Case Study

The Welsh Ambulance Services NHS Trust is the national ambulance service to 3 million residents across Wales. The Trust employs more than 3,000 people with a mix of skills, ranging from advanced clinicians, through to a variety of clinical and non-clinical and support staff. We operate from in excess of 100 different bases across Wales, including traditional ambulance stations, shared facilities with other services, clinical contact centres, maintenance, repair and cleaning facilities, administrative and training centres. We are also the host for NHS 111 Wales service, which is an amalgamation of NHS Direct and the front end call handling and clinical triage elements of the GP out-of-hours services.

This last year has been like no other and for us as a public service; the need to effectively listen to people during the pandemic, help them with their concerns about covid-19, invest time in sustaining our relationship with communities and be a visible source of support, comfort and information has been vital.

The pandemic helped nurture a creative and innovative environment to engage online, we acted quickly to deliver information and resources. From the outset we recognised that not everyone was able to access or interpret Government, local public health information; people told us they felt overlooked and invisible, heightening their sense of worry. Acting as the public/patient voice we ensured this was shared across the Trust, Public Health and Welsh Government. Through continuous engagement and surveys we have asked people the impact our response has had with engagement reports being shared with our Quality Committee. This last year has enabled us to reimagine the role and function of patient experience and as we move out of the pandemic we have developed a vision for sustaining a far reaching online channel supported by face-to-face sessions, re-enforced through continuous engagement.

Prior to covid-19 pandemic the Patient Experience & Community Involvement team within the Welsh Ambulance Service had a well-established, very strong continuous engagement model. This model provides a rich, ongoing conversation between the public and the Trust. It creates and nurtures a sustained relationship with the public that stimulates interest, encourages involvement and builds trust needed to achieve service improvement whilst ensuring the delivery of quality services.

Overnight our working practices changed but peoples need for help, advice and information didn’t. We needed to ensure continuity of engagement, access to relevant information and having a point of contact within the organisation for communities. We didn’t want people to feel ‘abandoned’ when the announcement came to stay home, self-isolate and only use the NHS for emergencies. For the public an ‘emergency’ meant many things, we prioritise 999 calls against three categories ‘Red, Amber and Green’.

We heard that people with genuine emergencies were not contacting 999 when they should. This was due to worries about covid; not wanting to put pressure on the NHS and not wanting to go into hospital. For many others they were confused by the messages; they couldn’t access information and struggled with the sense of isolation and loneliness of lockdown.

From previous engagement we anticipated that learning disability; dementia and sensory loss groups in particular would be experiencing the impact of the pandemic harder than most. We wanted to ensure we address this and shared our learning with other teams across the NHS.

The Covid-19 pandemic impacted on the way we engaged and communicated with patients, their families, carers and the wider public. Our continuous engagement model moved online, we continued to talk/listen to communities throughout the year without losing pace.

It quickly became apparent that people with a learning disabilities were feeling frightened and nervous about seeing NHS staff wearing PPE and; for people who were Deaf, PPE was creating a barrier to communication. In helping people understand the need to wear PPE and alleviate any anxieties or fears we created 2 key resources explaining the need for PPE. We developed an animation video explaining the PPE staff wear and presented it in such a way that the community would understand the contents and an easy read information sheet to accompany the video. To improve communication we sourced clear masks and provided information to staff on what they could do to help communication with people who were Deaf.

Throughout the year we worked in partnership with communities in considering their needs and the key messages/information needed and how we would present the information. Requests ranged from immediate, up-to-date covid information; self-help information and access on what we were doing to keep people safe. Influencing factors included the need for translation; managing communications and behavioural practices of the audience; and responding swiftly and meaningfully to those with different language and communication needs.

