Introducing 'Access to the Stack'

New way of working piloted in East and North Herts called “a bright spot in difficult circumstances”.

A week of implementing new flexible approaches to improve patient outcomes in Hertfordshire has seen EEAST paramedics working alongside a multi-disciplinary team to make sure patients are seen as quickly as possible.

The pilot commissioned by Hertfordshire and West Essex ICB involved EEAST and Hertfordshire Community NHS Trust working together to carefully assess patient needs before directly referring them to an urgent community service if it is clear they will not need to go to hospital. 

This meant patients were seen earlier by the right healthcare practitioner – saving hours of delays and in many cases providing more appropriate care and improving treatment for people.

The new approach – called ‘clinical conversations - explored the best ways have these discussions between paramedics and community providers and medics about patient care. The pilot found the best results came through the teams working in the hub in Stevenage contacting crews directly to discuss relevant cases.

The next steps are to see how the service can improve and grow and be rolled out across the Hertfordshire and West Essex area.

 

A Q&A on these services can be found below:

 

Explain how this works?  

The ambulance control room call handling system categorises cases in order of urgency, from category 1 to category 5. Ambulances must be dispatched to those most in need and therefore category one and two calls are prioritised. 

This new system will mean that category three to five calls will automatically be able to be reviewed by clinicians, who can ask for patients go straight to appropriate urgent community response services. These are services such as same day emergency care, urgent community two hour response, rapid intervention services, intensive support teams, early intervention vehicles (for instance, for non-injured falls), social care, or mental health services.

This means patients will be seen more quickly by the appropriate level of care. And in many cases will not have to wait for an ambulance and then go to A&E well the emergency department, and then wait again to be seen before being referred to the care that they need.

This will not only improve individual patient experience and outcomes but will also free up ambulance resources to respond to more patients in urgent need. 

Any patients who do not go to UCR services do not lose their place in the ambulance call system and are managed as normal. 

This builds on the recent success of the West Midlands Ambulance Service, who introduced a similar system in summer 2022 with 60-70% of referrals through the system seen and treated through UCR services. 

 

Who diagnoses the patient and says ‘this person doesn’t need to go to hospital?’ Who is clinically responsible? 

The call will be answered as normal via 999 and then a clinical lead will assess the case against agreed criteria. If suitable, the case will be passed to the alternative care provider will make the decision to accept or decline the call.

When accepted, the alternative care provider takes clinical responsibility for the patient and will review the patient – and can, for example, make the assessment if the patient needs conveyance to hospital if required.

 

Is there a risk a patient is misdiagnosed through not seeing a hospital doctor? 

Once a call is passed to the clinicians they will be able to review cases and can decide where the best place is for patients to be treated. EEAST still has clinical oversight during the process until the alternative care provider agrees to take the case.

This improves the outcome for many patients as they are seen much earlier than if they attended hospital. 

If - for whatever reason – the clinical decision is that patients should be seen in the traditional manner, then they are not disadvantaged and do not lose their place in the queue.  Should the call be declined within 60mins for whatever reason the call will return to the same place within the 999 system – so patients never lose their place.

 

What happens if patient refuses care at home or other care and wants to go to hospital? 

It is for the alternative care provider to make a clinical decision on the treatment for the patient following review.

 

Does this all rely on software to work? Is that safe?

This is part of an existing system called Cleric and the relevant resilience has been built into the platform, however in the event of a system failure we have business continuity procedures as you would expect that would be enacted.

Clinical oversight of the system will be continually monitored to ensure patient safety.

 

How does this work for individual paramedic /crews in Herts and West Essex? Paramedics have to call the number - is that number staffed 24 hours a day?

Initially the service will run from 8am to 8pm, there is an intention to review this and move to 24/7 if the activity supports this.

 

Which community services is this response generated from?

From acute services it could be same day emergency care, hot clinics or frailty clinics. From our community providers it might be urgent community 2 hour response, rapid intervention services, intensive support teams, early intervention vehicles (for instance, for non-injured falls), social care, or mental health services. In future we may be able to use same-day primary care services and pharmacy.

 

What sort of response time is the community response held to?

The response time will be determined during assessment, and is dependent on the patient’s need, it could be anything from a response within 2 hours, 4 hours for example or a next day planned appointment.

 

What happens if paramedics can't get through on the phone number?

The aim is to have the phones answered within 2 mins for the clinical conversation, following assessment (clinical conversation). Where the decision is to use an alternative care provider, the aim to get confirmation from that alternative provider and referral sent, and the crew to handover within the national standard of 15 minutes, recognising this may be longer in the early days.

 

Published 3rd November 2022