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G U I D A N C Egrey

The Ambulance Service Association
Clinical Governance Working Group  

Clinical Governance in the NHS ambulance service
Reference Pack

CONTENTS

Published by the Ambulance Service Association National Clinical Effectiveness Project
FEBRUARY 2000 - VERSION 1a - ASA/NCEP/CG02

CONTENTS
INTRODUCTION
EXECUTIVE SUMMARY
LIST OF CONTRIBUTORS
GLOSSARY
COMPONENTS OF CLINICAL GOVERNANCE
- PREFACE - What they mean to ambulance services
- INTERPRETED FOR USE IN UK AMBULANCE SERVICES
(Clinical Governance Components presentation)
APPENDICES
LIST OF REFERENCE MATERIAL
1. Terms of Reference
2. Trust Clinical Governance Leads
3. Trust Clinical Audit/ Effectiveness Leads
4. Regional Office Contacts
5. Reference Material for Clinical Governance
6. Internet links relevant to Clinical Governance
7. AMBEX 2000 - Towards Perfect Vision 2000-2010
8. Clinical Excellence 99 - Spreading Good Practice
9. Related Products
10. Suggested content for Annual Report
11. Presentations relevant to Clinical Governance
a) Clinical Governance - Year 1 (SYMAS)
b) Clinical Governance in North Thames (NHSE London)
c) Clinical Effectiveness & Patient Information (ASA)
d) Clinical Governance Guidance Document (ASA)
e) Clinical Governance Components (ASA)
12. NHS Clinical Governance Support Team
13. ASA/JCALC Minimum Data Set
14. Development Plans for Clinical Governance
15. Model linking development plans to NSF on CHD

This list will be updated as new material is added to the reference pack and will be distributed by ASA Clinical Effectiveness Project.
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INTRODUCTION
A Proposed Strategy for the Implementation of Clinical Governance into the NHS Ambulance Services
ASA Guidance on Clinical Governance

At the October 1998 meeting of the ASA Executive, it was agreed that a special working group should be formed to produce a guidance document on Clinical Governance for the members of the ASA.

Following the outcome of several initiatives, the first meeting of this group was held on 4 June 1999. It was recognised there was a need for the co-ordination of initiatives regarding Clinical Governance, with a focus on the provision of education and information materials for use by all UK ambulance services. This document is presented as a source of guidance and reference for any Trust formulating their Clinical Governance strategy.

It was agreed that the term Clinical Governance should be interpreted as meaning -

"A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish"

as laid down in the NHS Documents 'A First Class Service Quality in the NHS' (DoH, 1998), and 'Clinical Governance - Quality in the new NHS' (DoH, 1999).

Future additions and amendments to this document will be managed through the joint ASA/JCALC Clinical Effectiveness Committee to avoid duplication and centralise on-going work.

All the contents of the pack are also available on disk for ease of use, and are held centrally by the ASA Clinical Effectiveness Project, which will continually update and maintain the reference material in light of further developments. This document is also available on the official ASA website.

This reference pack is very much version one of an on-going development. As further guidance is issued or initiatives are undertaken and shared, subsequent versions will assist in answering any new questions posed. It will be an interactive document with ambulance services feeding in to its' resources as well as taking from and using them.

So if you have anything of interest you wish to share with others relating to Clinical Governance or any of its components, please feel free to contribute to the evolving reference pack by contacting the ASA Clinical Effectiveness Project Manager, Stuart Nicholls Tel/Fax 01622 664929, e-mail: [email protected]
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EXECUTIVE SUMMARY
A Proposed Strategy for the Implementation of Clinical Governance into the NHS Ambulance Services

CLINCAL GOVERNANCE - A definition

"A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish"

This document is a reference source for use by all UK ambulance services. In this, version 1 of the document the foundations for good practice in Clinical Governance are laid down.

All the key components of Clinical Governance have been presented in a way that makes them specifically relevant to NHS ambulance services. Also for each of these components a list of suggested material for supporting evidence is included.

The appendices then form a compendium of current practice in Clinical Governance amongst UK ambulance services whom have contributed thus far, including useful contacts and other relevant material.

It is intended that these foundations will assist in compiling information required for the baseline assessment of capability for Clinical Governance which all trusts are required to undertake by the end of September 1999.

This document will then become of even more use when further contributions are made so that Version 2 of the document can show the various approaches being taken amongst UK ambulance services in formulating their action plans in response to the baseline assessment.

This will truly allow for sharing of best practice as we all seek to improve the quality of care provided by our service.

It is anticipated that Version 2 of the guidance document will build on ambulance services sharing their experiences with Clinical Governance, highlighting in an open and honest way the relative strengths and weaknesses of capability and capacity drawn out by the baseline assessments. This will enable sharing of best practice to the benefit of all ambulance services. Information can then be fed back centrally to ensure that the specific and complex requirements of ambulance services are represented in future Department of Health guidance.

The real power of this document and subsequent versions lies in the openness and honesty of contributions.

PLEASE CONTRIBUTE

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LIST OF CONTRIBUTORS
This document was put together on behalf of the ASA Executive Group by the special Clinical Governance Working Group.
This working group consisted of:

Mr Paul Leopold, Chairman, West Midlands Ambulance Service NHS Trust
Mr David Griffiths, Chief Executive, Sussex Ambulance Service NHS Trust
Dr Chris Carney, Chief Executive, Beds. & Herts. Ambulance Service NHS Trust
Mr Noel Wade, Director of Outpatient Services, South Yorkshire Metropolitan Paramedic & Ambulance Service NHS Trust.
Mrs Judy Duck, Quality Manager, Essex Ambulance Service NHS Trust
Mr Steve Edwards, Clinical Effectiveness Manager, West Midlands Ambulance Service NHS Trust
Mr Stuart Nicholls, ASA Clinical Effectiveness Project Manager
Mr Steve Spurling, Director of Operations, Tees, East & North Yorkshire Ambulance Service NHS Trust

Following a very useful and constructive meeting in June members of the group were tasked with producing this document. Thanks must go to the following who contributed fully to the production of this document, with thanks also going to their respective secretarial/ administrative support:

Mr Noel Wade, Director of Outpatient Services, SYMAS
Mr Steve Edwards, Clinical Effectiveness Manager, WMAS
Mr Stuart Nicholls, ASA Clinical Effectiveness Project Manager

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GLOSSARY

ASA
Ambulance Service Association. The voice of NHS ambulance services.

