1 Accountability and commissioning
1.Ambulance services provide a valuable service that
is held in high regard for the care it provides to patients.
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.
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.
2. Ambulance services are currently commissioned
by primary care trusts. These form commissioning clusters in line
with the ambulance regions.
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.
The NHS Commissioning Board will directly commission the clinical
commissioning groups as well as some other specialised services.
The Department has not confirmed whether clinical commissioning
groups will commission ambulance services themselves or if the
NHS Commissioning Board will.
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. Due to the
variation in costs of ambulance services, core services will take
up a different proportion of the clinical commissioning groups'
budgets. 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.
4. Currently, the Department is accountable for the
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.
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
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.
6. We are concerned that no-one has responsibility
for acting on poor performance or enforcing best practice across
Instead, ambulance services told us that they use peer pressure
as a mechanism to drive improvements in performance.
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.
7. The situation is made worse by the lack of comparable
performance information to enable benchmarking.
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.
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.
2 Q 85; C&AG's Report, para 15 Back
C&AG's Report,paras 1 and 4 Back
Q 30; C&AG's Report, para 4 Back
C&AG's Report, para 1.8 Back
Department of Health, Government Response to the NHS Future
Forum report, June 2011 Back
C&AG's Report, National Health Service Landscape Review,
HC (2010-11) 708 Back
Qq 13, 18-21 Back
Qq 19-20 Back
Qq 39-41 Back
Qq 21, 25, 123 Back
Q 1 Back
Qq 2-4 Back
Q 10 Back
Qq 11-12 Back
Qq 118-119 Back
Q 122 Back
Q 117 Back
C&AG's Report, para 14 Back
Qq 101-102; C&AG's Report, para 17 Back
Qq 120-121 Back