ࡱ> %' !"#$ ^bjbj ʐ=%%i%i%i%D%%%-&'%%(+(+++E7h>$@Ȑʐʐʐʐʐʐ?ʐi%AM6@6AAʐ%%++ ߐ?H?H?HA^%8+i%+Ȑ?HAȐ?H?H<@Q%+`鴔Q"%CB|:0%Cfti%AA?HAAAAAʐʐ?HAAA%AAAAAAAAAAAAA #:     Contents  TOC \o "1-2" \h \z  HYPERLINK \l "_Toc224440520" LOCAL CONTEXT  PAGEREF _Toc224440520 \h 3  HYPERLINK \l "_Toc224440521" Review of 2008-09  PAGEREF _Toc224440521 \h 3  HYPERLINK \l "_Toc224440522" Looking Ahead  PAGEREF _Toc224440522 \h 3  HYPERLINK \l "_Toc224440523" REFORM, MODERNISATION AND EFFICIENCY  PAGEREF _Toc224440523 \h 6  HYPERLINK \l "_Toc224440524" CURRENT SERVICE PROVISION  PAGEREF _Toc224440524 \h 6  HYPERLINK \l "_Toc224440525" service reconfiguration  PAGEREF _Toc224440525 \h 7  HYPERLINK \l "_Toc224440526" MINISTERIAL PRIORITIES FOR ACTION 2008-2011  PAGEREF _Toc224440526 \h 8  HYPERLINK \l "_Toc224440527" AMBULANCE SPECIFIC PRIORITIES  PAGEREF _Toc224440527 \h 8  HYPERLINK \l "_Toc224440528" NIAS PROPOSAL TO DELIVER AMBULANCE SPECIFIC MINISTERIAL PRIORITIES  PAGEREF _Toc224440528 \h 9  HYPERLINK \l "_Toc224440529" OTHER MINISTERIAL PRIORITIES AMBULANCE RELATED  PAGEREF _Toc224440529 \h 11  HYPERLINK \l "_Toc224440530" RESOURCE UTILISATION  PAGEREF _Toc224440530 \h 13  HYPERLINK \l "_Toc224440531" Efficiency Savings  PAGEREF _Toc224440531 \h 13  HYPERLINK \l "_Toc224440532" Income and Expenditure  PAGEREF _Toc224440532 \h 17  HYPERLINK \l "_Toc224440533" Capital Investment Plan  PAGEREF _Toc224440533 \h 18  HYPERLINK \l "_Toc224440534" MEASURES TO REDUCE ADMINISTRATIVE BURDEN AND MAXIMISE RESOURCES  PAGEREF _Toc224440534 \h 25  HYPERLINK \l "_Toc224440535" GOVERNANCE  PAGEREF _Toc224440535 \h 27  HYPERLINK \l "_Toc224440536" INVESTING FOR HEALTH  PAGEREF _Toc224440536 \h 28  HYPERLINK \l "_Toc224440537" USER EXPERIENCE  PAGEREF _Toc224440537 \h 29  HYPERLINK \l "_Toc224440538" APPENDIX  PAGEREF _Toc224440538 \h 31  HYPERLINK \l "_Toc224440539" Appendix 1  PAGEREF _Toc224440539 \h 32  LOCAL CONTEXT The Northern Ireland Ambulance Service (NIAS) faces a range of significant challenges and major issues over the period covered by this Trust Delivery Plan. Chief among these is the need to deliver improved performance and service modernization in terms of both speed of response and quality and efficacy of clinical treatment provided in line with Ministerial Priorities while also ensuring that financial requirements are met, in particular the need to balance income and expenditure. Review of 2008-09 During 2008-09, NIAS delivered a 5% improvement in Category A, life-threatening emergency calls (Cat A) responded to within 8 minutes, averaging 67% against a target of 70% for N. Ireland. Peak response was in February with 70% of Cat A calls responded to within 8 minutes. NIAS is committed to delivering the fastest possible response to Cat A calls as the rapid provision of paramedics at scene of incident offers the greatest potential for effective clinical intervention leading to positive outcomes and enhanced patient experience. NIAS operated within budget, balancing income and expenditure, supported the introduction of significant acute hospital service changes throughout Northern Ireland, and absorbed a 6% increase in emergency calls over the previous year. During the year, NIAS worked with colleagues, in particular DHSSPS and Health Boards, to introduce proposals jointly agreed as being necessary to further improve ambulance services including response and clinical quality, thereby contributing to improved health and well-being and saving lives. Bids submitted through the Comprehensive Spending Review (CSR) process have secured additional investment funds (Capital 17 million & Revenue 12.1million) to support service improvement and modernization. In addition, NIAS extended the provision of paramedic-delivered thrombolysis originally piloted in the Western Board area) to the whole of N. Ireland ; developed and refined automatic vehicle location and satellite navigation technology in our fleet and control rooms; extended alternatives to automatic emergency ambulance response and transportation for appropriate emergency and non-emergency calls; increased the number of singe paramedic response vehicles in operation; secured funding for and procured significant numbers of emergency ambulances, non-emergency ambulances, rapid response cars and clinical equipment such as defibrillators essential for effective clinical care. Looking Ahead Plans and proposals for ambulance service development for the CSR period, 2008-11, are driven primarily by the Programme for Government endorsed by the NI Assembly and delivery is undertaken within the context and confines of the supporting Budget approved by the NI Assembly. The Minister for Health has outlined specific priorities in his Priorities for Action (PfA) related to the Programme for Government. The immediate and prime priority for NIAS remains the requirement to deliver faster response to life-threatening emergency calls within 8 minutes within available ambulance resources. NIAS has extracted ambulance-specific priorities from the PfA and presented DHSSPS and Health Commissioners with proposals to deliver improved ambulance response in line with PfA. Funding has been identified through the CSR process to progress these proposals. The CSR process also places a requirement on NIAS, as with all other NI HSC Trusts, to deliver 3% per annum Efficiency Savings, which amounts to 4.5million over the three-year period. Consequently, NIAS has revisited options for improving response performance in light of our experience during 2008-09 and refined plans to deliver PfA priorities and service development within stated resource constraints. In addition to Ministerial PfA priorities and particularly the primary requirement to deliver improved response times, endorsed by the NIAS Trust Board, NIAS has a range of other key challenges to address or progress during the year. While not necessarily or explicitly referenced in plans, it will be necessary to progress these challenges in addition to specific priorities if we are to continue to seek to deliver a balanced ambulance service providing quality clinical care appropriate to the individual patient as quickly and efficiently as possible. These key challenges facing the Trust, including PfA targets, reflect the need to effectively manage the totality of the organisation and are outlined below. Deliver enhanced emergency response to achieve 72.5% of Cat A calls within 8 minutes for NI by March 2010, rising to 75% by March 2011 and deliver baseline Cat A response at Board level of 65% within 8 minutes by March 2010. Maintain financial balance and deliver efficiency savings (cash/non cash release) Deliver other ministerial priorities for action relevant and applicable to NIAS in particular clinical prioritisation of non-emergency demand for patient transportation (fracture; dialysis; active treatment for cancer such as radiotherapy or chemotherapy; discharges, etc.) Modernise paramedic and non paramedic staff recruitment, training and development to include development and introduction of third level paramedic qualification. Introduction of regular, planned, funded replacement programme for clinical equipment (monitor defibrillators); accident and emergency and non emergency fleet; information and communications technology and estate development and upgrade. Develop clinical audit and supervision to assure governance requirements in relation to the quality of care provided. Deliver