to deliver care and co-ordination of health and social care transport
compassion, dignity, equality and respect, resources and, where appropriate, explore
openness, honesty and responsibility, quality opportunities to link systems and technology to
and teamwork; facilitate this.
20 A Strategic Framework for 2015-2020 Scottish Ambulance Service 21Towards 2020
Building on the achievements made during the prioritise investment in enhancing the clinical
lifetime of “Working Together for Better Patient decision support available to our frontline staff, in
Care” our aims going forward are to continue technology solutions and advanced clinical skills
to build on the strong foundations laid between within our Ambulance Control Centres to support
2010 and 2015 and to: safer, more effective, person-centred decision
making;
make further improvements in pre-hospital
cardiac care by leading a national programme of work in partnership with NHS Boards to provide
improvement for out of hospital cardiac arrest and an efficient and effective ambulance service for
in doing so continue to improve survival outcomes those patients with a medical need for ambulance
for patients; transport and to work in partnership with other
community transport providers to improve access
work with external partners and the national to alternative transport solutions within localities
Stroke Managed Care Network to improve where the need is social and geographical;
outcomes and access to specialist care for stroke
patients; strengthen the expertise and support provided by
our Specialist Operations Response Team and
work with the newly established Integrated Joint support the wider NHS by sharing this specialist
Boards to embed the guidance for frail and elderly expertise.
patients who have fallen with an aim to improve
outcomes for people who have fallen and help develop our education model further, to provide
prevent people falling in the future; more comprehensive care at the point of contact
for our patients and offer new role opportunities
continue to develop access to local services for our staff alongside other Allied Health
and intermediate care services through the Professionals and nurses;
development of new care pathways with a focus
on respiratory disease and mental health as extend our work with partners in local communities
two of our top priorities for further care pathway to build stronger safer communities and strengthen
development work in 2015/16; resilience particularly in those hard to reach
localities;
continue to provide an improved person-centred
response to those patients suffering from invest in technology to develop enhanced
dementia and requiring care from the Service diagnostic capability and where necessary a
within our scheduled, unscheduled and emergency reliable interface to share clinical information to
care service; enable our Service to operate as an effective
integrated provider of unscheduled care; and
further develop ScotSTAR as a national service
to improve outcomes for those patients requiring contribute to the national Scottish Patient Safety
a specialist response and implement new trauma Programme with a focus initially on developing
pathways; diagnostic testing on scene for patients with
Sepsis and Chest Pain, but moving to a holistic
patient safety programme that covers all
of our activity.
22 A Strategic Framework for 2015-2020 Scottish Ambulance Service 23Our Clinical Model
Delivering Improved
Outcomes
The operational environment development of specialist The Scottish Ambulance The Scottish Ambulance every time, we need to do a the focus towards providing
for the Scottish Ambulance centres of care for specific Service is an integral part of Service has historically delivered number of things over the next the most appropriate response
Service is changing in response clinical conditions, such the healthcare system and, as a traditional ambulance service five years to: based on clinical need,
to the wider strategic context as stroke, PPCI (specialist such, we are developing our model with a bias towards including;
and there are a number of key cardiac treatment) and major clinical model to reflect the taking patients to hospital create the right conditions for
drivers for change that are trauma, which affect traditional need for greater integration and delivery of response change and equip our clinical an aim to increase the level
determining the design of our boundaries and patient flows; with key partners, and to seize time targets. In recent years, workforce with the skills, capacity of ‘hear and treat’ through
future model of care, including: the opportunity to develop however, we have looked and capability to deliver more improved telephone triage,
public sector reform and the and utilise the full breadth of to develop new roles and care at home; clinical intervention and referral
demographic challenges of an drive for efficient and effective enhanced paramedic practice models of working; to date to alternative pathways at the
increasingly elderly population use of NHS resources and along with the opportunities these have been small scale work in partnership to develop point of the initial telephone call;