Caldicott Report Review of Patient Identifiable Information with recommendations on appropriate safeguards to govern access to and storage of confidential patient information.

Calman-Hine Report
A Policy Framework for Commissioning Cancer Services which recommended that cancer services be organised at three levels: primary care; Cancer Units in local hospitals to manage commoner cancers; and Cancer Centres in larger hospitals to manage less common cancers and provide support services for Cancer Units.

Clinical Audit
A clinically-led initiative which seeks to improve the quality and outcome of patient care against agreed explicit standards.

Clinical Effectiveness
A process of clinical quality improvement incorporating clinical audit, evidence based practice and research.

Clinical Governance
A framework through which NHS organisations are accountable for continuously improving the quality of their services.

Clinician
Those directly involved in the care and treatment of patients, including doctors, dentists, nurses, midwives, health visitors, pharmacists, opticians, chiropodists, radiographers, orthoptists, physiotherapists, dieticians, occupational therapists, medical laboratory scientific officers, orthotists and prosthetists, therapists, speech and language therapists and all other health professionals.

Commission for Health Improvement (CHImP)
A new national body to support and oversee the quality of clinical governance and of clinical services.

Community Health Councils
Independent statutory bodies which represent the interests of the public in the health service in their area.

Continuing Professional Development (CPD)
See Lifelong learning below.

Corporate Governance
A framework through which NHS organisations are accountable for the standards in conducting corporate business including meeting statutory financial duties.

CHD
Coronary Heart Disease

Health Improvement Programmes (HImP's)
An action programme to improve health and healthcare locally. Led by the Health Authority, they will involve NHS Trusts, Primary Care Groups and other primary care professionals working in partnership with the local authorities and engaging other local interests.

Health Professional
See clinician.

Hospital and Community Health Services
The main elements of these are the provision of hospital services and certain community health services (for example, district nursing) mainly provided by NHS Trusts.

JRCALC
Joint Royal Colleges Ambulance Liaison Committee.

Lifelong Learning
A process of continuing development for all individuals and teams which meets the needs of patients and delivers the healthcare outcomes and healthcare priorities of the NHS and which enables professionals to expand and fulfil their potential.

Medical Devices Agency
Assesses the safety and performance of healthcare products.

Medicines Control Agency
Licenses medicines on the basis of safety, quality and efficacy.

National Confidential Enquiries
The four National Enquiries look at clinical performance to help develop clinical standards. These are Perioperative Deaths (CEPOD), Stillbirths and Deaths in Infancy (CESDI), Maternal Deaths (CEMD) and Suicide and Homicide by People with Mental Illness (CISH).

National Framework for Assessing Performance
The Performance Framework is designed to give a rounded picture of NHS performance and will cover six areas: health improvement; fair access to services; effective delivery of appropriate healthcare; efficiency; patient/carer experience; and health outcomes of NHS care.

National Institute for Clinical Excellence (NICE)
A new Special Health Authority (see below) to be established to promote clinical and cost-effectiveness.

National Service Frameworks (NSF's)
Evidence-based National Service Frameworks setting out what patients can expect to receive from the NHS in major care areas or disease groups.

National Survey of Patient and User Experience
A new annual National Survey on what patients feel about the care offered by the NHS. The first survey will take place in 1998.

NHS Executive
The NHS Executive is part of the Department of Health, with offices in London and Leeds and eight Regional Offices across the country. It supports Ministers and provides leadership and a range of central management functions to the NHS.

NHS Information Strategy
A strategy to harness the enormous potential benefits of IT to support the drive for quality and efficiency in the NHS. To be issued in Summer 1998.

NHS Organisations
This includes non-ambulance service NHS Trusts, Primary Care Groups, Health Authorities, and any health providing NHS Trust.

NHS Trusts
Public bodies providing NHS hospital and community health care, including NHS ambulance services. See Trusts below.

Personal Development Plan (PDP)
Developed by individual health professionals as part of lifelong learning.

Primary Care
Family health services provided by family doctors, dentists, pharmacists, nurses, midwives, health visitors, optometrists and opthalmic medical practitioners.

Primary Care Groups
New Groups announced in the New NHS which bring together family doctors and community nurses. These Groups will have the opportunity to become Primary Care Trusts.

Primary Care Trusts
A new form of Trust for Primary Care Groups who wish to be free-standing are capable of being so.

Professional Self-Regulation
Standards set by national professional regulatory bodies (for example, the General Medical Council) for professional practice, conduct and discipline.

Regional Offices
See NHS Executive.

Secondary Care
Specialist care typically provided in a hospital setting or following referral from a primary care or community health professional.

Special Health Authority
Health Authorities with unique national or supra-regional functions which cannot be effectively undertaken by other kinds of NHS bodies (for example, NICE, the prescription Pricing Authority).

Trust
For the context of this document Trust refers to an ambulance service NHS Trust.

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COMPONENTS OF CLINICAL GOVERNANCE
What they mean to ambulance services
Preface
The Department of Health documents 'A First Class Service - quality in the new NHS' and 'Clinical Governance - quality in the new NHS' spell out the quality strategy for the NHS for the next ten years. At the heart of these initiatives is Clinical Governance as depicted in the diagram below.

Clinical Governance affects all NHS trusts including ambulance services who need to implement the guidance published within the above documents. Clinical Governance will impact on all parts of NHS Ambulance Trust from the Trust Board, all Directorates, and every member of staff concerned with providing patient care or support services.

Clinical Governance ensures both the organisation as a whole and it's individuals are accountable for the clinical quality of the service. Ultimately the Chief Executive is accountable for implementing and achieving Clinical Governance but through professional self regulation each member of staff is also accountable for the quality of the service they provide.

Here we have taken each of the components for measuring and achieving Clinical Governance and have shown how they apply to UK NHS ambulance services specifically.

This will be useful in identifying what is required to complete the baseline assessment of capacity and capability and will form the foundation for developing the subsequent action plans. It will also assist in identifying what is required for the first Clinical Governance annual reports due at the end of this year in April 2000.

Version 2 of this guidance document will share these action plans and identify best practice for each of the components outlined here. Again through your contributions it should be a very useful document assisting in improving the quality of patient care provided by ambulance services.

