Ambulance services: the canary in the coalmine for NHS pressures

 Matthew Taylor
Hello and welcome to the latest edition of Health on the Line produced by Health Comms Plus. On behalf of the NHS Confederation.  We and our members have been waiting with eager anticipation for sight of the model region blueprint, the document that will set out how the English regions we managed in the future and what that means for ICBs and providers alike.

It's an important document because without sight of it, members are unable to move forward with their planning. With me to discuss the implications of not yet having the model region blueprint is Sarah Walter, director of our ICS network. Welcome to Health on the Line, Sarah. 

Sarah Walter

Thanks for having me.

 Matthew Taylor

So, some people will know all about this issue, Sarah, others will have no idea at all. So can you bring us up to speed on this question of the the model region blueprint. What is it and why is it important to our members? 

Sarah Walter

Well, I'm sure all of our listeners will be aware that there's significant change going on within the health service at the moment.

We've seen announcements earlier on this year about changes to the centre, NHS England becoming absorbed into the Department of Health and a cost reduction headcount reduction of around 50 per cent. ICBs, so integrated care boards, also told in the spring this year that they would be expected to achieve a cost reduction of 50 per cent and changes also to providers. 

And so lots of change within the overall NHS operating model, of which the region is an important component. And we've seen a lot of activity, I think, underway. In particular in relation to integrated care boards. ICBs have been part of developing the model ICB blueprint, which was published at the beginning of May – process led by Penny Dash NHS England. And in parallel work has been underway on the model region, which is a really important component of this operating model. ICBs already work really closely with the region, as do NHS trusts and providers across regions, and so understanding how the regional component of the new operating model is going to work is a really important dependency for all the other parts of the system.

The original expectation was that that model region blueprint work would be complete by the end of July. And we understand that work was largely complete by then, but we have yet to see a final published document that ICBs and providers can use to support their own planning and think about their functions and their way of operating in the future.

So it's an area that I know many members will be keen to see and engage with as soon as NHS England are in a position to release that.

Matthew Taylor

And do you have any sense, Sarah, of what is the, the cause of the holdup? 

Sarah Walter

I think, clearly there's been a need for engagement. You know, the regional component has an interdependency and a kind of interplay with ICBs, with providers and also with the centre.

And so I think there's clearly a desire from NHS England and the department for that regional layer to benefit from those kinds of connections and really make sure that it works in the context of how the new centre is going to operate as well. And we know that those conversations are live right now. Richard Barker is leading that process of change for the centre and the regional component is important part there. 

So we understand there's discussions happening. Between NHS England and the department in particular over the summer, and we're hopeful that we'll be able to see something soon, but certainly our members are pushing for NHS England to be releasing that blueprint as soon as is possible.

Matthew Taylor

Yeah, and Richard Barker is clearly, you know, couldn't choose for a better person to be overseeing this process. And from what I'm hearing, Sarah, it echoes what you are saying, which is that this has partly got wrapped up in this question of NHSE moving into the department, you know, these are NHSE regions that will soon be departmental regions. And those are rather different kinds of things. It also picks up differences - I hear, you know, when you talk to people in the department, they talk about NHSE being subsumed, abolished, being subsumed in the department. Whereas in NHSE, they tend to talk about merger and they tend to point out that there isn't yet an absolute date which this is going to take place.

So there are differences, but what impact does it have on our members, in particular ICBs, the fact that we don't yet have this regional blueprint?

Sarah Walter

I think ICBs, there'll be a certain degree of frustration, I think, given the pace at which ICBs have been required to pull together their plans. So, the Model ICB Blueprint was published at the beginning of May and ICBs had until the end of May to submit their first cut of cost reduction plans.

So how were they going to change their organisations in order to deliver that, that model ICB blueprint? We know ICBs have been in discussion about clusters and mergers, and that is all progressing at pace. But there's a really significant interdependency between how ICBs operate in the future and how regions operate.

The Model ICB Blueprint lists a number of functions which are anticipated to move to the region, and I think it's quite difficult for ICBs to kind of plan their future design and how they're going to operate without also understanding how regions are expected to operate and being able to kind of develop that ICB plan and how it's going to dock into the new regions and their way of working. 