living at home with multiple sharing services across public technology affords to better and predominantly focussed integrated care pathways,
and more complex long term sector particularly collaborating manage, diagnose and treat around local initiatives. The supported by senior clinical an aim to increase the level
conditions; with other emergency services, patients in an out of hospital current service model is largely decision support and access to of ‘treat and refer’ following
i.e., police and fire; environment. weighted, with the intention of alternative pathways for those face-to-face assessment by an
the clearly stated aims of being risk averse, to delivering a patients who do not require appropriately skilled paramedic
the ‘2020 Vision’ to redesign the need for a flexible and Whilst demand for our services response based on an 8 minute emergency care within an acute or other healthcare professional
emergency, unscheduled and responsive workforce working continues to increase, we Category A target, with a desire hospital environment; and with access to enhanced
scheduled care services across across an integrated health recognise the role we can to secure a timely response to decision support and alternative
the NHS to shift the balance and social care environment; play in influencing the flow patients in cardiac arrest or in ensure we have the right referral pathways;
of care away from traditional of patients across the system an immediately life threatening mix of skills and resources
acute hospital environment to developments in technology across Scotland to deal with an aim to ensure patients are
through integration with wider condition. That model does
community based, day case which facilitate remote increasingly complex needs of treated in the right place first
health and social care services. not support our future strategic
and increasingly planned and diagnostics and enhanced patients, including specialist time and in doing so reduce the
The challenges of providing vision. Current analysis shows
anticipatory care; decision support and information teams and fulfilling our statutory number of patients unnecessarily
sustainable services can only that only 5-10% of patients who
sharing to improve patient care; responsibilities under the Civil taken to Accident and
be met through increased call 999 have an immediately
greater health and social care integration and effective life threatening condition and Contingencies Act. Emergency and improve value
integration in designing and opportunities to work more through greater integration of
partnership working. As a therefore require that 8 minute
delivering services that are closely in partnership with services, skills development and
national service operating 24/7, response.
sustainable and person-centred; communities and voluntary At its heart, this new clinical access to more appropriate care
we are ideally positioned to
organisations; and model seeks to place quality pathways; and
support the change necessary In addition under the current
challenges to the sustainability outcomes for patients at the
a need to work with partner across the whole system and clinical model only 3 or 4
of traditional services and heart of its decision making. a commitment to delivering
organisations and communities to deliver frontline emergency patients out of every 10 require
operational models, not least This means that engaging some services “Once for
to address health inequalities. and unscheduled care in an the services of Accident and
GP out of hours, across the with patients, carers and Scotland” where there is tangible
increasingly responsive, person- Emergency or require admission
NHS, most acutely in rural other providers of health evidence of benefit and value to
centred and efficient manner. to hospital yet 8 out of every
Health Board areas; and care services to deliver the system as a whole.
10 are conveyed to hospital.
outcomes that matter to people.
In order to redress the balance
Our emerging clinical and
and ensure patients get to the
operational model aims to shift
most appropriate care first time,
24 A Strategic Framework for 2015-2020 Scottish Ambulance Service 25Our Clinical Model
SAS Clinical Model Immediately Life Threatening
Patients whose condition is potentially life-threatening and a
fast response is vital. This accounts for less than 10% of 999
calls received. These patients will be responded to by skilled
paramedics and will normally be taken to A&E or specialist
IMMEDIATELY LIFE care. An example would be a patient in cardiac arrest.
THREATENING
Urgent and Emergency
SAS TRIAGE URGENT & EMERGENCY HOSPITAL Some emergency and urgent calls will also require a quick
& DISPATCH NON LIFE THREATENING response and conveyance to hospital i.e. GP calls and non life
threatening emergencies.
Hear, Treat & Refer
Patients whose condition is not serious enough to require
an ambulance to attend or likely to result in any need to go
HEAR, TREAT & REFER SPECIALIST/ to hospital. These patients can safely be given telephone
ADVANCED advice by a paramedic, referred onto NHS24 for further advice
PARAMEDIC or referred onto another service, such as a GP. An example
would be a person with flu like symptoms.
