Motivation for non-conveyance: opportunity or risk

Senior management in some ambulance services described non-conveyance as an opportunity to offer the most appropriate care to patients and as embedded practice within their organisations. In one organisation (Service C), non-conveyance was described as an historically important activity and there was an ongoing goal to improve or sustain high non-conveyance rates. Interviewees in both managerial and paramedic roles in this organisation described how they took a ‘whole organisation’ approach to non-conveyance and increasing rates of non-conveyance:

I think we’ve had that culture a lot longer [than other ambulance services. Staff [here] almost a decade ago were leaving people at home. Whereas in some services their non-conveyance rates are awful and I think their staff have still got to get their head around that’s what their job is’. (Service C, interviewee 4)

In contrast, interviewees in some ambulance services described non-conveyance as an activity that had been prioritised in recent times (Service I) or was seen as less of a priority (Services B, E, F and H). At an extreme, senior management in one service was described as risk averse to non-conveyance. Senior management interviewees did not want to increase discharge at scene rates because of the risks involved to ambulance crews if something went wrong. The healthcare commissioner also viewed non-conveyance as a low priority within this ambulance service and a paramedic described this activity as a ‘new concept’.

the [healthcare commissioners] and the GPs, and everybody else hate us, because, we, I won’t release the crews to just leave people at home and make a call to a GP receptionist to say I’ve left this person at home because that crew member themselves doesn’t realise what he’s doing there, he’s putting himself in the coroner’s court in a non-defendable position, unless it’s a safe structured handover recorded, and shared, I won’t let it happen. The fact that it does happen all over the place is another matter and when I go round other ambulance services, I do think that this point is sometimes missed. (Service F, Interviewee 39)

In two services (Services C and H), there appeared to be high levels of motivation to undertake clinical telephone assessment to manage demand for ambulances. In both services, there was a perception that services had a strategic vision for telephone assessment and provided workforce investment to support this:

Invested heavily [in the clinical hub] high level of expertise…invested a lot of time in that group of staff… we’ve put quite a large amount of investment into the structure. For us it’s not just pulling paramedics off the road and sticking them in the control and getting them to [take] calls. We’ve got a whole [telephone advice] strategy here… we really thought through the whole thing. (Service H, Interviewee 49)

This contrasted with other services (Services A, D, E and G) where interviewees perceived risk linked to the non-visual aspect of assessment, the use of paramedics rather than nurses (experienced in telephone triage) to undertake this role, and a potential risk to the organisation in not meeting patient expectations:

with [clinical telephone advice] … what’s your appetite for dealing with a high level of complaints… very simply, the more non-conveyance you do the [more] dissatisfaction you will have. People didn’t phone 999 for a chat, they phoned 999 with an expectation that an ambulance was going to appear. (Service E, Interviewee 32)

Structural stability

The stability of the organisation was described differently for each ambulance service at the time of the interviews. Most ambulance services appeared to be stable, with no discussion of significant restructuring within their senior management. However, interviewees in four services (Services A, H, I and J) reported current or recent challenges in terms of loss of key senior personnel, or poor outcomes in a national quality assessment, which created challenges for senior management within the organisation. Interviewees did not expand explicitly on how this might impact on non-conveyance rates but it was clear from their discussions that their focus was on their key priority of meeting response time targets in the context of this instability rather than the innovation necessary for increasing non-conveyance rates:

it’s been a difficult year because we were in such a difficult situation. We were very much around meeting [response time targets] and all of our focus was around increasing [staff] numbers and getting the response target right in the first instance, we were not necessarily entertaining anything that took paramedics away from core frontline business. (Service A, interviewee 5)