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Follow one of these links to see the Components of Clinical Governance interpreted for ambulance services
Microsoft Powerpoint Presentation
HTML version

APPENDIX 1
TERMS OF REFERENCE
CLINICAL GOVERNANCE GROUPS/ BOARD SUB-COMMITTEES

List of Trust's included
South Yorkshire Metropolitan Ambulance Service NHS Trust
Essex Ambulance Service NHS Trust
West Midlands Ambulance Service NHS Trust

Others available from the ASA Clinical Effectiveness Project:
London Ambulance Service NHS Trust
Lincolnshire Ambulance Service NHS Trust
Bedfordshire & Hertfordshire Ambulance Service NHS Trust
Tees, East and North Yorkshire Ambulance Service NHS Trust
Twoshires Ambulance Service NHS Trust
Warwickshire Ambulance Service NHS Trust
WestCountry Ambulance Service NHS Trust
Kent Ambulance NHS Trust
Lancashire Ambulance Service NHS Trust

Note:
Below is a list of Trust's who did not have explicit terms of reference for their Clinical Governance groups/ board sub-committees but did submit other information relating to Clinical Governance to be shared. Details are available from the ASA National Clinical Effectiveness Project.

Northern Ireland Ambulance Service
Oxfordshire Ambulance NHS Trust
Hereford & Worcester Ambulance Service NHS Trust
East Anglia Ambulance NHS Trust
Staffordshire Ambulance Service NHS Trust
North East Ambulance Service NHS Trust

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SOUTH YORKSHIRE METROPOLITAN AMBULANCE SERVICE NHS TRUST
Terms of Reference of the Clinical Governance Committee

1. Functions
The duties of the Committee shall be to review, monitor, make recommendations and oversee the implementation of policies in respect of the following activities of the Trust.

1.1 The lines of responsibility and accountability for the overall quality of clinical care offered by the Trust.

2. The programme of quality improvement activity, including:

2.1 Internal clinical programmes and any external audit programmes.

2.2 The implementation of the National Service Framework (NSF's), the National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI) recommendations.

2.3 Workforce planning and development, including the recruitment, regular review and retention of an appropriately trained workforce.

2.4 Continued professional development, including the recruitment, regular review and retention of an appropriately trained workforce.

2.5 Continuing professional development programmes, including education and training, to meet the development needs of individual members of the workforce and the service needs of the Trust.

2.6 The Paramedic Steering Committee.

2.7 Procedures to monitor clinical care and the maintenance of high quality systems for clinical records and other relevant information.

2.8 The integration of clinical care quality controls of the Trust generally.

3. Policies directed to the management of risks, including:

3.1 Controls assurance programmes.

3.2 Clinical risk assessment programmes.

4. Procedures to identify and remedy poor performance with sufficient post-incident analysis particularly the following:

4.1 Adverse incident reports.

4.2 Complaints procedures.

4.3 Individual, team and departmental performance.

4.4 Procedures to encourage staff to report concerns about the professional conduct and/or performance of colleagues pursuant to Board guidelines.

5. To ensure that the Board receives reliable and timely management information concerning clinical governance.

6. To initiate special projects or investigations on any matter within the above terms of reference.

May 1999. Version 1.

SOUTH YORKSHIRE METROPOLITAN AMBULANCE SERVICE NHS TRUST
Terms of Reference of the Clinical Governance Committee

Constitution: The Board has established a Clinical Governance Committee (The Committee).

Membership: The Committee shall be appointed by the Board from among the non-executive directors of the Trust, the Director of Accident and Emergency Services, Out-patient Services, Corporate Development and Human Resources and a lead clinician (normally 7 members). A Quorum shall be 4 members, two of whom must be non-executive directors.

Attendance: The Clinical Audit Manager shall normally attend meetings. In addition, the duly appointed representatives of the Community Health Councils serving South Yorkshire shall be invited to attend at least one meeting a year.
The Committee may wish to meet without others in attendance and may wish to invite others to attend.

Frequency: Meetings shall be held not less than 4 times a year.

Authority: The Committee is authorised by the Board to investigate any activity within its terms of reference. It is authorised to seek any information it requires from an employee and all employees are directed to co-operate with any request made by the Committee.
The Committee is authorised by the Board to obtain outside legal or other independent professional advice and to secure the attendance of such others with relevant experience and expertise as it considers necessary.

Administration: A summary of the Clinical Governance Committee minutes shall be submitted to the Board at regular intervals and shall form part of the formal agenda for the appropriate Board meeting.
The Clinical Governance Committee shall produce an annual report to the Board setting out its activities for the year and reporting on any significant matters.

May 1999. Version 1.

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ESSEX AMBULANCE SERVICE NHS TRUST
Terms of Reference of the Clinical Governance

1. Establishing Leadership, Accountability and Working Arrangements.
1.1 By April 1999 to identify a lead clinician, provide regular reports to the Chief Executive to account for progress and appoint a sub committee of the Board representing a balance of skills and interests to oversee clinical governance.

1.2 The Trust currently has a part time Medical Advisor who is also the Chairman of the Paramedic Steering Committee. At the present time the Quality Manager - a senior nurse has responsibility for the clinical lead.

1.3 The Local Ambulance Paramedic Steering Committee is now constituted as a sub-committee of the Board and linked by the Director of Operations and the Medical Advisor.

1.4 A bi-annual review of clinical and quality issues is undertaken and whilst this has worked well in the past the Board as a whole may feel they now need more frequent reporting arrangements in light of the recommendations.

2. Baseline assessment of Capability and Capacity
2.1 The Trust has a robust quality and clinical audit programme which measures the strengths and weaknesses of the quality of clinical care. Continuing accreditation to BS EN ISO 9002 ensures quality of the overall system.

2.2 An annual programme of clinical audit is already in place, many of the audits complementing the Health Authority programme aimed at national priorities. Joint working with the Primary and Acute sectors has recently been focused on the development of Integrated Care Pathways for the care given to patients suffering from Coronary Heart Disease.

2.3 The Trust has an excellent complaints procedure which follows the recommendations made by the Wilson Committee on NHS complaints management.

3. Formulating an Agreed Development Plan
3.1 The Trust has evidence based standards of care, agreed by the local Ambulance Paramedic Steering Committee. Any developments or concerns are discussed at these meetings and recommendations made for improvements where necessary.

3.2 The Human Resources and Training Department is currently formulating a plan for continuing professional development and training for all staff.

3.3 Regional ambulance audits of specific audits of pre-hospital clinical care are being carried out and recommendations for changes to existing policies made for the nine ambulance services involved.

