HARTLEY McMASTER Ltd

Evaluation of the Humberside Paramedic Initiative
Final Report

Matthew Sheppee May 2007

Contact Hartley McMaster Ltd Broadway Chambers 1-5 The Broadway St Peters Street St Albans Herts AL1 3LH Tel: 01727 855432 Fax: 01727 848646 Email: consultancy@hmcm.co.uk

Evaluation of the Humberside Paramedic Initiative

DOCUMENT CONTROL
Version 0.1 0.2 Date 5 April 2007 25 May 2007 Author Matthew Sheppee Matthew Sheppee Comments Initial draft for review Second draft for review

ACKNOWLEDGEMENTS
The work reported here would not have been possible without the assistance of a number of people. In particular, we would like to thank those who attended the workshop and provided local performance data. Also, Karen Ravenscroft at the Home Office, for her advice and support throughout the evaluation.

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CONTENTS
1 Introduction..................................................................................................... .......................4 2 Management Summary................................................................................................ ..........5 3 Background................................................................................................................. ...........7 3.1 Alcohol and Violence............................................................................... ........................7 3.2 Paramedic Initiative................................................................................... ......................7 4 Methodology........................................................................................................................... 8 5 Evaluation........................................................................................................ ......................9 5.1 Analysis of Incidents....................................................................................... .................9 5.2 Ambulance Calls.................................................................................................... ..........9 5.3 Police Calls........................................................................................................... .........10 5.4 Ambulance Response Times.............................................................. ...........................11 5.5 Casualties at A&E............................................................................................... ...........13 5.6 Waiting Times at A&E.............................................................................. ......................14 5.7 Violent Incidents at A&E...................................................................... ..........................14 5.8 Prisoners Attending A&E.............................................................................................. ..15 5.9 Staff Safety.................................................................................................... ................15 5.10 Other Outcomes.................................................................................... ......................15 6 Conclusions......................................................................................................................... .17 7 References..................................................................................................................... ......18

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1

INTRODUCTION

The Humberside Paramedic Initiative is a joint initiative between Humberside Police and Yorkshire Ambulance Service (YAS) that teams a paramedic with a police officer to provide an emergency response overnight on Friday and Saturday. Hartley McMaster was commissioned by the Home Office Police and Crime Standards Directorate (PCSD) to establish the effectiveness of the initiative. This evaluation sought to identify the benefits resulting from the initiative and analyse performance data for evidence of these benefits. This report presents the findings of the evaluation and is structured as follows: • • • • • Section 2 provides a management summary of the report; Section 3 summarises the background to the Humberside Paramedic Initiative and this evaluation; Section 4 describes the methodology of the evaluation from both a qualitative and quantitative perspective; Section 5 presents the findings of the benefit identification and statistical analysis; Section 6 summarises and concludes the report.

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2

MANAGEMENT SUMMARY

Humberside Police have been working with Yorkshire Ambulance Service in a joint initiative to respond to calls for medical treatment overnight on Friday and Saturday. Where the call is associated with an increased risk of violence, this emergency response consists of a paramedic teamed with a police officer. Hartley McMaster has undertaken an evaluation on behalf of the Home Office Police and Crime Standards Directorate to establish the effectiveness of the initiative. There were two stages to the evaluation: • • Consultation with local stakeholders to identify the benefits from the initiative; and Statistical analysis of performance data for evidence to support achievement of these benefits.

Although the initiative is limited to Hull, other city centres experience similar problems with alcohol related violence. The findings presented here should help to inform and support the introduction of similar initiatives in other areas. The first stages of the evaluation focused on identifying the outcomes, both positive and negative. The response has been overwhelmingly positive with all those involved having seen significant benefits. These are summarised as follows: • Reduced number of ambulance calls – as a result of the paramedic providing treatment for minor injuries at the scene, there have been fewer occasions where an ambulance is required to transport a patient to Accident and Emergency (A&E); Reduced number of police calls – the paramedic response car is able to attend incidents where a police unit would otherwise be called to support an ambulance crew; Reduced ambulance response times – the reduced number of ambulance calls and reduced time spent on calls where police support is required means that more ambulances are available to respond to emergency calls. This results in improved response times particularly when the demand is high and ambulances would otherwise be dispatched from surrounding stations; Reduced number of casualties at A&E – as a result of the paramedic providing treatment at the scene, the number of patients attending A&E is reduced. Since these are the patients with relatively minor injuries, this gives doctors more time to treat the seriously injured patients; Reduced waiting times at A&E – a consequence of fewer patients attending A&E is that the waiting times are reduced; Reduced number of security incidents at A&E – there have been fewer occasions where hospital security staff are called to deal with disruptive or violent patients; Reduced number of prisoners attending A&E – there have been fewer occasions where police have escorted a prisoner to A&E for medical treatment; and Improved staff safety – the paramedic response car attends those incidents with an increased risk of violence, improving the safety of frontline ambulance and hospital staff.

