1.On the basis of a report by the Comptroller and Auditor General, we took evidence on NHS ambulance services from the Department of Health (the Department), NHS England, NHS Improvement, and the Chief Executive of Yorkshire Ambulance Service NHS Trust.
2.The ambulance service provides urgent and emergency healthcare, including life-saving care for some patients, and is held in high regard both the by public and this Committee. In England, 10 regionally based ambulance services provide urgent and emergency care (with separate arrangements for the Isle of Wight). The provision of urgent and emergency ambulance services cost £1.78 billion in 2015–16. In the same year the ambulance service received 9.4 million telephone calls from the public or other health professionals, and an additional 1.3 million electronic transfers from the NHS 111 service requiring an ambulance response, which between them led to 6.6 million face-to-face attendances from the ambulance service.
3.The ambulance service has a pivotal role to play in the performance of the entire urgent and emergency care system, as a conduit to other services and helping patients access the facilities they need close to home. For ambulances, this means applying new models of care rather than taking all patients to hospital. The new models of care include: resolving calls over the phone by providing advice to callers; treating patients at the scene; and taking patients to non-hospital destinations. The Committee of Public Accounts last reported on ambulance services in 2011.
4.Since July 2012, ambulance responses have been split into Red and Green calls. Red calls are calls where the patient’s condition is considered to be life-threatening. Red 1 calls are the most time-critical and cover patients suffering cardiac arrest, who are not breathing and do not have a pulse, and other severe conditions such as airway obstruction. Red 2 calls are serious but less immediately time-critical, and cover conditions such as stroke and heart attack. For Red 1 and Red 2 calls, the ambulance service has a target requiring an emergency response to arrive at the scene within 8 minutes in 75% of cases. If onward transport is required, a vehicle capable of conveying the patient should arrive at the scene within 19 minutes in 95% of cases. Green calls are calls where the patient’s condition is considered not to be life-threatening. Locally agreed targets are in place for Green calls.
5.The ambulance service believes current response categories and practices mean many patients are being coded as Red 2 unnecessarily as they do not clinically require an 8-minute response. In order to meet the Red 2 target, the ambulance service has adopted a number of operational behaviours that undermines its efficiency. For example, dispatching resources 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 diverts ambulance resources away from other patients, potentially including those 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 (which is known as a ‘tail breach’).
6.NHS England has established the Ambulance Response Programme, to address some of these issues. The Ambulance Response Programme has three parts. The first part, the ‘dispatch on disposition’ trial, allows ambulance trusts to spend more time assessing the patient over the phone before deciding what type of response is needed. This is paired with a new set of questions used before the assessment to better identify the highest risk patients more quickly. It is expected that the Programme will recommend increasing the time allowed on the telephone to deal with Red 2 calls from 60 to 240 seconds. The second part, involves updating patient categories and codes, so that they specify the patient complaint and the response (covers type of clinician and vehicle) required. The third part involves developing a new set of performance measures that cover safety, clinical outcomes and efficiency. NHS England told us that once it receives ministerial approval, the Programme could be rolled out across all ambulance trusts by autumn 2017, and that benefits should be seen by 2018. NHS England noted that these gains may be negated if the wider health system is not also updated.
7.In 2011, the previous Committee identified significant variations in the performance and efficiency of ambulance services, and made recommendations intended to help improve performance and reduce variation. Despite this, significant variations remain in the performance and efficiency of ambulance trusts across a range of performance and efficiency indicators. For example, in 2015–16, the proportion of Red 1 calls responded to within 8 minutes varied between trusts 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. Much of this variation is caused by factors within the control of ambulance services or the wider health system (though some factors, such as the rurality of the location and population demographics, are not).
8.Each ambulance trust has developed its own operating framework, which has contributed to these variations. Key variables in the operating frameworks include: the workforce mix, such as the proportion of paramedics, advanced paramedics and technicians; the type of vehicle used, such as the proportion of rapid-response vehicles and double-crewed ambulances; and number and type of ambulance stations, such as whether a hub and spoke model is employed with fewer ambulance stations and more standby points.
9.In addition, ambulance services are not commissioned consistently across England, with differences in how trusts are funded and which services they are funded to provide. NHS Improvement told us there were a number of reasons for these variations in commissioning; some were historical and came about because of factors such as the merging of smaller, county ambulance services into larger regional services, while others factors related to geography or population demographics. NHS Improvement noted that by April 2018 ambulance services would be commissioned on a consistent basis.
10.In moving to standard operating and commissioning framework, there is a risk of imposing a ‘one size fits all’ approach across the ambulance service that will not suit all parts of the system. NHS England confirmed that the new arrangements are seeking ‘commonality not uniformity’, and should not restrict local initiatives such as locally-agreed co-responding schemes with the fire service.
11.Many of the key issues discussed at our evidence session, and in the accompanying National Audit Office report, were identified as issues in 2011, when the previous Committee 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, and remain so. NHS England launched the Urgent and Emergency Care Review in 2013 that sets out its ambition to integrate urgent and emergency care systems, and the Ambulance Response Programme in 2015, whilst NHS Improvement launched a review of ambulance trust sustainability in 2016.
2 Q222; , para 1.2
3 Q1; , para 1, 1.2, 1.9
4 Qq124, 126; , para 1.6–1.7;
6 Qq5, 14, 104; , para 1.3–1.4
7 Qq3–7, 14; , para 2
8 Qq16–21; , para 3.4
9 Qq7, 105–107
10 Qq21, 40, 57, 108; , para 3.5
13 Qq136, 151; , paras, 3.3, 3.6, 3.8, Figure 4, Figure 13,
14 Qq65–66, 70; , para 3.4, 3.6
15 Qq70–71, 81, 136; , paras 1.15
17 Qq3–7, 86–89, 108, 126–130, 176–177, 182, 217; Committee of Public Accounts, Forty-sixth Report of Session 2011–12, Transforming NHS ambulance services, HC 1353, paras 4–7; C&AG’s Report, Transforming NHS ambulance services, Session 2010–12, HC 1086, para 17
18 Qq13, 39, 66, 134, 143, 167, (2017), paras 1.6, 1.14, 3.5
25 April 2017