ALTERNATIVE CARE
PATHWAYS
See, Treat & Refer
INTEGRATED
SEE, TREAT & REFER Patients whose condition requires face-to-face assessment
COMMUNITY CARE
TEAMS by a skilled paramedic but, in many cases, may be safely and
effectively treated by that paramedic at scene without any need
ANTICIPATORY CARE PRIMARY AND to go to hospital. Alternatively, these patients may be referred
SOCIAL CARE directly to more appropriate services. An example would be
EMERGENCY an elderly patient who has fallen but is uninjured who could be
AMBULATORY referred onto a specialist community team and their care could
ROUTINE CARE be managed at home.
DISCHARGES INTERMEDIATE
CARE Anticipatory Care
TRANSFERS
MINOR INJURY Patients living with one or more long-term conditions whose
SCHEDULED CARE
UNITS care can be managed proactively at home, where a package
Figure 1: SAS Clinical Model
of care has been put in place to support patients to stay
GP OUT OF HOURS at home. Specialist paramedics can help deliver this care
OTHER HOSPITAL package working alongside colleagues in health and social
SERVICES & care. An example would be a patient living with Chronic
Figure 1 illustrates the key components of the new clinical and offers some examples within DIRECT ACCESS TO Obstructive Pulmonary Disease whose acute exacerbation
each of the identified patient flow groups. SPECIALIST CARE requires urgent care.
Our developing clinical model better reflects the needs of patients and aims to ensure we send the right Non-Emergency (Scheduled Care)
response to meet that need. Our aim is to improve how we assess and triage patients’ condition on the
telephone. We may take a little more time to do this once we have established the patient’s condition is Patients who require to be admitted or discharged from
not immediately life-threatening, to ensure we send the right staff with the most appropriate skills. Where hospital, or transferred between hospitals for further treatment
patients do not need to go to an emergency department, our skilled paramedics may treat them at home and patients attending hospital for a scheduled outpatient
or access a more appropriate care pathway. In some cases, we might refer patients directly to specialist appointment. These patients do not normally require the skills
services. We will work as part of an integrated health and social care system to access the right care of a paramedic and are in a stable condition. An example
first time for patients. would be a patient admitted for elective surgery or attending an
outpatient appointment where ambulance transport was required.
26 A Strategic Framework for 2015-2020 Scottish Ambulance Service 27Our Clinical Model
Building this model by developing our paramedics effectively supporting the flow
2020 will require: to operate confidently at the of patients both in unscheduled
full scope of their practice, and scheduled care, where the
more effective triage of all making the best possible right response will be determined
calls, including those from other clinical decisions with and for by the needs of patients and the
healthcare professionals and patients, which will result in traditional demarcation between
agencies. We must continue fewer avoidable attendances at emergency, unscheduled and
to ensure rapid identification accident and emergency, where scheduled care services will be
and response to immediately safe and in the patient’s best removed within the concept of
life-threatening calls and those interest to do so; ‘one ambulance service’;
requiring a specialist operational
response, whilst recognising increasing the number of development of our mobile
that these account for less than patients treated at home, tele-health infrastructure to
10% of demand for our service. including those with minor increase capacity and capability
Nevertheless, it is vital that our injury and illness; for near patient testing and
response is fast and a crew with remote diagnostics; and
a paramedic present is available increasing direct conveyance
to respond and convey the to specialist departments all of these actions will be
patient to the most appropriate such as trauma, stroke and developed within a robust and
healthcare facility. Alternatively, orthopaedics and linking in effective governance framework,
where the call is not immediately with other services across ensuring that patients are
life-threatening, that we are able primary care and community protected and that there is
to determine the level of clinical based teams and networks evidence for the safe and
response more effectively; to route patients to more effective implementation of
appropriate care; these new ways of working.
