Tackling
demand
together
Enter here
A toolkit for improving urgent
and emergency care pathways
by understanding increases
in 999 demand
Forewords
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Home
Introduction
Forewords
Introduction
Gus Curry – Head of Ambulance Commissioning,
Derbyshire County PCT; Mike Damiani – Analyst,
London Ambulance Service NHS Trust; Geraint
Davies – Service Development Director, South East
Coast Ambulance Service NHS Trust; Emily Duncan –
Analyst, North East Ambulance Service NHS Trust;
Madeline Harding – Service Development Director,
North West Ambulance Service NHS Trust; Kathy
“Demand for ambulance services is influenced by
Jones – Service Development Director, London
multiple complex and interrelating factors. Urgent
Ambulance Service NHS Trust; Liz Kendall – Director,
and emergency care services are also complex
Ambulance Service Network; Lis Rodgers – Clinical
systems, and commissioners and providers need to
Lead, Doncaster PCT; Bob Webb – Head of
make the best use of the available information so that Ambulance Commissioning, Bedfordshire PCT;
they can offer the right services to meet the health
needs within their local area.
“Our group of ambulance providers and primary
care trust (PCT) commissioners has worked closely
with the Department of Health (DH) to develop this
toolkit. We wanted to create a practical tool which
could be used by commissioners and providers to
inform decisions affecting the commissioning of
urgent and emergency care services.
Factsheets and checklists
Tools
“A number of us have tried and tested this toolkit
in our own local areas with positive results and we
encourage you to do so too.”
Ambulance Demand Toolkit
Sounding Board Group
Page 1
Toolkit map
References
Back Next
Introduction
Forewords
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ipsaest uta nos eum ut molum quas eum quatemped eos ut invelit prep
eles eat aspit qui omnit qui cuptatur ad quam duntota quassit.
Home
Forewords
Introduction
“Ambulance demand has been rising steadily at a
rate of around 6.5% per year. This toolkit is the first
attempt to take a view across the wide range of factors
that are influencing this steep rise. Working through
this toolkit will help ambulance trusts and PCTs to
make the best use of the data that is available to them.
Crucially, it will also help them in working together
to use the data to support reducing demand where
possible, and handling demand efficiently where it
cannot be reduced. Ambulance services are working in
increasingly closer partnership with other urgent and
emergency care services to provide seamless, 24-hour
integrated care, and this toolkit will help to achieve
that goal.”
Peter Bradley,
National Ambulance Adviser
“Urgent and Emergency healthcare is the first point of
contact that millions of patients each year have with
the NHS. Many of these are very unwell, anxious and
in need of a fast and high quality response. The NHS
provides a wide range of urgent and emergency care
services, however the Emergency Services Review
(ESR) has identified that more work is needed to make
sure that, through excellent commissioning practices,
these services are well integrated, clearly signposted
to patients and the public, and able to refer patients
appropriately.
Factsheets and checklists
Tools
Alongside the tools developed as part of the ESR, this
toolkit offers real, practical support to help all PCTs
and networks, not just lead ambulance commissioners,
make the best use of the wealth of information that
the ambulance services have to offer. Specifically, by
better understanding the factors affecting the ongoing
trend of year on year increases in ambulance demand,
the NHS can provide better urgent and emergency care
services to patients as part of a well planned system.
I encourage all PCTs, ambulance trusts and urgent &
emergency care networks, to make use of this toolkit
and the support offered by the ESR, as part of an
integrated approach to delivering high quality care
for all.”
Mike Farrar,
North West Strategic Health Authority Chief
Executive, Lead for the Emergency Services Review
Page 2
Toolkit map
References
Back Next
Introduction
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ipsaest uta nos eum ut molum quas eum quatemped eos ut invelit prep
eles eat aspit qui omnit qui cuptatur ad quam duntota quassit.
Home
Forewords
Factsheets and checklists
Introduction
Who should use this toolkit?
This toolkit is for ambulance trusts and PCT
commissioners of urgent and emergency care services
– not just lead commissioners of ambulance trusts.
• More efficient use of ambulance resources
should mean less pressure on services at times of
high demand, supporting good performance on
ambulance response times and A&E waiting time.
• 999 demand is going up by 6.5% per year.
• Ambulance and A&E services are expensive –
managing the rise in 999 demand through making
better use of alternative pathways can save money.
• 999 demand is growing faster than both
population growth and the growth in demand
for other urgent and emergency care services
such as A&E.
• Most importantly, addressing ambulance demand
can help patients get the right care from the
right service at the right time, to achieve the best
health outcomes.
Why look at 999 ambulance demand?
• 999 demand reflects how well other urgent and
emergency care services are functioning, and how
well integrated they are.
• Using World Class Commissioning principles
to support integrated urgent and emergency
care services can lead to better use of
ambulance resources.
Factsheets and checklists
Tools
What does this toolkit do?
Tackling rising demand for services can seem like
a daunting task. This toolkit helps to break demand
down into factors and create manageable workplans
to address them and achieve real local change, in line
with QIPP – Quality, Innovation, Productivity and
Prevention.
Page 3
Toolkit map
References
Back Next
Introduction
Home
Forewords
Introduction
How to use this toolkit
• calculating cost efficiencies
The toolkit is designed with a series of worksheets
that can be filled in electronically or printed out.
They each set out an issue, the evidence, and
a set of checklist questions for providers and
commissioners. You can work through the toolkit
page by page, or choose particular issues that you
want to focus on from the toolkit map.
• linking to QIPP
You can also input your own data into the tools:
Outcomes from using this toolkit
• Demography ready reckoner
We hope that by using this toolkit PCT
commissioners and ambulance providers will:
• PCT ambulance activity benchmarking tool
• Costings and activity flows tool.
You are encouraged to use this toolkit at
commissioner–provider meetings, where both parties
can review an issue (or issues), answer the checklist
questions and generate action grids.
The grids guide you through a series of questions,
helping to make links with key drivers such as:
Factsheets and checklists
• looking at how best to support system alignment.
Tools
Please ensure that actions that are taken as a result
of working through this toolkit are supported by an
equality impact assessment where necessary, as this
is a legal requirement.
• have a greater understanding of the factors
affecting increasing demand for ambulance
services and what can be done to address them
• use ambulance service data to inform
commissioning strategies across all urgent and
emergency care services, leading to more costeffective and efficient services in line with QIPP
• have in place strong relationships and partnership
working practices between ambulance providers
and PCT commissioners.
Toolkit map
References
Page 4
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Introduction
Toolkit
map
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ipsaest uta nos eum ut molum quas eum quatemped eos ut invelit prep
eles eat aspit qui omnit qui cuptatur ad quam duntota quassit.
Home
Introduction
Forewords
Introduction
By how much is
ambulance demand
increasing?
What effect does
demand have on
performance standards?
Which conditions
account for the greatest
increase 999 calls?
Factsheets and checklists
Tools
Commissioning urgent and emergency care services
Ambulances, major A&E, walk-in centres, minor injury units, GP out-of-hours services, NHS Direct, Primary
Care, GP-led health centres, pharmacy services, dental services, plans for a 3-digit number, etc.
Factors affecting demand
Seasonal
factors
Social/attitude
change
Long-term
conditions
Changes to
patient care
Demographic
change
Frequent
callers
Deprivation
Alcohol
Back Next
Factsheets and checklists
Home
1 By how much is ambulance demand rising?
Forewords
At an average cost of £200 per call, this equates to
an additional cost of £60 million pounds each year.
These cost pressures increase significantly if the cost
of subsequent hospital attendances are included.
Introduction
Number of emergency and urgent calls to the ambulance service, England
8.0 Average annual growth in calls of
Number of calls (millions)
The number of calls handled by ambulance services in
England is increasing by 6.5% each year on average,
which is equal to approximately 300,000 extra calls
each year.
7.2
6.5% from 1997/98 to 2006/07
7.0
6.0
5.3
5.0
4.0
3.6
3.8
4.2
4.4
4.7
5.6
4.9
3.0
2.0
1.0
0.0
1997-98 1998-99 1999-00 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09
Emergency calls
Emergency &
Urgent calls
* From 2007/08 figures include urgent calls; Although figures are thus not directly comparable
across the entire time series, despite small variations in growth rates between individual years
the continuing underlying growth in call volumes is clear.
KA34 Collection, NHS Information Centre
There is some regional variation in the growth in
demand for ambulance services, with particularly
high growth recoreded in the North East, South West
and East of England regions. However, all ambulance
trusts have continued to report average annual
growth rates exceeding 4%.