• • • •

The second stage comprised a statistical analysis of incident and performance data for evidence of these improved outcomes. This showed that an ambulance was required at just over one in every five incidents attended by the paramedic response car, representing 589 saved ambulance call outs. This is reflected in the ambulance performance data for the Hull Primary Care Trust area, which shows a statistically significant improvement in the proportion of Category A calls1 where the response arrives at the scene within 8 minutes. This improvement is despite an
1

Category A calls are those deemed immediately life threatening.

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increase of 10% in the number of Category A incidents when compared to the corresponding period of the previous year. The number of Category A and B calls2 within the 19-minute standard have both increased when compared to the corresponding period of the previous year. This increase is less than that for the total number of incidents resulting in an apparent decrease in performance. However, this deterioration in performance may have been worse without the paramedic initiative. The number of violent incidents reported to hospital security services has decreased. Violent incidents include actual physical violence and verbal abuse but exclude substance abuse, intended self-harm, sexual assault and sexual harassment. The decrease is not statistically significant but includes incidents for all hospitals in the Hull and East Yorkshire NHS Trust. In conclusion, the paramedic initiative appears to have been very successful and this is reflected by plans to purchase a dedicated vehicle and extend the operating hours. The initiative has increased the flexibility of the emergency services when responding to incidents and allows the ambulance, health and police services to better allocate their available resources and improve the level of service they provide.

2

Category B calls are those deemed serious but not immediately life threatening.

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3 3.1

BACKGROUND Alcohol and Violence

Hull city centre, and the surrounding area, contains almost 80 pubs, bars and clubs and these are popular destinations for a night out. With this late night economy comes a culture of binge drinking – drinking with the intention of getting drunk. As a result, the ambulance service expects to receive several emergency calls for alcohol related injuries in the town centre overnight on Fridays and Saturdays. These injuries might result from accidental falls, excessive alcohol consumption or violent assaults. Alcohol is strongly associated with violence. According to the British Crime Survey for 2005/06 (Walker, Kershaw and Nicholas, 2006), offenders were thought to be under the influence of alcohol in 44% of all violent incidents. Furthermore, 47% of violent incidents occur at the weekend, between Friday 6pm and Monday 6am, and 47% of violent incidents occur during the evening between 6pm to midnight. The National Survey of NHS Staff for 2005 (Healthcare Commission, 2006) reports that: • • 11% of staff have experienced physical violence from patients or their relatives in the previous 12 months, rising to 25% for ambulance trusts; and 24% of staff have experienced harassment, bullying or abuse from patients or relatives in the previous 12 months, rising to 43% for ambulance trusts.

Because of the increased risk of violence, the ambulance service is unable to send a singlecrewed paramedic response car to emergency calls on Friday and Saturday nights. This means that a double-crewed ambulance has to be dispatched and the easiest and safest option for the ambulance crew is to transport the patient to A&E even if the injuries are relatively minor. In some case, the ambulance crew will request police support and the ambulance has to wait for a police unit to arrive before attending the incident. Unlike the police service, an ambulance cannot be diverted to a more serious incident once assigned to a call. This means, that if all the ambulances from the Hull Central ambulance station are assigned, ambulances have to be dispatched from the surrounding stations, reducing the available emergency cover in these areas. Patients under the influence of alcohol also cause problems for the A&E department at Hull Royal Infirmary. Prior to the initiative, hospital security staff would regularly call the police to deal with violent incidents and the A&E department was regarded as a hotspot for violent crime.

3.2

Paramedic Initiative

Since April 2006, Humberside Police have been working with the Yorkshire Ambulance Service in a joint initiative to address the problem of responding to emergency calls in the town centre overnight on Friday and Saturdays. The initiative teams a paramedic with a police officer to provide a double-crewed response to emergency calls for medical treatment. On arrival at an incident, the paramedic assesses the situation and can decide to call directly for an ambulance or treat the patient themselves. The paramedic response car operates between the hours of 20:00 and 04:00 every Friday and Saturday night as well as Sunday nights before a Bank Holiday and occasional days such as England football matches. A second paramedic response car has recently been introduced to respond to emergency calls outside the city centre, particularly incidents of domestic violence. The team has also purchased a dedicated vehicle for the city centre with additional cameras and spotlights.

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4

METHODOLOGY

In order to identify the benefits of the initiative, a workshop was held with representatives from the following organisations: • • • • Hull Citysafe; Hull and East Yorkshire Hospitals NHS Trust; Humberside Police Service; and Yorkshire Ambulance Service.

