Partners involved in this collaboration:
- Birmingham and Solihull ICS
- Black Country and West Birmingham ICS
- Coventry and Warwickshire ICS
- Herefordshire and Worcestershire ICS
- Shropshire, Telford and Wrekin ICS
- Staffordshire and Stoke-on-Trent ICS
- West Midlands Ambulance Service University NHS Foundation Trust
Background
The West Midlands Ambulance Service University NHS Foundation Trust serves a population of 5.6 million people covering an area of more than 5,000 square miles1 and work across six systems. While they are a regional ambulance service, they currently have a lead commissioner, Black Country and West Birmingham ICS, that works on behalf of the 22 CCGs within the six ICS regions, and a lead ICS.
The trust employs approximately 7,000 staff and operates from 15 new fleet preparation hubs across the region through a programme called 'make ready' - an approach that led to improved efficiency and productivity and less variation in care and infrastructure. The trust took over provision of the NHS 111 service in the West Midlands (except Staffordshire) in November 2019 and provides non-emergency patient transport services across some parts of the region for patients who are unable to travel unaided because of their medical condition or clinical need.
Vivek Khashu, director of strategy and engagement at West Midlands Ambulance Service, tells us that one of the key challenges for ambulance trusts is getting the partnership engagement piece right, particularly at place level. This includes managing the benefits of being a regional service with no borders but making sure they are also plugged in at a local level so that they can better connect with people and communities. He emphasises some of the complexities that exist around being an ambulance service across a particularly wide geographic footprint.
The impact of COVID-19
Vivek tells us the COVID-19 pandemic has brought provider leadership at system level to the fore and made partners much more aware of the NHS' role in tackling health inequalities and improving public health services, particularly as public health responsibilities sit with local authorities.
Restoration of elective care and other services is an important conversation taking place at the moment across all six ICSs. While recovering services isn't necessarily applicable to ambulance services as they never stopped, they have been plugged into the wider system recovery and transformation planning, which is focused around waiting times. However, Vivek highlights that there are important related issues for the ambulance sector particularly to manage handover performance or the elimination of long delays outside hospitals.
He also discusses what financial recovery will look like given changes to contracting. "I think capital will be an interesting issue for ambulance services, and this is where system working may start to collide with organisational-interest… there may be a need for some arbitration or independent review to mitigate any tensions".
The context for ambulance services
Vivek highlights how all ten ambulance trusts work within different contexts, so for example while the West Midlands Ambulance Service operates across six ICSs, the North East Ambulance Service NHS Foundation Trust works within one ICS. Vivek says having a 'forum' in the form of the Association of Ambulance Chief Executives and its subgroups to share learning and discuss challenges is useful and will continue to be as collaborative working arrangements evolve.
Ambulance services work within a slightly different hybrid context of emergency services, including fire and rescue and the police, so they don’t see their function as "purely NHS". This makes the world of system working quite complex for ambulance services, although there are opportunities to drive further integration across the system.
The case for change
In terms of integrated care, he stresses that most of the work they do as an ambulance service is supporting people with exacerbations of long-term conditions, frailty, or chronic diseases, and so from an integrated care perspective they have an opportunity "to integrate patients into a continuum of care".
Vivek says he feels that working in collaboration also provides more opportunities for better population health management and reducing health inequalities. He says the ambulance service has some valuable population health data about the people who call them and integrating this across the system could help address some wider health issues in their patch. "Ambulance services can act as a real integrator of care because like primary care, we are often the first port of call, and it’s about how we plug people into the right parts of the health and social care system. I think we have a big responsibility as we move closer towards integrated care, not just from a public health perspective but also with regards to addressing health inequalities".
He also notes the importance of strengthening the delivery of local people plans, equality, diversity and inclusion, and the important role ambulance services have in addressing some of these challenges. He says, "we have thousands of contacts, many in person with our clinicians every day”. That is a lot of contact where we can influence health and well-being within the communities we serve and ask things like 'Have you had your flu jab?' You can start to see how we could make a difference". The trust will be refreshing its organisational strategy to consider strategic priorities in these areas. He also notes, for example, how "ambulance services could potentially work alongside and virtually with integrated care teams to assess the needs of our patients and deliver the right outcomes first time".
Vivek also illustrates some of the shared benefits that could be realised by sharing the population health data they have with local trusts to help prevent patients needing to be admitted into hospital. So, for example, they could provide an individual, who would otherwise call the ambulance service on a regular basis, with necessary equipment and adaptations to their property so that they are not as vulnerable as they previously were. Vivek says, "we're going to increasingly have be more involved in helping people live independently, live longer with more dignity and contribute to reducing demand on the healthcare system".
Over the next year, the trust will also be thinking about the potential dividend for integrating care in this way. They will be thinking about opportunities to support greater productivity and efficiencies in healthcare across the region and the need to adapt commissioning arrangements to achieve this. He says, ultimately "the principle of ICS working is to remove boundaries and barriers and to support each other to achieve a collective goal".
While there are opportunities with regards to population health management there are also some associated risks. Vivek questions, "How will we be commissioned? How will we have a seat at every ICS table? How will we have a say, and a voice?".
Sharing lessons learned
One thing that has worked well for the West Midlands Ambulance Service and its patients is having a lead commissioner who works on behalf of the 22 CCGs that exist within the six ICS boundaries. They are also hosted by one ICS on behalf of the six, and this simplifies the planning and commissioning arrangements. Vivek has some concerns about how this will change as the national policy around ICSs develops, preferring a regional commissioning board model with a lead ICS, or potentially a specialised commissioning approach.
Another challenge they've had to navigate is balancing at-scale collaboration with place. "One of the biggest challenges, I don't think is at system level, but actually at place level, particularly as a regional ambulance service trying to make sure we’re still plugged in locally". He says one way they've been building relationships at this local level is by getting the collaborative's senior operational managers involved in projects, such as rebuilding emergency departments, at place within their patch.
He also discusses the role PCNs will have in employing paramedics in primary care, which has been particularly challenging as there are 110 PCNs within the six ICSs. He explains how the ICSs have had an important role in bringing together voices from appropriate partners to streamline this process. "ICS workforce leads set up a forum with us to exchange views and are now working on our behalf with PCNs within their patch, which has been very helpful."
Next steps
Regarding his concerns about the future role of ICSs in terms of resources and planning for the ambulance sector, Vivek sees value in maintaining a single lead commissioner role in some form or shape.
Vivek also touches on some of challenges associated with moving towards shared accountability, particularly for systems where performance at an organisation level is variable. "At the moment we’re achieving all of our objectives as we’re measured as a standalone trust, and that gives us a lot of pride, but we don’t know how it will play out as we move closer towards collaborative working arrangements and collective accountability…". There is a need to ensure everybody has the necessary influence over decisions at system level, including ambulance trusts.
However, the benefit of "a collective accountability arrangement means we are of course bound together with the obvious requirement to support one another" to address system wide challenges. Vivek says the trust is now thinking about how they can re-orientate themselves and continue delivering an outstanding service with a shared responsibility on a much greater level across their partners.
National policy to support provider collaboratives
Vivek agrees that putting ICSs on a statutory footing is absolutely the right thing to do when it comes to clear accountability and decisions about resources. But this is not without its challenges, as his trust recently had to work through, when it wanted to use its own capital to replace some aging fleet reaching the end of their five-year lifespan, when the ICS itself was resolving a challenging financial position. Working with partners the matter was resolved, however previously we wouldn't have had to go outside of the organisation to even discuss the matter. "There may always be this issue of organisational interest versus collective good, and with organisations still being held accountable for the care and welfare of their patients and staff, there will inherently continue to be tension".