Achievements against local priorities for 2022/23

The following provides information on achievements against local priorities set for 2022/23

Priority One: Patient Safety

Developing a learning from deaths programme to benefit patients.

Our aim within the year was to further develop the Learning from deaths programme through several actions including:

Finalise standard operating procedure to identify cases that meet the learning from deaths criteria in all the specified categories.
Finalise training for Trust clinicians to begin undertaking Structured Judgement Reviews (SJRs) and work with the Clinical Lead team to identified suitable clinicians.
Deliver training to Trust clinicians.
Design learning and feedback mechanisms to fully embed the learning from deaths programme.

Due to operational system pressures and the need to focus on contractual and statutory duties, the programme has not progressed as far as initially planned in the 2022/23 financial year and not all actions have been completed, however the Trust now has a robust identification system in place, to ensure that patients who meet the inclusion criteria are known and a dashboard is set up which will be presented through the Trust’s Patient Safety and Experience Group six times throughout the year.

The next step is to train a group of clinicians to undertake the structured judgement review process and embed the learning identified. The Trust’s Patient Safety Improvement Specialist is working closely with a small team and will lead the work to ensure triangulation of themes is identified and actions are set for improvements to be made.

Next steps:

This important piece of work has already begun and will continue in 2023/24 as a priority.

Development and Implementation of the Patient Safety Incident Response Framework.

During 2022/23, the Patient Safety Incident Response Framework (PSIRF) planning has commenced and is on target to be implemented into the organisation to enable us to improve our ability to learn from incidents using the methodology principles of the Framework.

This piece of work, led by the NHS, was affected by the ongoing pandemic and has not been able to progress national migration to the PSIRF as planned. The early adopter sites have now evaluated the new framework for investigating when things don’t go to plan and EEAST has worked with local and national partners to have a plan in place for when the full migration occurs. In order to progress this plan, the Trust appointed a project lead to ensure implementation is achieved, working closely with the lead commissioner and regional Patient Safety Specialist. The plan includes staff training, development of the PSIR Plan and Policy and recruitment of Patient Safety Partners, which will be in place for the September 2023 national go live date. The Trust also has Patient Safety Specialists in post to progress this work and transition into PSIRF once training has been completed as part of the project.

Next steps:

This important piece of work has already begun and will continue in 2023/24 as a priority.

Non-Conveyed Patients

Following a rise in the number of incidents reported by staff and other health care providers seen for patients who were not conveyed to hospital following assessment and treatment by our staff, and a commitment to treat more patients in the community, a priority was set to ensure that appropriate safe decision making was applied for these patients.

Our aim for 2022/23 was to embed the non-conveyance care bundle, implemented in the previous year, with the aim of a reduction in taking patients to hospital, where safe to do so, and an improved patient experience and outcome.

Unfortunately, the number of SIs relating to patients left at home for 2022/23 was slightly higher within the year - 21 compared to 18 in the previous year – however the Trust overall saw a much higher rate of reported SIs for 2022/23. Please see page 41. The Trust continues its commitment in learning and improving from these cases.

Support to safely discharge patients in the community has been strengthened by additional safety-nets, including ‘call before you can convey’ and ‘access to stack’ in some areas of the Trust.

A clinical guideline has been drafted including an in-depth explanation of the non-conveyance care bundle, a make own way decision aiding tool and a patient refusal tool. This is currently being reviewed by the Trust’s clinical leads before being approved through Clinical Best Practice Group and released to staff later in the year.

The non-conveyance audits are still in their infancy and to date 668 audits have been completed of which 65% were fully compliant. These audits are mainly from Cambridgeshire and Bedfordshire, however work has been undertaken with the other areas to promote ten audits being completed per locality per month with a feedback loop to staff. One of the Trust’s Patient Safety Specialists is leading on this work and monitoring compliance across the organisation. Indicators of lower levels of compliance identified for improvement relate to the documentation of the use of a risk stratification tool such as NEWS2, shared decision making with another Health Care Professional (HCP) and documentation of adequate safety netting.

Safety engagement events were facilitated at acute hospitals where the patient safety team met with colleagues to discuss the non-conveyance care bundle, in addition to other commonly seen themes in patient safety incidents.