This workshop focused on identifying the outcomes, both positive and negative, for each of the stakeholders. The consultant from the A&E department at Hull Royal Infirmary was invited to the workshop but was unable to attend. After identifying the outcomes, the evaluation analysed current and historical performance data for evidence to support the achievement of these benefits. This statistical analysis used the following sources of data: • Hull and East Yorkshire Hospitals Security Incident Data – this details the number of incidents reported to security for all hospitals in Hull and East Yorkshire including the Hull Royal Infirmary. The data covers the period from January 2005 to December 2006. Humberside Police Service Incident Data – this details the number of requests for assistance received from the ambulance service and the number of incidents responded to at Hull Royal Infirmary. The data covers the period from April 2005 to March 2007. The Tackling Violent Crime (TVC) Database – this database contains details of every incident attended by the paramedic response car from 14 April 2006, when the initiative started, up to 4 March 2007. For each incident, the database records information on the patient, details of the incident and any injuries sustained. Yorkshire Ambulance Service Performance Data – this details all calls received, broken down into the twelve Primary Care Trust (PCT) areas, and the number of incidents within the relevant performance standard. The data covers the period from January 2005 to January 2007.

The following section presents the main findings of the evaluation. The outcomes identified are described together with the analysis undertaken to provide evidence of each benefit.

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5 5.1

EVALUATION Analysis of Incidents

The initiative started in April 2006 and in the period up to March 2007, the paramedic response car has attended 753 incidents. The following graph shows the types of incident and whether these were alcohol related.
300

250 Number of Incidents

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150

100

50

0 Not Known Alcohol Related Unrelated to Alcohol 1

Accidential Injury 88 11

Drug Related 22 14

Excessive Injury due In Custody Alcohol to Assault 258 3 Incident Type 38 9 183 37

Other 38 51

Figure 1 – Summary of Incidents by Incident Type A total of 628 incidents (83% of the total) have been recorded as alcohol related. Of these incidents, accidental injury, excessive alcohol and injury due to assault account for over 84% of alcohol related incidents attended by the paramedic response car. A detailed analysis of incidents is given in Appendix A. Interestingly, 43 of the alcohol related incidents (7% of all alcohol related incidents) attended by the paramedic response car involve people under the age of 18 with the youngest being 13 years old.

5.2

Ambulance Calls

When attending an incident, the paramedic assesses the injuries sustained and decides whether the patient needs to visit A&E. Where the injuries are minor, the paramedic is able to provide treatment at the scene. Even where medical treatment is required, the patient may be able to make their own way to the hospital or attend a local minor injuries clinic the following day. This reduces the number of occasions where an ambulance is required to transport a patient to A&E. The following chart shows the proportion of incidents where the patient visits A&E and the method of transportation in each case.

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Paramedic 12% Own 2%

Not Known 1% Ambulance 22%

No Further Action 63%

Figure 2 – Summary of Incidents by Method of Transportation to A&E An ambulance is required for just 164 incidents (22%) attended by the paramedic response car. Without the paramedic response car, every incident would be attended by an ambulance meaning that ambulance would be unavailable to attend a more serious incident. This means that between April and March 2007, the paramedic response car has saved 589 ambulance call outs. An ambulance call out is estimated to cost between £120 and £150. Combined with the number of saved ambulance call outs, this suggests a saving of over £70,000. However, this has to be offset against the cost of the paramedic response, which costs around £28,000 for a full year, or £25,600 for eleven months. This means that the initiative has made a saving of £45,000 over the eleven-month period. As the ambulance still has to be available, this saving is non-cashable but can be reinvested in providing a better service. As well as a cost saving, the reduced number of ambulance calls results in a time saving. For those calls where an ambulance is not required, the paramedic response car spends an average of 14 minutes at each incident. Unfortunately, it’s not possible to know how long an ambulance would have taken at these incidents. However, anecdotal evidence suggests that ambulances often spend longer than this just queuing at the A&E department.

5.3

Police Calls

The paramedic response car is able to attend incidents where an ambulance crew would have requested police assistance. As well as requiring more resources, this can result in an additional delay waiting for a police unit to arrive. Figure 3 shows the number of requests for police assistance received from the ambulance service between 20:00 and 04:00 each day.

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250

200 Number of Requests

150

100

50

0 2005/06 2006/07

Monday 85 89

Tuesday 81 102

Wednesday 109 88

Thursday 139 129 Day of Week

Friday 226 202

Saturday 210 231

Sunday 111 130

Figure 3 – Number of Requests for Police Assistance from Ambulance Service The number of requests on Friday and Saturday nights has decreased slightly from a total of 436 in 2005/6 to 433 in 2006/7, compared with an increase on other nights from a total of 525 in 2005/6 to 538 in 2006/7. Although this appears to show an improvement, the number of requests on a Saturday has increased by 10% (from 210 to 231). Also, many of the requests for assistance relate to road traffic collisions or sudden deaths and would not be impacted by the initiative. This means that no firm conclusions can be made from this data about the effect of the initiative on the number of requests for police assistance.