4. Clarifying Reporting Arrangements
4.1 This is the second formal report to the Board on the subject of clinical governance and it is anticipated that regular reporting will continue. A clinical audit report has been produced in anticipation of the requirement and will be discussed later in the agenda. This will also provide a further opportunity to discuss clinical quality.

5. Conclusion/Recommendations
5.1 An internal review of the arrangements for clinical governance has already been conducted and while the Trust is doing well in many areas, there are some further requirements necessary to achieve full clinical governance. These are:
i) Develop a risk management strategy to include an adverse events recording procedure.
ii) Maintain and widen individual monitoring and clinical audit in a non-threatening and non-disciplinary way.
iii) Maintain the training, development and appraisal of clinical staff.
iv) Expand research and development work.

May 1999.

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WEST MIDLANDS AMBULANCE SERVICE NHS TRUST
Terms of Reference of the Clinical Governance Committee

1. The purpose of the West Midlands Ambulance Service NHS Trust's Clinical Governance Committee is to provide the Trust Board with an independent ad objective approach to maintaining quality within the organisation. It will ensure that best practice and best value is being pursued in a systematic method within the Trust.

1.1 The scope of the Committee will encompass all aspects of governance including:
i) Clinical Governance.
ii) Clinical Risk Management.
iii) Health and Safety.
iv) Clinical Effectiveness.
v) Corporate Governance.
vi) Clinical Audit.

1.2 The Committee also has the power to examine and report upon any other areas which constitute governance, or effect the quality of care delivered by the West Midlands Ambulance Service NHS Trust.

1.3 Within the scope of the above Aims and Objectives, the Clinical Governance Committee will take a comprehensive view of the Trust's management of quality issues to ensure that the provision of health care within its remit is deemed to be best practice and exceeds the required standard.

1.4 The Committee will provide assurances to the Board that the necessary central mechanism and standards are operating with the West Midlands Ambulance Service NHS Trust.

2. Authority
The Chief Executive authorises the Committee to:
i) Investigate activities within its terms of reference by seeking any information required from any member of the WMAST.
ii) Request any documentation that may be available within the Trust to examine quality issues in relation to the level of provision of healthcare.

3. Duties of the Committee
3.1 The duties of the Committee compromise of the following:
i) Safeguarding the clinical standards within the WMAST.
ii) Ensure lessons from mistakes are learnt and action plans formulated to stop a repeat.
iii) To provide a blame-free culture framework whereby all grades of staff are encouraged to report clinical risk or near misses. Irrespective of causation.

4. Frequency of Meetings
4.1 The Clinical Governance Committee will normally meet four times per year, arranged in line with managers commitments.

4.2 The proposed dates for meetings together with a short agenda is as follows:
i) Examine clinical risk issues.
ii) CNST portfolio.
iii) Annual Audit report.
iv) SPC 102D Clinical intervention.
v) Any outstanding items.

5. Membership
5.1 The Chief Executive
5.2 The Medical Adviser (Chair)
5.3 Director of Personnel
5.4 Director of Finance
5.5 Clinical Risk/Effectiveness Manager
5.6 Staff Welfare Officer
5.7 Director of Operations
5.8 Head of Training

August 1999.

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APPENDIX 2
TRUST CLINICAL GOVERNANCE LEADS (ENGLAND)

Service Clinical Governance Lead Title Contact Telephone No.

Avon Elaine Scott Corporate Services Manager 01179 280221
Beds & Herts Lesley Cave Clinical Standards Manager 01234 408999
Cumbria Mr T Lynch Director of Operations & Training 01228 596909
Dorset Chris Thomas Personnel Manager 01202 896111
East Anglia Dr John Scott Medical Director 01603 424255
East Midlands Dr Tracy Cooper Acting Medical Director 0115 9296151
Essex Judith Fisher Medical Director 01245 443344
Gloucestershire Martyn Whatmore Training Officer 01452 395050
Greater Manchester Dave Thomas General Manager (Training) 01204 492419
Guernsey Avelyn Jelly Staff Officer Training Manager 01481 725211
Hampshire Mark Rowell Operational Manager 01962 842156
Here & Worcs Brian Chambers Director of Corporate Resources 01886 834200
Isle of Man Steve Sieling Deputy Chief Ambulance Officer 01624 624157
Isle of Wight Dr Andrew Watson Medical Director 01983 524081
Kent Dr Iain McNiel Medical Director 01622 747010
Lancashire Dr R Fairhurst Clinical Director 01772 862666
Lincolnshire Dave Boyd Superintendent for Clinical Governance 01522 889500
London Peter Bradley Director of Operations 0171 921 5100
Merseyside Doug Wisener Training & Recruitment Manager 0151 2605220
North East Mr D Hodge Director of Human Resources 0191 2731212
Oxfordshire Joanna Manning Director of Personnel & Administration 01865 740100
Royal Berks Linda Morris Finance & Corporate Services Manager 0118 9365500
Shropshire Kevin Wynn Assistant Chief Ambulance Officer (Training) 01743 261230
South Yorkshire Robert Waterhouse Director of A&E Services 01709 820520
Staffordshire Simon Davies Clinical Nurse Specialist 01785 253521
States of Jersey Mr R Connan Assistant Chief Ambulance Officer 01534 622333
Surrey Dr Iain McNeil Medical Director 01737 353333
Sussex Dr Peter Janes Medical Director 01273 489444
Tees, East & North Yorks Ken Billings Director of Standards & Complaints 01904 666000
Two Shires Bob Willis Training & Development Manager 01908 262422
Warwickshire Steve West Director of Operations & Training 01926 881331
Westcountry Dr Gillian Bryce Medical Director 01392 261500
West Midlands Steve Edwards Clinical Risk/Effectiveness Manager 01384 215555
West Yorks Mr G Johnson Medical Director 01274 707070
Wiltshire Martin Whibley Clinical Audit Manager 01249 443939

Please inform the ASA Clinical Effectiveness Project if any of the details above require updating

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APPENDIX 3
TRUST CLINICAL AUDIT/ EFFECTIVENESS LEADS (UK)

Service Clinical Governance Lead Title Contact Telephone No.