Next steps:

In 2023/24 we will undertake a series of focus groups to understand staff perception of the tool, what can be done to improve the safety of discharges, and to set the appropriate actions. We have also introduced the monitoring of the associated tools as a monthly Key Performance Indicator (KPI) for our operational teams.

Learning from incidents and patient experience

Our aim within the year was to build on the robust systems already in place for patient safety and patient feedback to ensure these two aspects were connected. By fully joining up learning from the triangulation of data from both, it was anticipated that lessons are learned and fully embedded within the organisation to improve the safety of delivery of care and an improved patient experience.

Over the past twelve months the team have taken significant strides in learning from complaints and incidents. With the introduction of the Patient Safety Improvement Specialist and Patient Experience Improvement Manager there has been a focus on developing pathways of learning from both complaints and serious incidents. This has seen successful delivery of Safety Matters, a staff platform for learning which includes learning from videos, podcasts and alerts and which is viewed by over 2,000 staff per month.

The CQC inspection in 2022 identified that staff knew what local risks were, what was being done about this and where to find any information that they might need. A ‘Just’ culture around learning from complaints and incidents has supported staff to feel safe in engaging with patient safety and patient experience, raising when something has gone wrong.

The triangulation of data across the patient experience, patient safety and patient and public involvement teams has started with the development of exciting new pathways of joint working across teams. This includes the use of discovery interviews with patients or complaints and how we implement Trust wide learning.

Processes are being developed and embedded to centralise the actions set through both patient experience and the serious incidents. The aim is to make sure that more achievable and measurable actions are set across the departments which can be reviewed to ascertain how effective they were.

This new way of working will link in with the 2023/24 priority regarding embedding the Patient Safety Incident Response Framework (PSIRF) and also links to the public engagement workstreams to support the patient’s voice.

Priority Two: Clinical effectiveness

Implementation of clinical supervision

Placing the patient at the centre of our organisation also means we need to focus on the clinician to enable them to care for others safely and effectively. The Trust recognised that there are gaps within the provision of clinical supervision with sometimes undefined processes.

Our plan for 2022/23 was to commit to clinical supervision in our patient-facing workforce delivered by approved supervisors, in a relationship-based education and training system that is work- focused and which manages, supports, develops and evaluates the work. This aligns with our Operational Improvement Plan which recognises that recruitment of additional supervisors and managers is required to ensure good levels of support against the ratio of staff.

Following the publication of our Clinical Supervision Policy, clinical supervision has now been implemented within two of our six operational sectors with the remaining four to be implemented by the end of quarter 1 2023/24.

In addition to this formal clinical supervision, the Trust has led nationally on the implementation of restorative clinical supervision. This model has utilised the Professional Nursing Advocate approach and has seen roll out across our Emergency Operations Centres (EOCs) and into some of the operational areas. This model came about following the Covid pandemic and recognised that healthcare professionals needed support and the opportunity to reflect on that period in their careers. The model has had positive uptake across the Trust and indeed has been recognised nationally. The Trust has been able to secure further training for more people to undertake this approach and develop the Professional Paramedic Advocate. The Trust “In the cab” model for this is based on confidential discussions between an advocate and a member of our staff and further actions are being implementation following feedback received. This has also been put forward for a national nursing award.

Next steps:

To ensure that this is fully embedded within our organisation as a vital component of our ‘Time to Lead’ and ‘Fit for the Future’ programmes as well as to meet expectations set by the CQC following their latest inspection (2022), work will continue with this priority in 2023/24.

Launch of the Trust’s Clinical Strategy

The aim for 2022/23 was to publish our Urgent and Emergency Care Strategy and complete/monitoring of year 1 metrics.

The ongoing pressures felt by all ambulance services within the year impacted on the timeline however EEAST completed its Urgent and Emergency Care - Clinical Strategy for 2022-25 and it was approved at our Board in November 2022.