Skill mix configuration

Interviewees described how the configuration of their ambulance crews could affect discharge at scene rates. Paramedics with extended skills were viewed as having more confidence to discharge patients at scene than paramedics with standard training and paramedics were described as having more confidence than crews without paramedics. This highlighted the potential for the skill mix configuration within an ambulance service to affect its discharge at scene rate:

we’ve been particularly challenged by a shortage of senior clinicians, that is, paramedics. Paramedic numbers have been very low, and that will affect the decision-making of the clinicians and their confidence level. The more senior clinician you get on [discharge at scene] the more confidence they’ll have to make a decision not to convey, whereas if you’re running a number of non-paramedic based ambulances, so emergency medical technicians, or student ambulance paramedics, or emergency care assistants, generally the lower the grade the more likely the conveyance rates will be affected. (Service A, interviewee 5)

A similar variation in views was apparent for the provision of telephone assessment within the ambulance services. Many interviewees perceived telephone assessment to be a specialism, beyond the basic training of paramedics. They described the success of their clinical hub being underpinned by the support of specially trained paramedics and other clinicians such as mental health specialists (Services B, C and H). In contrast, in other services (Services A, E and G) interviewees described resource challenges within their service which appeared to limit the utilisation of multidisciplinary teams or senior paramedics within the clinical hub:

we don’t have the resources to do hear and treat effectively…depleted in staffing, it’s not supported enough to be able to work it effectively, and they’re overwhelmed with work …so, I would say the setup here is just under resourced, massively under resourced. (Service A, interviewee 17)

Perceived value of higher skill mix

The perceived value of paramedics with extended skills, for example, Emergency Care Practitioners, was described differently by interviewees in each ambulance service. In some ambulance services, there was consensus among the interviewees that paramedics with extended skills were established within the service and were perceived to be a valued resource for reducing conveyance to hospital (Services C, D and G). In these ambulance services, paramedics discussed being able to access their senior colleagues—paramedics with extended skills—and refer patients to them, also describing them as a support mechanism for seeking advice to facilitate their own decision-making regarding non-conveyance. Interviewees in these ambulance services wanted to expand this part of the workforce because of its perceived value to non-conveyance. In contrast, interviewees in other ambulance services described limited implementation of paramedics with extended skills, or a recent renewed interest in them, which implied that they had possibly been neglected within the organisation in the past (Services A, E, H and J). Reasons given for limited implementation of paramedics with extended skills included a need to focus resources elsewhere in the workforce or a lack of interest at a senior management level:

It’s a bit of a ‘dying on the vine’ situation. Yes we have [paramedics with extended skills], a small number that were from the prerequisite arrangements. I’ll never get rid of them, but we haven’t trained [them] here [for a number of years]’. (Service E, interviewee 32)

Organisational support for the workforce

While many interviewees described how ambulance crews followed protocols and policies when making non-conveyance decisions, they also highlighted the importance of the confidence of crew members when deciding to discharge at scene. Indeed, one interviewee identified paramedic confidence as the most important factor affecting the decision to discharge patients at scene. Interviewees described how confidence could be improved through experience in the role, training to extend skills, mentoring in non-conveyance, the ability to discuss potential cases for non-conveyance with clinicians in the clinical hub, and being part of an organisation that was supportive of their workforce. Senior managers described the importance of supporting their workforce and understanding that a decision not to convey could be the right decision at the time even if it appeared not to be at a later stage. In contrast with the views of these senior managers, paramedics in some services openly described a fear of retribution if things went wrong (Services B, D, E, G, H and J). Indeed, in some ambulance services, the managers described how supportive they were of the workforce when things go wrong but the paramedics interviewed expressed the opposite view (Services E, G, H and J).

probably the most important one is the support for staff. If we’re encouraging the staff to non-convey it’s making sure we’re supporting them in that decision and if it does go wrong, making sure again that we understand the reason why it’s gone wrong, but again continue to support the staff because they’ve probably made the right decision in the first place. (Service G, interviewee 30)

sadly, if something goes wrong out on the road, then obviously knowledge might get back to the station and it’s talked about. And you’re sadly in this job, you are known for being bad rather than being a good clinician. (Service G, interviewee 29)