So, I think it does add an extra layer of complexity into what is already an incredibly complex situation for ICBs to manage. 

Matthew Taylor
And this affects, of course, the capacity of anybody to deal with what are challenging issues, but also areas where there is potential given the financial constraints we're under to think about how we could do things better.

So, for example, continuing healthcare, well, we know there are huge variations, one part of the country to another difference in the kind of criteria for accessing that has a big impact on patients; postcode lottery; safeguarding, where I think there's a sense at the centre that potentially more money has been spent on safeguarding than needs be, could be potentially rationalised and needs to be clear about what it's about.

But I just want to focus, just a little bit on one other issue, which is around emergency planning. That's a function, as I understand it, you’ll correct me if I'm wrong, it's going to slated to move from ICBs to regions. Now winter is starting to come and that's when that kind of capacity, emergency interventions, particularly is important. We do need to sort this out ahead of winter, don't we?

Sarah Walter

We do, although there has been some clarification. So some FAQs were published back in June. So this is after the model ICB blueprint was published, saying exactly that. So some of these functions that ICBs have historically managed, in particular things like EPRR, things like system control centres and managing winter.

So the FAQs published in June clarified that ICBs will continue to hold that responsibility for this winter. Each ICB has been told to nominate a winter director. They'll remain accountable for that EPRR function for this year. But how this works longer term is clearly an important question.

And even in the short term, there's clearly significant change underway in ICBs with their cost reductions and the potential redundancies that may flow from that. Although, you know, I think as we've described in previous episodes with Health on the Line, and certainly have been talking about within the Confed, those restructures themselves are also at risk given some of the questions still about redundancy and how those financial costs will be born. 

I guess one of the principles around all of this is trying to have clarity in the midst of complexity and that clarity continues to not be forthcoming while we are waiting for big parts of this jigsaw to be confirmed.

Matthew Taylor

Well, I think we can say in summary, can't we, that ICBs continue to find themselves in the situation of doing their best, preparing for winter, but not really being supported in undertaking the changes they've been required to undertake. And that colleagues at NHS England and the department are coming back from their summer holidays with a pretty big and urgent in-tray.

Sarah, thank you so much for joining me. 

Sarah Walter

Thanks for having me. 

Matthew Taylor 

Now, the ambulance sector some say is the ‘canary in the coalmine’ signalling first when the NHS is under pressure. Ideas for how to address the ambulance sector’s many challenges feature in both the ten-year plan and the UEC plan, and so we thought, who better to address these issues than representatives from the ambulance sector itself.

So we're delighted to be speaking to Anna Perry, managing director of the Association of Ambulance Chief Executives, or AACE as it's more commonly known. And we're also really fortunate to be joined by two ambulance trust chief executives, Simon Weldon of South East Coast Ambulance Service, and Dr John Martin, who's based at South Western Ambulance Service. I'm really pleased they're able to join me this morning. Welcome, Anna, John, and Simon to Health on the Line. 

Anna, let me start with you getting your take as MD of a AACE representing the ambulance sector on what you think are the kind of major implications of the ten-year plan for the ambulance sector.

Does it go far enough in mapping the future of the sector? What's your kind of general view of the ten-year plan? 

Anna Parry

Thank you, Matthew, and thank you for the opportunity to join you this morning. So we really welcome the publication, the ten-year plan within the Ambulance Sector, AACE, and within our wider membership.

It outlines a clear vision of the NHS of the future. We welcome the ambition and  are very supportive of and in agreement with the three shifts. We published a vision last year, a vision of the ambulance service of the future with the NHS Confederation and [NHS] Providers, which very much aligned with the aspiration outlined in the ten-year plan.

As we all know, the focus is very much on neighbourhood health. Ambulance services operate on a regional footprint while interacting, of course at a neighbourhood level too on a daily basis with patients. But there's a potential risk for us there, and a job that we've got to do is ensure that the excellent work that ambulance services do at a regional level in relation to call taking, call navigation, clinical triage and so on, supports the realisation of the plan and the delivery of much more healthcare where appropriate at a neighbourhood level.

