Conclusions and recommendations|
1. Ambulance services provide a valuable service
that is held in high regard for the care it provides for patients,
but more could be done to improve efficiency and value for money.
Wide variations exist in unit costs and efficiency across ambulance
services. Better benchmarking and sharing of best practice could
help to reduce these variations. Monitoring and interventions
at a national level are needed to increase efficiency and achieve
better outcomes and value for money. The recommendations set out
below are intended to help the Department, commissioners, and
ambulance services achieve these aims.
2. Under the NHS reforms, it is not clear
who will be responsible for achieving efficiencies across ambulance
services or intervening if an ambulance service runs into financial
difficulties or fails to perform. The
NHS Commissioning Board will be accountable for the continuation
of '999' services in all situations, but individual trusts will
be accountable to Parliament. However, the Department could not
clarify who will be responsible for improving efficiency across
ambulance services or taking action in cases of underperformance.
The Department should clarify roles and accountabilities for the
emergency care system and quickly develop an intervention regime
to protect '999' services in situations where providers fail.
3. The Department was unable to tell us who
will be responsible for commissioning ambulance services under
the NHS reforms. Ambulance services are
currently commissioned by primary care trusts. These trusts must
commission the emergency care response to '999' calls from the
ambulance service in their region, but the degree of choice in
how they procure additional services, such as using paramedics
in GP surgeries, is unclear. The Department must clarify how ambulance
services will be commissioned and what choice commissioners will
have over the providers of emergency and urgent care.
4. Performance information on ambulance services
is not always comparable, making it difficult to benchmark services
and identify the scope for efficiency improvements.
Ambulance services will have to meet demanding efficiency targets
in the next few years. Although they work closely together through
various forums, there is still considerable variation between
ambulance services in areas such as cost per incident, the staff
skills mix in ambulance crews, sickness absence and back-office
costs. In addition, ambulance services do not have a standard
way of measuring the use made of ambulance crews while on duty
(utilisation rate). The Department should set standard definitions
for the data to be measured by each ambulance service to enable
benchmarking, and certify the quality of data-generating systems.
Commissioners should use this data as a basis on which to seek
service efficiencies. Ambulance services should use it to share
best practice and maximise efficiency.
5. Focusing on response time targets has improved
performance but has also led to some inefficiencies.
A focus on response time targets was needed to improve basic standards
and achieve consistency across the country. But currently response
times are measured from the moment the '999' call is received
from BT, rather than after obtaining sufficient information on
a patient's condition to determine the most appropriate response.
This has led to an over-commitment of vehicles and staff as ambulance
services often send more than one team to an incident. This can
waste resources and result in other patients not getting the most
appropriate care. The Department introduced a wider range of clinical
quality indicators in April 2011 and plans to review them in a
year. The Department should review how response times are measured
to ensure ambulance services have sufficient flexibility to identify
the most appropriate response to calls before resources are deployed.
6. Delays in handing over patients from ambulances
to hospitals lead to poor patient experience and reduced capacity
in ambulance services. Over one-fifth
of patient handovers from ambulance crews to Accident and Emergency
staff at hospitals take longer than the 15 minutes recommended
in guidance. If ambulances are queuing in hospitals, they are
not available to take other calls. Commissioners should take a
consistent approach to penalising hospitals that do not adhere
to the guidance of 15 minute handovers and the Department should
also develop a quality indicator for hospital trusts on hospital
7. Ambulance services do not collaborate sufficiently
with other emergency services to generate efficiency savings.
Although ambulance services collaborate with fire services and
police forces in some areas, there is scope for a more systematic
approach to sharing procurement and back office services across
the emergency services. The Efficiency Reform Group should work
with the departments responsible for fire, ambulance and police
services to commission an independent review. The review should
examine what efficiencies and enhanced service delivery could
be achieved by increased joint-working across the emergency services
and should look to maximise opportunities for co-location, for
example in the empty regional fire centres.