Average annual growth in emergency ambulance calls (2002/3 to 2006/07)
12.0%
Average annual growth
7.5
10.0%
8.0%
6.0%
4.0%
Factsheets and checklists
6.3
6.0
2.0%
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
Yorkshire
Isle of
Wight
South East
Coast
East
Midlands
London
West
Midlands
North West
South
Central
Great
Western
East of
England
South
Western
North East
England
0.0%
KA34 Collection, NHS Information Centre
“Demand for ambulance services is rising by over 6% each year.”
Case Study
Checklist
Page 1
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Factsheets and checklists
Home
1 By how much is ambulance demand rising?
Forewords
Introduction
Number of emergency and urgent* calls, incidents and patient journeys,
England
8.0
7.0
Volume (millions)
The increase in 999 ambulance calls is reflected by an
increase in incidents (where an emergency response is
sent to the scene of the call) and patient journeys by
ambulance to a healthcare provider.
6.0
5.0
Incidents
Calls
Patient Journeys
Factsheets and checklists
Average annual growth in emergency
activity from 1997/98 to 2006/07:
- Calls - 6.5%
- Incidents - 5.4%
- Patient Journeys - 3.2%
4.0
3.0
2.0
1.0
0.0
Incidents (or conveyances) per call
Variation in "response at scene" and "conveyance from scene" rates for
emergency and urgent calls, England, 2008/09
Incidents per call
1.00
199798
199899
199900
200001
200102
200203
200304
200405
200506
Emergency activity
Conveyances per call
* from 2007/08 figures include urgent incidents
0.90
200607
200708
200809
Emergency &
Urgent activity
KA34 Collection, NHS Information Centre
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
Ambulance Service
London
Great
Western
East
Midlands
Yorkshire
North East
South
Central
North West
West
Midlands
South
Western
East of
England
Isle of Wight
South East
Coast
England
0.00
KA34 Publication, NHS IC
Different regions experience different incident and
transportation rates for 999 calls. For example, in
2008/09 just over two-thirds of calls to the London
Ambulance Service resulted in an incident and only
54% of calls resulted in a patient journey, while
nationally 82% of calls resulted in an incident and
60% of calls resulted in a patient journey.
Case Study
Checklist
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
Page 2
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Factsheets and checklists
Home
2 What effect does increasing demand have on performance?
Forewords
Periods of greater demand, particularly at the height
of summer and winter, are associated with dramatic
declines in performance against the response time
standards for ambulances, as the top graph shows.
Volume of Category A ambulance incidents and performance against
Cat A 8 minute response time operational standard
Cat A Performance
Cat A Operational Standard
Number of Cat A calls
90%
85%
80%
75%
70%
65%
60%
55%
50%
45%
40%
50,000
45,000
40,000
35,000
The graph below shows how increased ambulance
activity (especially for high-acuity Category A serious
and life-threatening calls) is clearly associated with
poorer performance against the A&E four-hour
waiting-time standard.
April
May
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
April
May
June
July
August
Sept
Oct
Nov
Dec
Jan
Feb
March
30,000
% of calls met within standard
Cat A Call Volumes
55,000
2006/07
Weekly SitRep data, DH
2007/08
2008/09
Details recorded (DR)
Call Connect (CC)
Effectively managing the root causes of rising
ambulance demand has the potential to improve
performance throughout urgent and emergency care
pathways, delivering better health outcomes for
patients and more cost-effective care.
Volume of Category A ambulance incidents and performance against
A&E 4hr operational standard (Type I A&E)
Type 1 performance
Operational Standard
98.0%
45,000
97.0%
96.0%
40,000
95.0%
94.0%
35,000
93.0%
92.0%
30,000
91.0%
Factsheets and checklists
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
Weekly SitRep data, DH
2006/07
2007/08
Jan
Feb
March
Nov
Dec
August
Sept
Oct
Jan
Feb
March
April
May
June
July
April
May
June
July
August
Sept
Oct
Nov
Dec
90.0%
Jan
Feb
March
25,000
% of attendances meeting 4hr standard
99.0%
April
May
June
July
August
Sept
Oct
Nov
Dec
Number of Category A ambulance incidents
Volume of Cat A incidents
50,000
Introduction
2008/09
“Higher ambulance demand is associated with poorer performance
against targets.”
Case Study
Checklist
Page 3
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Demand
Questions for ambulance trusts
A1. What are the long-term patterns in ambulance demand in your
area? Are you breaking down increases in demand by case mix
and age group?
A2. What is the ratio of patient journeys and incidents to calls?
Could more ambulance incidents could be handled by clinical
telephone advice (hear and treat) or referral to other healthcare
services?
A3. Have you calculated the effect of increases in demand on
performance against response time standards in your area?
A4. What is the proportion of ambulance-conveyed A&E
attendances where no follow-up is needed or where patients
are immediately referred to other services such as GPs or
fracture clinics? TIP: Use the tools to help calculate this.
Questions for PCTs
P1. What is the scale of the problem of increasing demand for
ambulance services for your PCT?
P2. What is the cost to your PCT of the ambulance staffing and
vehicle provision that will be needed if the trend of increasing
ambulance demand continues? What will the increased cost be
next year and over the next five years?
P3. What are the downstream cost savings for your PCT that could
be realised by understanding and reducing demands on the
ambulance service, e.g. through avoidable A&E attendances?
TIP: Use the tools to help calculate this, and look at the
NHS Institute for Innovation and Improvement, Better Care,
Better Value indicators.
P4. What improvement in performance against national targets
could be delivered through reducing demand on the
ambulance service?
A5. How are you supporting ambulance crews to feel comfortable
leaving patients at the scene or referring to other services,
where appropriate? How are you using advanced practitioners?
Factsheet
Action Grid
Factsheets and checklists
Home
3 Is demand increasing for other services too?
Forewords
Growth in demand for emergency and urgent care services, 2003/4 to 2007/8*
8.0%
6.0%
4.0%
2.0%
Walk-in
Centres,
Minor Injury
Units
Specialist
A&E
Major A&E
GP
consultations
-4.0%
NHS Direct
-2.0%
Emergency
Admissions
0.0%
Emergency
and urgent
ambulance
calls
Average annual growth in activity
10.0%
Demand for ambulance services is growing faster
than demand for most other urgent and emergency
care services, except for type 3 A&E services (minor
injury units and walk-in centres).
Rising ambulance activity is probably related to
the next highest grower, A&E admissions. Hospital
Episode Statistics show that 23% of attendances and
55% of admissions are brought in by ambulance.
Attendances at A&E departments
-6.0%
Ambulances - KA34 Collection, NHS Information Centre; from 2007/08 figures include urgent incidents (2007/08 figures therefore carry forward 2005/06 growth)
A&E - QMAE data, DH; *data presented from 2004/05 to 2007/08, data excludes 6 Walk in Centres with a commuter focus
GPs - QResearch data
Emergency admissions - HES data, NHS IC
NHS Direct - Calls to 0845 service
Many of these patients need emergency care.
However, of the A&E attendances that were
brought in by ambulance, 43% were discharged
from A&E and over two-thirds of these did not
need follow-up treatment. It is likely that some
of these patients could have been cared for more
appropriately and more cost-effectively by other
urgent care services.
“Many patients transported by ambulance to A&E are discharged from
A&E without the need for follow-up.”
Case Study
Checklist
Introduction
Factsheets and checklists
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
Page 4
Back Next
Factsheets and checklists
4 Does commissioning of other urgent and emergency care services affect the
demand for ambulances?
Patients have a wide choice of where to access care
when they have an urgent, but not an emergency,
need. The range of services can be confusing and
includes A&E, 999, walk-in centres, minor injury
units, GPs out-of-hours, primary care, GP led health
centres, pharmacies and NHS Direct. Effective public
information is needed to help patients get the right
care at the right time by the right service.
Recent data shows that only two-thirds of patients
know how to contact a GP out-of-hours service, and
over a quarter of the patients using these services felt
that they took too long to deliver care.
Gaps in provision of high-quality, accessible urgent
care services may be a factor in the increase in 999
calls, and ambulance use may be greater in places
where the accessibility or quality of other urgent
care services is relatively low.
Home
Forewords
Introduction
Factsheets and checklists
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
Case Study
Checklist
Page 5
Back Next
Commissioning across urgent and emergency care
Questions for ambulance trusts
Questions for PCTs
A6. How are you using ‘hear & treat’ and ‘see and treat’ and other
urgent care services to minimise unnecessary journerys to A&E?
P5. What is the relationship between ambulance demand and
demand for other urgent and emergency healthcare services in
your area? TIP: Use the tools to help calculate this.
A7. Have you analysed the relationships between ambulance
demand and demand for other urgent and emergency services
in your area? Have you shared that data with PCTs?
P6. How easy is it for people to access primary care in and out of
hours in your area? Have you measured this?