effective clinical supervision
and senior decision making working with NHS Boards and
in our Ambulance Control partners to develop better and
Centres to strengthen decision more consistent access to
making, call management and professional-to-professional
response and, more especially, senior clinical decision support
to provide clinical telephone and direct access to local care
advice or onward referral to a pathways and intermediate
more appropriate service to care services where clinically
patients who do not require an appropriate;
ambulance;
embedding specialist and
advanced paramedic practitioner
roles within integrated and
multi-disciplinary teams working
effectively in partnership with
colleagues in primary care, out
of hours, secondary and acute
care and in the community;
28 A Strategic Framework for 2015-2020 Scottish Ambulance Service 29Our Clinical Model
Responding to Patient Flows Acuity Response/skills
Figure 2: Responding to Patients’ needs
Patients’ needs
Immediately Life Threatening Immediately life threatening Paramedic/Specialist paramedic
Delivering this clinical model These patients need a rapid paramedic response. We will
will require a fundamental shift 8 minute response Conveying resource
dispatch an additional paramedic responder and an ambulance
in how we respond to calls and to these patients as evidence shows additional support saves
significant development of the lives as does getting to hospital as quickly as possible. An
current and future workforce in example would be a patient in cardiac arrest. We may also
a way that is more responsive deploy specialist teams to retrieve some patients or deal with
to the needs of patients and major or hazardous incidents.
the severity of their condition.
Being sophisticated enough
to deploy the right resource to Serious but not Immediately Life-Threatening Time-critical Conveying resource
those patients based on more
effective clinical triage is also These patients require a paramedic response and will generally
Urgent GP admissions Paramedic plus support
required. need to go to hospital. We will dispatch an ambulance with a
and hospital transfers
paramedic on board. Whilst their condition is not immediately
Our response to patients aims life-threatening, time can still be important and make a difference
to always dispatch the right to the outcome. An example would be a patient having a hyper-
skills to deal with the severity acute stroke who needs to be at a hospital with a CT scanner
of the patient’s condition within an hour.
based on improved triage.
We are therefore moving from
a response which is biased See, Treat & Refer Non time-critical Specialist paramedic/Paramedic
towards hospital attendance to These patients require a paramedic response but our aim would
one where our staff are skilled to Face-to-face assessment Enhanced minor injury/illness
be to treat as many of them safely at home as possible. We will
treat patients at home and refer dispatch a paramedic, with advanced assessment skills and in
directly to more appropriate some cases a specialist paramedic, able to treat minor injuries
services as part of an integrated and minor illness and if necessary access appropriate care
health and social care system. pathways as an alternative to hospital. An example would be a
This model will be supported diabetic patient or a patient with an exacerbation of an existing
by a number of specialist teams long term condition.
able to deal with complex
or hazardous situations and
stabilise and retrieve critically Hear, Treat & Refer Low acuity 999 calls Clinical advisor in
ill patients. We will also continue Ambulance Control Centres
to develop our network of These patients do not require an ambulance to attend and are
Calls passed to NHS24
community first responders and unlikely to need to go to hospital. We may transfer some patients
Paramedic level
work with volunteers, including to NHS24 or to our paramedic clinical advisors who will offer
other healthcare professionals, advice, telephone assessment and directly refer patients to a
to build and strengthen more appropriate service. An example would be a patient with
community resilience. a minor ankle injury which could be seen by their GP. On some
occasions, where circumstances or patient vulnerability require it,
we may still dispatch an ambulance with a paramedic on board.
Non-Emergency Scheduled care Conveying resource
These patients need to be admitted to, discharged from,
Low acuity urgent-discharge/ Enhanced Ambulance Care
or transferred between hospitals. This will also include some
transfers Assistant, Basic Life Support,
scheduled care outpatient and day care activity. These patients
oxygen, Automated External
do not require a paramedic and will generally be responded to
Defibrillator.
by a scheduled care ambulance.
30 A Strategic Framework for 2015-2020 Scottish Ambulance Service 31Our People
Developing our
Workforce for the future
As we move towards 2020, the Scottish Ambulance Service
faces a number of challenges which influence the future workforce
required to deliver the 2020 Vision. In developing our strategic
workforce plan, we have sought to align our commitments with
those set out in the 2020 Workforce Vision below, and to ensure
we develop a workforce capable of delivering the highest levels
of quality service and clinical, person-centred care, in line with
the NHS Quality Strategy.
