7 Ambulance services |
Improving emergency care
128. It is clear from the evidence presented to the
Committee that demand for ambulance services has increased substantially
in recent months. The Association of Ambulance Chief Executives
(AACE) report that in 2011-12, the total number of emergency calls
was 8.49 million; this was an increase of 415,487 (5.1%) over
2010-11. As of
February 2013, of the 12 ambulance trusts in England, only London,
the North East, the West Midlands and the Isle of Wight were meeting
the core target of responding to 75% of 'red 1 calls' within 8
129. The King's Fund undertook an analysis of the
performance of ambulance services in southern England as part
of their review of urgent and emergency care. The review found
Ambulance services are reporting significant
increases in demand across all types of calls. A recent review
by South Central Ambulance Service NHS Foundation Trust of ambulance
demand over a 3-month period (Sept-Nov 2012, compared to Sept-Nov
2011) found that there was an increase in demand for ambulances,
but the range between areas was quite significant (the lowest
was 1.94% and highest was 11.6%). The review also found:
· There was uncertainty as to whether 111
is driving up ambulance call outs
· For most areas (but not all) the majority
of the increase was in out of hours calls
· In all areas there were only small increases
in calls from care homes
· There is a fair amount of variation between
areas in the main health conditions accounting for the increase
in calls, although psychiatric conditions accounted for 10%+ increase
in four areas and falls accounted for 10%+ in three areas.
130. The South Western Ambulance Service NHS Foundation
Trust (SWASFT) made the case in its written evidence that the
nature of the service determined that staffing levels could not
simply be reactive to short term trends in demand. They say that:
The 999 service is described as a "waiting
service". In other words regardless of activity levels (unplanned)
sufficient resource must be available to respond to an emergency
call whenever and wherever it is received.
131. The West Midlands Ambulance Service NHS Foundation
trust (WMAS) believes that a workforce predominantly made up of
paramedics can alleviate demand in A&E, even if this does
not mean an overall reduction in demand for health services. They
say that "moving towards a target of 70% of frontline staff
who are Paramedic trained" will:
ensure that every patient can be guaranteed to
receive Paramedic care which will increase the proportion of patients
treated at scene and therefore reduce the number of patients conveyed
to Emergency Departments.
132. Mark Docherty explained the benefits of this
in more detail, telling the Committee that:
It is taking time for skill mixes to increase,
but in some parts of the country, we are getting close to a 70%
paramedic skill mix. The significance of the 70% paramedic skill
mix is that with that skill mix you can ensure that every vehicle
has a paramedic on board, so that whichever vehicle responds to
the patient the first response that gets to the patient will include
a paramedic. Up to now, that has not been possible. With a less
than 70% skill mix, that will always be a challenge, but most
ambulance services are increasing their skill mix fairly rapidly.
133. Supplementary evidence provided by AACE shows
that the current number of paramedics as a proportion of ambulance
crews across the 10 mainland ambulance trusts in England stood
at 62%.The numbers ranged from a low point of 50% in the East
of England to 66% in the West Midlands. Professor Willett questioned
the reasoning behind the 70% objective, suggesting that there
was no firm evidence base to support the figure.
134. In oral evidence Mike Farrar acknowledged the
importance of equipping ambulance services with skilled paramedics
who were able to make clinical judgements:
all the evidence is showing that the investment
in ambulance services, in having good qualified paramedic support
on ambulances, is helping to relieve pressure on both attendances
and potential length of stay for people with conditions if they
135. The Urgent and Emergency Care Review acknowledges
the significance of utilising paramedics at "key decision
also specifically acknowledges that high quality care can be achieved
by bypassing some emergency facilities and instead sending patients:
to specialist centres for stroke, heart attack,
major trauma and specialist children's services; those centres
to have consistent network pathways and concentrate expertise
to improve patient outcomes and efficiency.
Mr Marsh built on this, pointing out that new structures
in emergency care and the centralisation of some services would
require paramedics with greater clinical skill and knowledge.
He explained that it was advanced paramedics who would make the
decision to bypass local A&E services and to transfer a patient
directly to a regional trauma centre.
136. The Royal College of Nursing, however, warned
that numbers of fully qualified paramedics might be falling:
Ambulance services have no control over their
patient load, this makes finding efficiencies and financial savings
particularly difficult. This means in parts of the country there
are recruitment freezes and an increasing ratio of technicians
to fully qualified paramedics.
Unison expressed concern in their evidence that in
some trusts staff numbers were falling:
Within the East of England Ambulance Trust there
has been a reduction in the number of staff and vehicles delivering
emergency response services across the area at a time when demands
on the service are increasing and population numbers are rising.
During this time the employer had decided to reduce the number
of staff and vehicles delivering emergency response services.
