London Ambulance Service Headquarters

This provider was rated as Good overall but Requires Improvement for providing effective services at the previous inspection on 2 September 2019 and 6 September 2019).

The key questions are rated as:

Are providers safe? – Good

Are providers effective? – Requires Improvement

Are providers caring? – Good

Are providers responsive? – Good

Are providers well-led? – Good

We carried out an unannounced unrated inspection of the NHS 111 London Ambulance Service on 6 December 2021. The inspection formed part of a review of urgent and emergency care within the wider healthcare system.

A summary of CQC findings on urgent and emergency care services in North East London.

Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for North East London below:

North East London

Provision of urgent and emergency care in Northeast London was supported by services, stakeholders, commissioners and the local authority. The health and care system in this area is complex, made up of a large number of health and social care providers. We did not inspect all providers within the system and did not inspect any GP services.

We undertook these inspections during the COVID-19 pandemic; the pandemic had put significant pressure on health and social care services and the staff working within them. Despite the challenging circumstances, we found examples of staff working in partnership. For example, there was good engagement between service leaders to understand the impact of demand on different services and to discuss opportunities to signpost patients to services under less pressure. However, system wide collaboration was needed to alleviate the pressure and risks to patient safety identified in the emergency department we inspected.

We were told there were capacity issues, especially in primary care, resulting in delays for patients trying to access urgent care or patients being signposted from 111 to acute services. We were told appointments for out of hours GPs were often unavailable. We observed patients queuing to access both the urgent treatment centre and emergency department and were told patients attended these services due to an inability to access their own GP. This put additional demand on the hospital and caused further delays in patients accessing treatment.

In addition, there had been an increase in the number of 111 calls from patients requiring dental treatment and patients reported a local reduction in dental providers accepting new patients.

There are opportunities for more effective integration between 999 and 111 services. Due to the way 111 and 999 services integrate nationally, the call system for the 999 service was unable to electronically send information to the 111 service if it was decided the caller did not meet the criteria for an ambulance. The caller was asked to redial 111. In contrast, 111 were able to communicate directly with 999 if they felt their caller required an ambulance. Ambulance service leaders in London were fully sighted on a national pilot to improve this issue and hoped this would improve people’s experience of urgent and emergency care, wherever they live.

We inspected one emergency department in North East London and found that local services did not always work together to reduce attendances or the length of stay in the emergency department. This resulted in situations of overcrowding, compromised infection control and extended waits for treatment which impacted on outcomes for patients. The ambulance service had commenced daily calls with system partners to try and reduce ambulance handover delays and to monitor demand across North East London. Leaders from services in North East London acknowledged their responsibility to support the emergency department and are working to implement improvement plans with colleagues from primary care and community services.

We identified an opportunity for more effective collaborative working and communication between an emergency department and the co-located urgent treatment centre resulting to improve people’s experience of accessing urgent and emergency care. Different digital operating systems within these services did not promote effective communication or integration between services and impacted on how services could work collaboratively to deliver safe, effective and timely patient care. These issues resulted in some people being sent from the urgent treatment centre to the emergency department without an effective referral mechanism and meant they experienced further delays whilst in another queue to be assessed. Leaders from a range of services were looking to further integrate services in the area and, in response to our findings, were collaborating to implement new and innovative ways of assessing patients safely and in a timely way.

We found examples of delays in discharge from acute medical care impacting on patient flow across urgent and emergency care pathways. This also resulted in delays in handovers from ambulance crews and prolonged waits in the Emergency Department due to the lack of bed capacity. We also found patients in the emergency department for whom a decision to admit had been made; however, they were still waiting in excess of 24 hours before being transferred to a bed on the ward. These delays exposed people to a risk of harm.

We identified a significant number of patients unable to leave hospital to return to their own home or move into community care. This was due to a number of complex reasons including delays in the provision of care packages due to lack of availability, a lack of residential and/or nursing care beds and because of a shortage of social care staff and the impact of vaccination as a condition of deployment. We were told that Local Authorities were working to increase capacity in social care and that they regularly met with system partners to discuss the provision of urgent and emergency care in London; however, the impact on patient flow through urgent and emergency care pathways remained a significant challenge across North East London. Increased collaboration and support from system partners was required to manage the risk being held in the emergency department we inspected.

This report covers the inspection of the London Ambulance Service’s (LAS) 111 Integrated Urgent Care, Clinical Assessment Service in North East London.

You can find the reports of our previous inspections by selecting the ‘all reports’ link for London Ambulance Service Headquarters on our website at www.cqc.org.uk.

This report comprises information from a combination of:

• What we found when we inspected the provider
• Information from our ongoing monitoring of data about the provider and information from the provider, patients, staff, the public and other organisations.

At this inspection we found:

• The provider had systems to manage risk so that safety incidents were less likely to happen. When they did happen, the provider learned from them and improved their processes. However, some staff reported that they were not always able to routinely read information disseminated so may be unaware of incidents that occurred.
• The provider routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

The provider had an overarching governance framework in place, including policies and

• protocols which had been developed at a provider level and had been adapted to meet the needs of the providers locally.
• Call audits were in place to monitor the performance of staff.
• Staff involved and treated people with compassion, kindness, dignity and respect.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to review call performance data to ensure national targets are being consistently achieved.
• Continue to proactively monitor call demand to ensure staffing levels are appropriate.
• Liaise with the clinical commissioning group to discuss ways to improve the Directory of Services.
• Take steps to improve methods of communication with staff to ensure disseminated information has been reviewed and understood.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Providers and Integrated Care