The emerging model of care described above clearly requires
development and re-profiling of our current workforce and
investment in new roles and enhanced skill sets. It is also clear
that the challenges faced in some areas of Scotland may require
us to develop a flexible workforce model that better supports
person-centred care and reflects those specific needs, for
example, by adapting local pathways or developing an urban
and a rural model, recognising that one size may not fit all.
Our aim is that by 2020, the workforce within Scottish Ambulance
Service will provide:
Everyone Matters:
2020 Workforce Vision all staff working to their full scope of practice, skills, knowledge and
experience, supported by Personal Development Plans and enhanced
learning opportunities;
“We will respond to the needs of the people we
care for, adapt to new, improved ways of working, increased levels of specialist paramedics, many
and work seamlessly with colleagues and partner of whom will operate as part of an integrated health and social
organisations. We will continue to modernise the care team, managing patients, primarily with long-term conditions
way we work and embrace technology. We will in the community, able to provide treatment at home with direct
do this in a way that lives up to our core values. access to alternative pathways if required, and able to provide
Together we will create a great place to work and additional face-to-face assessment for those patients without an
deliver a high quality healthcare service which is immediately life-threatening condition who do not require to go to
among the best in the world.” hospital; and
appropriate number of specialist critical care paramedics able
to respond to critically ill or injured patients and provide support
to specialist retrieval teams and seriously unwell patients with
a life-threatening condition;
32 A Strategic Framework for 2015-2020 Scottish Ambulance Service 33Our People
appropriate number of specialist paramedics The transformation of our workforce will be
and support staff able to respond to patients aligned to the career framework that is familiar
requiring clinical care in hazardous or difficult to the wider NHS. This framework will enable
access environments, including confined spaces, us to have discussions about what essential
collapsed structures, entrapment; including at skills are needed at each level to provide good
height, inland water operations and similar to clinical decision-making and to provide safe and
provide decision making, advice and direct appropriate care in all settings. New roles will be
clinical care; grouped according to their level of complexity
and responsibility in practice and the level of
an appropriate level of conveying resources for experience and learning required to carry them
emergency and unscheduled care, ensuring that out. The framework will demonstrate how different
patients can be taken to hospital when required, jobs build on one another to allow progression
meet expectations for planned scheduled work, up and across the paramedic career ladder.
and manage the increasing demand for transfers
and discharge; Our Strategic Workforce Plan “Delivering Our
Future Workforce” will support this strategic
enhanced clinical decision support in the framework by providing clarity about how many
Ambulance Control Centres (ACCs) through of each level of staff we will need by 2020. This
increased impact of clinical advisors; for example, will be supported by training, education and staff
continuing the practice of appointing nursing development of our existing workforce and will
staff to this role; providing access to more senior guide our recruitment of new staff. The career
clinical decision support from medical staff framework also aims to makes it clear that we
through a professional-to-professional support will develop our existing workforce through the
network; and through development of our call various levels as well as recruiting directly into
handlers and dispatchers to make most effective each level.
use of our triage tool and referral pathways;
Finally, aligning the career framework for
more tailored models specific to the needs paramedics to the national framework in place
of local communities, such as the Retained across the wider NHS provides scope for
and Emergency Responder models, involving understanding the roles of other clinical staff from
ourselves, NHS Boards and the voluntary sector nursing and other allied health professions within
supported by appropriate tele-health facilities and the delivery of the 2020 Vision. This provides an
decision-support; opportunity for a richer mix of clinical skills and
builds on the good practice established in Angus
enhanced skills and development of scheduled with the paramedic/nurse co-responder model.
care staff, within our control centres and those
delivering care on the frontline development of
corporate and support staff;
significant development of leadership and
management capabilities, building on the
development of a ‘just culture’ where staff feel
supported to learn from mistakes and near-misses.
in essence, the Scottish Ambulance Service
workforce of the future will be more highly skilled,
operating across traditional boundaries, accessing
improved decision-support, more clinically
focussed, but with sufficient capacity to manage
the movement and flow of patients through the
wider system effectively.
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