Conclusions and recommendations
1.Ambulance trusts have organised themselves to meet response-time targets, at the expense of providing the most appropriate response for patients. The ambulance service believes current response categories and practices mean too many patients are being coded as Red 2, when they should be Green. Despite this, ambulance services have adopted a number of operational behaviours that undermine the efficiency of the service in order to meet the Red 2 target of arriving at the scene within 8 minutes in 75% of cases. For example, dispatching vehicles before they have fully determined the nature of the patient complaint; and dispatching multiple ambulance vehicles to the same patient and then standing down the vehicles least likely to arrive first. This has the knock-on effect that other patients wait longer for an ambulance, potentially including patients who are clinically a higher priority. It also means patients who are less seriously ill, but who nonetheless may need an ambulance (‘Green’ calls), can wait a very long time before an ambulance arrives. NHS England has established the Ambulance Response Programme to address some of these issues, and told us that the changes recommended from the programme can be implemented quickly once ministerial approval is received.
Recommendation: The Department, NHS England, NHS Improvement and ambulance trusts should implement the recommendations of the Ambulance Response Programme at pace. Any changes to the response-time target system should address ‘tail breaches’ (very long delays) and the lack of focus on Green calls.
2.Despite this Committee identifying significant variations in ambulance service performance and efficiency in 2011, the causes of these variations are still not well understood. Substantial variations persist between ambulance trusts across a range of performance and efficiency measures. For example, in 2015–16, the proportion of Red 1 calls responded to within 8 minutes varied from 68.1% to 78.5%; the proportion of incidents where one or more vehicles were stood down after mobilisation varied from 4% to 46%; and income per head of population varied from £26.7 to £36.6. Many of the factors contributing to these variations are within the control of ambulance trusts or the wider health system, though some factors, such as rurality and population demographics, are outside of their control. Each ambulance trust has developed its own operating framework which contributes to the variations and inefficiencies in performance. Key operating framework variables include workforce mix, the types of vehicle used, and number and type of ambulance stations. In addition, ambulance services are not commissioned consistently across England, with differences in how they are funded and what they are funded for.
Recommendation: NHS Improvement should determine the underlying causes of variations in performance, identify an optimal operating framework for ambulance services and work with NHS England to incorporate this framework into commissioning arrangements for 2018–19. The new framework and commissioning arrangements should establish commonality but allow flexibility where appropriate.
3.Various ambulance service improvement programmes are now underway, but this has taken too long to happen. Many of the key issues discussed at our evidence session, and in the accompanying report by the National Audit Office, were identified as issues in 2011, when we last reported on ambulance services. For example, too great a focus on response times, delayed patient transfer at hospital, a lack of consistency in key data sets, and integration with the wider health system, were all identified as areas of concern. Since 2011, NHS England has initiated the Urgent and Emergency Care Review and the Ambulance Response Programme, and last year NHS Improvement launched the Ambulance Trust Sustainability Review. We had expected to see greater progress over the past six years, and will be looking to see real improvements being delivered over the next two years.
Recommendation: The Department of Health, NHS England and NHS Improvement should set out a trajectory with clear milestones for all its modernisation programmes that focus on ambulance services, by October 2017. As part of these programmes, they should ensure consistent and reliable data sets for key performance measures are available, including clinical outcomes, new models of care, efficiency metrics, and patient-transfer times at hospital.
4.To deliver new ways of working, ambulance services will need a different mix of skills and vehicles. They will also need to work with their commissioners to fund a paramedic pay increase from 2018–19. It is not clear how the costs associated with these changes will be funded. The Urgent and Emergency Care Review and likely changes from the Ambulance Response Programme will require ambulance services to continue to adopt new ways of working rather than taking all patients to hospital. This requires significant changes to the vehicle fleet and workforce. There will need to be changes to the vehicle fleet, with a move from lower-cost rapid response vehicles to more expensive double-crewed ambulances. To address the shortfall in paramedic staff, the number of trainee paramedics has doubled in recent years, and these trainees began joining the workforce in 2016, alongside an increasing number of ambulance technicians. In addition, paramedics have recently received a pay increase, in recognition of the increased skill set they have developed. There is no additional funding planned for staff cost and capital investment in vehicles. Ambulance trusts and commissioners will therefore need to find efficiencies across the urgent and emergency care system to fund vehicle fleet changes and the paramedic pay-uplift from 2018–19 (NHS England and the Department are funding the increase for 2017–18).
Recommendation: NHS England and NHS Improvement should assess whether sufficient resources are available to ambulance trusts to support new ways of working including capital expenditure. They should also provide additional assurances to the Department regarding how increased paramedic costs will be met from 2018–19 onwards if the provision of central funding to cover these costs does not continue after 2017–18.
5.Ambulance services have struggled to recruit and retain staff, and staff shortages are exacerbated by many trusts having high sickness absence rates. Ambulance trusts face resourcing challenges that are limiting their ability to meet demand. Most ambulance trusts struggle to recruit the staff they need, while paramedics are increasingly being recruited by organisations outside the ambulance service. Staff shortages are made worse by high sickness absence rates, up to 6.7%, in some trusts. To help improve staff retention, NHS England and NHS Improvement are planning initiatives to better support ambulance staff, such as mentoring schemes for new staff and more support from senior staff when they attend a patient. However, currently there is no programme in place for the career development of staff below the paramedic grade.
Recommendation: NHS England and NHS Improvement should set out their plans for tackling ambulance workforce issues and report back to the Committee on progress by April 2018; including progress against recruiting additional staff, reducing staff turnover rates, and reducing staff sickness absence rates.
6.Many patients are waiting too long to be transferred from an ambulance to hospital care, and this situation has got worse since we last reported. Transferring patients from an ambulance to an emergency department should take no longer than 15 minutes. Each failure to meet this standard results in a poor experience for the patient and a delay in an ambulance crew being available for a new emergency call. Just 58% of patient transfers were completed within 15 minutes in 2015–16, compared to 80% in 2010–11. NHS England told us that ambulances not being able to offload patients is one of the most serious concerns in the urgent and emergency care system currently and to address this issue much firmer performance management of the system is happening. After the transfer is complete, ambulance crews are expected to make their vehicle ready for the next call within another 15 minutes. Ambulance crews are failing to achieve their own 15-minute standard, adding to the delay. In 2015–16, this was achieved in just 65% of cases. Despite this Committee recommending in 2011 that a quality indicator should be developed for hospital performance in meeting the transfer-time target, this has not happened.
Recommendation: NHS Improvement should publish a set of improvement trajectories for hospital turnaround times and introduce transparent reporting on progress by October 2017.
7.Ambulance services are pivotal to the wider health system but it is not clear how they will be incorporated into local Sustainability and Transformation Plans or become fully integrated into the wider health system. Effective collaboration is key to ensuring that all urgent and emergency care services are connected and integrated. However, the complexity of the healthcare system creates challenges for ambulance trusts in terms of engaging with all the relevant local stakeholders. NHS England has introduced 44 Sustainability and Transformation Plan areas, in which health and care leaders in each area are required to set out how local services will change and improve over the next five years, to meet rising demand within the resources available. However, it remains unclear how locally driven plans will fit with the national aim of connecting and integrating all urgent and emergency care services and getting a consistent service offer across regions. The ambulance service has to fit in with plans made elsewhere in the NHS; this has an impact on its ability to respond to emergency calls.
Recommendation: As part of their planned commissioning guidance for 2018–19, NHS England should provide greater clarity on how ambulance services will have a seat at the table in local Sustainability and Transformation Plans, and how they will become fully integrated into the wider health system.
25 April 2017