the Priorities for Action target on absence, reducing levels of absence to 5.5% in the year to March 2010, further reducing to 5.2% in the year to March 2011. Further development of alternative care pathways to support care in the community and alternatives to hospital attendance by emergency ambulance. Revise operational structure to support delivery of clinical and other performance objectives. Develop and introduce proposals to enhance delivery of non emergency booking and transportation of patients. Further developments of PPI/community engagement/user focus and involvement/staff engagement. Extend and consolidate information management and technology designed to manage the deployment of NIAS resources in line with patient needs. Clarify the information requirements of key stakeholders (internal and external) and extend the management information framework to accommodate. REFORM, MODERNISATION AND EFFICIENCY Since 2001, consistent with the Strategic Review of 2000, NIAS has implemented a challenging modernisation programme which has changed almost every aspect of service delivery. In addition, NIAS has supported and facilitated, often at short notice, acute service change linked to Developing Better Services and Acute Hospital Risk issues. The scale of the new targets arising from Programme for Government and the Budget are such that the NIAS Trust Board, having scrutinised expenditure and opportunities for efficiency savings have come to the view that these requirements cannot be met in full within current budget and service profile. To meet the new targets a more radical solution requiring service delivery reconfiguration is required. Proposals developed have been designed to assign priority to rapid emergency response in line with the targets set and limit the likely impact on the quality of the ambulance service provided and to preserve as far as possible equity of provision of ambulance services across N Ireland. However, the NIAS Trust Board remains concerned at the risks identified within these proposals and has sought and will continue to seek to identify measures to mitigate risk. The Board is also concerned that proposals emanating from other trusts in response to this exercise will present further changes which have a detrimental effect on the delivery of ambulance services and place at risk both NIAS proposals for service reconfiguration and measures to protect service delivery to patients. The service reconfiguration proposals are presented with the recognition that successful implementation is dependant upon the full and timely introduction of CSR revenue and capital investment outlined. Although some additional CSR investment funding has been identified to support specific service developments, the 3% per annum efficiency savings applied to base budgets present a significant hurdle to maintaining the foundations on which current performance is delivered as the platform for future service development. CURRENT SERVICE PROVISION NIAS provides a range of ambulance response and transportation resources dealing with emergency calls, urgent and non-urgent calls. All emergency calls are assigned to a category reflecting clinical urgency: Category A (life threatening), Category B (non-life threatening but serious) or Category C (neither life threatening or serious but requiring some form of clinical intervention). A significant proportion of NIAS workload undertaken by emergency ambulances arises from the treatment and transportation of patients referred by GPs. NIAS has experienced significant growth and demand for emergency 999 response calls over recent years and activity has climbed by approximately one third since 2001. 2006/7 showed the greatest increase at 10,000 extra calls, which was an 11.2% increase on the previous year. In addition to the111,660 emergency calls responded to in 2007/8, ambulance staff also transported 34,603 patients for GPs and other clinical professionals and undertook 218,310 non-emergency patient transports. In total the ambulance service undertook in excess of 350,000 patient transports during the course of 2006/07. NIAS is currently projecting for 2008/9 a 5.6% increase in 999 emergency calls; a 4.7% increase in GP Urgent calls, and a 1.7% fall in non-emergency patient transport requests. service reconfiguration In essence the proposals to deliver Ministerial Priorities within the context of ambulance modernisation emphasize a shift in focus from patient transportation to pre-hospital care and treatment. This new focus further emphasizes the requirement for clinical prioritization to identify and prioritise life-threatening calls and interventions, providing clinically appropriate alternatives to ambulance attendance and transportation to support care closer to home thereby reducing pressure on accident & emergency departments, alongside rapid response to life-threatening emergency calls. NIAS is committed through this process to matching supply of available resources to demand for emergency and non-emergency services. The process of matching supply to demand will be applied to all expenditure areas in the Trust Emergency/Non-Emergency Response, Control & Communications, Non-Pay Expenditure and Administrative/Support Areas. This is viewed as being the primary means for delivering prompt response performance and quality clinical care within a sound balanced financial framework. Demonstration of effective utilization of available resources to deliver service priorities will be key to bidding for and securing additional resources to support service development proposals. NIAS, in common with other Health Trusts, is required to deliver clinical services within available financial resources which reflect recurring efficiency savings extracted from NIAS baseline budgets by Health Commissioners. Financial Proforma FP3(T) records how NIAS will deliver the necessary savings with monitoring arrangements already in place. MINISTERIAL PRIORITIES FOR ACTION 2008-2011 AMBULANCE SPECIFIC PRIORITIES From April 2009, an average of 70% of Category A (life-threatening calls) should be responded to within eight minutes, increasing to an average of 72.5% by March 2010 (and not less than 65% in any LCG area). March 2009Average of 70% of life threatening calls responded to within 8 minutes At least 62.5% of life threatening calls responded to within 8 minutes at individual Board levelMarch 2010Average of 72.5% of life threatening calls responded to within 8 minutes by March 2010 and not less than 65% in any LCG areaMarch 2011Average of 75% of life threatening calls responded to within 8 minutes NIAS PROPOSAL TO DELIVER AMBULANCE SPECIFIC MINISTERIAL PRIORITIES NIAS Investment Proposal for 2008/09 to 2010/11, previously submitted, outlines NIAS proposals to deliver the Ministerial priorities identified above. In essence the proposal establishes that response performance in February 2009 was broadly in line with that required for 2008/9 above and having identified the measures which have delivered that level of response performance seek to secure funds to maintain and enhance those measures and the response performance associated with them. The key measures identified are: The introduction of additional rapid response staff and vehicles to provide flexible targeted paramedic response to emergency calls The introduction of additional intermediate care hours of cover to provide flexible targeted