A number of consistent themes from all communities was that covid-19 meant changing our engagement approach; improving communication and accessibility to information however; four groups in particular were significantly impacted. The following examples show what we achieved during a challenging and unique year:

Learning Disability (LD): we adapted to the new virtual world of communication overnight, we carried on building strong partnership links and maintained those we already had with the community. We continued to communicate and stay connected by facilitating community/group events via virtual platforms ensuring access to information that they wanted in a way that they understood. The LD community were really grateful that their voice and been heard and importantly that we had listened to their fears and decided to take positive steps by developing these resources

Dementia: we quickly moved our engagement to digital platforms where we worked heavily with third sector partners to listen to issues people affected by dementia were faced with. Skills in using online technology was a concern for many and many people were not able to get help, advice and peer support due to this, so writing letters and telephone calls become common place. As well as concern over staff using PPE equipment and this being a barrier to communication for most, another area of difficulty for people living with dementia was their carer not being able to be transported with them into hospital. We carried out a lot of information sharing to let people know what we were doing and alleviate anxieties in advance.

Information for people with sensory loss: Right from the very start of the pandemic we began receiving feedback from the sensory loss community, telling us that they were concerned about communication and accessing all the information they needed about how to keep themselves and their families’ safe during the pandemic. Some told us they felt abandoned as there seemed to be so much important information out there, but none of it was accessible to them. Others also told us that the additional PPE our staff must now wear was creating an extra barrier for them when trying to communicate with us.

We produced our own bespoke information in formats that were accessible to people with a sensory loss. These included a BSL video about what coronavirus is, symptoms to look out for and when to isolate. We produced an accessible video in BSL and with voice over audio that explained PPE and why staff wear it, as well as an accessible video again in BSL and with audio voiceover that encouraged people to download and use the NHS Covid symptom tracker app.

Children: with children being home schooled during the pandemic we were unable to deliver our annual face to face ‘Shoctober – life saving’ sessions in schools across Wales, so, in partnership with Centre of Sign Sight Sound, we developed a trilingual (Welsh, English and British Sign Language) educational animation for foundation phase and Key stage 2 learners. Watched as an assembly, classroom lesson or as part of blended learning, the animation explains when to call 999 by playing a big/little accident quiz and how to do CPR safely while help is on its way (considering Covid safety measures). The animation has been supported by the Welsh Government and hosted on the educational platform Hwb for all learners across Wales to access.

Following discussions with a Clinical Psychologist and a Cardiff Lecturer in Social Development to understand and consider how to influence positive behaviours and encourage children/young people to become resilient members of the community, in partnership with DotC Studios Ltd a bilingual gaming app ‘Blue Light Hub’ was developed. The app hosts four games covering content around familiarisation of uniforms (including the wider NHS and emergency services), what happens when you call 999, appropriate use of 999 and managing expectations regarding Ambulance resources.

The lightly challenging elements allows the player to become familiar with appearances, and take on various roles and challenges taken on by the emergency services. The player is encouraged to return to the hub frequently, developing a familiarity with the theme, further encouraging them to make better choices about how to treat the emergency services, and what to do in difficult situations.

An important question we have kept asking ourselves is ‘So What’? With all this engagement carried, so what effect has it had? So what has been the outcome for people? The challenge with patient experience is that it is often difficult to measure the impact.

What we have demonstrated is that ‘Engaging & Championing the Public’ is not a one off activity but works by being part of an integrated system, in our case, part of a continuous engagement model. We engaged, listened, involved people in developing and disseminating information and captured feedback on how this had been received by communities. The ‘public’ is not one homogenous group but is made up from many characteristics and needs, a one size approach to communication and information does not work and you have to consider the reach and accessibility of information and your organisation.

As part of our Trust wide evaluation of how we responded to the pandemic, we ran a Covid-19 Patient Experience survey. This allowed us to better understand what people thought about the services we delivered, how we continued to engage and the information we produced during the first stages of the pandemic. To enable us to gather feedback from as many people as possible, we also produced an accessible version of the survey in BSL and with audio voiceover.

The impact of the pandemic, the immediacy in which people were affected and the sudden change in our practices have never been experienced before and have shaped and strengthen the way we plan engagement in the future. In the past our approach was very much on the needs, experiences and expectations of a particular group. In looking at the larger picture and how we, as a service, impact on people from an equality perspective means that we no longer engage with groups as a particular characteristic. Instead we look at whether our services, information and systems reflect the needs of all.

• Develop a strong foundation with your communities.
• Invest in time; time to build trusted relationships and get to know their needs, expectations and preferences.
• Always listen and consider the reach and accessibility of your messages, information and organisation