In South East Wales, with £1.7 million capital support from the Assembly Government, the ambulance trust has established a new control room at its regional headquarters at Vantage Point House. As well as consolidating staff from the previous ambulance control centres at Mamhilad and Church Village into a single control room, the new control room houses other unscheduled care call handling services. These include call handlers and nurse advisors from NHS Direct and call handlers from Gwent primary care out-of-hours service.

Staff from the various unscheduled care services are co-located within Vantage Point House but are not yet operating in a fully integrated manner. Co-location is beneficial and aids communications, with the ambulance control staff, NHS Direct nurses and GP out-of-hours call handlers able to communicate and work together more effectively as a result of being in the same room. However, their IT systems do not talk to each other, which leads to ongoing duplication and unnecessary handovers between the different types and levels of service as a result of numerous points of access and boundaries between services. For example, the Clinical Desk is not able to link electronically with other co-located services within the Vantage Point House control room. If a patient speaks to an NHS Direct nurse on the Clinical Desk but is referred to the GP out-of-hours service, the caller has to end their call with the NHS Direct nurse, and ring a different number to speak to an out-of-hours call handler who can physically see the NHS Direct nurse who took the previous call; the lack of inter-operability between the IT systems means that the caller will have to provide the same information to the out-of-hours service which they already provided to the NHS Direct nurse. There are plans to move to a common platform which will support integrated working. This integration would help embed stronger clinical governance across the points of access to unscheduled care. It could also help address the need for stronger clinical governance arrangements and clinical support in the control room, for example through GPs providing advice, support and coaching to those handling calls in the control room. Since June 2009, there has been an ongoing trial in the control room whereby a GP is present in Vantage Point House to support nurse advisors triaging Category ‘B’ calls during periods of escalation because of high levels of demand.

Vantage Point House represents a prototype for a health care communications hub, which forms a key part of the model within the Community and Primary Care Strategy. Subject to robust evaluation, there are significant opportunities to further develop the Vantage Point House model in Gwent, and if this is successful extend it to other parts of Wales, for example through:

a creating a flexible workforce to deliver joint call handling, cross-training across NHS Direct Wales, 999 and primary care out-of-hours services so that all staff could use all three systems using common software systems to direct people to the most appropriate part of the unscheduled care system;
b addressing current problems with the lack of inter-operability between the primary care out-of-hours service, NHS Direct Wales and ambulance control software, to enable the creation of a single Electronic Patient Record (EPR) to reduce the current duplication and improve information sharing with the patient’s consent;
c as whole systems working in Vantage Point House becomes more mature, exploring the opportunities to bring other neighbouring out-of-hours GP call handling services into the Vantage Point House initiative; and
d using spare capacity in Vantage Point House out-of-hours when the ambulance trust’s Patient Care Services staff go home at 5pm.

The Clinical Desk pilot

A clinical model of triage, the ‘Clinical Desk’, was first introduced as a three-month pilot to two of the three ambulance control centres in November 2007. The aim of the Clinical Desk pilot was to manage the high number of inappropriate emergency ambulance responses to 999 calls from people with neither life-threatening nor serious conditions. For low acuity calls, the aim is to ensure callers get the appropriate advice or were effectively signposted to healthcare services. The Clinical Desk uses the skills of NHS Direct Wales nurses to assess or triage low acuity 999 calls, and in some instances where calls are serious but a full emergency ambulance response is not necessary. Nurse advisers assess callers using the same computer decision software (CAS) utilised by NHS Direct Wales so that callers receive the most appropriate advice and support for their needs.

The Trust’s evaluation of the first phase of the pilot concluded that there was frequently the potential to stand down the ambulance that had been dispatched at the start of the call. The Clinical Desk was given insufficient time to triage patients before dispatching an emergency ambulance. The second phase of the Clinical Desk pilot considered whether an emergency ambulance response could be stopped once low acuity 999 calls were transferred to the Clinical Desk. Over a two-month period between August and October 2008, Nurse Advisers working on the Clinical Desk triaged more than 500 low acuity 999 calls (one-fifth of eligible calls for transfer). Two-fifths (39 per cent) of these calls were resolved with advice to self care or to contact their GP or other healthcare professional. This meant that 211 emergency ambulance responses were stopped, freeing up the equivalent of 3.5 ambulances each day. Sixteen per cent of calls were transferred back for a 999 emergency ambulance response, which the Trust believes illustrates the safety of the clinical desk model, as these calls would have been designated a low priority response by the Advanced Medical Priority Dispatch System. Of the remaining calls, 30 per cent were downgraded to an urgent ambulance response, 14 per cent were categorised as ‘other’ because the caller refused nurse triage and one per cent were returned to ambulance control because they should have been excluded from the Clinical Desk.

At the time the evaluation was carried out the Clinical Desk was not operational at peak times (8am to midnight) seven days a week. The Trust estimates that if the Clinical Desk had been fully operational then an additional 1,420 calls could have been resolved without the need for an emergency ambulance response. Avoiding an unnecessary emergency response, when safe and appropriate to do so, can be positive for the patient, the wider public and the whole system of unscheduled care. It reduces unnecessary journeys to hospital for patients, and releases emergency ambulances to respond to other life threatening calls.