non-emergency patient transportation to increase capacity for emergency calls and timely response for non-emergency calls The targeting of Accident & Emergency hours of cover, principally at week-end and nights, to match demand and provide flexible targeted paramedic response to emergency calls and patient transportation where appropriate The introduction of Clinicians (GPs) to Ambulance Control to provide clinical triage of non life-threatening 999 calls and alternative care pathways which negate where appropriate ambulance transportation/attendance (pilot in the first instance). The extension of paramedic delivered thrombolysis on a phased basis which commenced during 2008/9 with the extension to 12-lead defibrillator-equipped paramedics in Southern and Northern Divisions before extending into Eastern Division, thereby providing NI-wide coverage with RRV paramedic officers. Phase two (2009-10) will be the extension to all emergency ambulances with paramedics which requires significant capital investment in replacement defibrillators and staff training. The introduction of Clinical Support Officers as a development of the existing operational management structure which emphasises and supports clinical excellence and supervision. This development also facilitates increased paramedic front-line response to emergency calls, supports the extension of paramedic-delivered thrombolysis, and is an essential step in the development of the ambulance paramedic role in Northern Ireland in line with national and international best practice. Continue to work with local communities in the development of Community First Response on a Northern Ireland basis with an emphasis on rural areas in the first instance and the provision of essential support and governance arrangements, again consistent with best practice and recent recommendations by the Health Care Commission in the UK. OTHER MINISTERIAL PRIORITIES AMBULANCE RELATED The emphasis in the targets listed is on the non-emergency transportation of patients. The previous section addressed performance improvement measures for emergency response, and this section illustrates the need to consider all aspects of the ambulance service in planning delivery. To this end NIAS will review the arrangements for provision of non-emergency transportation in conjunction with DHSSPS and Health Board Commissioners to identify and clarify eligibility for ambulance transport and to establish during 2008 a system of clinical prioritization for non-emergency ambulance transport to ensure that the limited resources available are used efficiently and targeted effectively at patients based on clinical priority consistent with the Ministerial priorities established. In undertaking this work, due consideration will be given to provision of non-emergency ambulance transport to key groups such the terminally ill. NIAS will develop relevant plans to support delivery of the priorities identified below, where we do not have sole or lead responsibility. Healthcare associated infections: in the year to by March 2010, secure an overall reduction of 35% in MRSA, MSSA and Clostridium Difficile infections compared to 2007-08. Patient Experience: by September 2009, Trusts should adopt Patient and Client Experience Standards in relation to Respect, Attitude, Behaviour, Communication, and Privacy and Dignity, and have put in place arrangements to monitor and report performance against these standards on quarterly basis. Service Frameworks: by March 2010, ensure the implementation of agreed standards from (i) the Cardiovascular Service Framework and (ii) the Respiratory Service Framework, in accordance with guidance to be issued by the Department in April 2009 and June 2009 respectively Fractures (PSA 3.3): from April 2009, 95% of patients should, where clinically appropriate, wait no longer than 48 hours for inpatient fracture treatment. A&E: from April 2009, 95% of patients attending any A&E department should be either treated and discharged home, or admitted within four hours of their arrival in the department. Stroke services (linked to PSA 3.5): by March 2011, ensure that 50% of patients attending hospital within 90 minutes of the onset of stroke symptoms receive a CT scan and report within a maximum of a further 90 minutes to inform the appropriate use of thrombolysis. Neonatal transport: from April 2009, ensure that a dedicated paediatric and neonatal intensive care transport service is in place on a 24/7 basis. Unplanned admissions (PSA 4.3): early intervention approaches should be further developed to support identified patients with severe chronic diseases (e.g. heart disease and respiratory conditions) so that exacerbations of their disease which would otherwise lead to unplanned hospital admissions are reduced by 50% by March 2010. Hospital discharges (PSA 4.4): from April 2009, 90% of complex discharges should take place within 48 hours, with no discharge taking longer than seven days. All other patients should be discharged within six hours of being declared medically fit. Finance: the Department and all HSC organisations should live within the resources allocated and achieve financial balance. Timely implementation of service developments: Commissioners and Trusts should ensure that not less than 90% of the monies but ideally, of course, 100% allocated for service developments in 2009-10 are expended during the course of the year in accordance with agreed plans, and assuming full resources are required to deliver the targets and commitments. This aim will be kept under review between the Department, Commissioners and Trusts to secure the best available balance between the overriding aim of actually improving services and the need to secure economy, efficiency and effectiveness in the full and proper use of the money available Absenteeism (PSA 9.1): each Trust should reduce its level of absenteeism to 5.5% in the year to March 2010, reducing to 5.2% in the year to March 2011. Investment programme during 2009-10, Trusts must ensure that, for all key strategic projects, agreed timescales are met for the completion of business cases, project procurement, and project delivery. RESOURCE UTILISATION NIAS has consistently delivered services on a sound financial footing in spite of significant pressures arising from increased demand and other pressures, and met the tests of financial performance required by DHSSSPS. Information sourced from the Welsh Audit Office illustrates that NIAS does not enjoy levels of investment comparable to UK ambulance services delivering similar or higher levels of performance typically in areas of greater population density, which facilitate faster ambulance response. As a result of the 2008-11 budget settlement NIAS is charged with delivering substantial efficiency savings. NIAS baseline annual budget will fall over the 3 year period from 49.5m to 45m, a reduction of 9% cumulative as a result of the removal of efficiency savings. There is potential for service development through capital investment of 6.5m in year 1, 5m in year 2 and 4.5m in year 3. These potential capital investments sums are further supplemented by indicative figures of associated additional revenue for service development of 2.5m in year 1, 4m in year 2 and 7m in year 3. The immediate requirement for NIAS is to deliver service priorities within revised budget making most effective use of the potential for additional