We're delighted that we've got a voice on all NHS England's ten-year plan work steams. We've recently depicted how the ambulance service simply how the ambulance service can support the delivery of neighbourhood health and want to continue to work with NHS England colleagues, Department of Health and Social Care colleagues and others to ensure that we are kind of doing our utmost to support the delivery to ensure ultimately the patients get the care that they need in the place that they need it.

Matthew Taylor 

So turning to you first, John, thinking about the ten-year plan, but also the UEC plan, what do you see as being the key success factors? The key determinants of whether or not things are going to improve for the ambulance service and in terms of the ambulance services contribution to the recovery and transformation of the service?

John Martin

Yeah, so I think the tenure plan really does outline lots of things that we need to do between us and those of us working in the NHS would certainly realise we're not delivering what we want to for patients right now. And I think that the free shifts that are outlined there, so the analogue to digital order, hospital to community and the treatment to prevention are all things that we would recognise in practice.

I'm sure like maybe many listeners, when it first landed, I did a quick search for the word ‘ambulance’, if you're working in ambulance services, only appears 16 times across the 171 pages, and six of them are in the references. But as you start working through that, you realise actually that we, we are a key component of the neighbourhood set up what might be coming in that. 

I think the big challenge, we've seen a lot of these shifts often framed in another way in the past, I've only ever worked for the NHS and in the last 25 years, for me, it's going to be about whether or not we can take the ambitions that are outlined, where the ambulance service fits, where does the paramedic profession fit within that and whether we can deliver it.

And I think you referenced there, the urgently emergency care plan. It's whether we can do it whilst we're still delivering the service that we are. There was a great advert a number of years ago from a software company that was a plane and the advert on TV was a plane being built whilst it was already in the air. And I think for me, that's the challenge of this plan is whether or not we are going to be able to make the changes and the shifts we need to make whilst still flying the plane that is the NHS or the ambulance service in our case. 

Matthew Taylor

So, Simon, I'm really interested to pick up on what John said. I have to say if someone said to me, do you want to take a journey on a plane that's going to be redesigned while you're in the air? I think I'd probably take the ferry. So, in a way that kind of reflects how challenging this is, well what's your takes on? 

Simon Weldon

So I think the plan perfectly encapsulates the kind of great challenges that face us in as a country and as an NHS.

If I was to highlight one area, which I think has to deliver this time is digital integration. All of the plans that I have seen, and I've seen quite a few of them now in my lifetime, in the NHS, digital technology and what it can promise has always been on the horizon that has never been fully delivered, and I think we're going to have to grapple with how do we really integrate all that we know?

Patients assume that we know everything about them, and they're always really startled to find out that we don’t. And I think if we don't get that integration, we won't get the synergies, we won't get the productivity, we won't get, in actual fact, the improved clinical outcomes that patients are expecting.

And I think to resolve that challenge, my take would be we've got to reconcile, the kind of, our organisation's sovereign or our system's suffering, because if we're going to solve this, somebody somewhere is going to have to make some decisions about we can't all plough our own furrow. And for us as a sector, we are starting to look at that.

We're starting to look at a collaboration of southern ambulance services, do we integrate some of our digital technologies for precisely that reason? Because we know that to serve patients better, we've got to make a difference in that space. That's my key challenge.

Matthew Taylor

And that's really interesting, Simon, and I'm going to come to you, John, on this first.

One of the things, of course, I've realised in my time at the Confed speaking with Anna and AACE and coming to Ambulance Leaders’ conferences and speaking one-to-one to leaders has been the challenge of integration often feels difficult because ambulance services work at a different scale to the way in which we often think about integration.

So, ambulance services work at a kind of regional level and then often focus quite a lot on their relationship in particular with acute hospitals - we’ll come onto some of those issues I in a moment - but integration is taking place at system level, place level and now neighbourhood level. The ten-year plan states ambulance services will play a key role in supporting neighbourhood health. That's a quote, but ambulance trusts weren't included in the bidding process for the National Neighbourhood Implementation Programme. 