Avon Wendy White Training & Development Manager 01179 280221
Beds & Herts Dean Eyres Clinical Standards Manager 01234 408999
Cumbria Deborah Wright Clinical Standards Manager 01228 596909
Dorset Ian Black Divisional Commander 01202 896111
East Anglia *********** 01603 424255
East Midlands Gary Spiers Clinical Audit Manager 0115 9296151
Essex Judy Duck Quality Manager 01245 443344
Gloucestershire Martyn Whatmore Training Officer 01452 395050
Greater Manchester Dave Thomas General Manager (Training) 01204 492419
Guernsey Avelyn Jelly Staff Officer Training Manager 01481 725211
Hampshire Ken Kelly Clinical Audit Manager 01962 863511
Here & Worcs Brian Chambers Director of Corporate Resources 01886 834200
Isle of Man Steve Sieling Deputy Chief Ambulance Officer 01624 624157
Isle of Wight Mike Essery Training Manager 01983 524081
Kent Rosemary Daly Clinical Audit Officer 01622 747010
Lancashire Phil Bastow Training & Research & Development Manager 01772 862666
Lincolnshire Dave Boyd Superintendent for Clinical Governance 01522 889500
London Helen Snooks Clinical Audit & Research Manager 0171 9215100
Merseyside Doug Wisener Training & Recruitment Manager 0151 2605220
North East George Marley Clinical Audit Manager 0191 2731212
Northern Ireland Tom McGarey Training Manager 01232 246113
Oxfordshire John Radburn Training Manager 01865 740100
Royal Berks Catherine Breen Clinical Effectiveness Manager 0118 9365500
Scottish Robin Lawrenson Clinical Audit Manager 0131 4477711
Shropshire Kevin Wynn Assistant Chief Ambulance Officer (Training) 01743 261230
South Yorkshire Mary Korna Clinical Audit Manager 01709 820520
Staffordshire ******* Acting Clinical Audit Manager 01785 253521
States of Jersey Mr R Connan Assistant Chief Ambulance Officer 01534 622333
Surrey Neil Fish Clinical Audit Manager 01252 781618
Sussex Phil Maiden Quality Manager 01273 489444
Tees, East & North Yorks Colin Pitcher Director of Personnel 01904 666000
Two Shires Lucy Evans Clinical Audit Manager 01908 262422
Warwickshire Steve West Director of Operations & Training 01926 881331
Westcountry Graham Brown Clinical Audit/ Effectiveness Manager 01392 261500
Welsh (1) Tim Jones Clinical Operations Officer 01495 765366
Welsh (2) Glynn Thomas Clinical Audit Officer
Welsh (3) Tony Hayward Clinical Operations Officer
West Midlands Steve Edwards Clinical Risk/Effectiveness Manager 01384 215555
West Yorks Lynne Gomersall Clinical Audit Manager 01274 707070
Wiltshire Martin Whibley Clinical Audit Manager 01249 443939

Please inform the ASA Clinical Effectiveness Project if any of the details above require updating

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APPENDIX 4
NHSE CLINICAL GOVERNANCE LEADS (ENGLAND)

Department of Health
Julian Brookes
Quality Team
Room 606
70 Whitehall
London SW1A 2NS
Tel. 0171 2105455

Regional Office Clinical Governance Contact Contact Number

Eastern Kate Phipps
Regional Nurse Director Tel. 01908 844553
Fax. 01908 844548
Email: [email protected]

London Dr Geraldine Walters
Assistant Nurse Director Tel. 0171 7255317
Fax. 0171 7255450
Email: [email protected]

North West John Badham
Regional Office Clinical Governance Co-ordinator Tel. 01925 704271
Fax. 01925 704249

Northern & Yorkshire Ken Snider
Clinical Governance Development Manager Tel. 0191 3011452
Fax. 0191 3011413
Email: [email protected]

South East Ray Greenwood
Regional Nurse Director Tel. 0171 7252500
Fax. 0171 2583908

South West Clare Perkins
Assistant Director of Public Health Tel. 0117 9841815
Fax. 0117 9841841
Email: [email protected]

Trent Ian Hill
Senior Acting Public Health Manager Tel. 0114 2820433
Fax. 0114 2820397
Email: [email protected]

West Midlands Dr Caron Grainger
Assistant Consultant/ Director in Public Health Medicine Tel. 0121 2244679
Fax. 0121 2244680
Email: [email protected]

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APPENDIX 5
REFERENCE MATERIAL
All of this material is available from the ASA Clinical Effectiveness Project.

Department of Health Circulars and Publications
Clinical Governance: Quality in the new NHS (DoH, 1999)
Faster Access To Modern Treatment: How NICE Appraisal will work. A discussion paper (DoH, 1999)
Performance Assessment Framework: Quality and Performance in the NHS: Clinical Indicators (DoH, 1999)
Performance Assessment Framework: Quality and Performance in the NHS: High Level Performance Indicators (DoH, 1999)
The New NHS, Modern Dependable (DoH, 1998)
A First Class Service Quality in the NHS (DoH, 1998)
Clinical Effectiveness Indicators: A consultation document (DoH, 1998)
Consultation Document Part 1 the role and responsibilities of Caldicott Guardians (DoH, 1998)
Research and Development: Towards an evidence-base for health services, public health and social care. Information Pack (DoH, 1998)
Clinical Effectiveness Reference Pack (DoH, 1996)
Review of Ambulance Service Standards: Final report of Steering Group (DoH, 1996)
Clinical Audit in the NHS: Using clinical audit in the NHS - a position statement (DoH, 1996)
Clinical Guidelines: Using clinical guidelines to improve patient care within the NHS (DoH, 1996)
HSC 1999/198 The Public Disclosure Act 1998 Whistleblowing in the NHS
HSC 1999/123 Governance in the new NHS Controls assurance statements 1999/2000 risk management and organisational controls
HSC 1999/110 Spreading good practice new facility available on the NHS Web the NHS Learning zone http://nww.learning_zone.nhsweb.nhs.uk
HSC 1999/078 The NHS Performance Assessment Framework
HSC 1999/033 A First Class Service quality in the new NHS - Feedback on consultation
HSC 1999/012 Caldicott Guardians
HSC 1998/218 National Service Framework for Coronary Heart Disease November 1999
HSC 1998/074 National Service Framework
HSC 1998/069 National Research Register guidance to NHS providers on data Submission