capital and revenue funds to support service development priorities and the achievement of Ministerial targets. NIAS is currently engaged in a formal pubic consultation on Proposals for Efficiency Savings and Comprehensive Spending Review Investment which will influence final proposals for progressing this area. l Efficiency Savings Overview Relevant and readily accessible measurements of efficiency and effectiveness for Ambulance Services currently in use are increased productivity and the achievement of response targets. NIAS has demonstrated achievement in both of these areas by absorbing the activity increases referenced previously without comparable increases in funding to offset demand growth, and by delivering faster emergency response to Cat A calls (from 51% in 2005/6, through 55% in 2006/7, to 67% in 2008/9). NIAS has been more efficient by dealing with this increase in demand, but has also been more effective by improving our responsiveness to patients and arriving at the scene more quickly at the same time. As previously stated, as a result of the 2008-11 budget settlement, NIAS is charged with delivering substantial efficiency savings. NIAS baseline annual budget will fall over the 3 year period from 49.5m to 45m, a reduction of 9% cumulative as a result of the removal of efficiency savings. Critical and extensive examination of both pay and non-pay areas of the budget has identified that delivery of cash release efficiency savings of the scale required will necessitate reconfiguration of ambulance service delivery. NIAS has engaged in public consultation on proposals in this regard. Efficiency Proposal This proposal seeks to deliver efficiency savings in line with ministerial requirements. The bulk of the savings required are delivered by reducing the number of hours planned to provide emergency ambulance response cover and using CSR investment funds to invest in paramedic RRVs and alternative care pathways for patients to reduce the requirement for emergency ambulances to respond to and transport 999 callers to hospital. Sufficient emergency ambulance planned hours are retained to meet demand for patient transportation while overall ambulance response capacity is increased. Measures to reduce the requirement for ambulance transportation of patients which have been introduced during 2007/8 will be extended and enhanced alongside other measures outlined to manage and minimise risk associated with the proposal. The proposal protects and enhances the capacity of the ambulance service to provide rapid paramedic response and treatment to emergencies which will support and sustain improvements in response times recorded during 2008/9, and facilitate service plans to extend provision of thrombolysis to the whole of N. Ireland. The proposal offers opportunities for staff redeployment and career development to paramedic positions for existing staff. INTRODUCTION NIAS has engaged fully with key stakeholders and has submitted proposals to deliver these savings in three key areas. Generic Efficiencies Reconfigure non-emergency Intermediate Care Vehicle hours of operation (50,000 in 2008/9 rising to 200,000 in 2010/11), More efficient use of Voluntary Car Service (25,000 in 2008/9 rising to 50,000 in 2010/11), In house servicing of fleet (10,000 in 2008/9 rising to 110,000 in 2010/11), More efficient delivery of training (25,000 in 2008/9 rising to 50,000 on 2010/11) More efficient delivery of administration (20,000 in 2008/9 rising to 50,000 in 2010/11) Develop and implement plans to deliver 20% phased reduction in absence and deliver associated efficiency savings of 250,000 in 2008/09 rising to 500,000 in 2010/11 Increased provision of paramedic rapid response hours and an associated reduction of emergency ambulance response hours, realizing 856,000 in 2008/9 rising to 3,489,000 by 2010/11. While all measures outlined present a challenge to the ongoing delivery of the service, item 3 warrants further elaboration to describe the rationale; benefits; risks; measures to minimize risk and impact on patients and staff. PROPOSAL RATIONALE The Ministerial PFA target is that 75% of potentially life threatening Cat A calls should be responded to within 8 minutes. This recognises the benefits to patients from a more rapid response and the earlier provision of treatment. A key contributor to this improvement in response, delivered during 2008/9, has been the increase in the number of paramedic rapid response vehicles and the extension of their operating hours and locations. This proposal seeks to invest CSR funds to sustain and build on this success. NHS guidance issued in April 2007 (Improving Ambulance Response Times: Gateway Reference 8048) emphasises and recommends the positive contribution which rapid paramedic response to life-threatening incidents can contribute to both speed of response and clinical care at scene. This proposal seeks to identify opportunities to improve efficiency by the increased provision of paramedic rapid response, in single manned vehicles, and the more appropriate deployment and use of emergency ambulances. This would be most effective when there are significant volumes of activity within a relatively confined area. In N. Ireland this would indicate that paramedic rapid response as a replacement for primary emergency ambulance response is best used in more highly populated areas which generate higher volumes of ambulance activity. PROPOSAL DESCRIPTION It is proposed that planned hours of ambulance cover be re-profiled to increase the proportion of paramedic rapid response to emergency ambulance hours. The base year 2007/8 saw on average 56 emergency ambulances and 5.5 RRV on duty the equivalent of 24 hours a day 7 days a week (24/7). By 2011 the re-profiling would result in an average of 48 emergency ambulances and 20 RRV on duty, a net increase in response hours of 61,320 response hours. The proposal will therefore deliver the required efficiency savings through a reduction of 70,080 hours of planned emergency ambulance hours (13% of total planned response hours) with a compensatory increase of 131,400 hours of planned paramedic rapid response hours(24.4% of total planned response hours) provided from CSR investment to enhance emergency response times. Another key element of the proposal is the introduction of alternative care pathways reducing the requirement to respond and transport to hospital approximately 10% of 999 callers with non life-threatening/non-urgent conditions. BENEFITS Increased response hours Additional paramedic cover Additional number of responding units Support achievement of Ministerial targets Achieving efficiency savings target 08/09. POTENTIAL RISKS The principal risk associated with this re-profiling of front-line service is the potential for delay in transport of patient to hospital following assessment and initial treatment as the paramedic rapid response vehicles do not generally transport patients. MEASURES TO MINIMISE POTENTIAL RISK: Recently introduced ambulance control technology, including tactical deployment plans allied to satellite navigation and automatic vehicle location, will support deployment of available ambulance resources on the basis of clinical priority. This will target available resources, for both response and patient transportation, at the most clinically urgent patients. Alternatives to transportation to hospital by ambulance will continue to be