Statements from the Commissioners, HealthWatch and Overview and Scrutiny Committees
The following section contains statements received from stakeholders following the 30-day consultation period. Some of the feedback received will also be used to formulate next year’s Quality Account.
Suffolk and North East Essex:
Date: 24 May 2023
The Suffolk and North East Essex (SNEE) Integrated Care Board (ICB) confirm that EEAST have consulted and invited comment regarding the Annual Quality Account for 2022/2023. This has been submitted within the agreed timeframe and the ICB are satisfied that the Quality Account provides appropriate assurance of the service.
SNEE ICB and other ICB’s within the region have reviewed the Quality Account (and enclose some feedback for your consideration). The information contained within the Quality Account is reflective of both the challenges and achievements within the organisation over the previous 12 month period.
SNEE ICB look forward to working with clinicians and managers from the service and with local service users to continue to improve services to ensure quality, safety, clinical effectiveness and a good service user experience is delivered across the organisation.
This Quality Account demonstrates the commitment of EEAST to provide a high quality service.
Lisa Nobes
Chief Nursing Officer
Healthwatch Suffolk:
Healthwatch response to the East of England Ambulance Service NHS Trust Quality Account 2022/2023
Healthwatch Suffolk (HWS) thank the Trust for the opportunity to comment on the Quality Account for 2022/23. We recognise this has been a period of extreme intensity for the Trust’s staff, clinicians and volunteers. As a Healthwatch, we are naturally also acutely aware of the heightened and at times sadly, too often, the unmet needs of the public, during these past 12 months. The number of 999 calls for 2022/23 was marginally lower than the previous year’s high, roughly 27,000 calls a week. This equates to yet another challenging period for the Trust and it is clear that some of the problems encountered stem from other parts of the health care system, such as overall demand levels and handover delays, and deficiencies in specific service areas like younger people’s mental health.
HWS is the region’s local healthwatch representative on the Trust’s Quality Governance Committee. We liaise directly with the Trust’s Suffolk based commissioners, and we are also responsible for coordinating regionwide healthwatch engagement with the Trust. This does of course only take place successfully because of the proactive support of all the other local healthwatch in the east, and a Trust that is open, responsive and engaging.
The Quality Account covers some involvement by the Patient Representative Groups of local healthwatch, the region’s Citizens Senate, and other organisations and specialist groups. There is no reference to the now established meetings between healthwatch leaders and the Trust’s CEO and Deputy CEO. These useful and action orientated meetings are now agreed to take place two or three times a year.
Co-production training was provided by us through several workshops, and this eventually led to the creation of what is likely to be a unique ambulance trust Patient & Public Involvement Strategy in 2021/22. The Trust refers to this work as having “emphasised the value of co-production”. There is a continued commitment to developing this culture of co-production and value of working with ‘experts by experience’. Two other examples are provided across the report.
There is the co-production of an Easy Read patient experience survey with the help of Norfolk & Norwich SEND Association. This will lead to videos explaining the use and benefits of the Easy Read survey, plus one to explain emergency services, and a virtual tour of an ambulance, that may help to alleviate anxieties for patients.
The other example is the co-production of the Patient and Public Involvement Strategy. We are informed that the latter brought about other co-produced projects that led to ‘service improvements’ and patient participated training for call handlers when receiving calls from people with a mental illness. It would be helpful to know more about these ‘service improvements’. Call handling public satisfaction is generally a concern for the Trust, possibly due to the intense pressures faced this past year. More information regarding steps being taken by the Trust to improve call handling experiences would be welcome e.g. increases in clinical staffing at call centres.
There are also examples of engagement on the part of the Trust. The Clinical Strategy was developed jointly with regional partners, and patient and community engagement groups. EEAST also continues to review the impact of Unmet Needs (a pilot project). We would ask that reports on the pilot are shared with local healthwatch for comment and feedback.
The Trust has worked with Community First Responders, volunteer car drivers, Co-responders, and the website page on volunteering is evidence of all such engagement. The Quality Account states that there have been over 400 engagement activities with ‘patients, representative groups and communities’. Is such activity information available to the public?
Engagement with minority ethnic communities is headlined by an excellent example. The Gypsy Roma and Traveller cultural awareness training project was 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 a ‘trust building’ event. There is more to follow in terms of working with this community, which is good to note.
On another equalities note, Healthwatch Suffolk would invite the Trust to consider the needs of vulnerable women and young people, who may be victims of the likes of domestic/sexual abuse and modern day slavery. Training in this area of safeguarding may help bring about better awareness, and the ability to support, record, refer and signpost.
