Transforming NHS ambulance services - Public Accounts Committee Contents

1  Accountability and commissioning arrangements

1.Ambulance services provide a valuable service that is held in high regard for the care it provides to patients.[2] Eleven regional ambulance services operate in England. In 2009-10, they handled 7.9 million emergency calls, and spent £1.5 billion on urgent and emergency services.[3] Ambulance services are expected to make 4% efficiency savings year-on-year (equating to £75 million in 2010-11), in line with the rest of the NHS, at a time when public demand for emergency health services continues to rise.[4]

2. Ambulance services are currently commissioned by primary care trusts. These form commissioning clusters in line with the ambulance regions.[5] Under the NHS reforms, clinical commissioning groups (previously called GP consortia but now requiring governing bodies with at least one nurse and one specialist doctor) will be created. They will commission most of the health services in their area.[6] The NHS Commissioning Board will directly commission the clinical commissioning groups as well as some other specialised services.[7] The Department has not confirmed whether clinical commissioning groups will commission ambulance services themselves or if the NHS Commissioning Board will.[8]

3. Core ambulance services will have to be commissioned in the ambulance region to which they relate. For example, ambulance services in an area in London must be provided by the London Ambulance Service, even if it is more expensive than a neighbouring ambulance service.[9] Due to the variation in costs of ambulance services, core services will take up a different proportion of the clinical commissioning groups' budgets.[10] The Department could not tell us how much choice commissioners would have over the provider of non-core services - such as having paramedics based in GP surgeries or patient transport services.[11]

4. Currently, the Department is accountable for the ambulance services.[12] Under the proposed NHS reforms, all ambulance services will be required to become foundation trusts and will be directly accountable to Parliament. We have expressed concerns in previous reports about a structure of direct accountability to Parliament for a plethora of independent health trusts. This cannot ensure robust accountability in a sustainable way. The Department also told us that the NHS Commissioning Board will be accountable for the continuation of '999' services in all situations.[13]

5. There is a lack of clarity around who will intervene should an ambulance service fail to perform. The Department told us it would expect other ambulance services to step in to cover operations.[14] However, the Department has yet to finalise the failure regime to cover the eventuality of an ambulance service getting into financial difficulties. The Department told us that these arrangements will be finalised and submitted during the legislative process for the Health and Social Care Bill.[15]

6. We are concerned that no-one has responsibility for acting on poor performance or enforcing best practice across ambulance services.[16] Instead, ambulance services told us that they use peer pressure as a mechanism to drive improvements in performance.[17] We were told ambulance services use forums to share best practice and help deal with the inefficiencies that exist between services. We remain unconvinced this will exert enough pressure.[18]

7. The situation is made worse by the lack of comparable performance information to enable benchmarking.[19] Ambulance services do not have a standard way of measuring their use of ambulance crews while on duty (utilisation rate) so cannot compare their frontline utilisation rates against each other. Ambulance services welcomed the NAO's recommendation on the need for a standard utilisation definition and committed to produce one within three months.[20] Clinical quality indicators, introduced in April 2011, will also mean more benchmarking information is available. The ambulance services told us that they plan to have a website with the performance of ambulance services against the clinical quality indicators from July 2011.[21]

2   Q 85; C&AG's Report, para 15 Back

3   C&AG's Report,paras 1 and 4 Back

4   Q 30; C&AG's Report, para 4 Back

5   C&AG's Report, para 1.8 Back

6   Department of Health, Government Response to the NHS Future Forum report, June 2011 Back

7   C&AG's Report, National Health Service Landscape Review, HC (2010-11) 708 Back

8   Qq 13, 18-21 Back

9   Qq 19-20 Back

10   Qq 39-41  Back

11   Qq 21, 25, 123 Back

12   Q 1 Back

13   Qq 2-4  Back

14   Q 10 Back

15   Qq 11-12 Back

16   Qq 118-119 Back

17   Q 122 Back

18   Q 117 Back

19   C&AG's Report, para 14 Back

20   Qq 101-102; C&AG's Report, para 17 Back

21   Qq 120-121 Back

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© Parliamentary copyright 2011
Prepared 16 September 2011