Transforming NHS ambulance services - Public Accounts Committee Contents


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 handover times.

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.


 
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© Parliamentary copyright 2011
Prepared 16 September 2011