In amongst next steps is a commitment to review the structure and workplan of the Community Engagement Group. We would like to suggest that such a process would benefit from an involvement of the region’s local healthwatch. The commitment regarding this Group is for the Trust to raise its profile, which again, local healthwatch can potentially be involved in. Is there any evidence of the Trust Board taking on advice and guidance from the Community Engagement Group; such evidence would equate to potential outcomes being achieved.
Survey projects have covered maternity, no-send, safeguarding, skin tear and young patient mental health. Results are mixed in their sentiments about the Trust’s service qualities, depending on the subject matter. It is good to see the Trust surveying about the ‘no-send’ subject, despite the expected predominance of negative experiences, in order to learn. We welcome the fact that the surveys and their results are all available for the public to view online.
The Trust reports a number of commendable achievements, including: Its performance on the STEMI bundle of 90.9%, which is the best in the country; its performance on stroke diagnostics, the ACOI bundle, which is also the best by a Trust; its recognition of sepsis; and its skin tear management pathway, which has attracted the Journal of Wound Care award.
Culture centred improvements are central to the CQC’s expectations of the Trust. The results of the Black and Minority Ethnic staff survey “made for difficult reading” for the Trust leadership, but an action plan is seeking to bring about change that would eradicate poor behaviour. Do staff have ready access to this action plan and updates of it? And are Staff Networks invited to be part of the governance and quality assurance of any culture action plans in order to ensure intended outcomes are brought about.
Staff support in the form of an Employee Assistance Programme, Crisis Support, and specific Menopause Support will hopefully be well used. The subject of the menopause transition has also benefitted from a mixed-methods study, the findings of which have been shared with all UK Ambulance Services. We would also ask if EEAST Staff Networks have been involved and are aware of the results?
Some progress is being made by the Trust, recognised by the CQC, in that two registration conditions have now been ‘lifted’, leaving a further six. The Trust remains in the Recovery Support Programme.
The Trust experienced a 72% increase in declared serious incidents during 2022/23, as compared to the previous year. The 2021/22 data was itself far higher than in the previous year, and so safeguarding alongside delays in the East of England, during these past two years, are the biggest public concern. The pressures faced by the Trust and its workforce have been unprecedented and so the wellbeing and mental health of staff and clinicians will have been equally concerning to the EEAST.
The key themes of serious incidents particularly highlight ‘delay’ as the biggest concern. We imagine that rural areas of Suffolk, and rural areas elsewhere in the region, would constitute a significant proportion of the 214 Serious Incidents on Delay. We have also noted an improvement in the theme of ‘patient injury’, the lowest number for four years, which is welcome news. Overall, EEAST uses a ‘when things go wrong’ learning model in order to help bring about more real time learning.
Duty of Candour (DoC) is similarly concerning in that there were 272 cases (same number discharged), as compared with 40 in 2020/21. That said, the timeframe for DoC to occur, and the timeframe for letter follow-up, are prompt. The Complaints section of the Quality Account has some good examples of ‘you said, we did’.
There is more EEAST can do in order to be compliant with the Accessible Information Standard. Whilst the example concerning learning disability access is particularly strong due to the co-production approach, there is no other recognition of this statutory requirement of an NHS trust.
EEAST should be congratulated for adding to their library of Discovery Interviews. These films made with patients supplement how the Trust learns from patient experiences. They are shown and discussed at the Trust public Board meetings. Discovery interviews are also used for training, handling complaints, serious incidents, and as part of the staff induction programme. 19 such interviews were completed in 2022/23, in a mix of face to face, virtual and also with translation services.
Two excellent examples are offered in the Quality Account. Mrs Porter is Deaf and communicates in British Sign Language, describing several poor experiences (67 YouTube views to-date), whilst Mr Oliver bravely relives a serious incident (9 views to-date). In the process of watching these films, we note Healthwatch Suffolk feels that impact and outcomes will only truly be forthcoming if the Trust can provide evidence of changes made as a direct result of such stories being discussed, by the Board, and other decision makers.
Finally, we were surprised to read nothing about the actions taken by the Trust in order to mitigate, where possible, against the impact on patients and families, from the national pay disputes during the latter end of the 2022-23 period.
Andy Yavoub
Chief Executive
Wendy Herber
Independent Chair
Healthwatch Norfolk:
Review of East of England Ambulance Service NHS Trust Quality Account 2022/23
Healthwatch Norfolk thanks the Trust for the opportunity to review the draft East of England Ambulance Service NHS Trust (EEAST) Quality Account for 2022-2023.
It has clearly been an extremely challenging year for the EEAST - as it has for ambulance services across the country, and indeed for the health and social care system as a whole.