The strategy which will reinforce putting the patient and clinician at the heart of the organisation to deliver better patient care, right time, right response, right profession to meet the needs of our patients, was jointly developed by EEAST alongside and with extensive engagement with our regional partners and patient and community engagement groups including;

All staff survey (399 responses)
Executive Leadership Team and Executive Clinical Group workshops
Regional UEC event in July
Regional Partnership Event (2 September)
Presentations at each ICS A&E Boards or equivalent for more detailed discussion
Consultation with partners via the Partnership Survey
Consultation session with EEAST’s Community Engagement Group
Consultation with staff via video and internal articles.

The strategy is ambitious and outlines an approach where EEAST plays a pivotal role alongside our ICBs (Integrated Care Boards) and partners to change and improve our delivery of care, to be more responsive to our patients in the most appropriate way according to their care need. By working more closely with our six Integrated Care Systems, we also aim to support and develop our workforce to improve the delivery of high quality care to all our patients.

Next steps:

Due to the delay in completing the Strategy, a priority has been set for 2023/24 for the implementation and completion of the first year’s objectives.

Launch of the Trust’s Clinical Strategy

With the extended period of Covid 19 as well as development of the new ICS Boards the Trust has been working in collaborative approach on its Urgent and Emergency Care Strategy. This document will incorporate the clinical priorities as well so will provide a single integrated direction for the Trust in how it will deliver high quality, safe and effective clinical care.

At the core of the strategy will be the need to work in collaboration with all providers to ensure the patient receives the appropriate care for their presenting condition. This could include a single 999/111 call system where patients are sign posted and managed by the appropriate part of the healthcare system. Over the last year several pieces of work have been occurring across the region which will influenc e the work and the direction of the strategy. The Trust will launch this integrated strategy over the forthcoming year and this will remain a priority for 2022/23.

Produce a Public Health Strategy in collaboration with Public Health England

During the previous year, EEAST has remained focussed on continuing to contribute proactively with the Public Health agenda and during this period, our wellbeing offer to our staff has increased considerably. Our staff now have access to multiple different sources of support including crisis support, the employee assistance programme, specific menopause support and much more.

EEAST appointed a full-time fixed term Consultant in Public Health during the 2022/23 period – their input was vital in developing our 5-year public health strategy. The final draft of this document has been produced and it is planned for this to be approved and launched in the coming year.

EEAST has fully rolled out a new electronic patient care record system and now is seeing >90% with the use of this system. This will significantly enhance EEASTs ability to access data sources in an effective manner enabling a focus on relevant data and evaluation. Making every contact count is vital and our advancing practice programme is producing a new generation of clinicians with high level education and clinical skills to enable patients to access the right care at the right time, first time.

Public health will remain a focus with a continuing priority in 2023/24

Enhancement of our Annual Clinical Audit Plan

Clinical audit is a crucial part of the Trust’s strategy to improve health care and enables the evaluation of clinical care provided to service users to identify any changes needed to improve the quality of care and also to provide assurance that the care delivered was aligned with evidence-based guidelines and directives.

As an organisation committed to provide high standards of safe and effective clinical care, it is vital that clinical audit is undertaken in addition to nationally mandated audits.

Unfortunately, the increased volume of cases for cardiac arrests, stroke and STEMI patients within the mandated national audits and the increase in records completed on paper whilst the Trust moved to a new ePCR platform, greatly impacted our own availability to undertake locally defined audits in previous years.

Our aim for 2022/23 was to complete an extended clinical audit plan which took into account a number of drivers, including patient feedback, themes from incidents and serious incidents, NICE guidance, NHS Long Term Plan and national mandated audits.

Despite a challenging year, 88% of all audits were completed with three outstanding at the end of March 2023. Two of these were set to be implemented as part of the national ACQI programme, mental health and falls in the elderly, however ambulance trusts are still waiting for confirmation from NHSE as to when these will commence.

The third topic not completed related to patients with learning difficulties, and has been included as a priority within the clinical audit plan for 2023/24.

Next steps:

Although this topic will not be included as a local Quality Account priority in 2023/24, clinical audit will continue with the plan being repeated to enable the Trust to determine as to what further improvements have been achieved. For information relating to audit outcomes, please see the clinical audit section on page 37 of this report.