5.4

Ambulance Response Times

The paramedic response car is able to respond to emergency calls more quickly than an ambulance. As well as being based in the city centre and covering a limited area, the car does not need to wait for police support before attending an incident. In some cases, a quicker response could potentially save a life. The paramedic car also has access to both the police and ambulance communication channels and can respond proactively to incidents. For example, the police officer might hear about a violent incident. Anticipating the need for medical treatment, the paramedic car can begin driving towards the incident before the police control room contacts the ambulance service to request an ambulance. Furthermore, the reduced number of ambulance calls reduces the likelihood of an ambulance being dispatched from a different station because no ambulances from Hull Central station are available. Case Study The paramedic response car was called to attend a male suffering from a stab wound to the left shoulder blade area. Due to the seriousness of the injury, an ambulance was also called but the paramedic car arrived at the scene first. This was a potentially fatal injury and the paramedic was able to reduce the amount of blood lost by the casualty. Emergency calls to the ambulance service are prioritised to ensure that immediately lifethreatening cases get the quickest response. All calls are classified as one of three categories: • • • Category A – emergencies which are immediately life-threatening; Category B – emergencies which are serious but not immediately life-threatening; or Category C – calls that are not urgent.

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Ambulance services are expected to reach 75% of Category A calls within 8 minutes. Where the initial response is by a paramedic response car, an ambulance is still required to attend the incident within 19 minutes of the call unless hospital treatment is not required. For Category B calls, the Yorkshire Ambulance Service should respond to 95% of incidents within 19 minutes of the emergency call. Between April 2006, when the initiative started, and January 2007, the number of Category A incidents has increased to an average of 1,013 per month. This compares with 921 per month between April 2005 and January 2006. This increase is statistically significant at the 1% level. Figure 4 compares the proportion of these incidents where the response arrives at the scene within 8 minutes with the corresponding month of the previous year. This removes the effect of any seasonality. Between April 2006 and January 2007, the proportion of Category A incidents where the response arrives at the scene within 8 minutes has increased to 86.7% overall. This compares with 84.6% between April 2005 and January 2006. This increase is statistically significant at the 1% level even though the paramedic response car typically operates for only 16 of a total 168 hours each week.
100 90 Proportion of Incidents within 8 minutes 80 70 60 50 40 30 20 10 0 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure 4 – Proportion of Category A Incidents within 8 minutes (Hull PCT) Although this analysis shows a clear improvement in response times, this does not take into account any other changes that may have affected the response times. For example, the proportion of incidents within the 8-minute standard is higher for the three months before the initiative started than for the three months after the initiative started. Figure 5 shows the proportion of Category A incidents within the 8-minute standard for the entire Yorkshire Ambulance Service excluding the Hull PCT area. Over the same period, there has been a slight increase in performance from 71.6% to 71.8%. However, this increase is not statistically significant.

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100 90 Proportion of Incidents within 8 minutes 80 70 60 50 40 30 20 10 0 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure 5 – Proportion of Category A Incidents within 8 minutes (YAS excluding Hull) Since the initiative started, there has been a significant improvement in the proportion of Category A incidents within the 8-minute standard, despite an increase in the number of these incidents. The ambulance service believes that this improvement is a direct result of the introduction of the paramedic initiative. This is supported by the fact that the Yorkshire Ambulance Service area excluding Hull PCT has not seen an equivalent improvement. However, the proportion of Category A and B incidents where an ambulance arrives at the scene within 19 minutes both show a significant decrease in performance since April 2006 when the initiative started. This compares with a significant increase for the Yorkshire Ambulance Service area excluding Hull PCT. Although the performance has decreased, the number of Category A incidents within the 19minute standard has increased by 9.8%, from 920 to 1,010 per month. This increase is less than the 10% increase (from 921 to 1,013 per month) in the total number of Category A incidents, explaining the decrease in performance. Similarly, the number of Category B incidents within the 19-minute standard has increased by 11.2%, from 1,058 to 1,176 per month. This compares with an increase of 11.7% (from 1,078 to 1,205 per month) in the total number of Category B incidents. For the Yorkshire Ambulance Service area excluding Hull, the number of Category B incidents has fallen by 3.5%, contributing to the improved performance for these incidents. A more detailed analysis of ambulance performance can be found in Appendix B.

5.5

Casualties at A&E

The paramedic can provide treatment for minor injuries at the scene of the incident. Some of these people would otherwise visit A&E, either being taken by ambulance or making their own way to the hospital. This means that the number of patients attending A&E is reduced and gives doctors more time to treat patients with serious injuries. As shown in Figure 2, 64% of incidents attended by the paramedic response car did not require hospital treatment. Unfortunately, it’s not possible to know how many of these would have been taken to A&E had they been attended by an ambulance. However, anecdotal evidence suggests that ambulance crews are more likely to decide that a patient requires hospital treatment. This is supported by the performance data for the Hull PCT area, which shows that the proportion of incidents where patients were transferred to hospital has decreased to 75.1% for the period between April 2006 and January 2007. This compares to 79.0% for the period between April 2005 and January 2006.