In terms of the Trust’s improvement journey, it is encouraging that in its most recent inspection report (published July 2022) the Care Quality Commission (CQC) recognised that improvements had been made and that, although it was decided to keep EEAST in the Recovery Support Programme to ensure continued relevant support to make the necessary changes, CQC confirmed that there had been improvements on the issues that led to the Trust being placed in the Programme in the first place.
We are also pleased to see that the CQC inspection team praised the treatment of patients and support given to their loved ones, and the efforts being made by staff who are working extremely hard at the sharp end of patient care.
However, the report was clear that significant issues remain including patient waiting times and how long ambulances are taking to reach people. We know that delays and blockages in other parts of the health and social care system are part of the problem and we are pleased to see that the ambulance service is working closely with system partners and has introduced schemes to help ease delays, such as ‘Access to Stack’ to support appropriate alternative pathways.
In addition to response times, the CQC highlighted significant ongoing issues, including adequate staffing levels, mandatory training and appraisals, staf f engagement and staff wellbeing, facilities/premises, and organisational culture. We note that actions to address these issues are embedded within the Trust’s new Continuous Improvement Assurance Framework, which draws on data from across the Trust and sh ould enable a clearer focus on areas in need of improvement.
Although improvements have clearly been made in relation to organisational culture there are significant ongoing issues, including, for example, those highlighted in the outcome of the Trust’s BME Survey published earlier this year. We welcome the fact that the leadership team are committed to focusing on delivering the improvements needed with the Board setting out the actions it intends to take to improve the working environment for all people a nd to eradicate poor behaviour across the organisation.
Specific points
Response times
This is an ongoing area of concern, as can be seen from the Trust’s performance against the national response time standards for 2022/23. It is understood that there are a range of contributing factors which the Trust is working to improve – both organisational issues (e.g. recruitment and growth of the clinical workforce) and others which rely on wider system working.
We note that the EEAST has established an Organisational Improvement Plan to address recruitment and growth of the clinical workforce to improve overall trust performance and that the Trust is working towards agreed levels of ambulance cover as part of its progression towards meeting national standards of performance times. We also note that the Trust is working with system partners and has implemented actions to improve its performance.
STEMI care bundle - we are pleased to note that EEAST continues to be the highest performing Trust for the STEMI care bundle (April - November 2022) performing 23.6% above the national average.
Stroke diagnosis bundle – we are also pleased to note that EEAST was the highest performing trust for this bundle achieving 100% in 2 out of the three reporting months (April - November 2022).
Sepsis Care bundle – we are pleased to note that EEAST was the third highest performing trust for this care bundle.
Non-Conveyance Care
We note that support to further improve the safety and experience of patients not needing hospital treatment is being strengthened, including draft clinical guidelines and supporting tools for ensuring appropriate safe decision making.
Incident reporting
It is concerning that the number of incidents reported during 2022/23 has been higher than previously seen, with a 72% increase in serious incidents declared in the 2022/23 financial year compared with the previous year, and that the majority were related to delays. We do, however, recognise the operational pressures that faced by EEAST and welcome the collaborative approach between the Trust and its system partners to review system serious incidents.
We also note the development of the new national Patient Safety Incident Reporting Framework to improve the quality of care delivered, both when things go well and when things could have been done differently, and that the Trust plans to fully implement this new Framework by September 2024.
Learning when things go wrong
We are pleased that the CQC inspection last year found significant improvements in complaints handling and learning from complaints, including improvements in the processes which support staff to feel safe in engaging with patient safety and patient experience, and speaking up when something has gone wrong.
Raising concerns and freedom to speak up
We are pleased to see that progress is being made with the Freedom to Speak Up function within the Trust and that staff confidence in raising concerns is improving, albeit still below the average for all trusts. We are also pleased to note that the Team’s capacity is being increased in response to identified needs.
People engagement and wellbeing
We note that the Trust is continuing with initiatives to improve staff wellbeing, such as leadership development, an ambulance staff support phoneline, and actions to address issues identified in the staff survey, including and a 3-year Inclusivity Plan which aims to address the issues raised in the Trust’s survey of BME staff.
Clinical supervision
We are pleased to see that revised clinical supervision is now being implemented in the Trust’s patient-facing workforce and that feedback so far has been positive.
Clinical Strategy
We are also pleased that progress has been made in the development of the Urgent and Emergency Care - Clinical Strategy 2022-25, which outlines how EEAST will work alongside its six Integrated Care Boards and partners to improve its delivery of care and to be more responsive to patients in the most appropriate way, according to their care need.
