When I heard about the potential closure of Oswestry Ambulance Service, I immediately contacted the Chief Executive, Dr Anthony Marsh, to ask for a briefing.
I also passed Dr Marsh some of the comments and concerns I have received from constituents.
I attach a copy of his response, below.
In addition to this briefing, Dr Marsh confirmed to me that the West Midlands Ambulance Service Trust is doing all it can to increase the number of ambulance crews on duty to deal with the unprecedented volume of patients requiring their assistance.
I am less concerned about physical infrastructure on the condition that it does mean more ambulances, more staff and a more efficient service.
Additional funding has been provided to all ambulance services by NHS England and the Trust is working hard to recruit additional staff.
I will continue to liaise with West Midlands Ambulance Service in response to concerns in Oswestry.
Briefing Regarding Review of Ambulance CAS Points in Shropshire
The following document sets out the reasons why West Midlands Ambulance Service has been reviewing the provision of Community Ambulance Stations (CAS) in Shropshire, which we hope will be useful background reading.
The Trust was formed in June 2006 and many of you will be aware that we initially had circa 70 ambulance stations across the region. Over the last decade we moved to a new model of operation which sees us use 15 large Make Ready Hubs; in Shropshire these are in Shrewsbury and Donnington in Telford. When the move was made, we initially created a network of rapid response vehicles (RRV), usually 4x4 cars, that worked from strategic locations known as Community Ambulance Stations (CAS), very often in market towns across the West Midlands. This was largely due to the call categorisation system that we were obliged to use at that time that concentrated on getting to calls very quickly, but not necessarily with the right resource.
A good example of this would be a stroke patient; an RRV would get there in under eight minutes but, if the patient was FAST positive, what they actually needed was an ambulance to take them to a hyper-acute stroke unit for immediate care – we aren’t able to transport patients by car. Doing so can make a huge difference to the life of the patient going forward. What happened in the West Midlands to some extent, but much more so in other areas of the UK, was that the car would wait sometimes for hours for an ambulance to arrive to take the patient to hospital. This severely limited the ability of the hospital to provide the necessary care. While we hit the statutory target, the patient didn’t get the care they needed, which clearly was not appropriate.
With the introduction of the Ambulance Response Programme in 2018, WMAS firstly reduced and then got rid of entirely, it’s fleet of cars – at one point we had over 100 operating each day! These were all replaced by ambulances. As that move took place, we reduced the number of CAS points as they were simply not being used. By 2020, we were down to just 13 sites. The money saved from not having the CAS sites was invested in additional staff and ambulances.
As you will be aware, the last few months have been extremely challenging; in July, we saw demand at levels that we could not possibly have envisaged. We set a new record for 999 calls on 19th July when we received and answered 6,418 calls in a 24-hour period! When you consider a busy day at the moment should see us receive circa 4,000 calls, you can see the level of challenge we face.
Another factor that has badly affected us over recent months have been the delays handing patients over at hospital. As you will be aware, we are supposed to do so within 15 minutes of arriving at an A&E Department. Unfortunately, many of the hospitals in our region are extremely challenged and this has led to some very long delays. Indeed, in recent weeks, we have had crews wait over 11 hours to hand their patient over. During July, there were many days when we were losing over 1,000 hours of ambulance time while crews waited to hand over patients – that is the equivalent of taking 85 ambulances off the road and putting them in a car park and deciding not to use them that day. You can only imagine the challenges this brought us. To put it into context, in July 2019 (pre pandemic) we lost 4,818 hours during the month of July due to handover delays. In July 2021, we lost 14,866 hours and in August that deteriorated further with us losing 15,651 hours! Almost 7,000 patients waited over an hour to be handed over in July and 6,500 in August, with many of them having to be kept in the back of the ambulance for hours. Not only was this poor for patients it put an intolerable strain on our staff with many regularly finishing their shift late, often to the tune of three hours on top of a 12 hour shift. No other NHS staff face such situations.
The Trust moved to REAP 4 (the highest level of concern) for the first time in its history. At one point, all ten English ambulance services were at REAP 4. Currently, only WMAS and one other Service have de-escalated to REAP 3. You may also have seen in the news that three services in other parts of the country are now receiving military assistance due to the level of challenge they face. Thankfully demand has calmed down a bit since the latter half of July, though it remains at about 10% above contract.
As a result of the above, we have implemented a number of changes to protect patients and our staff. One of the biggest changes has been the introduction of the Clinical Validation Desk. Calls continue to be triaged by our call assessors in the normal way: they are divided into four categories – Cat 1 is the most serious and includes a patient in cardiac arrest. Category 2 included heart attacks and strokes while Category 3 are classed as ‘urgent’ and Category 4 as ‘non-urgent’ by NHS England. Under the new scheme, a number of Category 3 and 4 calls are further examined by a team of advanced paramedics in our control rooms. The aim is to take these lower category calls and make better use of the alternative pathways that are available in the NHS.
This could be through directing occupational therapy teams, fall co-ordination services or advanced nurse practitioners working in the community to visit the patient instead of an ambulance. Many other calls are being resolved with advice only. The work of the team is expected to reduce the number of ambulance dispatches by several hundred each day purely by arranging for more appropriate healthcare staff to visit the patients. Our ‘Hear and Treat’ rate has risen from around 5% to 15% each day and may go higher still. This allows us to focus our ambulances on the calls that really need our help and will allow us to respond more quickly.