So as I say, starting first with you, John, this, how does the ambulance service solve this really tricky problem of the kind of scale at which integration needs to take place, which isn't always compatible with the scale at which ambulance services need to work. 

John Martin

Yeah. So, down here in the south west, we cover seven integrated care boards, moving to free clusters shortly. So all of them have got different ideas. We're a key part of each of those seven systems. Working then with 18, 19 acute hospitals across the region as well, and multiple mental health providers as well as police and fire services. And it is a really key challenge. 

I think for us as an ambulance service probably is focusing at a broad level on two different groups of patients. There's those that are an emergency and need a high acuity 999 calls, lots of calls coming via 999, but the high acuity ends where actually the influence of neighbourhood is probably less and actually you can have a regional response. It's similar whether you are calling from lands ending in Cornwall for us or right up in Bournemouth or Tewkesbury at the other end. 

But then there's this big group of patients that often are frail or other groups might include mental health patients, we know where actually their delivery of their care at a neighbourhood level is what will make the biggest difference to their outcomes. And that's where we as an ambulance service need to be embedded on a day-to-day clinical basis. 

Simon has already touched on this. There's something about digital here. We see in the ten-year plan’s case study from Estonia about how do we access other information systems and then I think it is into referral pathways. I think some of them are going to have to be designed with us at a local level. 

Certainly here in the south west, I've encouraged that we think about ourselves as part of a system. So that for us has been at ICB level. The question now I think is how do we do that at a neighbourhood level as it comes through? Because you're right, at the moment that's very much in its infancy and there's so many meetings going on in this based across the south west, how do we represent that?

But I think that's a challenge for us as an ambulance service about, well actually, does it have to be the executive directors or can it be further down the organisation? And the difference between providing that really high acuity emergency care, which I think can be done at a regional level, we want a universal service in that space versus this other big proportion of patients who really, a local flavour will be important.

But it is a challenge and it is difficult to work out how that's going to play out at the moment. 

Matthew Taylor

I think that's fascinating, Simon, turning to you, because arguably one of the vulnerabilities in terms of implementation of the ten-year plan, and it's something we've seen before, is that we don't invest in the kind of organisational development capacity, the brokerage capacity, that as someone once put it, politicians invest in bricks, but they don't often invest in the mortar that is necessary to make those bricks work together to build a wall.

Thinking about the ambulance service, there are conversations around the country now around who's going to be the integrator about IHOs, about multi neighbourhoods. It's a kind of prosaic challenge, but how do you simply have enough people with sufficient autonomy and seniority to be in the room when those conversations are taking place?

Simon Weldon

So I think you talked about integration and one area I'd add to your list of areas where integration needs to take place is commissioning, because I think this actually starts at a level above organisation. I think if you live in the south east and then you look at our neighbour service in south central, although we are part of the same region in NHS terms, we are commissioned in fundamentally different ways. And that has driven different clinical outcomes. 

This year we've actually brought our commissioners together, and so for the first time as we start to face into the commissioning round and the three-year plans that we're all going to be producing from October through December, we will actually have one set of commissioners working right across the south east. And I think that reframes the conversation. 

I also think that the other thing that changes in that commissioning construct is things that were traditionally commissioning tasks now need to pass into providers. That's part of giving people more autonomy to make local decisions. And then I think, back to your point, we've got to, as ambulance services invest in local leadership. So we've just moved in CCAM to a divisional structure, and I'm saying to our divisional leaders, very familiar in hospitals to have divisional structures. Not so familiar in the ambulance sector. And I'm saying to those local leaders. It's your job to develop the deep subject matter knowledge of a local area, so neighbourhood means something to people as well. But I'd make a strong plea that we don't forget commissioning, and we don't forget ambulance service commissioning because I think there's a lot that can be gained by reframing that conversation. 

Matthew Taylor

No really important point now.