Clinical audits
We note that despite a challenging year, 88% of all audits were completed, helping to ensure safe and effective clinical practices.
Patient experience and feedback
We are pleased to see that the Trust is making progress with work to join up learning from incidents and from patient experience, with the aim of fully embedding the learning within the organisation and improving both the safety of delivery of care and the patient experience. We note that the triangulation of data across the patient experience, patient safety and patient and public involvement teams has started, including the use of discovery interviews to better understand the patient and families’ stories.
We note that EEAST continues to focus on improving the experience and quality of care for people with learning disabilities or autism, by strengthening and developing an all-inclusive approach to care delivery, including the delivery of mandated training in 2023/24.
We also note that an Easy Read Patient Survey is now available for patients to complete and that all patient survey reports are published in line with the Accessible Information Standard, with alternative survey formats also available as options.
Format of the Account
Finally, this detailed Account is provided in a clear and readable way for the lay person and contains information on how to obtain the document in large print, Braille or another language.
Healthwatch Norfolk is happy to assist EEAST in any way we can to ensure that the views of the patients, their families and carers are taken into account as the Trust works to deliver the improvements needed.
Alex Stewart
Chief Executive, Healthwatch Norfolk
Healthwatch Central Bedfordshire:
East of England Ambulance Service NHS Trust Quality Account 2022/23
This detailed report clearly reflects how the Trust was operating, in what were the most testing of conditions (during the pandemic), and how it is responding to previous inspections and advice. For the lay-man the document is not an easy read and could perhaps benefit from a shorter Executive Summary, but it is appreciated that, under its legal obligations, there is a lot of information that the Trust needs to supply to the public.
The Trust has been honest and open in facing up to criticism - and we note the staff survey results (which are a concern), but equally the Trust has been able to point out areas where they perform well, for example in relation to dealing with heart attacks and strokes.
The Trust covers a vast geographical area, and this includes much open countryside and some areas of true deprivation. Its work crosses many ICSs and it is recognised that each of these entities will be placing differing demands on EEAST in the future.
It would have been helpful to Healthwatch Central Bedfordshire to see some localised information – for context. All the figures/data and graphics relate to the overall performance of the Trust. As a local Healthwatch we would seek some reassurances around local performance and ask that in future such data might be added.
That said, we recognise the outstanding work that our ambulance service has carried out in truly testing times and pass on our thanks to all who were engaged in managing the response to the pandemic, and dealing with the ‘ordinary’ and extra-ordinary.
Specific observations
Although improvements have clearly been made in relation to organisational culture there are significant ongoing issues, including, for example, those highlighted in the outcome of the Trust’s BME Survey published earlier this year. We welcome the fact that the leadership team are committed to focusing on delivering the improvements needed with the Board setting out the actions it intends to take to improve the working environment for all people and to eradicate poor behaviour across the organisation and the implementation of a cultural dashboard is planned.
It is encouraging to see that the trust has developed a clinical strategy with a focus on public health and that priority is being given to the achievement of objectives over year one. It is also good to see the continued drive on patient safety and that a safeguarding lead has been
appointed for each sector.
Stroke diagnosis bundle – We are also pleased to note that EEAST was the highest performing trust for this bundle achieving 100% in 2 out of the three reporting months (April - November 2022).
Learning from Deaths - It is disappointing that this work was not able to be progressed as planned but we are pleased to note that this work will be prioritised in the next year.
Non-Conveyance Care - We note that support to further improve the safety and experience of patients not needing hospital treatment is being strengthened, including draft clinical guidelines and supporting tools for ensuring appropriate safe decision making along with clear performance indicators and supporting audit.
Learning when things go wrong - We are pleased that the CQC inspection last year found significant improvements in complaints handling and learning from complaints, including improvements in the processes which support staff to feel safe in engaging with patient safety and patient experience, and speaking up when something has gone wrong and the continued focus in the new priorities.
Raising concerns and freedom to speak up - We are pleased to see that progress is being made with the Freedom to Speak Up function within the Trust and that staff confidence in raising concerns is improving, albeit still below the average for all trusts. We are also pleased to note that the Team’s capacity is being increased in response to identified needs and are keen to see increased reporting in the next financial year along with a continued decrease as reported in bullying and harassment.
Clinical audits - We note that despite a challenging year, 88% of all audits were completed, helping to ensure safe and effective clinical practices. It is also encouraging to see the focus on research and the continued commitment to support ongoing research.
We note that EEAST continues to focus on improving the experience and quality of care for people with learning disabilities or autism, by strengthening and developing an all-inclusive approach to care delivery, including the delivery of mandated training in 2023/24 and fully support the patient experience priorities for 2023/2024.