Provision of alternative services to hospital

A consistent issue raised by interviewees from all ambulance services was the importance of having health and social care services available in the wider emergency and urgent care system to facilitate non-conveyance. Ambulance crews could work with these services to obtain information about patients to help them make a decision about non-conveyance or refer patients to those services to allow non-conveyance:

there’s lots of expectation on ambulance services to single-handedly reduce conveyance to [an emergency department] but a lot of that, the success, is down to the buy-in from the local health community in terms, if they’ve not got the alternative pathway we can’t use it. (Service C, interviewee 4)

There was variability in how interviewees described the provision of services that could enable non-conveyance. In one service (Service C), interviewees spoke positively about provision and the range of pathways available to the ambulance service. In contrast, interviewees in two services (Services A and I) spoke about a significant lack of pathways. Most other services (Services B, D, E, F, G, H and J) described variation in provision across their region:

It’s fair to say, very few options available to us as referral pathways. (Service A, interviewee 15)

Some areas have got really good pathways, so where you’ve got direct access to GPs, minor injuries units, walk in [centres], admission to certain [hospital] wards for certain clinicians. But then in other areas, actually the only place you’ve got is the emergency department, so the GPs won’t take a referral from the paramedics […] you’ll get a minor injuries unit, often called a walk-in centre, and often the reason why we call it a walk-in centre is they don’t take stretcher patients. So they have a perception that if you’re an ambulance, the patient must be on a stretcher, therefore, they won’t accept you. (Service D, interviewee 20)

Connectivity with the wider system

While ambulance services had no control over the availability of health and social care provision in their region, they are able to exert some influence over their engagement with these services. Interviewees in one service (Service C) shared consistently positive views about the connections between their ambulance service and services in the wider emergency and urgent care system. They described an initiative that linked ambulance crews with other services necessary for non-conveyance rather than the crews having to locate and contact these services themselves. This initiative was perceived as successful and to operate differently from other models across the country because it took some of the responsibility for discharge at scene off the ambulance crew. In contrast, another service described a similar initiative as a barrier to non-conveyance because it was not consistently provided across their region and thus caused more, rather than less, work for ambulance crews because they travelled across different localities with different processes and considerable efforts were required to identify the appropriate processes when wanting to non-convey.

some [models in other ambulance services] don’t clinically take on the patient. They just say ‘oh you need to phone such and such and refer them there’. With our [model] you basically hand [the patient] over and one of their clinicians [will] take responsibility for the patient […] and they sort everything else out behind the scenes. (Service C, interviewee 4)

each one of the [Clinical Commissioning Groups] puts in what they call an SPA, a single point of access. Some of them put in several single points of access, which in itself is a bit of an oxymoron because it’s not single point, it’s several points of access, and so what we’ve done is then created another obstacle that a crew has to navigate before they can pass this job on. (Service B, interviewee 43)

In other services (Services A, B, D, E, F and I), interviewees perceived that relationships with key services in the wider system were poor because they could not access some services that might support non-conveyance, could not access services reliably when needed in the short time frame of needing to make non-conveyance decisions or were not confident in the quality of the service they needed to refer patients to. These services included primary care—both in or out of hours—community services, falls services, minor injury units and urgent care centres.

Complexity of the system

Interviewees described some ambulance services as situated within more complex emergency and urgent care systems than others. Clinical Commissioning Groups commission services for the population in their geographical locality. One ambulance service had 12 of these localities within their region whereas another had 33. Ambulance service managers described how each locality could have different priorities in terms of commissioning non-conveyance, creating complexity in terms of a single ambulance service having to deal with multiple commissioners’ needs. Further complexity was highlighted by managers and paramedics who described how each Clinical Commissioning Group locality had different services operating in different ways. Understanding this variation between geographical areas within their region, or within the same service over time, created a burden for crew members who would decide to convey to an emergency department because this was the easiest option.

[the crew] go to a [patient who has had a] fall in [PLACE A], and [the crew] might be very familiar with the falls service that’s back in [PLACE B], but now they’re in [PLACE A] it’s all completely different, the criteria’s different, they haven’t a clue, so they’re left with the decision ‘well, I haven’t a clue what’s going on here so do you know what, I’m just going to take them to the [emergency department]. (Service B, interviewee 43)