Anna, you see there you are AACE, on the one hand as an advocacy organisation, you want to be in the room where the decisions are being made. So you'll recognise this challenge of ensuring that the ambulance service is part of the conversation at neighbourhood place and system level, even if that isn't the kind of footprint of the ambulance provider. But on the other hand, AACE is also involved in supporting chief executives, other executives, in their leadership development. 

So it's interesting, isn't it? Absolutely, what Simon has said, bringing those two things together that actually for the ambulance service to make sure that it can make the biggest possible contribution to recovery and reform, itis going to require chief executives to build the capability to trust their staff, to devolve within the organisation because they simply can't be in all those rooms. 

Anna Parry

Yeah. Absolutely. And that's been something that has been an issue for some time now in the commissioning space. If we sort of take that specifically because I think that is so important, as Simon has articulated, we sort of lobbied for a number of years ago for sort of pan-ICS commissioning approach that hasn't really been realised in the majority of places for ambulance services, which is so important because so much of our provision is at that kind of regional level, as John's talked about, a lot of that we would advocate needs to be commissioned at a regional level with the discussions going on, at a place, neighbourhood, local level where that's required to get the sort of best patient outcomes. 

I think from NA's perspective, we've produced a graphic clearly sort of outline, and people have welcomed this, we've had a lot of positive feedback from within the sector and outside primarily, and that's the important bit really about, about what our role is, what we can contribute, but identify, Matthew, as you said, we have very lean organisations, they're becoming leaner in the context of the current sort of financial climate how best can we interact at a national, regional, and, and local level. 

We recently published our proposed commissioning model, and in that I've talked about what needs to happen at a national level around comprehensive service specifications that enforce mini minimum standards so we can ensure, and it's very important to AACE and of course very important to all our members too, even though they're working in those regional areas, that we are attempting to level up rather than tolerating sort of huge variation, which we, we do currently see with regard to performance, delivery and clinical outcomes. So a national level has that clear sort of comprehensive service specifications that enforce minimum standards. We would advocate at an enhanced regional commissioning model, where you have performance management against those national standards, considering the regional context, considering the financial variability and as well where we haven't seen that much progress so far, but hope the ten-year plan gives us an opportunity for, this is around better system level workforce development and planning and moving out of the sort of artificial organisational boundaries that have prevented some of that work being done. And then at a local level, a real focus on health inequalities, formal agreements in place, underpinning work with system partners and then robust feedback mechanisms. 

So one of our USPS is the ambulance sector, is the data we have, the intelligence that we have on patient populations, so feeding that into neighbourhood and integrated care system conversations. And Simon's talked about the great work that's being done across the south east to come together with a desire to sort strategically commission rather than transactionally contract. And there's too much of the latter still happening, which isn't in the best interest of patients or organisations or the system. And again, we hope that the ten-year plan provides us with a foundation, an opportunity to transform that so we can move to position whereby we are commissioned to deliver the services that we know would be better for our patients.

Matthew Taylor 

Thanks. And, I think, again, going back to what I said before, one of the things we're kind of trying to gauge the centre and is just being realistic about the capability that exists. You know, and we are transferring quite a lot from ICSs to regions, but do regions necessarily have that kind of capability?

And particularly kind of when things go wrong, regions can be a long way away from the action, for example. So that's something that we really need to delve into.

Now, clearly, for the ambulance service, as for the rest of the service, we have to balance our desire to do things very differently with our need to recover tomorrow and the next day and the next week.

So let, let's kind of turn a bit more to some of those kind of operational questions. And Simon, just starting with you, obviously, the whole question of the interface between ambulances and accident emergency departments, the issue of handover delays, it's been really one of the kind of big questions, clearly one of enormous importance to politicians - what do you think we've learned over the last few years as that issue has come to prominence? We've seen the development of different ways of trying to solve this problem, different targets. What do you think we've learned, Simon? 

Simon Weldon

So I think fundamentally the challenges for all of us, we're going to have to work out how we move away from sending you an ambulance to see if you need an ambulance, because there's no doubt that at the moment all of us still convey far too many people to hospital for a huge variety of reasons. But that starts with, in actual fact, we need to influence and change the model of care, so we don't send out as many ambulances to patients. 