A8. How do you support good working relationships with
PCT commissioners? How do you engage with non-lead
commissioner PCTs?
P7. What is the relationship between four-hour A&E performance,
ambulance response time performance, GP access performance
and GP out-of-hours service national quality standards in your
local health economy?
A9. Are you using your local operations managers effectively to
make links with PCTs and local services?
P8. How do you support good working relationships with your
ambulance trust and other PCTs in your area? How do nonlead commissioner PCTs engage with the trust?
P9. How are you engaging with practice based commissioners to
support provision of integrated urgent and emergency services
and reducing unnecessary 999 demand?
Next
Factsheet
Action Grid
Commissioning across urgent and emergency care
Questions for ambulance trusts
Questions for PCTs
P10. Is there an option to safely refer or redirect some calls from the
ambulance service to NHS Direct and GP out-of-hours services
in your area? How much would this save?
P11. Are you commissioning advanced paramedic practitioners to
help deliver appropriate care closer to home and link up with
other local services?
P12. Are you working with ambulance services to populate a real
time directory of services that provides clear referral alternatives
to services other than A&E?
Factsheet
Action Grid
Factsheets and checklists
Home
5 Which conditions account for the greatest increase in 999 calls?
Forewords
Sick Person(Specific
Diagnosis)
5%
Traffic Accidents
Traumatic Injuries,
Convulsions/Fitting
Haemorrhage/Lac
Abdominal
Sick
Chest Pain
Breathing
• traumatic falls/back injury,
Convulsions/Fitting
5%
• breathing problems
Chest Pain
9%
Unconscious /
Passing Out
19%
Time series for each chief complaint
2000/01
2007/08
Unconscious/Pass
Falls/Back Injury
(Traumatic)
27%
Factsheets and checklists
Falls/Back Injury
Allergy/Rash/Med
Reactns/Sting
All Other Chief
Complaints
10%
180
160
140
120
100
80
60
40
20
0
All other incidents
Heart Problems
3%
Introduction
Growth patterns for high-volume patient conditions,
from 2000/01 to 2007/08, London
Number of emergency and urgent incidents
(thousands)
Although the year-on-year increase in incidents
for some chief complaints is steady (e.g. breathing
problems), other chief complaints show spikes
in demand (e.g. chest pain in 2004/05) or even
decreases in activity over the period (e.g. traffic
accidents).
Breathing Problems
20%
Constituents of increase in emergency and urgent incidents (2000/01 to 2007/08)
Four patient conditions account for just under 75%
of the increase in ambulance incidents from 2000/01
to 2007/08 in London:
• unconsciousness/passing out
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
• chest pain.
A similar case mix of ambulance activity was
observed in the East Midlands and North West regions.
“A small number of patient conditions account for a large proportion of
the increased demand for ambulance services.”
Case Study
Checklist
Page 6
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Conditions
Questions for ambulance trusts
A10.Are you analysing long-term trends in the case mix of
ambulance demand? Where could targeted interventions help
to tackle key patient conditions that are particularly driving
increases in demand? Have you shared this data with PCTs?
A11.Are you doing work to determine specific drivers of demand
within broader call categories, e.g. breaking down ‘breathing
problems’ to look at asthma or Chronic Obstructive Pulmonary
Disease? Have you shared this data with PCTs?
A12.Do you know what time of day and day of week these
conditions are mostly presenting? Have you shared this data
with PCTs?
Questions for PCTs
P13. Which patient conditions account for the majority of the rise
in 999 demand in your area? Have you used data from public
health observatories, ambulance trusts and A&E departments
to identify patient conditions that are contributing most to
healthcare activity?
P14. What time of day and day of the week are these conditions
mostly presenting? How do these patterns align with the
provision of other in-hours and out-of-hours services (e.g. are
falls units available outside business hours and at the weekend?)
P15. How do you reflect changes in the case mix of demand
in service planning across urgent and emergency care?
P16. How does your demand case mix and your provision of services
compare with other PCTs with similar needs? (*TIP use the
tools to help compare PCTs.)
Factsheet
Action Grid
Factsheets and checklists
Home
6 Is the increase in ambulance demand due to seasonal factors?
Forewords
Demand for ambulance services is greatest during
the winter months, although there are also smaller
peaks in the summer.
2006/07
2007/08
Factsheets and checklists
2008/09
50,000
45,000
40,000
35,000
Jan
Feb
March
Nov
Dec
June
July
August
Sept
Oct
Jan
Feb
March
April
May
Nov
Dec
August
Sept
Oct
April
May
June
July
Jan
Feb
March
Nov
Dec
August
Sept
Oct
30,000
April
May
June
July
However, there is a small trend for the months of
October to December accounting for a greater than
average share of the annual increase in ambulance
demand. Some 29% of the increase in ambulance
demand from 2005/06 to 2008/09 came solely from
increases in demand over the months of October to
December.
55,000
Number of Cat A calls
It does not appear that the year-on-year increases
in ambulance demand are solely due to winters
becoming progressively worse.
Introduction
Weekly number of category A ambulance incidents, England
Weekly SitRep data, DH
Proportion of the increase in category A and B incidents from 2005/06 to
2008/09 that is accounted for by individual quarters, England
This highlights the need for strong resilience
planning by the whole health economy during
the demanding winter months.
Apr to Jun
23%
Jan to Mar
24%
Oct to Dec
29%
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
Jul to Sep
24%
Weekly SitRep data
“Winter months contribute slightly more to the annual
increase in ambulance demand.”
Case Study
Checklist
Page 7
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Seasonal factors
Questions for ambulance trusts
A13.Is your trust able to predict seasonal variation in demand,
including the case mix of calls, using analysis and forecasting
techniques?
Questions for PCTs
P17. How much does seasonal variation in specific patient
conditions (e.g. breathing problems) lead to increased demand
on ambulance services and consequent pressure on A&E
departments in your area?
A14.How does this data inform your winter resilience planning?
A15.Do you proactively place ambulance resources in other
services during winter, (e.g. by placing advanced practitioners
in primary care settings to help manage chronic respiratory
conditions, and establishing links with falls units)?
A16.What arrangements do you have in place to manage demand
in partnership with local acute trusts and primary care services?
(e.g. divert policies, referral pathways with GP led health
centres, urgent care centres, and mental health teams.)
P18. Does the ambulance service act as an ‘early predictor’ of
demand on other services such as A&E in your area, at times of
peak demand such as winter?
P19. Have you worked through the Emergency Services Review
toolkit, available online at www.osha.nhs.uk. This includes
good practice guides, international best practice information,
and analysis of system resilience.
Factsheet
Action Grid
Seasonal factors
Questions for ambulance trusts
Questions for PCTs
A17.What are you doing to support clinicians and staff to be able to
direct patients to self-care where appropriate?
A18.Have you worked through the Emergency Services (ESR)
Review toolkit (available online at www.osha.nhs.uk). This
includes good practice guides, international best practice
information, and analysis of system resilience.
Factsheet
Action Grid
Factsheets and checklists
7 How have changes in the attitudes and expectations of the general public
affected ambulance demand?
Over recent years, lifestyle changes – including
new media and technology – may have influenced
attitudes towards calling 999.
For all 999 calls, it is for ambulance trusts and
commissioners to ensure that the right response is
given, whether this is to send an ambulance, to offer
telephone advice or to refer to another service.
A future 3-digit number for urgent care may help
patients who are confused by the range of services
available at different times of day – GPs, out-ofhours services, walk-in centres, minor injury units,
NHS Direct, community services such as district
nurses, etc. In the meantime, work on real-time
directories of local services is under way and is a key
element of supporting appropriate referrals by the
ambulance service to a range of other urgent care
services. Media campaigns such as Choose Well can
also raise awareness of local services and help people
to choose an appropriate route to healthcare.
Home
Forewords
Introduction
Factsheets and checklists
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
“Changes in people’s attitudes and expectations may mean that they
are using 999 to get rapid and convenient access to health services.”
Case Study
Checklist
Page 8
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Social/attitude change
Questions
Questions for
for Ambulance
ambulance trusts
Trusts
Questions for PCTs
A19.What work have you done to understand who is calling 999
in your trust, and why? Do you repeat qualitative work to find
out if attitudes are changing?
P20. What work have you done to understand who is using urgent
and emergency services, and why? Do you repeat qualitative
work to find out if attitudes are changing?
A20.What are the different attitudes towards calling 999 within
your population? Are they linked to age, ethnicity, gender or
socioeconomic status, specific long-term conditions or specific
settings (such as residential and nursing homes)?