developed by NIAS to compensate for the reduction in patient transport capacity by reducing demand for patient transportation. Existing measures to reduce the requirement for emergency ambulances to attend and transport patients will be further developed and their scope of operation extended. IMPACT ON PATIENTS For the general public there will be more ambulance vehicles on the road capable of responding promptly to emergencies compared with 2007/8. For life-threatening emergency calls, it will become more common for the initial ambulance response to be a paramedic RRV closely followed by an emergency ambulance, generally within 21 minutes. The RRV will provide paramedic response and stabilise and prepare the patient for the arrival of the emergency ambulance which will undertake patient transportation. Assessment of the impact of paramedic RRVs has shown that they can reduce the time spent at scene prior to transport of patient when compared with single emergency ambulance response. Patients calling 999 with non life-threatening, non-urgent conditions will be offered appropriate alternatives to ambulance attendance and transportation to hospital. IMPACT ON STAFF Reducing the planned hours for emergency ambulances will result in those staff remaining on emergency ambulances spending proportionately more time in direct patient care and transportation. NIAS will mitigate against a reduction in staff numbers resulting from efficiency savings through vacancy controls and redeployment to new positions arising from CSR investment and other planned developments such as fractures. NIAS will address any related skill-mix issues arising by providing opportunities for re-skilling existing staff to paramedic level. Income and Expenditure Financial Pro-forma are attached (as FP2A (T)) which provide details of NIAS forecasted income and expenditure for 2008-11. These have been prepared in conjunction with the four Boards and are recognised in their individual Health and Well-Being Investment Plans Compliant with the new accounting regime introduced by DHSSPS, income is shown excluding capital charges. The allocations from Health Boards are shown in draft and may be subject to revision. A summary of the forecasted income by Board area is shown below: DESCRIPTION 2008/09000SNorth12,807South9,440East18,596West11,124Other trusts1,166DHSSPS508Direct Income400Total54,040 The forecasted income levels are shown following deductions for cash releasing efficiency savings as advised by each of the Boards at the date of compilation of this document. It is recognised that such underlying assumptions may change during the forthcoming year. The associated efficiency savings are outlined in the attached financial Performa (FP3 (T)). The total amount of cash releasing efficiency savings required from the Trust is as follows: 2008/09 1,236k. 2009/10 2,719k. 2010/11 4,516k. Agenda for Change Work continues across DHSS to establish the full cost of Agenda for Change. At this stage, final allocations have not yet been released, however, there is a Ministerial target focused on the programme of this work INVESTMENT PROPOSALS Modernisation and improvement proposals, driven by the Priorities for Action programme target are under discussion with key stakeholders. The anticipated additional funding streams described in full in Appendix 1. Cost Pressures The Trust is continuing to liaise with Commissioners to fund the effect of unavoidable cost pressures. Capital Investment Plan NIAS priorities for capital investment have been reviewed with DHSSPS and Commissioners and will be progressed through the Outline Business Case currently being developed by PA Consulting. The immediate priorities for the 2008-11 period are: Clinical Equipment Replacement Monitor-Defibrillators (Essential for provision of Paramedic-administered Thrombolysis throughout NI in line with Ministerial PfA) Replacement of Emergency and Non-Emergency Ambulance Fleet Initial Risk-Management Corrective Investment in Year 1 followed by scheduled annual rolling investment thereafter (Essential to maintain current response performance and provide stable platform for safe future service delivery) Investment in Ambulance Estate Development and Renewal (Necessary to maintain existing estate contributing to ambulance response performance in safe and appropriate condition, and develop new deployment locations to improve ambulance performance) Investment in Technology and Communications (Essential to maintain existing capacity to provide 999 communications and control systems in a robust and safe environment and provide a platform for future development) The planned capital investment for 2009/10 is shown in the attached Financial Proforma (FP4). The forecast capital resources (subject to final confirmation) are 5M in 2009/10 and 7M in 2010/11. WORKFORCE STRATEGY NIAS has an overarching HR Strategy that was reviewed during Year 2005/06 with the resultant new Strategy covering the period 2006-2010. The HR Strategy continues to place high priority on the following: Workforce Planning; Employee Relations; Equality; Human Rights; Performance Management; Reward and Recognition; Education, Training and Development; Health and Welfare; Managing Change; The role of the Human Resources Directorate. This Strategy is underpinned by the Workforce Plans, Recruitment and Training Plans and various action plans which include managing attendance priorities and Equality. In consequence of the current financial climate within HPSS, NIAS has had to make core assumptions in relation to the workforce, recruitment, training and Agenda for Change implementation plans as follows: Boards accept the proposals put forward by NIAS in relation to the efficiency targets, modernisation and reform; Workforce, recruitment and training plans will be developed for posts where recurrent funding is available; Agenda for Change implementation will be fully funded; The labour market will provide the supply of applicants with the required skills, qualification and experience for NIAS vacancies; Further Service developments will be addressed as discrete projects with appropriate funding and timescales NIAS continue to strategically plan in relation to Service developments and future projections regarding the supply and demand of staff. 1.1 Absenteeism Management absence continues to be a priority for the Trust. NIAS % absenteeism for the last 5 years is detailed below:-  2004/05 2005/06 2006/07 2007/08 2008/09 Hours Lost 8.17 8.17 8.38 8.38 7.09  The management of absence within NIAS is challenging, but provides opportunities to improve overall health and wellbeing in the workplace, which ultimately boosts organisational productivity and supports service improvements for patients. The target for NIAS, in line with Priorities for Action (PFA), is to reduce absence to 5.5% by March 2010 and to 5.25% by March 2011. In order to achieve this target the Trust will introduce a number of initiatives including the development of a Health & Wellbeing Strategy coupled with a Work-Related Stress Management Strategy. In addition a local review of the Trusts Attendance Management Policy will be undertaken based on the Regional Attendance Management Framework which will continue to facilitate best practice principles in the management of absence. This review will incorporate the development of an early interventions framework. The Trust will also continue to