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5.6

Waiting Times at A&E

The waiting times for treatment at A&E can be up to four hours on a busy Friday or Saturday night. A consequence of reducing the number of patients attending A&E is that these waiting times are reduced.

5.7

Violent Incidents at A&E

Many of the patients attending A&E on a Friday and Saturday nights are under the influence of alcohol. Combined with waiting times of up to four hours, some of these patients become disruptive and even violent, resulting in hospital security staff being called. Between April 2006, when the initiative started, and December 2006 there were 891 incidents involving violence, abuse or harassment where assistance from the hospital security services was requested. This compares with 890 incidents between April 2005 and December 2005. These incidents include actual physical violence or verbal abuse against staff as well as incidents between patients or visitors. Figure 5 compares the number of violent incidents compared with the corresponding quarter of the previous year. Violent incidents exclude substance abuse, intended self-harm, sexual assault and sexual harassment. Between April 2006 and December 2006, the number of violent incidents has decreased to 689. This compares with 743 between April 2005 and December 2005. This decrease is not statistically significant but includes incidents from all hospitals in the Hull and East Yorkshire NHS Trust.
350 300 Number of Violent Incidents 250 200 150 100 50 0 Apr - Jun Jul - Sep Quarter 2005/06 2006/07 Oct - Dec Jan - Mar

Figure C3 – Number of Violent Incidents (All Hospitals) Hospital security services also believe that that the incidents reported by A&E have decreased in severity since the introduction of the paramedic initiative, resulting in fewer occasions where police attendance is requested. Figure 6 shows the number of incidents at Hull Royal Infirmary reported to the police service between 20:00 and 04:00 each day.

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60

50 Number of Incidents

40

30

20

10

0 2005/06 2006/07

Monday 47 41

Tuesday 32 45

Wednesday 35 39

Thursday 45 37 Day of Week

Friday 43 56

Saturday 43 43

Sunday 49 29

Figure 6 – Number of Requests for Police Assistance at Hull Royal Infirmary The number of requests on Friday and Saturday nights has increased from a total of 86 in 2005/6 to 99 in 2006/7, compared with a decrease on other nights from a total of 208 in 2005/6 to 191 in 2006/7. However, incidents relating to anti-social behaviour and violence accounted for less than 20% of requests for police assistance at all times of day from Hull Royal Infirmary in 2006/7. This suggests that, although there are more incidents on Friday and Saturday nights, many of these are likely to be unrelated to drunken or violent behaviour and would not be affected by the introduction of the paramedic initiative.

5.8

Prisoners Attending A&E

An offender arrested and taken into police custody can request medical treatment for any injuries. This requires two police officers to accompany the prisoner to A&E and wait until they are treated, which can take several hours. As a result, these prisoners are often bailed due to lack of available resources and some repeat offenders use this as a tactic to avoid remaining in custody. Under the initiative, the paramedic is able to provide treatment for minor injuries and police time is not spent escorting these prisoners to the hospital. Between April and March 2006, the paramedic response car has attended 47 patients in custody. Of these, 79% did not require any hospital treatment. Since these incidents were considered serious enough to require assessment by a paramedic, these patients would otherwise have been bailed or accompanied to A&E.

5.9

Staff Safety

A key outcome of the initiative has been an improvement in staff safety. The paramedic response car attends those incidents with an increased risk of violence in preference to an ambulance, reducing the risk to the ambulance crews. Meanwhile, the paramedic is accompanied by a police officer who is trained to assess and deal with these potentially violent situations. The safety of frontline staff at A&E has also improved, as demonstrated by the reduced number and severity of incidents where hospital security staff are called.

5.10 Other Outcomes
The initiative has resulted in a number of other benefits in addition to those already discussed. These include: • An emergency vehicle based in the city centre acts as a deterrent to potential offenders as the chance of being seen increases. Also, the paramedic response car can monitor an area for trouble when not attending an incident.

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Some of the incidents attended by the paramedic car have involved underage drinkers. Where these incidents are associated with licensed premises, details of the incidents are passed to the licensing department, providing additional evidence to support any objection to a license renewal. This is only possible because the data is collected by the police officer rather than collected by the ambulance service and then shared with the police. With a police officer and a paramedic, the team can respond to incidents differently. For example, police officers are trained in entering properties by force where no answer is obtained from an address.