P21. What work with patients have you done to find out what the
different attitudes are towards urgent and emergency services
within your population? Are they linked to age, ethnicity,
gender or socioeconomic status, specific long-term conditions
or specific settings (such as residential and nursing homes)?
A21.How do you engage with local communities to communicate
when to call 999?
P22. Are you using social marketing techniques to communicate
to patients which service to use when they have a need for
urgent healthcare? If so, have you evaluated the success of
these campaigns?
A22.Are you referring patients to other urgent care services where
appropriate, both at the point when a person calls in on the
phone, and at the scene?
P23. What are you doing to support ambulance trusts to be able to
refer people to other urgent care services where appropriate?
Factsheet
Action Grid
Factsheets and checklists
8 What contribution have long-term conditions made to ambulance demand?
Home
Forewords
24.5
Average BMI
27.1
24.0
27.0
23.5
27.0
23.0
26.9
22.5
26.9
22.0
26.8
21.5
26.8
21.0
26.7
20.5
26.7
20.0
26.6
19.5
Average BMI of adults
Percentage of population with obsese BMI
Body Mass Index (BMI) of adults, England
% of population with obese BMI
26.6
2000
2001
2002
2003
2004
2005
2006
2007
Health Survey for England 2007, NHS IC
Increase in number and proportion of incidents related to obesity,
London Ambulance Service
16%
120,000
Number of incidents
18%
14%
100,000
12%
80,000
10%
60,000
8%
6%
40,000
4%
20,000
2%
Obesity-related incidents as a
proportion of all incidents
140,000
Diabetes-related conditions (Chest pain, Heart Problems, Stroke)
Diabetic Problems
Proportion of incidents that are obesity-related
Due to an ageing population and changing lifestyle
choices there are now many more people living
longer with long-term conditions such as heart
disease, diabetes and asthma. It is estimated that by
2025 the number of people with at least one long
term condition will rise by 3 million to 18 million.
Rising obesity levels have been identified as one
of the main causes of the increase diabetes and
heart disease prevalence. Over recent years, the
average body mass index and the proportion of
the population classified as obese have continued
to increase.
This increase in obesity is translating into more
hospital admissions and ambulance incidents
related to diabetes.
Introduction
Factsheets and checklists
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
0%
0
2000/01
2001/02
2002/03
2003/04
2004/05
2005/06
2006/07
2007/08
Case Study
Checklist
Page 9
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Long-term conditions
Questions for ambulance trusts
A23.What proportion of ambulance activity in your trust can be
attributed to long-term conditions? Have you shared this
information with PCTs?
A24.Does your trust have a public health strategy that looks at
what it can do to prevent people with long-term conditions
from needing to call 999 due to poor management of their
conditions (e.g. proactively offering diabetes testing for
patients aged over 40)?
Questions for PCTs
P24. How much do ambulance calls from people with long-term
conditions cost per year (including downstream hospital
attendance/admission? How many of these calls could be
prevented?
P25. What are you doing to support prevention, early diagnosis
and good management of long-term conditions to
help improve health outcomes and reduce costs from longterm conditions-related ambulance activity, (for example the
introduction of personalised care planning)?
P26. Is the ambulance service part of your long-term conditions
strategy/public health strategy, given they see large numbers of
patients in their homes?
P27. Have you commissioned services to support people to self-care
and to make the best use of assistive technologies to ensure
more people are seen in their homes and exacerbations are
minimised?
Factsheet
Action Grid
Factsheets and checklists
Home
9 How have changes in patient care affected ambulance demand?
Forewords
• longer journey times
• extended job cycle times, including taking patients
home
• inter-hospital transfers.
Commissioners and providers should model the
impact of these major changes on ambulance services.
Average LoS (in year discharges)
Emergency readmits, ages 16-74
Emergency readmits, ages 75+
Factsheets and checklists
9
8
14%
7
12%
6
10%
5
8%
4
6%
3
4%
2
2%
1
0%
Average length of stay (days)
16%
0
2002
2003
2004
2005
2006
National Centre for Health Outcomes Development (NCHOD); Hospital Episode statistics, NHS IC
Increase in number and proportion of patient transfer incidents,
East Midlands Ambulance Service
Patient Transfers (e.g. Interfacility or to/from Palliative Care)
Proportion of incidents that are patient transfers
1.6%
10,000
1.4%
1.2%
8,000
1.0%
6,000
0.8%
0.6%
4,000
0.4%
2,000
0.2%
Patient Transfer incidents as a
proportion of all incidents
Service reconfigurations and specialisation of
healthcare facilities like hyper-acute stroke and
trauma centres can also affect ambulance services,
if they result in:
Emergency readmissions as a proportion of all
admissions
While this is a positive step, shorter lengths of stay
could lead to increased ambulance demand due to
readmissions. Many emergency readmissions are for
chest pain and breathing problems, which are the
symptoms that account for much of the increase in
ambulance calls (see patient conditions factsheet).
Introduction
Changes in inpatient care practices, England
Number of incidents
Over recent years the NHS has moved towards
treating patients as close to home as possible and
avoiding unnecessary hospital stays. The ambulance
service is also working towards more treatment
of patients at the scene, reducing unnecessary
patient journeys.
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
0.0%
0
2006/07
2007/08
2008/09
Case Study
Checklist
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Changes to patient care
Questions for ambulance trusts
A25.Are you using evidence-based models to calculate and
communicate the effect of service redesign on your
ambulance service?
Questions for PCTs
P28. Do your discharge support plans for patients include
information on supported self-care and primary care
as well as calling 999 if their symptoms get worse?
P29. How much does it cost to put an additional ambulance on the
road in your area, including procurement and staff costs?
P30. When redesigning services or commissioning new ones
(e.g. specialist stroke and trauma centres), how do you
calculate the impact on the demand for ambulances and
patient transport services?
P31. How have you used the recent Transforming Community
Services guides to improve services along care pathways and
help to prevent the need for people to call 999?
Factsheet
Action Grid
Factsheets and checklists
Home
10 What impact does demography have on ambulance demand?
Forewords
Changes in the age structure of the population
affect the demand for ambulance services, as older
people use ambulances more than younger people.
In London, people aged over 60 account for over
one-third of all ambulance incidents, even though
the over-60s only make up a sixth of the general
population. Due to an ageing population, it is
estimated that by 2030 there will be 41% more
people in England aged 60 or over, and it is estimated
that by 2030 almost half of all ambulance incidents
will be for patients aged over 60.
Introduction
Number of ambulance incidents per 1000 head of population,
by age group, London Ambulance Service, 2007
Ambulance incidents
per 1000 head of population
We would expect ambulance demand to increase
as the population grows. However, the 6.5% annual
increase in ambulance demand far outstrips the 0.5%
annual increase in population size.
800
700
600
500
400
300
200
100
0
0 to 9
10 to
19
20 to
29
30 to
39
40 to
49
50 to
59
60 to
69
70 to
79
80 to
89
90+
Age group
Estimate of 2007 ambulance incidents, based on 2000 ambulance
utilisation rates and 2007 age structure, London Ambulance Service
Number of ambulance incidents
180,000
Looking at the way the population is changing can
help to understand who is using 999. In London, for
example, there has been an increase in ambulance
use among 20–29-year-olds and in older age groups
since 2001, compared with how much those groups
have grown in size. Applying ambulance utilisation
rates from 2000/01 to the population in 2007/08
suggests that 17% of the rise in ambulance demand
in London is due to both the growth and ageing of the
general population.
Factsheets and checklists
900
2000 Actuals
2007 Actuals
2007 Estimates
160,000
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
“Almost 20% of the increase in ambulance activity is due to
ageing and population growth.”
Age group
Case Study
ONS Mid-year population estimates;
London Ambulance Service data
Checklist
Page 11
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Demographic change
Questions for ambulance trusts
Questions for PCTs
A26.Which population groups in your area are using 999 services at
higher-than-expected levels? (TIP use the ready reckoner in the
Tools section to help calculate this.)
P32. Which population groups in your area are using 999 services at
higher-than-expected levels, and why? What specific action are
you taking to address unexpected levels of calls from particular
age groups?
A27.Have you analysed why these age groups might be calling
999 more? (E.g. is the increase in demand by 20–29-yearolds in London linked to alcohol use?) Have you shared this
information with PCTs?
A28.What will the future effect on your service be as the population
gets older? In five years? In ten years?
P33. What measures are you putting in place to support an ageing
population? (E.g. commissioning of falls units, geriatric units,
intermediate care facilities, proactive case coordination.)
P34. Have you involved ambulance services and other urgent and
emergency care services in long-term planning strategies for
an ageing population?
P35. How are you linking health and social care services to help
support older people and other age groups in staying healthy
to prevent the need to call 999?