Articles
Black N (1998) The new NHS: commentaries on the white paper. Encouraging responsibility: different paths of accountability. Clinical Governance: fine words or action? BMJ 316:297-8
Brookes J (1999) Clinical Governance Looking at the Bigger Picture, Health Care Risk Report 5(8):15
Donaldson LJ (1998) Clinical Governance: a statutory duty for quality improvement. Journal of Epidemiology & Community Health, 52: 73-4
Goodman NW (1998) Clinical Governance, BMJ 317(7174):1725-7
Heard S (1998) Educating towards clinical governance, 59(9):728-9
Hopkins B (1999) Clinical Governance Nursing a Grievance?, Health Care Risk Report 5(8):16
Manley K (1998) Shared Clinical Governance, Nurs. Crit. Care 3(2):57-8
Muller Prof. C, Scholes Dr J, Freeman P (1998) Evaluation of the 'Assisting Clinical Effectiveness' Programme, NHSE South Thames.
Scally G, Donaldson LJ. (1998) The NHS's 50th anniversary. Clinical Governance and the drive for quality improvement in the new NHS in England. BMJ 317:61-5
Scott A (1988) Clinical Governance relies on a change in culture. Br J Nurs. 7(16):940
Wilson J (1998) Clinical Governance, Br J Nurs. 7(16):987

Publications
Allsop J, Mulcahy L. (1996) Regulating Medical Work- -Formal and Informal Controls, Open University Press
Audit Commission (1998) A Life in the Fast Lane, Audit Commission, Belmont Press
Cluzeau F, Litteljohns P, Grimshaw J, Feder G (1998) Appraisal Instrument for Clinical Guidelines, Health Care Evaluation Unit, London.
Dewar S (1999) Clinical Governance Under Construction. King's Fund. London
Kelson M (1995) Consumer involvement in initiatives in clinical audit and outcomes, College of Health
Middleton S, Roberts A (1998) Clinical Pathways Workbook, Clinical Pathways Reference Centre
Royal College of Physicians (1999) Physicians Maintaining Good Medical Practice: Clinical Governance and Self-Regulation
Lugon M, Secker-Walker J (Eds.) (1999) Clinical Governance Making it Happen, Royal Society of Medicine
Smith R. (1998) Regulating Doctors: what makes them practise as they do? In Developing Clinical Excellence. King's Fund, London
Walshe K, Dineen M (1998) Clinical Risk Management: making a difference? The NHS Confederation, Birmingham
Walshe K, Spurgeon P (1997) Clinical Audit Assessment Framework, Health Services Management Centre. Birmingham

Miscellaneous
ASA/JCALC Clinical Effectiveness Committee - Response to Faster Access to Modern Treatment: How NICE Appraisal will work (1999)
ASA Clinical Effectiveness Project - Evidence for Change II survey of clinical audit 1998
ASA Clinical Effectiveness Project - Leaflet 1998 (Introduction, Aims & Objectives)
ASA Clinical Effectiveness Project - Leaflet 1999 (Resources & Information)
ASA/JCALC Clinical Governance & Effectiveness Conference Delegate Pack (May 1999)
Clancy CM, Managing for Clinical Excellence Conference (HSMC July 1999): Lessons from the U.S.
NHS Executive London, Effective Health Care CHAIN
NHSLA Review, CNST Update: New assessment criteria aim to raise standards, Issue 15, 1999
NMET (Bedfordshire consortium),Clinical Effectiveness Training in Bedfordshire April 1999 to March 2000
South Thames Research Programme, Critical Appraisal Skills Workshop (September 1997)
Surrey Ambulance Service, Clinical Effectiveness Matters - Newsletter
Walshe K, Managing for Clinical Excellence Conference (HSMC July 1999): Implementing Clinical Governance
West Midlands Regional Office, Critical Appraisal Skills Workshop (March 1999)

This list is not exhaustive. Please contribute to this list if you know of any other useful reference material.
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APPENDIX 6
Internet Links Relevant to Clinical Governance

Ambulance Service Association
http://www.ambex.co.uk

Department of Health - Home page includes search facility (links, HSC's, publications)
http://www.doh.gov.uk//dhhome.htm

National Institute for Clinical Excellence
http://www.nice.org.uk

National Research Register
http://www.update-software.com/nrronline

The New NHS Modern and Dependable - White Paper
http://www.doh.gov.uk/nnhsind.htm

Northern & Yorkshire Regional Office - Clinical Governance Activity
http://www.doh.gov.uk/nyro/clingov/cghome.htm

London Regional Office - Clinical Governance Activity
http://www.doh.gov.uk/ntro/cgov.htm

London Regional Office - References and useful links
http://www.doh.gov.uk/ntro/links.htm

Northern & Yorkshire Regional Office - References and useful links
http://www.doh.gov.uk/nyro/clingov/links.htm

Effective Health Care CHAIN (Contact, Help, Advice and Information Network)
http://www.nthames-health.tpmde.ac.uk/chain/introduction.htm

National Primary Care Research & Development Centre
http://www.npcrdc.man.ac.uk

North Thames Regional Office - Clinical Risk Report Template
http://www.doh.gov.uk/ntro/risktemp.htm

North Thames Regional Office - Themes arising from clinical governance workshops
http://www.doh.gov.uk/ntro/themes.htm

North Thames Regional Office - Clinical Audit Report Template
http://www.doh.gov.uk/ntro/carerep.htm

A First Class Service - NHSE
http://www.doh.gov.uk/newnhs/qualsum.htm

South West Regional Office - Promoting clinical effectiveness in education & training
http://www.doh.gov.uk/swro/040101.htm

Northern & Yorkshire Regional Office - Clinical Governance Slideshow
http://www.doh.gov.uk/nyro/clingov/slides

NHSE Clinical Effectiveness
http://www.doh.gov.uk/nhsexec/nhsclini.htm

South West Regional Office - Clinical Effectiveness
http://www.doh.gov.uk/swro/0401.htm

The Evaluation of Methods to Promote the Implementation of Research Findings
http://www.doh.gov.uk/ntrd/rd/implem

The New NHS - NHSE
http://www.doh.gov.uk/newnhs/quality.htm

Netting the Evidence - A ScHARR Introduction to Evidence Based Medicine on the Internet
http://www.shef.ac.uk/~scharr/ir/netting.html

Clinical Governance Research & Development Unit (formerly - Eli Lilly Clinical Audit Centre)
http://www.le.ac.uk/cgrdu/

North Thames Research Appraisal Group
http://cebm.jr2.ox.ac.uk/ntrag/ntrag.html

King's Fund - Clinical Governance Reading List
http://www.kingsfund.org.uk/reading/clingov.htm