build on other initiatives currently in place including improved collaborative working between local management, Human Resources and Occupational Health; the provision of improved management information; development of a management training programme; and building upon its system of performance management which will target management of absence as a priority linked to improving response capacity and ensure delivery of departmental targets. The Trust will ensure that a stringent system of monitoring is applied to this. The Trust will also continue to work with its Trade Union colleagues in the management of absence. Staff Retention Annual turnover in the region consistently of 3% would indicate that NIAS is not experiencing a workforce retention problem. However, there are staff filling posts which have non-recurrent funding or are temporary and this creates an internal flow of staff with a knock-on effect throughout each level. Training The Trusts training plan sets out the priorities for the clinical and non-clinical training, education and development of all staff within the Trust. The plan takes account of the strategic objectives of the Trust, and supports the delivery of priorities as set out in Priorities for Action and the Trust Delivery Plan. The plan is developed in light of new pressures in terms of changes in service provision and delivery that are as a result of organisational reform within NIAS and developments in the wider HPSS. It identifies the need for increasing the current manpower levels, maintaining a safe skill mix and improving the skills and competencies of ambulance professionals to meet the challenges of the future. The following actions are key to ensure continued safe delivery of the service and provide the necessary foundation upon which future changes can be built: The Trust will ensure the timely delivery of core training in order to address skill mix establishment levels, in line with organisational reform and the Trusts Workforce Planning Strategy. Changes in the dynamics of ambulance service provision particularly in the pre-hospital emergency care and treatment environment continue to challenge NIAS. Therefore, to ensure the highest standards of out of hospital care are provided to patients, the NIAS education framework will evolve with the advancing national training and research agenda and international ambulance education standards. This will include the provision of nationally recognised education for ambulance personnel, and the development of third level education, through linking and engaging with Higher Education Institutions (HEIs). In parallel, the Trust will continue to develop Paramedics to fill vacancies and meet service developments through traditional IHCD modules (Paramedic-in-Training Programme). The Trust will ensure all mandatory requirements are fulfilled as set by the Institute of Health Care Development (IHCD), the Health Professions Council (HPC), and other regulatory bodies, and will ensure all statutory and legislative training obligations are met. This will include maintaining IHCD and HPC accreditation, and Continuous Professional Development. The Trust will prioritise core, mandatory and refresher training which enhances the quality of care provided for patients and meets the changing needs of acute services. The RATC will continue to support the introduction of new equipment to the Service by taking a flexible approach to ensuring ad hoc training is developed and delivered as the need arises. Training for the non-emergency Patient Care Services (PCS) tier of the Service has historically been accredited through the national ambulance awarding body, the Institute of Health Care Developments (IHCD) Ambulance Care Assistant Award. As the IHCD has ceased to provide this accreditation, given the national move towards higher education for ambulance education, the Trust is working towards achieving accreditation to deliver the replacement BTEC Award. Now that Paramedics are professionally registered with the HPC, the Trust must undergo an HPC Approvals visit to demonstrate it meets the HPC Standards of Proficiency for Paramedics and Standards of Education and Training for the delivery of current IHCD modules of Paramedic training. The Trust will develop and source accredited clinical supervision and mentorship programmes that adhere to HPC requirements. The Trust will ensure that management development and best practice programmes are sourced, developed and delivered to relevant individuals in order to equip them with effective managerial skills to strengthen leadership, heighten awareness of and help contribute to organisational values, goals and objectives, and meet ministerial targets. The Trust will promote and support the continuous professional development of all staff through the application of life-long learning principles within the working environment and through the implementation of the Knowledge and Skills Framework (KSF) and Personal Development Reviews (PDRs). A learning culture will be encouraged where staff learn from past experience, ensuring reflective practice, and transfer of learning. The Trust will support personal development of all staff by developing sound systems for managing performance and under-performance issues effectively and constructively, establishing clear relationships between organisational and individual standards and objectives. NIAS will continue to provide training in other priority areas as part of a structured training plan: Staff Development Over the next year, NIAS will continue to implement the knowledge and skills framework for Agenda for Change. NIAS is also pursuing the accreditation for Investors in People. Workforce Planning and Recruitment NIAS has considered the demand and supply of staff over the next 3 years and has developed Recruitment and Training Plans to address priority requirements. NIAS has included funded service developments; consolidating RRV; recruiting additional staff to reduce overtime and meet efficiency targets; and address in-year labour turnover. 1.2 Agency Staffing The use Agency staff within NIAS is minimal. Agency staff are primarily used to cover hard to recruit non-recurrent funded and short-term temporary administrative posts. In addition Agency staff have also been used for posts which have proved difficult to recruit due to vacancy control mechanisms applied under the Review of Public Administration (RPA). Administrative Staff The % of administrative staff within NIAS is significantly lower than other HSC Trusts, currently sitting at 3%, indicating that the Trust is not experiencing a problem with the % of administrative staff within the Trust. MEASURES TO REDUCE ADMINISTRATIVE BURDEN AND MAXIMISE RESOURCES NIAS will continue to work in collaboration with its current partners and develop links with others both inside and outside the DHSSPS and nationally and further a field as well as locally. These will include:- The development of alternative care pathways to meet the needs of the patient more appropriately and as an alternative to hospital admissions with the development of referral systems to other healthcare providers at the time of initial contact such as:- Primary care; Community nursing; Mental health services; Crisis response teams etc. Participate in the development of managed care networks with other healthcare providers in accordance with the Area Board priorities from