Factsheet
Action Grid
Factsheets and checklists
Home
11 What contribution do frequent callers make to ambulance demand?
Forewords
This toolkit includes information on factors
affecting large-scale and long-term shifts in
ambulance demand. However, short-term
high‑volume demand can also be addressed
by ambulance trusts and PCTs working together
to address frequent callers to the service.
A large volume of calls to the ambulance service are
attributable to individuals who call 999 multiple times
a day. These individuals often have mental health
problems, and some areas now employ dedicated
health professionals to work with them to meet
their needs and prevent repeated 999 calls.
High volumes of calls can also be made by
organisations and businesses. Police services
are frequent callers, but other frequent calling
organisations are:
• supermarkets
Investigating disproportionate demand from other
services (including nursing homes and GP practices)
can help to address gaps in services and reduce
999 calls.
The North West Ambulance Service NHS Trust
identified that over 7% of ambulance activity was
accounted for by calls from GP practices in 2008/09.
Regional variations were also highlighted, e.g. the
GP call rate was four times higher than the regional
average in Cumbria. This data could be used to
investigate whether the demand arising from
certain practices is greater than would be expected
compared to the health needs of the local population.
Making the local PCT aware of this kind of
ambulance information can lead to greater
consistency in the use of 999 by other health
services.
Introduction
Factsheets and checklists
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
• nursing homes
• pubs.
“A small number of patients account
for a disproportionately large portion of
ambulance activity.”
Case Study
Checklist
Page 12
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Frequent callers
Questions for ambulance trusts
A29.Are you taking proactive action to tackle frequent callers, e.g.
employing dedicated staff to work with them?
A30.Are you working with the police, GPs, nursing homes and
other frequently calling organisations to ensure that your
collaborative working is efficient and appropriate?
Questions for PCTs
P36. How many ambulance calls are from frequent calling
individuals and organisations in your area? What is the
cost associated with this (including the downstream cost of
A&E attendances)?
P37. How do you support ambulance trusts to manage frequent
caller individuals and organisations in your area? Are urgent
and social care services in place to support the needs of
frequent callers and to help to reduce inappropriate 999 calls?
A31.Are you working with PCTs, other urgent care services and
social care services to manage frequent callers, both individuals
and organisations?
Factsheet
Action Grid
Factsheets and checklists
Home
12 Is demand for ambulance services greater in more deprived areas?
Forewords
Deprived areas, such as the most deprived one-fifth
of PCTs (the Spearhead PCTs), are identified using
a range of indicators such as income, employment,
health, education, housing and living conditions.
Number of ambulance incidents per 1000 population,
by deprivation of local area, North East Ambulance Service (NEAS)
2000/01
250
2007/8
Average number of incidents
per 1000 head of population
200
Demand for ambulance services is greater in more
deprived areas of the country, and growth in demand
is also greater in more deprived areas.
150
100
50
0
1
2
3
4
5
6
7
8
9
10
Index of Multiple Deprivation Decile (1 = least deprived, 10 = most deprived)
Average ambulance Category A activity per 1000
population, 2006/7, North West
Spearhead PCTs
Non-Spearhead PCTs
46.5
34.3
It is unclear to what extent this increased demand
is due to the greater health needs of deprived
areas, and to what extent it is due to other factors
associated with deprivation (such as population
density and lower car ownership levels).
Work in deprived areas is often focused on helping
people to access healthcare rather than reducing
demand. However, knowing which areas have high
rates of 999 calls can help to inform commissioning
of other urgent and emergency care services to help
patients in deprived areas get the right care at the
right time.
“Ambulance demand is greater in more deprived areas.”
Case Study
Checklist
Introduction
Factsheets and checklists
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
Page 13
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Deprivation
Questions for ambulance trusts
A32.Where are the hotspots of deprivation in your area that have
greater health needs or rely more on ambulance transport
to A&E? Have you mapped ambulance activity in relation to
deprived areas to find these? Have you shared this information
with PCTs?
A33.How do you tailor services to support deprived areas?
Questions for PCTs
P38. How high is ambulance demand in the most deprived areas of
your PCT?
P39. Could additional services be made available in those areas to
help people access healthcare without calling 999? Could you
provide better public information to signpost people to the
health services that are available?
P40. How are you engaging with local authorities to provide the
right services to deprived areas?
P41. Do you share information with the ambulance trust about your
most deprived areas and the services you have commissioned
for them, to enable the ambulance service to work more closely
with other partners in those areas?
Factsheet
Action Grid
Factsheets and checklists
Home
13 What contribution has alcohol-related behaviour made to
ambulance demand?
Introduction
Alcohol-related ambulance incidents are increasing
in London, and are accounting for a growing share
of total ambulance activity. Currently, nearly 1 in 20
London ambulance incidents are alcohol related.
Increase in number and proportion of incidents related to alcohol,
London Ambulance Service
1.5%
10,000
1.0%
5,000
0.5%
0.0%
2006/07
Adults heaviest drinking day, 2007, England
% reporting this day as heaviest for drinking
Sun Noon
Sat Noon
Sat Midnight
Fri Midnight
Fri Noon
0.0%
Thu Midnight
2007/08
30%
0.2%
“Alcohol-related incidents account for an increasing
proportion of ambulance activity.”
Alcohol-related incidents as a
proportion of all incidents
Number of incidents
2.0%
15,000
0.4%
Wed
Midnight
Sun Noon
Sat Noon
Sat Midnight
Fri Noon
Fri Midnight
Thu Midnight
0.0%
Wed
Midnight
2.5%
20,000
2007/08
Thu Noon
0.2%
Thu Noon
3.0%
25,000
2005/06
Wed Noon
0.4%
Wed Noon
3.5%
30,000
0.6%
Tue Midnight
0.6%
Tue Noon
35,000
4.0%
0.8%
Mon
Midnight
0.8%
Tue Midnight
4.5%
1.0%
Tue Noon
1.0%
1.2%
Mon Noon
1.2%
% of weekly incidents occuring within the hour
1.4%
Mon
Midnight
5.0%
40,000
0
2000/01
Sun Midnight
2007/08
1.6%
Mon Noon
45,000
Total number of falls incidents by hour of week
as a percentage of the weekly total, LAS
1.8%
Sun Midnight
% of weekly incidents occuring within the hour
2000/01
2.0%
Factsheets and checklists
Alcohol-related calls
Proportion of incidents that are alcohol-related
The effects of changes in binge-drinking behaviour
and the increasing affordability of alcohol may be
reflected in other ambulance activity trends, such
as the significant increase in the number of calls
from 20–29-year-olds (see Demographic change
section) and changes in the day and time of
calls to ambulance trusts. Between 2000/01 and
2007/08 London has seen a greater proportion of
trauma and falls ambulance incidents occurring on
weekend evenings.
Total number of trauma incidents by hour of week
as a percentage of the weekly total, LAS
Forewords
25%
Demand
Performance
Commissioning across urgent and
emergency care
Conditions
Seasonal factors
Social/attitude change
Long-term conditions
Changes to patient care
Demographic change
Frequent callers
Deprivation
Alcohol
Tools
20%
15%
10%
5%
0%
Saturday
Sunday
Friday
Monday
Tuesday
Wednesday Thursday
General Household Survey, 2007. Office for National Statistics (ONS)
Case Study
Checklist
Page 14
Alcohol
Questions for ambulance trusts
A34.Have you done any geographical or time-of-day
mapping in relation to alcohol hotspots? Have you
shared this information with PCTs? Do you tailor services
to support these hotspots?
A35.Are you making effective use of alternatives to taking patients
to A&E, such as ‘field hospitals’ and ‘booze buses’?
A36.Have you worked with your PCT to share information on
alcohol hotspots with your local Crime and Disorder Reduction
Partnership (CDRP)?
Questions for PCTs
P42. Where are the hotspots of alcohol-related ambulance demand
in your area? What services/projects/strategies have you
commissioned in relation to these?
P43. How do you work with ambulance trusts on hotspot areas?
Has your PCT explored entering into separate arrangements
with ambulance services, if you are in an area that is
particularly affected by alcohol?
P44. Have you worked with ambulance trust to share information on
alcohol hotspots with your local crime and Disorder Reduction
Partnership (CDRP)?
Factsheet
Action Grid
Tools
Home
Demography ready reckoner
Forewords
What does the ready reckoner do?
The ready reckoner estimates how much of
the increase in demand for ambulance services
is due to changes in the size and age structure
of the general population, and also estimates what
effect an ageing population will have on future
demand for ambulances.
How is the ready reckoner structured?
The ready reckoner presents a series of charts
which ask:
• How has the age structure of the local population
changed over time?
• How much do different age groups use
ambulance services?