We've now got some of the intel, some of the tools that allow us to make a different disposition for calls. We need to do more of that.

So segmenting our calls, diverting them away from an ambulance response, diverting them away from taking them to hospital. Here's a practical, real-world example. We've got a hub in one of our centres in Ashford, which is actually staffed, I was there a couple of weeks ago, by a GP, mental health nurse, A&E consultant, and I spoke to the AACE consultant when I was there and he said to me, it's absolutely fantastic this hub because I saw a woman in A&E and I sent her home having treated her, she rang the ambulance service back, and because he was in the hub, he was able to intervene and say, you don't actually need to go back to A&E. Here's what I can do for you, and a different disposition was reached. Now that's the example for me.

That needs to be scaled up right across the system. If we're ever going to cope with the tide of demand, that is inevitably going to grow as time goes on, ageing population, et cetera, et cetera. We need to develop different models of care. Simply doing the same thing, keeping on doing the same thing will inevitably result in the people who most need us being not served well, but also the people who could be treated differently, not being served well.

So the existential challenge for the ambulance services, what we've had has worked hugely well, and I know people really affiliate and are responsive to the ambulance service, but if we carry on with that model for the next five years, we will not succeed. That's the challenge for me. 

Matthew Taylor

John, do you have anything to, to add to what Simon said?

John Martin

Yeah, I agree. So we are all working hard on safe alternatives for patients and certainly we've got down here in the southwest low conveyance rates. There's more we could do and more we are doing. I think the other bit of learning for me is that we've gone over the last few years is how do we understand risk at both system level, hospital level and bring that together as a conversation. 

So we saw in industrial action for both doctors, but also ambulance services had some industrial action a number of years ago. We also saw through the covid period how we adjusted some of our thresholds. We need to understand that in potential harm for our patients, but also in our culture, potentially around litigation. So I think there's something about how do we, how do we understand who owns the patient? We mentioned earlier about the sovereignty of organisations that we, what you might call peace time, so our time outside of those areas, I've just mentioned, we very much focus on keeping our bit safe.

But what we really, I think, need to do is think about the population as a whole and when it comes to hospital handover delays, when it comes to response times, it's often weighing up one part of the system against another part of what's contributing in the system. And I think if we could get better at doing that, if there's more learning in that space between us, that will make a huge difference to how we go forward with some of these decisions.

What Simon's really outlined in terms of alternative to emergency departments are clinical risk-based decisions about where you draw that often in the best interest for patients, but we need to re rethink some of our understanding of risk across the whole. And often when we are on calls, when it's gone difficult we have a habit, I think, of retrenching into organisations.

Whereas if we could get a bit more of that covid or industrial action mindset saying, well actually we've got the population at a whole, I think some other countries are better at doing this. This is the population, whether that's a neighbourhood place or regional level. This is the population you're responsible for. How are we going to do the most or the most in that, rather than what's in the best interest of my individual organisation. I think that will make a big difference to us. 

Matthew Taylor

I think that's absolutely fascinating and, and you know, when we talk about workforce, we tend to talk about numbers, but actually we know that an enormous part of why the NHS succeeds, or doesn't succeed is to do with, on the one hand discretionary effort and on the other hand, people's willingness to take risks, to make judgements and to take judgements when they know that there might be the possibility that they will have to be answerable for those judgments if they go wrong. And having a workforce that feels sufficiently respected and supported, not only to want to add discretionary effort when it's absolutely necessary, but also be willing to take responsibility even when that involves risk for them. I don't think we think deeply enough about the kind of culture we need to create to get that. And this is not marginal. The stats are pretty powerful on the reduction, for example, in discretionary effort that's taken place in the NHS over recent years. It really has a big impact on productivity. 

Now, Anna, I want to take some of these kind of themes and ask you a question that you and I have discussed a bit in the past, which is that I envy you in in many ways, you know? In the Confed, we've got hundreds of members. I can't get them all in a room together, they do very different things. You know, mental health trust, community trust, whatever. You've got this small group of chief executives, you can put them all in a room together. Although they serve very different geographies, they have very recognisable jobs. There are variations in practice. And also there are variations in perspective. 