DBS. Particularly in the area of emergency care to improve the effectiveness and efficiency of services to the patient. Contribute to the development of an integrated out of hours service both at regional and local level with DHSSPS, area health boards and GP out of hours services. Participate in emergency and contingency planning with other emergency services, the M.O.D., N.I.O. and DHSSPS particularly in areas of CBRN, major incident management, pandemic flu & SARS. Develop in association with GP practices and hospital trusts an electronic booking system for routine non-emergency patient transport. Develop and extend pre arrival alert information in hospital A&E Departments linked to Ambulance Control to automatically inform the hospital of impending patient arrivals. Develop the role of the Emergency Admissions Co-ordination Centre (EACC) in emergency planning and throughout all four health boards. Implement a system of prioritisation for GP Urgent calls based on the patients condition in consultation with the GPC and LMCs to more effectively manage this activity. Participate with other HPSS trusts, bodies and agencies in regional finance initiatives, HR systems and equality initiatives and developments. GOVERNANCE The Board of the NIAS HSC Trust is accountable for internal control. The Chief Executive of NIAS has responsibility for maintaining a sound system of internal control that supports the achievement of the policies, aims and objectives of the organisation, and for reviewing the effectiveness of the system. The system of internal control in NIAS accords with Department of Finance and Personnel guidance. The Board exercises strategic control over the operation of the organisation through a system of corporate governance which includes: A schedule of matters reserved for Board decisions; A scheme of delegation, which delegates decision making authority within set parameters to the Chief Executive and other officers; Standing orders and standing financial instructions; The establishment of an Audit Committee; The establishment of a Remuneration Committee; The establishment of a Clinical Governance Committee; The establishment of a Risk Committee. NIAS recognises that effective risk management is an essential component of good management and that it must be utilised if the NIAS is to achieve its strategic aims as identified within its Strategic Plan 2005-2010. NIAS has introduced a comprehensive risk management strategy based on the Australian Standard AS/NZS 4360:2004. This strategy brings together and standardises all of the risk identification and management processes as well as prompting the development of new risk assessment and management tools and appropriate structures and processes. The Trust is committed to ensuring that good risk management processes are adopted at all levels and for all activities and that these processes will support initiative and innovation whilst enabling the organisation and its employees to learn from mistakes and take responsibility. The Trust is committed to fostering an open and honest culture where people are prepared to challenge and be challenged about why and how they do things in the interest of their patients, staff, the Trust and the public. The key objectives of the strategy are to provide: Integration of the present risk management and related processes with other Trust functions such as contract monitoring and management, clinical audit, continuous quality improvements, controls assurance, the management of claims, complaints and the Health and Safety agenda. Integration of risk management activity in both the non-clinical and clinical areas, in order to maximise the potential for decreasing risk related to ambulance patient services, staff and others. Assistance in the realisation of the significant benefits from minimising risk and improving quality of processes and systems. Assistance to the Trust in achieving statutory compliance in all relevant areas. A system for proactively identifying, analysing, controlling and managing those areas of significant future risk to the Trust. Ensuring, as far as possible that the Trust has made adequate contingency and major accident/incident plans. Assistance to the Trust in ensuring that appropriate and necessary control mechanisms are in place to reduce and control risks and satisfy the requirements for Controls Assurance. INVESTING FOR HEALTH The Trust has developed an education programme focusing on raising awareness within selected community groups, in particular schoolchildren; the aim is to role this out to all secondary and primary school children. Issues around securing recurring funding have only allowed partial implementation to take place to date. There is also the opportunity of NIAS providing external training to various groupings that would have a major impact on the understanding and first response to accidents/incidents where human life is at risk. At present no funding is in place to support this work, so we continue to work in support of the voluntary sector in this area. The Trust provides a range of services to all staff to promote health and well-being which include; flu vaccinations; staff counselling service. USER EXPERIENCE The Trust is committed to continuing to promote a patient-centred service by improving the quality and effectiveness of user and public involvement as an integral part of its governance arrangements. In this regard the Trust will work to implement DHSSPS guidance on Personal and Public Involvement. Leadership in this area will be provided by the Trusts Medical Director. A multi-disciplinary group has been established within the Trust to drive this agenda and implementation will be monitored through the Trusts Clinical Governance Committee. During 2009-10 NIAS will build on the work undertaken in the previous year to establish a Personal and Public Involvement (PPI) agenda within NIAS. This will involve implementation of a PPI Action Plan involving the establishment of systems to garner and respond to feedback from key stakeholders in respect of the planning, delivery and evaluation of ambulance services. The Trust will continue to work with community representatives through Ambulance Liaison Groups to facilitate the representation of the public and user and provide access to key decision makers within NIAS. Senior managers will continue to attend meetings with public representatives such as Health Councils, Local Councils, and specific interest groups as a means of gauging the views of users and their representatives to inform policy development and implementation. The Trust is committed to the promotion of Equality, Good Relations and Human Rights. It will continue to implement its Equality Scheme and work to mainstream equality within the organisation. A comprehensive programme of work in this regard will be monitored by the Trusts Equality Steering Group. In addition the Trust will work alongside other HSC organisations to implement the DHSSPS Equality, Good Relations and Human Rights Strategy. Work will continue within the Trust to promote positive attitudes towards disabled people and encourage participation by disabled people in public life, in keeping with its obligations under the Disability Discrimination Order (DDO) 2006. In this regard the Trust will continue to implement its Disability Action Plan and progress of this will be monitored by the Trust Equality Steering