• How do changes in the size and age
structure of the population affect demand
for ambulance services?
• What changes can we expect to how different age
groups use ambulance services?
You can select data for your relevant strategic health
authority and ambulance trust, and compare changes
in population and ambulance use across a range
of years.
How can the outputs of the ready reckoner
be used?
The ready reckoner can highlight demographic
groups (e.g. males aged 20–29) that have seen
unusual increases in demand – increases that are
significantly greater than would have been expected
based on demographic changes in the population
over time.
Introduction
Factsheets and checklists
Tools
Demography ready reckoner
Activity benchmarking tool
Costings and activity flow tools
Interventions and further analyses can then be
targeted to particular demographic groups.
• How will the age structure of the population
change in future years?
access the ready reckoner
Page 1
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Tools
Home
PCT ambulance activity benchmarking tool
Forewords
Introduction
What does the benchmarking tool do?
How to use the tool
This benchmarking tool can be used to compare the
growth in demand for ambulance services across
different PCTs, by inputting data on activity in urgent
and emergency care services.
• Select an individual PCT’s data
The benchmarking tool presents a series of charts
which set out:
• How the growth in the demand for ambulance
services within a selected PCT compares to:
average growth rates in ambulance demand for a
group of similar PCTs (i.e. PCTs within the same
demographic “cluster”) average growth rates in
ambulance demand for all PCTs in the region
• How the growth in the demand for ambulance
services correlates with a range of factors such
as disease prevalence, deprivation, performance
and access to other emergency and urgent care
services. Experimental data on the number of A&E
attendances by ambulance have also been included.
Data from North West SHA is provided as an
example.
• Specify whether to compare growth in calls,
incidents or patient journeys
• Specify a patient condition
• Specify out-of-hours or in-hours (out of hours
defined as 6pm – 8am on weekdays, and all of
Saturday and Sunday)
Factsheets and checklists
Tools
Demography ready reckoner
Activity benchmarking tool
Costings and activity flow tools
• Select whether you wish to view growth as
percentage or volume increases.
How can the outputs of the benchmarking tool
be used?
The benchmarking tool can highlight PCTs which have
experienced growth in ambulance demand that is
higher than in other similar PCTs. Detailed information
on particular patient conditions or times of the day
that display high growth rates can also be obtained.
These data can suggest possible areas for targeted
interventions and help PCTs identify high performing
areas and share good practice.
access the benchmarking tool
Page 2
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Tools
PCT urgent and emergency care activity-costs benchmarking tool
Home
Forewords
The benchmarking tool allows PCTs to compare their
spread of activity per 1000 population and associated
costs against:
Introduction
• the activity and costs of any other PCT
Tools
Demography ready reckoner
• Ambulances (categories A, B and C, calls, incidents
and journeys)
• the average activity and costs of a group of
similar PCTs
• the average national activity and costs
Activity benchmarking tool
• A&E and walk in centres attendances (by
streaming)
• different levels of activity (lower, median and upper
quartiles)
• Emergency admissions
How can the outputs of the activity-cost tool
be used?
What does the activity costs tool do?
This tool can be used to compare PCTs on their spread
of activity, and associated costs, across a range of
urgent and emergency care services. The tool contains
PCT level activity and unit cost data for the following
urgent and emergency care services:
• GP consultations in hours and out of hours (home
visit, telephone, surgery)
• NHS direct (calls and website visits)
• District nurse contacts
Factsheets and checklists
Costings and activity flow tools
By using this tool, commissioners and providers can
view different models of urgent and emergency care
provision and explore the possible cost savings that
can be achieved by redirecting their activity.
access the activity-costs tool
Page 3
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Tools
Disclaimer
Home
Forewords
The best available data have been used within the
Demography ready reckoner, PCT ambulance activity
benchmarking tool and PCT urgent and emergency
care activity-costs benchmarking tool. However, it is
important to note that some of the data are historical
or have limited coverage or quality. It was also not
possible to obtain data on all aspects of the urgent and
emergency care system.
Updated versions of these tools may become available
over time, and questions on their use should be
directed to the mail box below.
Introduction
Factsheets and checklists
Tools
Demography ready reckoner
Activity benchmarking tool
Costings and activity flow tools
Disclaimer
urgent&[email protected]
Page 4
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Case study: Commissioning across urgent and emergency care
The Birchwood Practice, Norfolk – urgent care in-hours
What was the issue?
How to handle urgent cases in GP practices during normal surgery hours in an effective manner.
What was the action/solution?
The Birchwood Practice in Norfolk uses an integrated team, with immediate phone assessments by a team leader to
assess patients quickly and treat them efficiently.
What was the measured outcome?
The practice has 16% fewer hospital admissions when compared to other local doctors’ surgeries.
Further information
See the Primary Care Foundation publication, Urgent Care – a Practical Guide to transforming same-day care in
general practice.
Close
Case Studies
Case study: Seasonal factors
Met Office Healthy Outlook
What was the issue?
Severe weather can increase the numbers of people coming into hospital with problems related to Chronic
Obstructive Pulmonary Disease (COPD).
What was the solution?
The Met Office has piloted an innovative project to help reduce the numbers of COPD sufferers affected by bad
weather. When severe weather is predicted, the Met Office will email patients with COPD, giving them information
about how to care for themselves.
What was the measured outcome?
Data from Cornwall, Worcester and Rhondda shows that GP practices which use the Met Office service have found
it to reduce hospital admissions by 20%. The service costs £21 per patient (plus a £10 start-up fee) – and with
COPD admissions costing around £2.500 per patient, the Met Office’s Healthy Outlook service has quickly shown
efficiency savings.
Close
Case Studies
Case study: Social/attitude change
Tower Hamlets social marketing
What was the issue?
Tower Hamlets found that people were going to the Royal London Hospital’s Emergency Department with minor
complaints instead of accessing alternative services.
What was the solution?
Tower Hamlets commissioned a management consultancy to use social marketing techniques to find out why
patients were doing this.
What was the outcome?
The research showed that patients attending Royal London Hospital’s Emergency Department fell into four
categories. They were confused about how to access Tower Hamlets healthcare, they were dissatisfied with the
alternatives, they believed that the emergency department service was better than GP treatment or they found that
going to the emergency department was more convenient.
This information can be used to plan healthcare strategies and in particular to devise educational and promotional
campaigns to reach these patients.
Close
Case Studies
Case study: Long-term conditions
East Lancashire PCT/North West Ambulance Trust – Utilisation management
What was the issue?
How to cut avoidable hospital admissions, improve capability and capacity and ensure good decision making in
this area.
What was the action/solution?
East Lancashire PCT has developed a utilisation management programme (UM) in conjunction with the North West
Ambulance Trust. This looks at hospital admissions which were avoidable, and takes action with key stakeholders
to improve the appropriateness of where patients are taken. Many of these patients have long term conditions, live
alone, and are in an older age group.
What was the measured outcome?
It was found that 49% of ‘UM’ patients arrived by ambulance at A&E. Solutions could then be found to give
patients more appropriate care.
Close
Case Studies
Case study: Changes to patient care
North West Ambulance Service and modelling changes to services
What was the issue?
How to measure the effect of changes to health services on the demand for ambulance services.
What was the action/solution?
The North West Ambulance Service has worked with consultancy services to develop a model that estimates
the effect of emergency service design (for example the introduction of a specialist stroke unit), on demand for
ambulance services.
What was the measured outcome?
The model estimates the staffing and vehicle provision that would be required to meet this increased demand,
enabling accurate planning for the use of resources.
Close
Case Studies
Case study: Demographic change
The London Borough of Croydon and Croydon PCT – virtual ward
What was the issue?
The London Borough of Croydon and Croydon PCT wanted to reduce the numbers of older people experiencing
emergency admissions to hospital and being admitted to residential and nursing care.
What was the action?
The core of the service is an investment by the PCT in primary care services, to set up a “virtual ward” in the
community. Using a software predictor tool from the Kings Fund (called the ‘Predicting and Reducing Readmissions
(PARR) Combined Model’) about 1500 people who are most at risk of a first hospital admission (and consequent
admissions to residential care) have been identified. Primary Health Care services are targeted at these people. The
local authority has invested in a 24-hour emergency response service, which supports ambulance crews when they
attend an older person and believe a hospital admission can be avoided through a bit of support. The PCT and the
local authority work closely with their providers and a vibrant voluntary sector, to ensure that people are supported
to live in their own homes.
What was the outcome?
No one in Croydon is discharged from hospital to a different residence from the place from which they were
admitted without an Intermediate Care assessment based on a model of recovery/re-ablement. This has led
to fewer admissions to residential care. Other councils such as Bradford and Coventry are now also taking this
approach.