Priority Three: Patient Experience

During 2022/23, the Trust has continued to actively seek feedback from patients in seldom heard groups, including patients with a learning disability, younger patients, and patients of an ethnic minority. The Patient and Public Involvement (PPI) Strategy is now imbedded within the patient experience and engagement workstreams and implementation plans, and a number of face-to-face and virtual engagement and involvement events have taken place across the region, ensuring inclusivity and accessibility for all. The patient experience teams have continued to work alongside experts by experience, ensuring people and communities are treated as equal partners in service design, development, and evaluation. Co-production has been a move away from the traditional consultation process, and the impact of our co-produced strategy has also been far reaching nationally and shared widely.

The past year has also seen the implementation of the Unmet Needs pilot project, thanks to the Ambulance Grants Programme, which was launched by NHS Charities Together. The Unmet Needs pilot project has provided an avenue for patient facing staff and community first responders to be able to signpost those with non-health related unmet needs (e.g., loneliness, lack of carer respite, self-isolation - which might not meet the formal threshold for social or community support) to the Unmet Needs team. The person is then appropriately guided to wider community support pathways, which better meets the needs of the patient, family and/or carers and subsequently reduces pressures on NHS services across the region.

Next steps

To continue developing patient experience and engagement activity, working with experts by experience, ensuring people and communities are treated as equal partners in service design, development, and evaluation.
To review and agree the Community Engagement Group structure and workplan, in line with the PPI Strategy and the Trust’s key goals and objectives.
To raise the profile of the Community Engagement Group and to improve recruitment and geographical coverage.
To continue to review the impact of the Unmet Needs pilot project and to capture feedback from people who have been signposted.
To relaunch the Learning Disability and Autism Strategy, contacting patients’ representatives and advocacy groups and working with the patient experience team to engage with other groups and system partners to support us in achieving the strategic aims which are to:
Deliver compassionate person-centred care and recognise the uniqueness of all those living with a learning disability, autism or both.

Develop a skilled and effective workforce able to champion compassionate person-centred care.

Develop the ‘Easyread’ option within all Trust communications workstreams and patient care documentation.

Seek and action feedback from people living with a learning disability, autism or both and their carers to improve the quality of service we provide.

Develop internal systems that allow the patient living with a learning disability, autism, or both to be placed at the centre of joint care planning whilst ensuring that their rights are protected and respected in all aspects of Trust business.
Develop effective partnerships with local agencies (health, social care, third sector) to improve care and outcomes.

The following table demonstrates achievements, outcomes and identified next steps from specific bespoke patient surveys undertaken within the year:

