The ambulance service bringing care closer to home

North West Ambulance Service is trying to reduce avoidable hospital admissions following a national review

North West Ambulance Service is trying to reduce avoidable hospital admissions following a national review

Picture: Alamy

A review of ambulance services in England by Lord Carter of Coles suggested last month that the NHS could save £300 million a year by 2021 by caring for patients closer to home.

The report for NHS Improvement, Operational Productivity and Performance in English Ambulance NHS Trusts: Unwarranted Variations, looked at the productivity of ten ambulance trusts across England and focused on the urgent and emergency service.

The review found sickness absence at the trusts was the highest of all NHS sectors and there were recruitment and retention issues across the service. There were also the highest levels of bullying and harassment in the NHS and unacceptable levels of violence towards staff.

Lord Carter warned: ‘Too many patients are being unnecessarily taken to emergency departments (ED) by ambulances, putting further pressure on hospital services that are already on the back foot. Not only is this financially costly, but it takes up staff’s time and means patients are having to spend time waiting in ED when they should be recovering at home.’

Transforming the service

North West Ambulance Service (NWAS) NHS Trust has been trying to improve its service with a number of initiatives to support patients to receive the right care closer to home, reducing avoidable hospital attendances and admissions.

The trust has said it has the aim of becoming ‘the best ambulance service in the UK within five years’. 

At the start of last year, the Care Quality Commission said the trust required improvement and cited an overall 5.7% vacancy rate alongside concerns about whether the service had enough staff to meet the needs of patients.

10 million

Number of 999 calls ambulance trusts respond to every year across England 

Source: Operational Productivity and Performance in English Ambulance NHS Trusts: Unwarranted Variations 

A new quality strategy was due to go to the board at the end of October for approval but NWAS was already evaluating new projects to improve care.

Under the Transforming Patient Care programme, which has been running for the past 18 months, the trust has been focusing on ways it can increase the number of patients it ‘see and treats’ through support on the scene and ‘hear and treats’ via phone support.

The trust claims that in the first quarter of this year, when compared to the same time period last year, hear and treat rates had increased by 43% and almost 7,000 fewer patients were transported in an ambulance despite an increase in incidents overall.

Urgent care team

It is evaluating the progress of a six-month pilot scheme involving nurses who are part of an initiative that is helping patients to be treated closer to home rather than in EDs when they call 999.

The NWAS team of urgent care practitioners is made up of eight nurses and five paramedics, who work across Manchester, Liverpool and Chorley.

The team rotates between working in an emergency operations centre, where it offers secondary telephone triage in a similar way to how NHS 111 operates and responds to selected 999 calls in a 'see and treat' vehicle.

Finding a strategy

NWAS chief nurse Angela McKeane joined the trust in May to a newly created role from Salford Royal NHS Foundation Trust where she was divisional deputy director of nursing. 


The average number of days a person per year has off sick across the ambulance trusts 

Source: Operational Productivity and Performance in English Ambulance NHS Trusts: Unwarranted Variations 

Ms McKeane is focused on giving nurses within NWAS a voice and has recently been meeting with groups of nurses at the trust to gather their views for a new nursing and midwifery strategy which she hopes will be out for consultation in January next year. 

‘I’ve always worked in hospitals, so this has been a different experience for me and when I started at the trust there was no visible nursing and midwifery strategy.

‘I wanted to meet all the nurses and get their take on what they think the gaps in the service are and how we can give them a voice. They are best placed in terms of leadership, there are only about 130 nurses at the trust but when I spoke with one group, we worked out there was over 300 years of nursing experience in the room.’

Clear career progression

She acknowledged the trust has a high number of vacancies and has identified that there needs to be a career structure for nurses to progress through the organisation and to encourage retention.

‘We don’t have any nursing students and we need to have them, but we also need to make sure when we do, we can support them. There are a lot of paramedics who had dual registration with nursing but who have let the nursing side go. That’s a shame,’ Ms McKeane says. 

£300 million

The amount of money that could be saved by the NHS by 2021 if safe and quicker care is offered

Source: Operational Productivity and Performance in English Ambulance NHS Trusts: Unwarranted Variations

‘I don’t want boundaries between paramedics and nurses, it all about putting the patient in the middle and wrapping around the care. They may have different skills, but they can complement each other.’

Feedback from the meetings she has had with nurses also ties in to Lord Carter’s review.

‘What has come out of my scoping exercise is the definite need for nurses to have a voice about treating patients away from EDs and closer to home, which is exactly what Lord Carter was talking about,’ she says. ‘Patients want to be treated by someone who is confident, competent and caring.’

Adding value

Maxine Power, NWAS director of quality, innovation and improvement was instrumental in Ms McKeane’s appointment and says: ‘Ambulance services benefit from a diverse clinical network of healthcare professionals to offer the right care at the right time in the right place. Our chief nurse is a significant and important senior leader appointment who adds significant value to our leadership team.

'Our strategy focuses specifically on emergency and urgent care. The complex needs of the patients we serve require us to have a breadth of expertise and skills to link with the integrated care system.' 

Integrated community services model

Lynne Hall-Bentley is a nurse and assistant director within adult community services at Bridgewater Community Healthcare NHS Foundation Trust. 

The trust has been working alongside NWAS and the local council as part of an integrated community services model to improve patient care and reduce emergency department visits for patients. 

Ms Hall-Bentley says: ‘When a paramedic gets called to a home to see a patient via 999 but thinks there may be another option to hospital, they will ring one of our advanced nurse practitioners directly and make a joint decision about what do. 

‘They may choose a wraparound care package from the community response team which includes advanced nurse practitioners, geriatricians, occupational therapists and physiotherapists, who would come out and visit the patient. 

‘There are other alternatives, if a patient doesn’t need to go to an emergency department but are not deemed safe to be at home. We have beds we can refer them to at nursing homes as an alternative or additional support in their own home. 

‘Joint working is making all the difference and having links with the council and ambulance service is crucial.’ 



Lord Carter of Coles’ review recommendations include:

  • The ambulance service should develop a five-year workforce, recruitment and staff wellbeing plan
  • NHS England should accelerate work to support reduction of avoidable conveyance to hospital, working with ambulance trusts and other organisations
  • NHS Improvement should make operational data routinely available to ambulance trusts to enable them to effectively benchmark their services, starting in autumn 2018



Operational Productivity and Performance in English Ambulance NHS Trusts: Unwarranted Variations (2018)

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