Close
Case Studies
Case study: Demographic change
South East Coast Ambulance Service – directory of services
What was the issue?
Older people who have fallen are sometimes taken to when A&E when they could have been cared for more
appropriately by other services.
What was the solution?
South East Coast Ambulance Service (SECAMB) is piloting a directory of urgent and emergency services for
ambulance services, to help ambulance crews refer patients to the right service. The pilot reviewed calls to
SECAMB’s falls team, which handles patients who have suffered falls.
What was the measured outcome?
Reviewing its data on the pilot directory, SECAMB founds that a significant number of patients who had suffered
falls and been referred to the falls team would otherwise have gone to A&E. Many PCTs are also considering adding
other services such as respiratory care, end of life pathways and pharmacy to directories of services.
Close
Case Studies
Case study: Frequent callers
London Ambulance Service and frequent callers
What is the issue?
How you deal appropriately with individual callers who may ring 999 hundreds of times a year.
What was the action/solution?
London Ambulance Service employs three full time and one part social worker to work with callers, who can
dial 999 hundreds of times per week. The Frequent Callers Unit was created in 2007. It is a dedicated taskforce
to review and manage the needs of patients who, for a variety of often complex reasons, persistently place 999
calls. The Unit is within the Patient Experiences Department, but works across boundaries to achieve better care
arrangements and alternative care pathways for patients.
What was the measured outcome?
Social workers manage individual cases and delivering strategic policy and practice. Initially, there were some 400
patients referred to the unit. A review was conducted which reduced the number of cases to 140. This is the usual
workload with more cases referred on a daily basis.
Many frequent and persistent 999 callers have underlying issues that need attention from other services, such as
mental health or social care. LAS employs social worker Clive Palmer to assess the needs of such callers and help
them access the care they need.
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Close
Case Studies
“My social work background helps me identify the issues behind their calls – anything from serious mental health
conditions to homelessness to old people suffering anxiety,” said Clive, who is part of the LAS’s dedicated frequent
callers unit.
“It also helps me to make the right contacts with other service providers – for example, if the person is receiving
social care, I can liaise with the service providers and call for a review of the care package. Often the providers have
no idea that the person is calling 999.”
Clive feeds information about frequent callers’ back into the system, so that 999 call takers can advise care or
accommodation providers when they call, often removing the need for an ambulance.
The result has been not only a reduction in 999 calls and ambulance attendance in these cases, but also a marked
improvement in care provision for the frequent callers.
Back Next
Close
Case Studies
Case study: Deprivation
North West Ambulance Service – Spearhead PCTs
What was the issue?
Of 24 PCTs served by North West Ambulance Service, 18 are ‘Spearheads’, defined as an area within the worst
20% of health and deprivation indicators nationally. Analysis showed that Category A calls per head in Spearhead
PCTs was much greater than in non-Spearhead PCTs – 46.5 per thousand compared to 34.3 per thousand in
2006/07.
Spearhead PCTs also see greater numbers of specific conditions, including CVD, stroke and falls.
What was the action?
NWAS focused on Cheshire and Merseyside where ambulance demand had been rising most rapidly, and produced
detailed reports for two PCT performance management committees in that area, setting out data for those areas
and identifying what additional resources the ambulance trust was providing to that area.
What was the solution?
This data could enable the PCTs to better understand those deprived areas and work with the trust to help provide
targeted services to support the population
Close
Case Studies
Case study: Alcohol
East Midlands alcohol hotspots
What was the issue?
Patient pick-ups related to alcohol abuse cost around £193 per person. PCTs need data on alcohol-related A&E
admissions in order to plan resources to tackle alcohol abuse. However, ambulance data is symptom-based and
does not clearly indicate which emergency calls are alcohol-related.
What action was taken?
The East Midlands Ambulance Service (EMAS) developed a way of identifying which calls were likely to be alcoholrelated by focusing on ages 14-30, assault, falls, unconsciousness, self-harm, traffic accidents and time of day and
week. EMAS then used Geographical Information Systems (GIS) to map the calls and display local hotspots for
alcohol abuse.
What was the measured outcome?
The GIS mapping demonstrated that the cost of alcohol pick-ups within the centre of Nottingham over one month
was £63,304. Local information developed using GIS mapping could be used by PCTs to help develop targeted and
cost-effective strategies to combat alcohol abuse.
Close
Case Studies
Case study: Alcohol
South Central Ambulance Service – actions on alcohol
What was the issue?
How to reduce the amount of alcohol-related ill-health, anti-social behaviour and calls to the emergency services.
What was the action/solution?
South Central Ambulance Service with the Safer Portsmouth Partnership employs ‘community health practitioners’
(CHPs) who patrol alcohol hotspots with a response kit, offering information and advice to the public, licensees and
door staff.
At weekends, the CHPs are located within the entertainment areas to provide a rapid response presence. During the
day the CHPs promote healthy living, including safe drinking, and advise on reducing accidents. Paramedics also
use a Clinical Audit Reporting Systems (CARS) which helps identify hotspots.
What was the measured outcome?
CARS evidence was used in court to tackle night clubs where frequent assaults and alcohol-induced emergencies
were leading to 60 999 incidents in 12 months. This was reduced to just 6 incidents in the following month, and
conditions were put on the night club’s licence.
Close
Case Studies
Page 1 of 2
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Action grid
‘QIPP’ workbox
How could decreasing 999 ambulance demand in this area support:
Quality?......................................................................................................................................
Innovation?.................................................................................................................................
Prevention?.................................................................................................................................
Productivity?...............................................................................................................................
System alignment workbox
What are the issues and impacts on other urgent and emergency care services?
A&E
Walk-in centres and minor
injury units
Primary care (in hours)
Primary care (out of hours)
NHS Direct
Pharmacy services
Community services
Other (e.g. GP led health
centres)
Costings workbox
What is the current annual cost of ambulance activity in this area?
What could be reduced or handled by other services?
What are the estimated savings? (short term and long term)
Page 2 of 2
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Actions workbox
Based on the checklist questions, what actions will be taken by providers and commissioners?
By when?
Measured how?
Is an EqIA
required?
Providers
Commissioners
Incentives workbox
How will this agreement be reflected in:
The contract?..............................................................................................................................
Local indicators/targets?..............................................................................................................
Other agreements between partners?..........................................................................................
Page 1 of 7
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References and data sources
Ambulance activity and performance information
Ambulance Services, England 2008-09, NHS Information Centre for Health and Social Care
http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/ambulance/
ambulance-services-england-2008-09
Annual number of emergency and urgent calls, incidents and patient journeys, by time of day
chief complaint and age and gender of the patient, East Midlands Ambulance Service Trust data
extract, London Ambulance Service Trust data extract, North East Ambulance Service Trust data
extract, North West Ambulance Service Trust data extract
Department of Health Weekly Ambulance and Accident & Emergency Situation Reports
(SITREPs)
A&E attendances conveyed by ambulance, Accident and Emergency Attendances in England
(Experimental Statistics), 2007-08
http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/
AccidentandEmergency/DH_077485
Ambulance Costings information
Weighted average costs for ambulance activity, Appendix NSRC04 NHS Trust and PCT Combined
Reference Cost Schedules, NHS Reference costs 2007-08.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_098945
Activity in emergency and urgent care services
Quarterly Monitoring of Accident & Emergency statistics (QMAE) data collection,
Department of Health
http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/
AccidentandEmergency/index.htm
Trends in consultation rates in General Practice – 1995-2009
http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/general-practice/trends-inconsultation-rates-in-general-practice-1995-2009
Hospital Episode Statistics (HES), NHS Information Centre for Health and Social Care
http://www.hesonline.nhs.uk
Page 2 of 7
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Number of calls to NHS Direct 0845 number, England, NHS Direct data extract
GP Patient Survey 2008/09
http://www.gp-patient.co.uk/results/
Patient conditions
Statistics on Alcohol, England 2009, NHS Information Centre for Health and Social Care
http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/alcohol/statistics-onalcohol-england-2009-[ns]
Statistics on Obesity, Physical Activity and Diet: England, February 2009, NHS Information
Centre for Health and Social Care
http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/obesity/statistics-onobesity-physical-activity-and-diet:-england-february-2009
Long term conditions compendium of information, Department of Health
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_082069
Population information
Estimated resident population, Primary Care Organisations in England, Office for National
Statistics
http://www.statistics.gov.uk/statbase/Product.asp?vlnk=15106
Population projections, Strategic Health Authorities in England, Office for National Statistics
data extract
Indices of Multiple Deprivation, Communities and Local Government
http://www.communities.gov.uk/communities/neighbourhoodrenewal/deprivation/
deprivation07/
Page 3 of 7
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Bibliography
Factors affecting demand for ambulance services
Hannah Wrigley, Steve George, Helen Smith, Helen Snooks, Alan Glasper, and Eileen Thomas
Trends in demand for emergency ambulance services in Wiltshire over nine years: observational
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Changes in the emergency workload of the London Ambulance Service between 1989 and 1999
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Brown LH, Lerner EB, Larmon B, LeGassick T, Taigman M.