Diana Blackmun, Chief Executive Officer
Healthwatch Central Bedfordshire
Email: diana.blackmun@healthwatch-centralbedfordshire.org.uk
Tel: 0300 303 8554
Registered Address: Capability House, Wrest Park, Silsoe, Bedfordshire, MK45 4HR
Registered Company No: 08399922. Registered Charity No: 1154627
Cambridgeshire County Council
The East of England Ambulance Service Trust Quality Account 2022/23 Statement by Cambridgeshire County Council Adults and Health Committee
The Adults and Health Committee received the draft Quality Account for the East of England Ambulance Service (EEAST) on 9th May 2023. A Task and Finish Group was established to consider the draft in the committee’s scrutiny capacity and to respond within the required timeframe.
The CQC’s short notice inspection of emergency and urgent care in April/ May 2022 gave a grading of ‘Good’ for services being caring, with the overall rating remaining Requires Improvement. It was recommended that the Trust remain in the Recovery Support Programme with an unannounced follow-up visit expected soon.
The Trust’s performance in 2022/23 must be in seen in the wider context of its historical difficulties, the lasting impact of covid, and industrial action amongst many groups of healthcare workers, including ambulance staff. EEAST twice declared critical incident status during December 2022 and, whilst we regret this was necessary, we recognise the acute pressures which led to this. We would though like to see more candour about the challenges the Trust continues to face and the strategies in place to address these.
We recognise that demand for services continues to increase, but response times are below national standards for all categories whilst data on non-conveyed patients shows that serious incidents are higher for patients left at home.
Delays in transfers at hospital remain an area of concern both locally and nationally, with news reports showing the real-life consequences of this on people who are already in pain and distress. In this context we welcome the implementation of ‘Access to Stack,’ but would encourage the Trust to go further in its use of alternative transport. We would also endorse a collaborative approach to identifying and addressing causes and patterns of unnecessary requests for ambulances to focus capacity on those in most need of emergency support.
The service is rightly recognised for its role in supporting patients being transferred to hospital for care, but the role of paramedics in treating patients on site should be celebrated too. New working practices can also deliver real improvements in patient care and experience. In Cambridgeshire, the pilot stroke video triage system saw those in most need directed straight to a CT scanner with door to imaging time cut from 22 minutes to 2 minutes.
The workforce strategy is welcomed, but seems only to focus on the Care Quality Commission’s areas of concern. We would encourage a wider perspective. Results from the National Staff Survey found 46% of EEAST staff in 2022/23 felt safe to speak up about anything that concerned them in the organisation. This showed a slight improvement against previous years, but still remains below the national average of 52%. The number of staff reporting bullying and harassment dropped to 59 compared to 115 the previous year, but this still remains within the top three categories of reported concerns. A further 20 incidents were reported under a new category of inappropriate attitudes and behaviours. A steady and slight increase in the number of concerns raised about managers in the past three years is also reported.
At a public scrutiny session in December 2021, councillors raised the issue of discriminatory attitudes as an area of concern. In May 2022, a whistleblower made allegations around bullying and excessive working hours. Councillor Richard Howitt, the Chair of the Adults and Health Committee, stated at the time that it was regrettable that EEAST had not been prepared to answer questions about the whistleblowing allegations and that this created concern about its efforts at transformation. Staff well-being will remain an area of focus for us in the coming year.
The fixed term appointment of a consultant in Public Health to support the development of a five year public health strategy during 2022/23 is a positive development. We look forward to hearing next steps and to collaboration under the Integrated Care System ethos.
EAAST continues to face fundamental challenges in the management and delivery of its services. The Committee is committed to continue working constructively in support of the improvements being put in place both as a system partner and through its scrutiny role as a critical friend. To support this we will be offering the Trust’s senior leadership team informal biannual meetings with the Chair and Vice Chair of the Adults and Health Committee to maintain an open dialogue.
Suffolk Health Scrutiny Committee
As has been the case in previous years, the Suffolk Health Scrutiny Committee does not intend to comment individually on NHS Quality Accounts for 2022-23. This should in no way be taken as a negative response. The Committee acknowledges the significant ongoing pressures faced by NHS providers and wishes to place on record our thanks for everything being done to maintain NHS services for the people of Suffolk in the most challenging of times.
County Councillor Jessica Fleming
Chairman of the Suffolk Health Scrutiny Committee
Norfolk Health Overview and Scrutiny Committee
Norfolk Health Overview and Scrutiny Committee has decided not to comment on any of the Norfolk provider Trusts’ Quality Accounts and would like to stress this should in no way be taken as a negative comment.