Performance Assessment Framework
http://www.doh.gov.uk/nhsexec/nhspaf.htm

Performance Assessment Framework - Clinical and High Level Performance Indicators
http://www.doh.gov.uk/indicat.htm

For the Record - Patient Information and Confidentiality
http://www.doh.gov.uk/nhsexec/forrec.htm

Caldicott Guardians - Patient Records and Confidentiality
http://www.doh.gov.uk/confiden/cgmcont.htm

National Service Frameworks
http://www.doh.gov.uk/nsf/hsfhome.htm

NICE Appraisal - Memorandum of understanding
http://www.doh.gov.uk/mounice.htm

Adobe Acrobat Reader - Free Download of reader for PDF (Portable Document Format) files
http://open.gov.uk/howto/acroread.htm

International Quality Assurance Links
Agency for Health Care Policy & Research, USA - Centre for Outcomes & Effectiveness Research
http://www.ahcpr.gov

Health Care Financing Administration - Quality Improvement (VFM), USA
http://www.hcfa.gov

National Centre for Quality Assurance, USA - HEDIS Performance Indicators
http://www.ncqa.org

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APPENDIX 7
AMBEX 2001

Click
HERE for the conference details

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APPENDIX 8

CLINICAL EXCELLENCE 2001 - SPREADING GOOD PRACTICE

Check out What's New or the Conference Page for details of this year's NICE Conference

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APPENDIX 9

The ASA remain impartial and have not endorsed either of these products, they appear here for reference purposes only. As the ASA become aware of other and/ or similar products they too will appear in this list.

MAKING SENSE OF CLINICAL GOVERNANCE
A WORKBOOK FOR NHS DOCTORS, NURSES AND MANAGERS
BY ROY LILLEY

Practical help and advice for everyone in primary and secondary care.
Vital for PCGs and Hospital Trusts.
New and up-to-date: incorporates latest regulations.
Includes free CD-ROM with fully working Clinical Governance Planning and Information System.
The workbook contains:
Think boxes to get you looking at issues from different angles.
Hazard warnings to identify traps and help avoid them.
Tips to provide short cuts and quick fixes to get the answer faster.
Exercises to let you apply the lessons learnt to your local situation.
Available from:
Radcliffe Medical Press Ltd, 18 Marcham Road, Abingdon, Oxon OX14 1AA
Tel. 01235 528820 Fax. 01235 528830
Email: [email protected]

GOVERNANCE  - ALL THE INFORMATION YOU NEED
What is governance?
A computer system designed to support the management of "best practice" in your organisation.
Designed to enable the measurement of performance against N.I.C.E. and other guidelines.
Provides a focus for clinical effectiveness.
Takes the guesswork out of Clinical Governance.
Available from:
Kairos (UK) Ltd, Stable Cottage, Thorganby, North Yorkshire YO19 6DA
Tel. 01904 448094 Fax. 01904 448701
Email:
[email protected]
Web address: http://www.kairos-uk.co.uk

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APPENDIX 10
MINIMUM EXPECTATIONS FOR ANNUAL REPORTS IN 1999/2000
CLINICAL GOVERNANCE REPORTS - 1999/2000

An explanation of the leadership, accountability and working arrangements for implementing Clinical Governance.
Work to ensure that clinical decision-making is increasingly evidence-based. This should include local action as well as progress on implementation of National Service Framework (NSFs) and NICE guidelines.
Progress on integrated planning for quality including information establishing explicit links to HImPs and where appropriate, National Service Frameworks.
Progress on continuing professional development and lifelong learning, and on designing the ways in which staff development, educational and workforce solutions are being used to support Clinical Governance.
Participation in and impact of multi-disciplinary clinical audit programmes - including national speciality and sub-speciality audits - and national confidential enquiries.
The identification of particular services in which there are identified shortfalls in quality and of deficits in other Clinical Governance support mechanisms (e.g. risk management, clinical audit).
Evidence of active working with patients, users, carers and the public.
An account of the mechanisms that have been established to ensure that lessons are being learned from complaints, adverse incidents and enquiries into services.
Source: Clinical Governance - quality in the new NHS (DoH, March 1999).

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APPENDIX 11
PRESENTATIONS
Presentations relevant to Clinical Governance

a) Clinical Governance - Year 1 (SYMAS)
Generic presentation on the background and key milestones for Clinical Governance in Year 1 (1999/2000).

b) Clinical Governance in North Thames (NHSE London)
Presentation of the North Thames Clinical Governance Working Group on the findings of an initial survey of readiness in the region.

c) Clinical Effectiveness & Patient Information (ASA)
Presentation made at AMBEX 1999 describing the link between Clinical Governance and the need for robust, accurate, and timely patient information.

d) Clinical Governance Guidance Document (ASA)
Presentation made to the Northern & Yorkshire Regional Clinical Governance Advisory Group on the purpose and future development of this document.

e) Clinical Governance Components (ASA)
See Components of Clinical Governance - What they mean to ambulance services.

All of the above presentations are Microsoft PowerPoint presentations.
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APPENDIX 12
NHS CLINICAL GOVERNANCE SUPPORT TEAM

The following is taken from a DoH Press Release (1999/0494) on Wednesday 11th August 1999. The ASA Clinical Effectiveness Project has made contact with the Director of the new support team and is looking to develop strong links either as a full or associate member. In any case this document and subsequent versions will be shared with the new team. It is recommended that the point of first contact regarding Clinical Governance in the ambulance service remains the ASA Clinical Effectiveness Project.

NEW TEAM TO SUPPORT NHS QUALITY IMPROVEMENT
Secretary of State for Health Frank Dobson today announced Professor Aidan Halligan as the new director of the NHS Clinical Governance Support Team.
The multi-disciplinary team will work with NHS organisations to develop practical models for implementing Clinical Governance at team and speciality level. It will be established for two-years from October. He will have the full status of a member of the NHS Executive Board.
Mr Dobson said:

"The feedback we are getting from the NHS is that there is a tremendous amount of enthusiasm for Clinical Governance, but that clinicians and managers would welcome greater practical support in putting it into action. This team will help to provide that support".

Aidan Halligan, currently Professor of Fetal-Maternal Medicine at the University of Leicester, has an impressive track-record of leading change at clinical specialty level, and will bring that expertise to bear in his new post.