Group. The Trust has also established links with other emergency services and will seek to work collaboratively with these services where possible, to take forward work in relation to these duties. In addition the Trust will give specific attention to these duties when planning new initiatives such as Personal and Public Involvement (PPI) which is also outlined within this document. NIAS will continue to implement good practice reviews and the related action plans devised from the agreed framework. NIAS will continue to collate information on complaints and compliments and report publicly to Trust Board on these as a measure of user experience. In addition the Trust will continue to engage in surveys of user experience as has been undertaken for the introduction of Advanced Medical Priority Dispatch System and the piloting of Rapid Response Vehicles. APPENDIX ONE Appendix 1 NIAS Investment Proposal for 2008/09 to 2010/11 Introduction The amount of additional revenue identified in CSR as being available for investment in NIAS modernisation and improvement over the next 3 years is 2.5M for 2008/09; a further 1.5M in 2009/10; and a further 1.6M in 2010/11. Modernisation and improvement proposals are driven by a PFA performance target for 2008/09 of 70% of Cat A responses within 8 minutes with the added constraint of performance in each Health Board area at a minimum of 62.5% of Cat A responses within 8 minutes. Investment proposals for 2008/09 reflect the continuation of measures introduced during Q4 2007/08 to deliver enhanced response performance consistent with ministerial PFA targets. The proposals also provide a platform for modernisation proposals to be introduced in 2009-2011. The proposals for 2008/09 also provide a base for the introduction of Thrombolysis service development by March 2009 consistent with ministerial priorities. The proposals below are dynamic and over the course of the 3 years will continue to be monitored and are therefore subject to revision. Proposal for 2008/09 The immediate priority for NIAS going into 2008/09 is to ensure that the levels of performance achieved in February and March of 2008 against the Cat A PFA target are consolidated and enhanced. Sufficient revenue will be required on a recurrent basis to provide the additional resources necessary to deliver performance targets at a Board specific level consistent with ministerial priorities. Therefore the following investment in order of priority is proposed for 2008/09: Maintain an additional 9 RRV running for 12 hours each per day for 7 days per week. This amounts to an annualised total of 39,420 hours or 4.50, 24/7 equivalents. The annual cost of this (applying appropriate uplifts for 2008/09) is 1127k (see Table 1) Provide an additional 144 hours per week of ICV (36 hrs per week for each board area). This amounts to an annualised total of 7,509 hours or 0.86, 24/7 equivalents. The annual costs of this (applying appropriate uplifts for 2008/09) is 292k (see Table 1) Maintain an additional 216 hours of A&E cover. This amounts to an annualised total of 11263 hours or 1.29, 24/7 equivalents. The annual cost of this (applying appropriate uplifts for 2008/09) is 644k (see Table 1) During 2008/09 begin the roll out Thrombolysis regionally. The revenue costs associated with this and the associated defibrillator replacement / installation are outlined in Table 1 During 2008/09 initiate infrastructure change by starting the phased introduction of Clinical Team Leaders providing enhanced operational and clinical day-to-day management. These additional front line staff would provide: an operational focus including a primary paramedic response to emergency calls; a team leader role with a focus on clinical governance, best practice and quality of patient care and clinical outcomes; operational and clinical liaison and facilitation with local health care professionals to support acute service reconfigurations and care in the community. Current proposals are to recruit 8 wte in 2008/09, rising to 20 in 2009/10, rising to a total of 28 by 2010/11 resulting in 24/7 availability. Costs over the 3 years are outlined in Table 1. The total revenue cost of the above for 2008/09 is 2,478k Proposals for 2009/10 - 2010/11 NIAS has worked with DHSSPS and Commissioners to develop and prioritise service development proposals. Within the constraint of planned investment consistent with the CSR process a number of measures are proposed for implementation during 2009-11 reflecting ministerial priorities. Sustain and build on the RRV investment in 2008/09. This would increase RRV investment in 2008/09 from 4.50 to 10 and then 15, 24/7 equivalents in 2009/10 and 2010/11 respectively. RRV costs for 2009/2010 and 2010/2011 years are outlined in Table 2. During 2009/10 establish a Community First Response scheme in priority rural areas of NI. The recurrent cost of this, based on costings done for the Regional Strategy for Community First Response Scheme is 77k in 2009/2010 and 2010/2011. To continue to pilot GPs in Ambulance Control providing clinical triage of non life-threatening 999 calls and alternative care pathways which negate where appropriate ambulance transportation/attendance. As proposals stand currently, the total amounts of additional revenue expenditure against the investments described for the next 3 years, is as outlined in Table 2 - 4,000k in 2009/10; and 5,600k in 2010/11. While no investment in A&E and ICV into 2009/10 and 2010/11 is shown, this will continue to be reviewed through the ongoing process of matching supply to demand for emergency and non-emergency patient transport and response. DescriptionCommentsRRVICVA&ETotalRRVICVA&ETotal2008/092009/102010/11Annual Hours24/7 EquivalentsAdditional RRV9 RRV x 12 hrs per day x 7 days per week39,42039,4204.504.501,1272,5033,756Additional ICV144 hrs per week7,50975090.860.86292Additional A&E216 hrs per week11,263112631.291.29644DefibrillatorsRevenue cost434343ThrombolysisRevenue cost252525Clinical SupervisionPhased intro-duction of 28 wte staff3478681,215Community First ResponseRural priority scheme7777Alternative Care Pathways 484484TOTAL COST K2,4784,0005,600Revenue Available K2,5004,0005,600@ 2008/09 price levels TABLE ONE - N I Ambulance Service - Next Steps for Modernisation and Improvement - March 2008 TABLE TWO - Northern Ireland Ambulance Service - Next Steps for Modernisation and Improvement March 2009 Description2009/102010/112009/102010/112009/102010/11kk24/7 EquivalentsHours of CoverPerformance Improvement PlanAdditional RRV2,5033,75610.0015.0087,600131,400Revenue Consequences Replacement Defibrillators4343Roll Out Of Thrombolysis2525Clinical Supervisor Infrastructure8681,215Community First Response7777Category C - Doctors in Control484484Total4,0005,60010.0015.0087,600131,400@ 2008/09 price levels       PAGE 33    PAGE 38  MARCH 2009  "#$%9:Ͽx\RAA!jhYhJ}OJQJU^JhXOJQJ^J6jh\eh\e5OJQJU\^JmHnHtHuh\eOJQJ^Jh\eh"S5OJQJ\^J&hYh"S5CJ OJQJ\^JaJ 0jhYhJ}OJQJU^JmHnHsH uhYh"S5OJQJ\^JhYh"SOJQJ^J)jhYhYOJQJU^JmH sH hYh"S>*OJQJ^J    $< ! ; ! :$a$$a$$a$$a$:;<XYZ[hijudN*jYh7h>0J'UmHnHu!h>OJQJ^JmHnHtH uhhmHnHu#jYh>UmHnHujh>UmHnHuh>mHnHu'h7h>0J'OJQJ^JmHnHu*jXh7h>0J'UmHnHuh>mHnHuh7h>0J'mHnHu$jh7h>0J'UmHnHu  ( ) * + , - . / 0 L M nccQ#j[h>UmHnHuh>mHnHu'h7h>0J'OJQJ^JmHnHu*jZh7h>0J'UmHnHuh>mHnHuh7h>0J'mHnHu!h>OJQJ^JmHnHtH u$jh7h>0J'UmHnHuhhmHnHujh>UmHnHu#jZh>UmHnHu. 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