Dear Mr Cox Regulation 28 letter following the death of William Watson Thank you for your letter dated 19th July 2018 regarding the death of Mr William George Irvin Watson. am writing to you as the co-ordinating commissioner for the South Western Ambulance Service NHS Foundation Trust (SWASFT) contract for emergency ambulance services, on behalf ofthe 10 CCGs in order to address the matters of concern: The specific details regarding this case regarding the High Dependency Transport and the Non-emergency transfers will be addressed directly by Kernow CCG as the commissioner of those services, therefore our response focus on providing you with further details regarding the Emergency Ambulance transport contract that we collaboratively commission. During the Autumn of 2017 all ambulance trusts across the country implemented the Ambulance Response Programme (ARP), which has fundamentally changed the way in which ambulance response times, categorisation of calls and dispatching of vehicles are managed and monitored, In order to understand the full impact of ARP, SWASFT commissioned piece of modelling work: The modelled resource gap to achieving the ARP standards currently states 241.7 whole Time Equivalent (WTE) or 15,147 vehicle hours per month, based upon 2017/18 contract activity level and the current resourcing and operational model. If this were to be addressed through a like-for-like operational model; there need to be recurrent revenue investment of E12m with associated capital cost of E4m. In accordance to your letter and the matters of concern raised, will now respond to each of your questions in turn: How is the current financial shortfallto be remedied and bY when? Supporting people in Dorset to lead healthier lives will would

Following round-table meeting held in February 2018 which was attended by SWASFT, Dorset CCG as Coordinating Commissioner, NHS England and NHS Improvement; a number of specific actions were addressed which has now led to the following developments.
1) A Joint Plan has been co-produced with commissioners and SWASFT which has number of components in order to address the gap in performance: To summarise: SWASFT Performance Improvement Plan set of actions owned at both executive and operational levels;
b. STP (Sustainability Transformation Plan) Action Plan Commissioner owned actions by all ten CCGs and regionally accountable to local STP and A&E/Urgent and Emergency Care (UEC) delivery boards; The Transition Plan covering transformation and funding: As well as increasing resources, modernising the service model and identifying additional funding, one of the aims of the Joint Plan is to reduce the overall demand into the ambulance service, to ensure the right patients are receiving the right care in the right place and achieving the best outcomes. This may mean being treated in an alternative setting to the ambulance service, This will ensure the resource is available for those who need it, when they need it. The STP action plan responds to opportunity areas, identified by SWASFT, which require STP system partners to collaborate in order to support improved performance against ARP. All actions have been developed based upon local pilots and national evidence: The projected impact assumes and requires actions are implemented across the entire SWASFT operational area:
2) A financial framework has been developed on the basis of the E12m funding gap as part of developing the Joint Plan and has been agreed by all 10 CCGs across the South West in August 2018. The framework sets out a 2.3% investment over 3 years, however recognising that for 2018/19 a maximum of only €1.774m can be made available, this requires a higher level of resource to be found for 2019/20 to balance the 2 years.
3) A fleet capital bid for E6.72m submitted by SWASFT to the Ambulance STP Capital Scheme Funding has been successful. This will provide an additional 63 vehicles and will be fully operational by February 2019. In order for SWASFT to meet the treasury rules and to achieve the operational deadline, €1.32m would need to be forthcoming: The agreed financial framework now ensures that this non-recurrent vehicle set up cost will be made available as part of the E1.774m investment during 2018/19_ The Financial Framework sets out a total overall investment of €13.8m by commissioners to support achievement of the ARP standards By what date do YOu expect the minimum acceptable performance standards to be met? all

SWASFT have provided commissioners with a draft business case which sets out how the investment in the Trust's A&E contract would be utilised to improve and deliver ARP performance standards. Based on the original analysis and recruitment profile, the trust would deliver the following ARP performance standards by the end of September 2020: Category 1 Mean and 90th Percentile Category 1 Transport Mean and 9Oth Percentile Category 3 Mean and 9Oth Percentile Category 4 Mean and 9Oth Percentile Category 2 Mean and 9Oth Percentile would be achieved in June 2021 when the paramedic recruitment is complete: The above timeline has been established on the basis of the performance model which was undertaken at a point in time in September 2017/18. We have agreed with SWASFT that this analysis will need to be revisited in quarter of 2018/19 and this will be jointly commissioned by the Trust and the CCGs. It is anticipated that the revised output will lead to adjustments to the proposal contained within the business case. trust this provides you with the detail requested and further assurance that significant work and developments have taken place. continue to work collaboratively with the ambulance trust in order to address the gap in performance and ultimately improve response times for all patients_

Dear Mr Cox Thank you for your regulation 28 report to prevent future deaths pertaining to Mr William George Irvin Watson: In your report you identify a number of concerns and the action to be taken by NHS Kernow as commissioners of high dependency and non-emergency transport services. The matters of concern relating to emergency ambulance transport will be addressed by Dorset CCG in a separate response_ The matters of concern you raised to be addressed by NHS Kernow and our response to them are as follows: High Dependency Transport You heard that the only provider of this service in Cornwall was Lifestar. You were also informed that on occasion when Lifestar has no available resource it is necessary to contact providers from out of county You heard evidence that there was a definite gap in service and wished to learn if this was accepted by NHS Kernow. Currently NHS Kernow purchases high dependency transport on a non-contract basis therefore each transport is booked/lpurchased based on the needs of each person: This is arranged through the Centralised Booking Service based at Royal Cornwall Hospitals NHS Trust (RCHT), commissioned by NHS Kernow to ensure that all non-emergency patient transport is booked to suit the individual health care needs. Chair; 01726 627800 Chief Officer kccg contactus@nhs net 'WW _ kernowccg nhs uk Head office: Inhskernow Sedgemoor Centre Road, St Austell; Cornwall, PL25 5AS have Priory