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CONCLUSIONS

The Humberside paramedic initiative has been running for just under a year and all those involved have seen significant benefits. The initiative is regarded as a successful example of partnership working by the police, ambulance and health services. As a result, the initiative is in the process of buying a dedicated vehicle and extending the hours of operation to selected weekday nights with a particular focus on incidents of domestic violence. The evaluation has identified positive outcomes for all the organisations involved with no significant negative outcomes. These benefits are summarised in the following table. ServiceAmbulance         Table 1 – Summary of Benefits by Stakeholder Between April 2006 and March 2007, an ambulance has been required at one in five incidents attended by the paramedic response car, representing 589 saved ambulance call outs. This is reflected in the proportion of incidents where patients are transferred to hospital, which shows a significant decrease since the initiative started compared to the corresponding period of the previous year. Analysis of the ambulance response data shows a significant improvement in the proportion of Category A incidents where the response arrives at the scene within 8 minutes, despite an increase in the number of these incidents. This compares with a slight, but not statistically significant, increase for the rest of the Yorkshire Ambulance Service. The proportion of Category A and B incidents within the 19-minute standard both show a significant decrease compared to a significant increase for the rest of the Yorkshire Ambulance Service. However, there has been a significant increase in the total number of these incidents compared to the corresponding period of the previous year. Further analysis of response data at a more detailed level is required to make any detailed conclusions about the effect of the initiative against these performance measures. The data recorded by the hospital security services shows a significant decrease in the proportion of violent incidents reported. This compares with no changes in the overall number of incidents relating involving violence, abuse or harassment. However, analysis of police incident data is inconclusive because of the difficulty in separating those calls for assistance arising from a risk of violence from those for other reasons such as road traffic accidents. The initiative has enabled the emergency services to improve the level of service they provide. This is a potential benefit to every member of the public who is unfortunate enough to require emergency medical treatment.   Health Service 17 Police Service Reduced number of ambulance calls Reduced number of police calls Reduced ambulance response times Reduced number of casualties at A&E Reduced waiting times at A&E Reduced number of security incidents at A&E Reduced number of prisoners attending A&E Improved staff safety Hartley McMaster Ltd.

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REFERENCES

Healthcare Commission (2006), National Survey of NHS Staff 2005. Walker, A., Kershaw, C. and Nicholas, S. (2006), Crime in England & Wales 2005/06. Home Office Statistical Bulletin 12/06.

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APPENDIX A – ANALYSIS OF INCIDENTS
The paramedic and police officer record details of every incident attended by the paramedic response car. These include information on the patient, any injuries sustained and whether hospital treatment was required. These details are then transcribed into the Tackling Violent Crime (TVC) database. Between April 2006, when the initiative started, and March 2007, the paramedic response car has attended 753 incidents. Of these, 628 or 83% have been recorded as alcohol related. The following graphs show the breakdown of incidents by: • • • • • • • • Age of Patient Gender of Patient Call Type Location of Incident Time of Incident Incident Type Method of Transportation Time Spent on Call
400 350 300 Number of Incidents 250 200 150 100 50 0 Alcohol Related Unrelated to Alcohol

Under 18 43 19

18 - 26 344 45

27 - 45 190 47 Age Group

Over 45 47 13

Not Known 4 1

Figure A1 – Summary of Incidents by Age Group This shows that almost 55% of alcohol related incidents involve people between the ages of 18 and 26. Also, almost 7% of alcohol related incidents attended by the paramedic response car involve people under the age of 18.

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450 400 350 Number of Incidents 300 250 200 150 100 50 0 Alcohol Related Unrelated to Alcohol Female 217 45 Gender of Patient Male 411 80

Figure A2 – Summary of Incidents by Gender This shows that the almost 2 in 3 incidents attended be the paramedic response car involve male patients, regardless of whether the incident is alcohol related or not.
350 300 250 200 150 100 50 0 Alcohol Related Unrelated to Alcohol

Number of Incidents

999 312 72

Police 315 52 Call Type

Not Known 1 1

Figure A3 – Summary of Incidents by Call Type Calls are received either from the public dialling 999 for an ambulance or from the police control room. The incidents attending by the response car are equally split between these two types of call, although a lower proportion of incidents (42%) unrelated to alcohol are received directly from the police.

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400 350 300 Number of Incidents 250 200 150 100 50 0 Alcohol Related Unrelated to Alcohol

Zone 1 379 56

Zone 2 80 24

Zone 3 58 14

Zone 4 27 6

Zone 5 83 25

Not Known 1

Location of Incident

Figure A4 – Summary of Incidents by Location The location of each incident is recorded as one of five zones: Zone 1 covers the city centre, Zone 2 covers the area north-east of the city centre; Zone 3 covers the area to the east; Zone 4 covers the area to the north-west and Zone 5 covers the area to the west. The majority of incidents (58%) take place in the city centre, which is the main area covered by the response car.
300

250 Number of Incidents

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150

100

50

0 Before 22:00hrs Alcohol Related Unrelated to Alcohol 92 27

22:00hrs 00:00hrs 168 36

00:00hrs 02:00hrs 248 35 Time of Incident

After 02:00hrs 112 20

Not Known 8 7

Figure A5 – Summary of Incidents by Time of Day This shows that almost 40% of alcohol related incidents occur between the hours of midnight and 2:00am.