This brings me on to the next significant area of work, a review of the Trust’s CAS sites. Two have already closed – Leominster after it was flooded 18 months ago, and Uttoxeter which suffered a leak. Stourport is due to close in early September. The Operations team have been examining the other ten sites (Evesham, Malvern, Craven Arms, Oswestry, Market Drayton, Bridgnorth, Biddulph, Leek, Rugby and Stratfor upon Avon) for the last few weeks.
There is a common misconception that where an ambulance starts or finishes a shift will have a substantial impact on the area that it is based in. What must be remembered is that as soon as an ambulance is available it will be sent to the nearest available case so that we can minimise the time a patient waits to be seen, something I am sure you would support. This means that vehicles can often end up in rather odd places. Recently, we had a Dudley ambulance in Malvern and a Hereford vehicle that had gone to Birmingham Children’s Hospital then getting a case in Birmingham itself as it was the nearest ambulance available.
If you look at the data from the first six months of the year, for the three CAS sites in Shropshire, you find the following:
Total cases: 27,156
Cases attended by Bridgnorth ambulance: 1,112
Total cases: 20,319
Cases attended by Craven Arms ambulance: 884
Total cases: 28,026
Cases attended by Market Drayton ambulance: 1,128
Total cases: 20,722
Cases attended by Oswestry ambulance: 1,185
Given what I have already outlined in regard to demand, it is now rare, if ever, that the crews who work at the CAS points ever get back to the site other than for their meal break or at the end of their shift. Like the crews based at the Hubs, they literally go from one emergency to the next, 24 hours a day; they are no longer sat on a station anywhere in the region waiting for a call. Therefore, one of the questions we are duty bound to consider is whether it is appropriate for the Trust to spend precious funds on a building that is rarely used when these could instead be spent on additional staff and vehicles; the things that save lives?
One of the questions we have been asked is whether a closure would mean that ambulances have to come from one of the hubs each time a call comes in and the answer is no. Currently, less than 50% of patients seen by our emergency crews are taken to hospital. This means that, for example in Market Drayton, in roughly 15,000 occasions for the time period above, an ambulance was in the area available to respond, even though it wasn’t the ambulance that is based in the town.
In cases where a patient needs to be taken to hospital, they will primarily end up in Royal Shrewsbury or Princess Royal in Telford, but also not irregularly to Royal Stoke, The Maelor Hospital in Wrexham and potentially Queen Elizabeth Hospital Birmingham for major trauma patients. If we assume that it was the Oswestry ambulance that took them to Royal Shrewsbury, then clearly it would not be in the town ready to respond to another call. Quite rightly you would not expect us to wait for the ambulance based in the town to finish with its current patient before we responded to any subsequent call that is waiting in the area. You can therefore see how the above figures come about.
Any changes made will not see a decrease in the number of staff or ambulances in the area, just change where they start or finish a shift. In fact, removing the CAS sites actually increases the amount of time ambulances are available to respond to patients.
When a crew come on shift at one of our Hubs they will get into an ambulance that is fully fuelled, clean, stocked and ready for the full shift. In contrast, when crews start at a CAS site, they are in a vehicle that has already been used for half a shift. The crew coming on will have to check over wat stock they have on board before they start responding, reducing the amount of time they are available. We will then lose further time because twice a day the crew have to go to a Hub to exchange their vehicle for a newly stocked vehicle.
We lose further time still because we have an agreement that crews will always return to their bases station for a meal break. This means a crew in say Evesham have to drive from Worcester back to the town before they can start their break. All of these issues reduce the amount of time that the ambulance is available to respond to incidents, often to the tune of 90 minutes in every 12 hour shift.
As we have already mentioned, hospital handovers cause us significant issues. This has a particular knock on affect for crews at CAS points. If a crew is late back at the end of their shift at a hub, the on-coming crew simply use another vehicle. At a CAS point, there is no other vehicle, so the on-coming crew have to wait for the previous shift to return before they can start responding. If a crew are two hours late, which is far from uncommon, we have lost the on-coming CAS based crew for two hours on top of the 90 minutes already lost due to the way the system operates. This is both inefficient and cannot be right in this day and age when we need to maximise the amount of time that crews are available to respond.
The welfare of staff is clearly one of our highest priorities, particularly when they are under so much pressure at the moment. By having the ambulance based in Stafford, we will be better able to support the 10 staff previously based in Uttoxeter. A manager is available at the Hub 24/7, whereas the staff in Uttoxeter would only have seen one when they went to the hub to change vehicle.
The Trust has discussed the review with staffside colleagues and wrote to all of the staff affected last week. What we have said to both staff and their representatives is that should a CAS site close we will do what we have in Leominster, Uttoxeter and Stourport and work with the staff so that they can choose which Hub they move to and if they wish to stay on a current roster, then that will also be accommodated.
I am sorry that the briefing is anything but brief, but I hope it provides a useful update about the current challenges and context about the review currently being undertaken. If I can finish by assuring you that we will only make a change if we are convinced that it will benefit patients. WMAS continues to be the highest performing ambulance service in the country and we aim to ensure that that position continues to be the case.
West Midlands Ambulance Service