There is more than one provider of this service_ The predominant providers of high dependency transport are Lifestar Medical and First Care Ambulances. Lifestar are based in Cornwall, First Care is based in Exeter and provides a service across the South West also provide services to Northern Eastern and Western Devon Clinical Commissioning Group. High dependency transport is non-emergency and therefore planned; if extra capacity is required above and beyond the capacity of the two providers mentioned above then provision may be purchased another provider out of county in order to meet that need_ NHS Kernow therefore is not aware of any gap in commissioned service Non-Emergency Transfers You were told at the inquest that the service commissioned by NHS Kernow was provided by E-zec You were further advised that its performance targets were to collect 95% of people within one hour and for short notice bookings, 50% were collected within one hour and 95% within two hours. You were also informed that these targets were not being met You have also raised the concern that people who required this form of transfer were kept waiting beyond acceptable performance standards deteriorate and potentially have their life at risk_ E-zec Medical Services is commissioned by NHS Kernow to provide non-emergency patient transport (NEPTs). This covers transport for a range of needs including outpatient appointments, transfers of care and discharges. NEPTs would only transfer someone in a very stable condition; for example a person transferred from an acute to a community hospital or their normal place of residence_ We would not wish people to wait beyond the performance standards for many reasons. With a de-escalation of care or the movement of an individual from an area of high health care need to lowerlno health care need, any deterioration in condition would be addressed, i.e. would be waiting in the safest place and assessed_ In the case of Mr Watson we would not expect E-zec Medical Services as our provider of non- emergency patient transport to convey a high dependency person as are not commissioned to provide that service and would not have a clinically appropriate vehicle or staffing resource and, as result, it would not be safe to do sO. We would also not expect a person to be transferred from specialist centre (Derriford) to another acute hospital unless the person was fit and safe to be transported, as this is a de- escalation of care. A delay in the high dependency transport arriving for the journey would not cause harm to the person as they would be in the most appropriate environment to meet their health care needs and able to access high quality care immediately if needed. If it was an escalation of care and the person's condition was deteriorating then we would expect the person to be transferred in an emergency ambulance by the South West Ambulance Service Trust (SWAST): Page 2 They from may put they they

For clarity the performance target refers to the window of collection from their agreed pick up time, not from the time of booking_ This is for a standard booking: Enough time should be given by the hospital booking the transport to allow the transport provider to time to plan the journey: This should be done as soon as possible, preferably the day before it is required, Wherever possible the performance requirements within the E-Zec Medical services contract for standard bookings are: 50% of service users to be collected at their agreed dischargelready time up to 30 minutes after their identified ready time 90% of service users to be collected at their agreed dischargelready time up to 45 minutes after their identified ready time 95% service users to be collected at their agreed dischargelready time up to 60 minutes after their identified ready time Our provider is currently performing at the following levels: 56% year to date average against the 30 minute target of 50% 73% year to date average against the 45 minute target of 90% (improved from 66% average in previous year) 86% year to date average against the 60 minute target of 95% (improved 74% average in previous year E-zec Medical Services has made significant improvements over the last 12 months and is currently on target to meet their trajectory of improvement in order to meet the required standards NHS Kernow continues to work with the provider and the health system to ensure demand and capacity is manged in order to achieve these standards. Short Notice Bookings At the time of this case the performance measure for short notice bookings was 95% of journeys to be collected within two hours of booking: These targets since been amended to meet the needs of the service and are currently: 50% within two hours (provider currently achieving year to date average 55%) 70% within three hours (provider currently achieving year to date average 75%) 85% within four hours (provider currently achieving year to date average 87%) NHS Kernow is currently reviewing the definition of a short notice booking to ensure that it meets the needs of people_ Page 3 from have

Procurement The inquest was advised that a new service provider would be taking on the business from April 2019. Of great concern to you was the revelation made at inquest that there are currently no compliant bids. would be pleased to learn what steps the commissioners propose to in place to remedy the difficulties that exist currently and the foreseeable risk that will arise from April. NHS Kernow was undertaking a procurement exercise at the time of the inquest which was open to many potential bidders including incumbent providers The procurement was closed on June 2018 The procurement was subject to EU regulations and at the time of the inquest on 20th June 2018 no information had been released relating to the outcome_ The procurement process was not successful in securing the universal non-emergency patient transport service we were trying to achieve so in order to mitigate future risk NHS Kernow been working with our current providers who have agreed, in principle, to an extension of their current contracts. This will ensure that the current service that people receive will not be disrupted _ The re-procurement is viewed by NHS Kernow as a potential opportunity to improve service provision and we are committed to achieving this. During this extension the CCG will finalise their future commissioning arrangements for one universal non-emergency patient transport service with the continued aim of meeting the needs of the population of Cornwall and the Isles of Scilly. Over the coming months NHS Kernow will be working with current and potential providers , stakeholders and the public in order to understand why the procurement exercise was unsuccessful and how we can improve going forward. hope this action provides you with some comfort: Please do not hesitate to contact me if you require anything further in relation to this case_