Patient group	Achievements/outcomes	Next steps
Patients with a Learning Disability	Co-production of an EasyRead patient experience survey with the D.R.A.G.O.N.S at the Norfolk and Norwich SEND Association (NANSA). This survey is now available for patients to complete both online and in alternative formats. This project has highlighted the importance of co-production and the need to work with experts by experience as equal partners. A case study of the co-production project has been shared with Norfolk County Council. Review and redesign of patient survey forms - more streamlined and user friendly; online patient experience surveys can be completed using the ReachDeck Toolbar Everything function, with alternative survey formats also available (e.g., large print, Braille, or a different language). Patient survey reports are now published using the accessible template format, in line with the Accessible Information Standard. 75.0% of respondents rated the service as ‘good’ or ‘very good.’ However, lower satisfaction was seen in relation to the call handling (68.8%) and the wait for an emergency response (56.3%). Ambulance service staff were generally rated as ‘good’ or ‘excellent’ (93.3%), with most patients recalling that they were treated with dignity and respect (93.3%). Patients (86.7%) generally understood the explanation of their treatment and care and felt involved to at least ‘some extent’ (93.3%) in decisions made.	Co-production of videos; • to explain how to complete the EasyRead survey and to outline what happens with feedback once received, • to explain the emergency services patient pathway, including a tour of an ambulance from a sensory perspective, which may help to alleviate anxieties for patients.
Young patients	Generally, results demonstrate satisfaction with the service received, however, 75.8% of respondents reported not being able to access mental health services/support prior to calling 999, with 24.5% of respondents unaware of services/support available. 32.4% of respondents also did not feel that their needs were understood or that they had been listened to during their emergency call. The survey results have been shared widely to ensure 360 feedback and to ensure learning and to discuss next steps. The PPI team have continued to support staff and volunteers at engagement events for young people (e.g., schools) to teach basic first aid and to promote children’s emergency services educational material e.g., StayWise.	Call handler engagement sessions with young mental health ambassadors to be undertaken, and further communications planned to explain the 999-call handling process. Lists of area specific mental health services/support to be signposted via the Trust’s social media channels as part of Integrated Care System focus weeks. Production of a video to explain the emergency service patient pathway from calling 999 through to journey/alternative pathway/referral. Continuation of the quarterly Instagram young person mental health survey. Co-production of a children’s survey to encourage feedback from children.
Patients of an ethnic minority	89.3% rated the service received as ‘good’ or ‘very good.’ The majority of respondents (80.8%) were satisfied with the handling of their emergency call, with slightly lower satisfaction levels seen for the length of wait for an emergency response (76.9%). Ambulance service staff were generally rated highly as ‘good’ or ‘excellent’ (92.3%), and most respondents (96.2%) recalled being treated with dignity and respect. Overall, 92.0% of respondents understood the explanation of their treatment and care, with the same proportion advising that they felt involved to at least ‘some extent’ in decisions made regarding their care. A number of additional comments were received which mostly highlighted the professionalism, kindness and care provided by staff. The main areas of dissatisfaction were in relation to ambulance delays and staff attitude. During 2022/23, Gypsy, Roma and Traveller cultural awareness training was offered to Trust staff (delivered by the Friends, Family and Travellers, and the Roma Support Group). The Trust has also met with the Hertfordshire Gypsy and Traveller Service to plan a Gypsy, Roma, and Traveller engagement event, to promote and encourage inclusivity, improve understanding and to build trust and mutual respect.	The demographical information received through surveys will continue to be monitored alongside the patient feedback received. The joint engagement event with the Hertfordshire Gypsy and Traveller Service to build links and two-way engagement, to provide information about how to access emergency/non-emergency care, and to gain an understanding of the specific needs of this patient group – particularly given the lower health outcomes often seen for this community.

Patient Transport Vehicles

Our aim for 2022/23 was to work with particular patients, specifically dementia patients, and their carers in the design specification of the new PTS vehicles.

This was superseded by work undertaken by the NHS Executive which included the national PTS vehicle specification with elements of dementia friendly design. This meant that there has been less scope for us to influence the design, however a member of the Trust’s fleet team was involved in the dementia work and has been able to bring this perspective to the project. Whilst we have not been able to engage with dementia patients as much as we had planned to, we have been able to bring forward the timescales for securing new vehicles by not duplicating work undertaken in other parts of the NHS and we have worked to procure 97 new PTS vehicles, to replace older, less reliable vehicles. This also means that our patients and staff have benefitted from a better experience; with new vehicles replacing older vehicles more quickly.

The Trust’s fleet team conducted a competitive testing process with the procurement department obtaining alternative quotes to assess the best value for money, to lease suitable replacement vehicles that meet the national specification. The contract was awarded, and the team worked with the supplier to convert base vehicles as per the specification. The first 40 vehicles began to arrive toward the end of the last quarter of 2022/23. The remaining vehicles will become operational during the first part of the new financial year, meaning that approximately two thirds of the PTS fleet has been replaced in the last two years.

Improving experience and quality of care for people with learning disabilities/autism

We continue to focus on this patient cohort to strengthen and develop our all-inclusive approach to care delivery. Nationally the learning disability community remains an outlier within health provision and outcomes.

Implementation of national workstreams such as the delivery of the mandated Oliver McGowan training on learning disability and autism in 2023/24 may form the catalyst to assist in the progression of the Trust LD strategy strategic aims. We will also continue to engage with and develop feedback mechanisms to assist in reducing inequalities in health care delivery and strengthening the all-inclusive approach to health care delivery.

We have also worked with the benchmarking team at NHS England to develop a specific ambulance service tool which will come into effect in 2023/24.

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