I remember a few months ago I had a conversation with one ambulance chief executive who spent quite a lot of time telling me about how proud they were of the fact that they had one of the highest here and treat records in the country. And then I spoke to another chief executive a few weeks later who said, well, you got to be a bit careful about this here and treat stuff because, you know we can measure the impact it's having on the ambulance service or even A&E, but what we don't measure is the impact it's having on other parts of the services as people are referred onto other services. So, you know, we, we need to be a little bit careful about assuming this is actually reducing demand or making us more productive. 

So I guess my question for you, Anna, it's been a bit of a tough question with two of your members sitting in on this call, but are you happy with the degree to which AACE is able to get leaders into a room together to look at challenging things like performance variation, to open up differences in perspectives, different kinds of analysis, and for your team of chief executives to really learn from each other by having that kind of quite a rigorous kind of conversation with each other?

Anna Parry

So a few things to start with, Matthew. So contextually, what AACE is now, we are an ambulance service that represents one part of the system and everything that we're about and advocating it is looking out. So we have been criticised historically, the ambulance service for, for looking in, for being too insular.

I think there are good and bad reasons for that, but in my role at AACE, supported by the chief executives, we need to be looking out. The only thing to be doing is to be looking out. I think one point and something else we've talked about Matthew, is around failure, demand and, and I think the ten-year plan provides us with an opportunity to address failure demand.

The ambulance service ends up picking up a lot of failure, demand, and we have the opportunity to straighten things out here to ensure that the patient's getting the right care, the right time from the right part of the system. And there's something about everybody understanding that the work we are doing with regard to sort of urgent care, community urgent response, what Simon's sort of spoken about clinical hubs working at sort of ICB level is very much about ensuring that we've got an emergency ambulance for the person that needs an emergency ambulance.

So it's not kind of one or the other with regards to that clinical space. So by looking to neighbourhoods, by looking to the local level, we are not turning our back on those emergency calls. And in the same way, I think my view, working very closely with the chief executive group, I think we're in in a strong position because we've got a really diverse mixture, could do being more diverse in some ways, but with regards to backgrounds, experience, and we've got examples here with John from the ambulance service, he's worked outside the ambulance service. And then Simon, who's worked within commissioning in acute. Bringing all that together. So to kind of pull that expertise and knowledge, learn from each other, share that best practice, and again, move away.

And we've talked about it with regard to sort of organisational boundaries at a system level, but knock some of that down. This is about patients primarily and our people. And I think, I hope that the ten-year plan we current. Do starting work on our 26 to 31 strategy at AACE, people coming behind that and seeking to do that and, and our end ambition is the same. It is about our patients and our people. 

So we've got Jason Killins as our current chair, chief executive of the London Ambulance Service. He's been at our chair for the last 12 months. Very progressive leadership, experience in Wales. Now experience in London. I think we are in a really strong position to respond in a really proactive, professional, sophisticated way to the ten-year plan Matthew, and the opportunities that it offers for the ambulance sector to be a fully integrated part of that urgent and emergency care.

Matthew Taylor

Well, thanks Anna. And you know, I could talk to you three for hours, but we we're kind of running out of time. So I'm going to focus on an issue that I know is one that is causing considerable kind of concern and it's going to grow at the centre and that is about winter because if things go wrong this winter and who knows, there may be even be industrial action in the background, but if things go wrong this winter it won't be possible for this government to blame its predecessors. It might try, but I suspect the public won't accept that. We know that the recovery in things like elective waiting lists, there is some recovery, but it's quite fragile. A bad winter could mean that those targets the government have set fall so far away that they kind of lose credibility and overall in the service where morale is quite fragile.

A bad winter I think could pull away a lot of the momentum that's being built up by the ten-year plan, for example. So winter is really, really important. Of course, most important of all for the patients and for the public. 

I'm somebody who kind of resists predictions because I think, you know, the question is not what do we think the future is going to be? It's what are we going to do to create the future we want? But I'm going to ask you.