Mr Dobson also announced the appointment of Catherine Elcoat, currently Executive Nurse Director at the Birmingham City NHS Trust, as the first member of the team. Ms Elcoat will take up post in October.

Notes to editors
1. Clinical Governance is a framework through which NHS organisations are accountable for continuously improving the quality of their service. Clinical Governance is a key component of the Government's NHS modernisation programme. Guidance on its implementation was issued to the NHS in March 1999.
2. The NHS Clinical Governance Support Team will start work in October 1999 and will operate for two years. It will be hosted within the NHS.
3. Aidan Halligan is Professor of Fetal-Maternal Medicine at the University of Leicester and has been the Head of Obstetric Service at the Leicester Royal Infirmary since February 1998. He has been instrumental in work to develop a patient-focused approach to O&G care at the Leicester Royal Infirmary. Professor Halligan is 41, and is married with three children.
4. The NHS Clinical Governance Support Team will consist of a three or four members from a range of backgrounds. Announcements on further appointments will be made in due course.

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APPENDIX 13
ASA/JCALC MINIMUM DATA SET

Follow this link to the relevant ASA publication.

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APPENDIX 14
DEVELOPMENT PLANS FOR CLINICAL GOVERNANCE

The following minimum requirement for the baseline assessment has been developed from correspondence between NHSE Trent Regional Office and SYMAS.

'Whilst there is no specific framework, it is expected that the requirements in paragraphs 32/33/34 of the guidance issued with HSC 1999/065 will be followed with confirmation how the 4 key steps for 1999/2000 will be achieved. Because of timing you are asked to identify specific plans for the balance of this year and firm proposals for 2000/2001. As a guide, Development Plans should be of 6 to 8 pages' (NHSE Trent, 23/08/99)

HSC 1999/065 Clinical Governance in the new NHS

'Step One: Establishing leadership, accountability and working arrangements
Action: Establishing leadership, accountability and working arrangements: By April 1999, Health Authorities, Primary Care Groups, Primary Care Trusts and NHS Trusts should have identified lead clinicians for clinical governance and set up appropriate structures. Arrangements should reflect this guidance. For NHS Trusts, arrangements should include Board Sub-Committees for overseeing clinical governance within their organisation.

Step two: The baseline assessment of capability and capacity
32. Implementation of clinical governance should start with a baseline assessment of the organisation's position. Primary Care Groups may wish to discuss with Health Authorities how they access the skills needed to undertake the baseline assessment, and which form part of their development plan. This baseline will inform the first year's plans. The timescale and process for completion should be agreed with Regional Offices (for Trusts and Health Authorities) or with Health Authorities (for Primary Care Groups, and Primary Care Trusts). The process should be organisation-wide and participative. It should, as a minimum, include:

  • A searching and honest analysis of organisations' strengths and weaknesses in relation to current performance on quality.
  • The identification of any particularly problematic services (drawing where possible on objective data or feedback from users of services or referring agencies).
  • An assessment of the extent to which data are in place for quality surveillance.
  • Establishing whether there are deficits in key mechanisms (e.g. for risk management, multi-disciplinary clinical audit, supporting information management,
  • patient participation).
  • Making sure that there is integration of quality activities and systems.
  • Establishing explicit links to Health Improvement Plans, National Service Frameworks - and for PCG/PCTs, locally identified priorities.
  • Designing the ways in which underpinning strategies (i.e. information management and technology, human resources, Continuing Professional Development, and research and development) will support clinical governance within the organisation. When a quality initiative has significant resource consequences, discussions should take place within the context of the HImP and the available resources. Decisions will have to be made about which improvements are feasible and which are not.

33. The baseline assessment should let the whole organisation see what it is good at, what it is less good at, and the areas needing to be developed. It should provide the basis for an action plan that includes clear milestones.
Action: The baseline assessment of capability and capacity

Baseline assessments should be carried out in accordance with the guidance and completed at the latest by the end of September 1999. NHS Trusts and Health Authorities should agree with their relevant NHS Executive Regional Office a process and timescale for conducting these baseline assessments. Primary Care Trusts and Primary Care groups should agree similar arrangements with their Health Authority.

Step three: Formulating and agreeing the development plan
34. On the basis of the baseline assessment, organisations can then put together a plan for developing clinical governance addressing issues such as:

  • Closing gaps in present performance of the organisation (agree plan that will bring a particular service or part of the organisation, over time, up to the desired standard).
  • Developing infrastructure (i.e. reporting structures, information management and technology, human resources, organisational structures, Continuing Professional Development cross linkages with other organisations and services.
  • Identifying and responding to staff and Board development needs (i.e. education and training, Personal Development Plans, Board members induction, and continued training and management skills for general and clinical management). Additionally, development planning and prioritisation should link closely to local Health Improvement Programmes (HImPS) and work to implement National Service Frameworks (NSFs).

Action: Formulating and agreeing the development plan

NHS organisations, in line with guidance should produce and begin to implement an agreed development plan for clinical governance locally. The plan should include the activities and timescale for closing gaps identified in performance, developing infrastructure, staff and Board development, planning and prioritisation, and where appropriate, milestones to assist in assessing achievement. For Trusts and Health Authorities, monitoring of the plan should form part of existing performance management processes. For PCGs and PCTs, a process for progress reporting should be agreed with the Health Authority.

Step four: Clarifying reporting arrangements
Action: Clarifying reporting arrangements

Organisations should ensure that they have appropriate mechanisms in place to deliver routine Board reports on progress made in implementing clinical governance. These reports should reflect guidance and look to both the short and medium term. Health Authorities, Primary Care Groups, Primary Care Trusts and NHS Trusts should produce annual reports on what they are doing to improve and maintain clinical quality. These annual reports should, as a minimum, address the issues identified in the guidance, addressing the three broad questions and the template in the section above.

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APPENDIX 15
CLINICAL GOVERNANCE DEVELOPMENT AREAS
LINKED TO THE NATIONAL SERVICE FRAMEWORK ON CORONARY HEART DISEASE

Aims of the model
1. To develop explicit links with the Clinical Governance Development Plan and the key areas from the National Service Framework relevant to the ambulance service.
2. To develop an integrated approach to the management of cardiac patients.
3. To improve the quality of pre-hospital care for patients with cardiac related emergencies.

[Image]

South Yorkshire Metropolitan Ambulance & Paramedic Service (NHS Trust)

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