Are EMS call volume predictions based on demand pattern analysis accurate?
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[Quantitative analysis of the demand for emergency medicine in Yokohama City, Japan]
Nippon Koshu Eisei Zasshi. 2003 Sep;50(9):879-89. Japanese.
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Predictors of demand for emergency prehospital care: an Australian study.
Prehosp Disaster Med. 1999 Jul-Sep;14(3):167-73.
Cadigan RT, Bugarin CE.
Predicting demand for emergency ambulance service.
Ann Emerg Med. 1989 Jun;18(6):618-21.
Baker JR, Fitzpatrick KE.
Determination of an optimal forecast model for ambulance demand using goal programming.
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Kamenetzky RD, Shuman LJ, Wolfe H.
Estimating need and demand for prehospital care.
Oper Res. 1982 Nov-Dec;30(6):1148-67.
Siler KF.
Predicting demand for publicly dispatched ambulances in a metropolitan area.
Health Serv Res. 1975 Fall;10(3):254-63.
Gibson G.
An analysis of the demand for emergency ambulance service in an urban area.
Am J Public Health. 1971 Nov;61(11):2158-61. No abstract available.
Demand management in wider emergency and urgent care services
Ronald T Hsu, Paul C Lambert, Mary Dixon-Woods, and Jennifer J Kurinczuk
Effect of NHS walk-in centre on local primary healthcare services: before and after observational
study. BMJ Mar 2003; 326: 530; doi:10.1136/bmj.326.7388.530
http://www.bmj.com/cgi/content/full/326/7388/530
James Munro, Jon Nicholl, Alicia O’Cathain, and Emma Knowles
Impact of NHS Direct on demand for immediate care: observational study
BMJ, Jul 2000; 321: 150 – 153.
http://www.bmj.com/cgi/content/full/321/7254/150
C J T van Uden and H F J M Crebolder
Does setting up out of hours primary care cooperatives outside a hospital reduce demand for
emergency care?
Emerg. Med. J., Nov 2004; 21: 722 – 723.
http://emj.bmj.com/cgi/content/full/21/6/722
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Ohshige K
Reduction in ambulance transports during a public awareness campaign for appropriate
ambulance use
Academic emergency medicine Volume: 15 Issue: 3 Pages: 289-293 Published: MAR 2008
Moll van Charante EP, van Steenwijk-Opdam PC, Bindels PJ.
Out-of-hours demand for GP care and emergency services: patients’ choices and referrals by
general practitioners and ambulance services.
BMC Fam Pract. 2007 Aug 1;8:46.
Román MI, de Miguel AG, Garrido PC, Medina JC, Carlos AJ, Díaz G, Torres EC.
Epidemiologic intervention framework of a prehospital emergency medical service.
Prehosp Emerg Care. 2005 Jul-Sep;9(3):344-54.
Lattimer V, Turnbull J, Burgess A, Surridge H, Gerard K, Lathlean J, Smith H, George S.
Effect of introduction of integrated out of hours care in England: observational study.
BMJ. 2005 Jul 9;331(7508):81-4.
Davis JH.
Control of demand.
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Prevention package for older people resources, Department of Health, 2009
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DH_103146
Transforming Community Services, Transformational guides covering six service areas, 2009
http://www.dh.gov.uk/en/Healthcare/Primarycare/TCS/
TransformationalGuidescoveringsixserviceareas/index.htm
Appropriateness of ambulance transport
H Snooks, H Wrigley, S George, E Thomas, H Smith, and A Glasper
Appropriateness of use of emergency ambulances.
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Hjälte L, Suserud BO, Herlitz J, Karlberg I.
Why are people without medical needs transported by ambulance? A study of indications for
pre-hospital care.
Eur J Emerg Med. 2007 Jun;14(3):151-6.
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Economic impacts
Fischer AJ, O’Halloran P, Littlejohns P, Kennedy A, Butson G.
Ambulance economics.
J Public Health Med. 2000 Sep;22(3):413-21.
Meta-analysis
L Hallam
Primary medical care outside normal working hours: review of published work
BMJ, Jan 1994; 308: 249 – 253.
http://www.bmj.com/cgi/content/full/308/6923/249
Department of Health
Taking healthcare to the patient: Transforming NHS ambulance services, 2005
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_4114269
Healthcare commission
Not just a matter of time: a review of urgent and emergency care services in England, 2008
www.cqc.org.uk/_.../Not_just_a_matter_of_time_-_A_review_of_urgent_and_emergency_care_
services_in_England_200810155901.pdf
Demographic information
Robin Carlisle, Lindsay M Groom, Anthony J Avery, Daphne Boot, and Stephen Earwicker
Relation of out of hours activity by general practice and accident and emergency services with
deprivation in Nottingham: longitudinal survey
BMJ, Feb 1998; 316: 520 – 523.
http://www.bmj.com/cgi/content/full/316/7130/520
Willem Jan Meerding, Luc Bonneux, Johan J Polder, Marc A Koopmanschap, and Paul J van der
Maas
Demographic and epidemiological determinants of healthcare costs in Netherlands: cost of
illness study
BMJ Jul 1998; 317: 111 – 115
http://www.bmj.com/cgi/content/full/317/7151/111
Wrigley H, Snooks H, Thomas E, Smith H, Glasper A, George S.
Epidemiology and demography of emergency ambulance calls: a review.
Pre Hosp Immed Care 1999; 3: 94-98.
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Kawakami C, Ohshige K, Kubota K, et al.
Influence of socioeconomic factors on medically unnecessary ambulance calls
BMC HEALTH SERVICES RESEARCH Volume: 7 Article Number: 120 Published: JUL 27 2007
Charles E. McConnel, Rosemary W. Wilson
The demand for prehospital emergency services in an aging society
Social Science & Medicine, Volume 46, Issue 8, 15 April 1998, Pages 1027-1031
Ruger JP, Richter CJ, Lewis LM.
Clinical and economic factors associated with ambulance use to the emergency department.
Acad Emerg Med. 2006 Aug;13(8):879-85. Epub 2006 Jul 6.
http://www.ncbi.nlm.nih.gov/pubmed/16825670
Kawakami C, Ohshige K, Kubota K, Tochikubo O.
Influence of socioeconomic factors on medically unnecessary ambulance calls.
BMC Health Serv Res. 2007 Jul 27;7:120.
Peacock PJ, Peacock JL.
Emergency call work-load, deprivation and population density: an investigation into ambulance
services across England.
J Public Health (Oxf). 2006 Jun;28(2):111-5. Epub 2006 Mar 10.
Strange GR, Chen EH, Sanders AB.
Use of emergency departments by elderly patients: projections from a multicenter data base.
Ann Emerg Med. 1992 Jul;21(7):819-24.
Brunette DD, Kominsky J, Ruiz E.
Correlation of emergency health care use, 911 volume, and jail activity with welfare check
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Ann Emerg Med. 1991 Jul;20(7):739-42.
The picture on factsheet 5 was supplied by Bob Henry, courtesy of West Midlands Ambulance
Service NHS Trust.
The picture on factsheet 6 was supplied by Tim Saunders, courtesy of London Ambulance Service
NHS Trust.
DH INFORMATION READER BOX
Estates
Commissioning
IM & T
Finance
Social Care / Partnership Working
Policy
HR / Workforce
Management
Planning /
Clinical
Document Purpose
Best Practice Guidance
Gateway Reference
12427
Title
Tackling demand together: A framework for improving urgent and emergency
care pathways by understanding increases in 999 demand
Author
DH
Publication Date
12 Oct 2009
Target Audience
PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs , Directors of
Finance, Emergency Care Leads, PCT Directors of Commissioning
Circulation List
PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs , Directors of
Finance, Emergency Care Leads
Description
A framework to provide practical support to help all PCT commissioners to
better understand factors affecting huge rises in ambulance demand, so the
NHS can provide better commissioned urgent and emergency care services to
patients
Cross Ref
Superseded Docs
Action Required
n/a
n/a
n/a
Timing
n/a
Contact Details
Ambulance Policy
Urgent and Emergency Care
New King's Beam House
22 Upper Ground, London
SE1 9BW
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0
For Recipient's Use
© Crown 2009
298050 1p Oct09
Published to DH website, in electronic PDF format only.
www.dh.gov.uk/publications
Policy