 John and Simon, I'll start with you, John, just to tell us how you are feeling about winter as it starts to approach. How confident are you, what are your biggest concerns, and what can the centre still do between now and then to reduce the risks?

John first. 

John Martin

Yeah. So hugely important for patients as you say, Matthew, as we get towards that period, we know that historically ambulance response times increase, ambulance response times we know are linked back to patient experience and in some clinical conditions to outcome. We had some horrible cases here last year where we had patients waiting for large periods of time, often fallers who might not have had injury but were older parts of the population.

So I think we'd all want to focus on what can be better this coming year. I think, as ever, we are in the midst of winter planning. We are putting down our initiatives on paper in a plan, some good learning from last year and previous years and some innovation. I think the thing we need to do to go further is really push ourselves on, over the next few months, we've got a bit of a run in how robust are those plans? When we do either major instant testing or actually clinical scenarios, what you do is you keep pushing people. You throw in new bits. I used to be a paramedic educator for a part of my career. As you get students who are really excelling, what you do is you give them harder and harder.

And I think what we need to do is really over the next few months test where can we push those boundaries so that when it comes to reality in a few months' time as we head into November and December that we've already rehearsed some of this, and actually we are better at taking those risks together at a system level.

We mentioned risk earlier in the podcast, and I actually, that for me is going to be critical. The situation is going to be dynamic. You've mentioned industrial action. Who knows what's going to happen with viral illness and other things. How do we understand risk between us? And often I find in winter worked lots of winters.

Now in the NHS, we, we reach a crisis and we say we've done everything possible. Often, we would say that's not true for either a major incident or in an individual clinical scenario. We would try more and I think it's that, that we need to be putting into our plans and maybe thinking the unthinkable in terms of what we might do, but actually so that we are ready and we're rehearsed for it more this winter than we have been maybe in previous winters.

Matthew Taylor

Well, thanks. And Simon, there are new risks it feels to me. John talked about major incidents. I mean responsibility for some of this stuff is moving from ICSs to regions. But as I said earlier, if something goes badly wrong in hospital and you rely on the region, the region is a long way and not just kind of physically, but a long way from the action that's taking place in the particular place.

We also know from our own research that the financial pressures on the health service means that some of the things that have been put in place to help with the winter pressures have simply been defunded over this year. So there are new risks. So how, how are you approaching this Simon?

Simon Weldon

So I think the first thing to say is that we're probably better prepared. I'm going to start with a positive, and I know that's a bit difficult when you're talking about winter. We're actually working further into winter, and we're working with the regions with NHS England centrally to make sure that we've done as much thinking as possible upfront, and we've done it together. And I think the focus on working in that way is actually really helpful. 

Then I'm going to go back to the point I made earlier about devolving autonomy, devolving authority, because I think paradoxically, when you're in the middle of a crisis, central command of control doesn't always work as you think it should. But you can find local solutions and the leaders that I've got working in Kent, Surrey, Sussex, are incredibly creative at working through issues on the ground. And you have to trust that they can do that, within a framework, obviously. 

And then you really have to respect thirdly, and, and I will pay tribute to my acute trust colleagues here who've done a stellar job at helping us deliver the 45-minute handover time. You have to really work out that, although again, the public may think all NHS hospitals are equal, they are not. And you really do need the context, specific solutions that local leaders only and only local leaders can develop. And my job, the board's job, is to back those solutions and to try and be innovative in that space.

So my plea would be don’t let's centrally control everything in the middle of a crisis. Let's trust people to come up with those solutions. Let's back them and let's recognise that, you know, all of our patches have differences that we need to work with. 

Matthew Taylor

Well, I think it's a wonderful way to end our conversation because I think if that's true of your ambulance service, I think if equally true of all parts of the health service, actually we are simply not going to thrive in the future unless we can create a kind of culture of evolution, empowerment and trust. 

Thank you so much, Anna, Simon, and John for really a fascinating conversation. And listeners, if you have an exciting or innovative programme of work you'd like to tell us about, please do you, you might end up talking with me on Health on the Line. Just contact HealthCommsPlus@nhsconf.org

Goodbye. 

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