Urgent and emergency services - Health Committee Contents

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.[149] 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 minutes.

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 that:

    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.[150]


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.[151]

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.[152]

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.[153]

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 are admitted.[154]

135. The Urgent and Emergency Care Review acknowledges the significance of utilising paramedics at "key decision points"[155] and 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.[156]

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.[157]

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.[158]

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.[159]

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.[160]

137. Professor Willett emphasised the importance in rural areas of having a highly skilled ambulance workforce. He said:

    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.[161]

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.


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.[162]

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.[163]

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".[164] 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."[165]

Integrating ambulance services into healthcare provision

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 paramedics—both those in the control room and responding paramedics—to 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.[166]

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.[167] 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.[168]

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.[169]

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.[170]

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[171]

Professor Willett emphasised that the new tariff was designed to be agreed locally.[172] Sir David Nicholson described his ambition for the ambulance service, saying:

    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 health services.[173]

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.[174] 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".[175] 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.[176]

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 trusts.

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

150   The King's Fund, March 2013, p 12 Back

151   ES 05, written evidence from South Western Ambulance Service NHS Foundation Trust, p 1 Back

152   Ev 85 Back

153   Q 111 Back

154   Q 82 Back

155   NHS England, June 2013, p 6 Back

156   Ibid, p 7 Back

157   Q 105 Back

158   ES 15, written evidence from the Royal College of Nursing, para 8.1 Back

159   ES 23, written evidence from UNISON, para 12 Back

160   Ibid, para 14 Back

161   Q 313 Back

162   Ev 70 Back

163   Ev 71 Back

164   Ev 85 Back

165   Ev 85 Back

166   Q 108 Back

167   NHS England, June 2013, p 11 Back

168   Q 365 Back

169   Q 141 Back

170   Ev 94 Back

171   Ev 71 Back

172   Q 310 Back

173   HC 119-iii, Q 290 Back

174   Ev 73 Back

175   Ev 87 Back

176   Ev 106-107 Back

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Prepared 24 July 2013