They also questioned whether ambulance trusts were,
in practice, moving towards a position where every vehicle would
be crewed by a fully-qualified paramedic. They said:
As a result of the drive for efficiency savings,
the deployment of double crewed Emergency Care Assistants (ECAs)
is becoming an increasing common policy in some ambulance trusts,
despite advice from other trusts who have discarded this model
due to the clinical risks involved. ECAs receive basic training,
are not subject to registration by the Health and Care Professions
Council and, unlike paramedics, are unable to administer medication
if an emergency arises.
137. Professor Willett emphasised the importance
in rural areas of having a highly skilled ambulance workforce.
What a skilled paramedic can do in an ambulance
now is most of what we spent the first 30 minutes doing in A and
E 10 or 15 years ago, so the options are very different. One of
the things for remote and rural communities is to supply at the
scene in an emergency the skill set that is most likely to be
able to maintain the patient there or to temporise until the local
general practitioner arrives.
138. Skilled paramedics are trained to make better
clinical judgements and administer care more appropriately than
ambulance technicians. Ambulance paramedics will increasingly
require the skills and knowledge to judge whether patients should
be treated at local emergency departments or regional specialist
units. Ambulance trusts that service rural areas should also recognise
that with sufficient staffing, ambulance crews can treat more
people at the scenes of incidents and prevent unnecessary and
lengthy journeys to hospital.
139. Ambulance services must demonstrate a commitment
to establishing a ratio of paramedics to technicians which ensures
that ambulance crews are able to regard conveyance to an emergency
department as only one of a range of clinical options open to
them. We recommend that NHS England undertakes research to establish
the precise relationship between more highly-skilled ambulance
crews and reduced conveyance rates.
DEVELOPING THE FUNCTIONS OF AMBULANCE
140. The King's Fund analysis in southern England
concluded that there was a general consensus that the potential
of ambulance services was under-used and could contribute a great
deal more to managing demand pressures and the development of
new care models. The Department of Health's evidence emphasised
the ability of ambulance services to deliver efficiencies across
the whole system rather than within the ambulance service itself.
The Department believed that ambulance services could be developed
to limit the number of patients conveyed to A&E units:
There is some potential to further reduce the
number of patients transported to hospital by ambulances and to
provide more efficient and local care. The number of calls to
the ambulance services which are managed through clinical telephone
advice has increased significantly over the last five years. Almost
90% of these calls result in no vehicle being sent to the scene
(where clinically safe and appropriate). Compared to 1999/2000
levels, there are now 10 fewer patient journeys per 100 ambulance
incidents, which reflects the increased use of 'see and treat'
and other efforts to provide levels of care that meet the clinical
needs of the patient.
141. The Department's evidence acknowledged the consensus
that a skilled paramedic workforce was central to achieving the
ambition of treating and discharging patients at the scene of
a call out. They outlined the provision of care by paramedics
and explained that:
Two models of 'see and treat' have emerged. Firstly,
there are some Trusts with much larger numbers of Advanced Practitioners
who require very little clinical field support and act as autonomous
practitioners. Secondly, there is a mixed model where, particularly
in urban areas (which often do not have good primary care services
but greater numbers of acute trusts) existing Paramedics are used
to undertake 'see and treat' work and are supported by a network
of clinical field supervisors.
Both models can work and a further assessment
of their relative benefits will be needed. However there is still
considerable variation in conveyance rates between ambulance services,
and more could be done to develop and support ambulance clinicians.
142. The WMAS say that as a result of a range of
initiatives they reduced conveyance rates "from 70% to less
than 58% from 2009-10 to the end of 2012-13".
However, "despite these initiatives WMAS staff are frequently
called as a last resort for patients who cannot understand or
access the services that are available to them."
Integrating ambulance services into healthcare
143. In evidence to the Committee Anthony Marsh,
Chair of the Association of Ambulance Chief Executives and Chief
Executive of the West Midlands Ambulance Service, made the case
that reforms were not simply required in relation to staffing
levels and improving the skills mix of ambulance crews. He outlined
the case for improving paramedics' access to nationally-held patient
data in order to make more informed judgements regarding a patient's
treatment. He told the Committee that:
It would also be enormously helpful for front-line
paramedicsboth those in the control room and responding
paramedicsto have access to the national spine, which would
enable them to pull down useful and critical information about
a particular patient, rather than looking at patients with very
limited information, as is very often the case.
144. As part of the process of ensuring that care
is delivered efficiently, objective 9 of the Urgent and Emergency
Care Review acknowledges the critical importance of information
being available to all those treating a patient. The review suggests
making all patient care records accessible and shared amongst
all urgent and emergency care providers.
It should be noted, however, that Mr Marsh did not ask that paramedics
have access to all historic patient information, but just the
key data that could inform decision making in emergency cases.
Professor Willett said it was "inexplicable" that some
ambulance crews were unable to access the minimum patient record
which showed key information and their most recent medical history.
145. In addition Mr Marsh demonstrated the need to
rectify basic elements of integrated working between the ambulance
service and primary care. He said that:
One thing we have really been pushing for, both
locally and nationally, is for ambulance paramedics to have access
both to the doctor in hours and to out-of-hours providers, so
that you can have that clinical conversation.