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300

250 Number of Incidents

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150

100

50

0

Accidential Injury 88 11

Drug Related 22 14

Excessive Injury due In Custody Alcohol to Assault 258 3 38 9 Incident Type 183 37

Other 38 51

Not Known 1

Alcohol Related Unrelated to Alcohol

Figure A6 – Summary of Incidents by Incident Type Accidental injury, excessive alcohol and injury due to assault account for over 84% of alcohol related incidents attended by the paramedic response car, compared to just 40% for other incidents. Interestingly, the incident type has been recorded as excessive alcohol for three incidents that are also recorded as unrelated to alcohol. This is almost certainly an error with the data recording.
450 400 350 Number of Incidents 300 250 200 150 100 50 0 Ambulance Alcohol Related Unrelated to Alcohol 124 40 No Further Action 422 58

Own 10 5

Paramedic 68 21

Not Known 4 1

Method of Transportation

Figure A7 – Summary of Incidents by Method of Transportation Two in every three (67%) alcohol related incidents attended by the paramedic response car result in no further action.

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200 180 160 Number of Incidents 140 120 100 80 60 40 20 0 Less than 5 137 19 More than 30 34 18 Not Known 7 1

6 to 10 190 23

11 to 15 99 26

16 to 20 93 23

21 to 25 39 10

26 to 30 29 5

Alcohol Related Unrelated to Alcohol

Time Spent on Call (mins)

Figure A8 – Summary of Incidents by Time Spent The response car spends less than 10 minutes at over half (54%) of alcohol related incidents. This compares with 33% of incidents unrelated to alcohol.

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APPENDIX B – ANALYSIS OF RESPONSE DATA B.1 Introduction
Emergency calls to the ambulance service are prioritised to ensure that life-threatening incidents get the quickest response. All calls are classified as one of three categories: • • • Category A – emergencies which are immediately life-threatening; Category B – emergencies which are serious but not immediately life-threatening; or Category C – calls that are not urgent.

Ambulance services are expected to reach 75% of Category A calls within 8 minutes. An emergency response by a rapid response vehicle, other than an ambulance, counts towards the 8-minute target. However, a fully equipped emergency vehicle able to transport the patient is required to attend the incident within 14/19 minutes unless hospital treatment is not required. For Category B calls, urban services should respond to 95% of incidents within 14 minutes and rural services within 19 minutes. The response data covers all calls received by the Yorkshire Ambulance Service (YAS), broken down into the twelve Primary Care Trust (PCT) areas, over the period from January 2005 to January 2007. The first three months, from January 2005 to March 2005, have been excluded from the analysis because of changes to the categorisation of calls introduced in April 2005. The analysis could be improved by looking at the performance data for individual shifts where the paramedic response car is operating. However, this level of detail was unavailable for this evaluation.

B.2 Category A Incidents
The following graph compares the number of Category A incidents in the Hull PCT area since the initiative started in April 2006 with the corresponding month of the previous year. This removes the effect of any seasonality in the number of incidents.
1,400

1,200 Number of Catefory A Incidents

1,000

800

600

400

200

0 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure B1 – Number of Category A Incidents (Hull PCT) This shows that the number of incidents has increased to 1,013 per month, compared to 921 per month for the corresponding period of the previous year. This increase is statistically significant at the 1% level. Figure B2 shows the proportion of Category A incidents where the response arrives at the scene within 8 minutes compared with the corresponding month of the previous year.

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100 90 Proportion of Incidents within 8 minutes 80 70 60 50 40 30 20 10 0 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure B2 – Proportion of Category A Incidents within 8 minutes (Hull PCT) Since the initiative started in April 2006, the proportion of incidents within the 8-minute standard has increased to 86.7%, compared to 84.6% for the corresponding period of the previous year. This increase is statistically significant at the 1% level. Figure B3 shows the equivalent performance for the Yorkshire Ambulance Service excluding the Hull PCT area. This only includes response data up to December 2006 as data for January 2007 was not available from all areas.
100 90 Proportion of Incidents within 8 minutes 80 70 60 50 40 30 20 10 0 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure B3 – Proportion of Category A Incidents within 8 minutes (YAS excluding Hull PCT) The proportion of incidents within the 8-minute standard has increased slightly from 71.6% to 71.8%, although this increase is not statistically significant. Figure B4 shows the proportion of Category A incidents where an ambulance arrives at the scene within 19 minutes.

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Evaluation of the Humberside Paramedic Initiative

100 Proportion of Incidents within 19 minutes 99 98 97 96 95 94 93 92 91 90 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure B4 – Proportion of Category A Incidents within 19 minutes (Hull PCT) Since the initiative started in April 2006, the proportion of incidents within the 19-minute standard has decreased to 99.7%, compared to 99.9% for the corresponding period of the previous year. This decrease is statistically significant at the 1% level. However, the number of incidents within the 19-minute standard has increased to 1,010 per month, compared to 920 per month for the corresponding period of the previous year. This increase of 9.8% is less than the 10% increase (from 921 per month to 1,013 per month) in the total number of Category A incidents, explaining the apparent decrease in performance. Figure B3 shows the equivalent performance for the Yorkshire Ambulance Service excluding the Hull PCT area. As previously, this only includes response data up to December 2006 as data for January 2007 was not available from all areas.
100 Proportion of Incidents within 19 minutes 99 98 97 96 95 94 93 92 91 90 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure B5 – Proportion of Category A Incidents within 19 minutes (YAS excluding Hull PCT) The proportion of incidents within the 19-minute standard has increased from 93.1% to 97.6%. This increase is statistically significant at the 1% level. The number of Category A incidents has risen by 7.0%, from 11,207 to 11,996 per month, but the number of Category A incidents within the 19-minute standard has risen by 12.7%, from 10,432 to 11,706 per month.