In their written evidence, the CEM said that emergency
departments ended up seeing patients who were transported to them
by ambulance crews even though:
"they often recognise that patients could
be better managed by GP review in the home (in particular those
residing in residential and nursing homes) but cannot get rapid
access to GPs.
146. An ambulance service that operates as a care
provider in its own right can help coordinate the delivery of
care by other parts of the system such as emergency departments,
NHS 111 and primary care. Therefore, the Committee believes that
ambulance services have the potential to drive collaborative working
and integration in emergency and urgent care. This is of particular
value in rural areas where there cannot be the same concentration
of services that would be found in an urban location.
147. There is still a considerable variation in
conveyance rates across ambulance trusts. NHS England should take
the lead in reviewing the various staffing models used by different
trusts to help understand which structures are most effective
in reducing conveyance rates and putting patients on the correct
pathway. This should establish an evidence base for both urban
and rural settings to help ambulance trusts determine how they
organise their resources and workforce.
148. Ensuring that all ambulance crews have access
to national patient data would increase the patient information
available and allow for better decisions to be made regarding
conveyance and care. The Committee recommends that UCBs take the
lead in assessing access to the National Spine for all key parties
in the delivery of emergency care and coordinate plans to ensure
that the minimum patient record is made available.
149. The tariff paid to ambulance providers is significant
in shaping the service available to patients. Professor Willett
told the Committee that the ambulance service tariff was being
restructured so that services could be paid for "receiving
the call, hearing and treating and [...] seeing and treating.
In written evidence the Department said that:
In April 2012, the Department of Health published
a currency for the contracting of emergency and urgent ambulance
services, in order to allow locally appropriate ambulance care
which may not involve conveyance, where such care is appropriate.
The four categories are:
· Urgent and Emergency Calls Answered
· Hear and Treat/Refer
· See and Treat/Refer
· See, Treat and Convey
Professor Willett emphasised that the new tariff
was designed to be agreed locally.
Sir David Nicholson described his ambition for the ambulance service,
The priority for us over the next period is to
make sure that the payment structures give the right incentives
to enable ambulance services to play a much wider role in providing
150. The Department's evidence also explained how
incentives had been used to tackle handover delays between ambulance
crews and staff in emergency departments. The Department said
that the problem of handover delays was complex and would require
a whole system approach to rectify. They added, however, that
as part of new key performance measures contractual fines could
now be imposed on ambulance trusts for delays of over 30 minutes.
The WMAS believed that financial penalties might deliver a short
term effect on behaviour but they would not "resolve what
seems to be a problem of a lack of resource planning and utilisation
in A&E units".
The AACE took a similar view and did not believe that financial
penalties were a long-term solution. They attributed delays to:
ownership by hospital/health system leaders;
A&E capacity; A&E integration with the rest of the hospital;
timeliness of in-Trust escalation; reductions in physical bed
capacity within hospitals and the community; attitude and behaviour
towards handover delays within the hospital; and the effectiveness
of urgent care pathways keeping demand away from the front door.
151. The Committee believes it is vital that commissioners
successfully introduce tariffs which encourage ambulance providers
to 'hear and treat' and 'see and treat' patients. Such encouragement
would provide ambulance trusts with further incentives to develop
a skilled workforce predominantly made up of paramedics. This
would be of particular benefit to patients in rural areas who
have only limited access to services.
152. A service that is paid to transport patients
will employ technicians to facilitate this; one that is paid to
treat patients will invest in recruiting and training paramedics.
The Committee therefore urges NHS England to closely monitor the
relationship between the use of the new tariffs, conveyance rates
and the balance between technicians and paramedics in ambulance
153. The Committee is concerned that blunt contractual
penalties are the main measure that have been applied to improve
handover times. Delayed handover is a symptom of the wider demand
pressures that exist across the service and most acutely in emergency
departments. Unless reforms are implemented across the urgent
and emergency care system, delayed handover will be a recurring
concern. Emergency and urgent care providers are interdependent
and therefore contractual fines targeted at one part of the system
will provide only short-term relief rather than a long-term cure.
149 Ev 106 Back
The King's Fund, March 2013, p 12 Back
ES 05, written evidence from South Western Ambulance Service NHS
Foundation Trust, p 1 Back
Ev 85 Back
Q 111 Back
Q 82 Back
NHS England, June 2013, p 6 Back
Ibid, p 7 Back
Q 105 Back
ES 15, written evidence from the Royal College of Nursing, para
ES 23, written evidence from UNISON, para 12 Back
Ibid, para 14 Back
Q 313 Back
Ev 70 Back
Ev 71 Back
Ev 85 Back
Ev 85 Back
Q 108 Back
NHS England, June 2013, p 11 Back
Q 365 Back
Q 141 Back
Ev 94 Back
Ev 71 Back
Q 310 Back
HC 119-iii, Q 290 Back
Ev 73 Back
Ev 87 Back
Ev 106-107 Back