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Evaluation of the Humberside Paramedic Initiative

B.3 Category B Incidents
The following graph compares the number of Category B incidents in the Hull PCT area since the initiative started in April 2006 with the corresponding month of the previous year.
1,400

1,200 Number of Category B Incidents

1,000

800

600

400

200

0 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure B6– Number of Category B Incidents (Hull PCT) This shows that the number of incidents has increased from the previous year in every month. This increase is statistically significant at the 1% level. Figure B7 shows the proportion of Category B incidents where the response arrives at the scene within 19 minutes compared with the corresponding month of the previous year.
100 Proportion of Incidents within 19 minutes 99 98 97 96 95 94 93 92 91 90 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure B7 – Proportion of Category B Incidents within 19 minutes (Hull PCT) Since the initiative started in April 2006, the proportion of incidents within the 19-minute standard has decreased to 97.6%, compared to 98.1% for the corresponding period of the previous year. This decrease is statistically significant at the 1% level. However, the number of incidents within the 19-minute standard has increased to 1,176 per month, compared to 1,058 per month for the corresponding period of the previous year. This increase of 11.2% is less than the 11.7% increase (from 1,078 to 1,205 per month) for the total number of Category B incidents.

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Figure B8 shows the equivalent performance for the Yorkshire Ambulance Service excluding the Hull PCT area. As previously, this only includes response data up to December 2006 as data for January 2007 was not available from all areas.
100 98 Proportion of Incidents witin 19 minutes 96 94 92 90 88 86 84 82 80 Apr May Jun Jul Aug Sep 2005/06 Oct Nov Dec Jan Feb Mar 2006/07

Figure B8 – Proportion of Category B Incidents within 19 minutes (YAS excluding Hull PCT) The proportion of incidents within the 19-minute standard has increased from 87.1% to 91.9%. This increase is statistically significant at the 1% level. However, the number of Category B incidents has fallen by 3.5%, from 13,575 to 13,099 per month, contributing to the increase in performance.

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APPENDIX C – HOSPITAL SECURITY INCIDENTS
The security department for the Hull and East Yorkshire Hospitals NHS Trust records details of every incident where assistance from hospital security services is requested. These incidents are categorised into two types: • • Security incidents such as theft, loss or damage to property; Incidents involving violence, abuse or harassment – this includes actual physical violence and threat of physical violence as well as verbal abuse.

The following graph compares the number of incidents related to violence, abuse or harassment for all sites since the initiative started in April 2006 with the corresponding quarter of the previous year.
400 350 300 Number of Incidents 250 200 150 100 50 0 2005/06 2006/07

Apr - Jun 359 285

Jul - Sep 341 313 Quarter

Oct - Dec 190 293

Jan - Mar 172

Figure C1 – Number of Incidents Involving Violence, Abuse or Harassment (All Hospitals) This shows that there were 890 incidents between April 2005 and December 2006 compared to 891 incidents between April 2006 and December 2006. Of these 891 incidents, almost 27% (239 incidents) were reported from the Accident and Emergency department at Hull Royal Infirmary. Figure C2 shows the proportion of these incidents in which staff were affected.

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82% Proportion of Incidents where Staff Affected 80% 78% 76% 74% 72% 70% 68% 66% 64% Apr - Jun Jul - Sep Quarter 2005/06 2006/07 Oct - Dec Jan - Mar

Figure C2 – Proportion of Incidents Involving Violence, Abuse or Harassment where Staff were Affected (All Hospitals) Since the initiative started in April 2006, the proportion of incidents where staff were affected has decreased to 73.1%, compared to 73.9% for the corresponding period of the previous year. However, this decrease is not statistically significant. Figure C3 shows the number of violent incidents compared with the corresponding quarter of the previous year. This excludes incidents of substance abuse, intended self-harm, sexual assault and sexual harassment.
350 300 Number of Violent Incidents 250 200 150 100 50 0 Apr - Jun Jul - Sep Quarter 2005/06 2006/07 Oct - Dec Jan - Mar

Figure C3 – Number of Violent Incidents (All Hospitals) The total number of violent incidents has decreased from 743 between April 2005 and December 2005 to 689 between April 2006 and December 2006. However, this decrease is not statistically significant.

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