12.The Urgent and Emergency Care Review and likely changes from the Ambulance Response Programme will require the ambulance service to adopt new ways of working rather than taking all patients to hospital. This will involve significant changes to the types of vehicle used and the workforce. The three ambulance trusts participating in the Ambulance Response Programme’s trial of new clinical codes have found that they require fewer rapid-response vehicles and more double-crewed ambulances. It is not yet clear how many more double-crewed ambulances will be needed across the 10 English ambulance trusts, but the Chief Executive of Yorkshire Ambulance Service estimated that his trust would need another 20 to 30. The cost of double-crewed ambulance (around £120,000) is a lot more expensive than the cost of a rapid-response vehicle (around £50,000). This suggests that the changing vehicle fleet-mix will represent significant capital expenditure nationally.
13.NHS England and NHS improvement told us that Health Education England had set up a programme to train more paramedics, with about 1,750 learners this year. This programme aims to help rectify existing shortfalls and ensure that trusts can implement the new ways of working required. However, there is no additional funding planned for additional ambulance staff or capital investment in vehicles.
14.In addition to increased number of paramedics, from 31 December 2016, in recognition of the increased responsibilities and skill set of paramedics, their pay was uplifted within the ‘agenda for change’ pay bands, from band 5 to band 6. This represents an increase from around £32,000 a year (including a £7,500 enhancement for unsocial hours) to around £39,000 a year (including a £9,000 enhancement for unsocial hours). Until 2018–19, funding to cover these costs will be provided by NHS England (one-third) and the Department (two-thirds). The Chief Executive of Yorkshire Ambulance Service told us that after 2018–19, the expectation is that funding will come through efficiencies achieved by having a workforce with enhanced clinical skills. The Department cited the example of West Midlands Ambulance Service who already pay their paramedics at band 6, and fund this from their existing resources.
15.Most ambulance trusts are struggling to recruit the staff they need and then retain them. For example, the paramedic vacancy rate was 9.3% in 2016 and paramedics remain on the immigration shortage occupation list. One of the contributing factors to recruitment and retention issues is the demanding nature of working within the ambulance service. NHS England the Chief Executive of Yorkshire Ambulance Service noted that ambulance staff: frequently work in isolation and make decisions on their own with limited support from senior colleagues; face high rates of violence and assault; and can struggle with stress and work-life balance. We also received written evidence identifying poor relationships between front-line staff and management, and confusion caused by organisational change as contributing factors. NHS England and the Chief Executive of Yorkshire Ambulance Service told us that workforce morale was one of their main concerns. Another contributing factor that NHS England told us about was that paramedics are increasingly being recruited by organisations outside the ambulance service, including acute hospitals, general practice, private ambulance services and by insurance companies (as injury assessors). NHS England told us that they have identified this trend as a risk, and a potential threat to the future workforce that needs to be monitored.
16.Staff shortages are made worse by high sickness absence rates in some trusts. In 2015–16, the ambulance service had a sickness absence rate of 5.5%, compared to 4.2% for all NHS clinical staff. While some of this may be explained by the demanding nature of the work, it is a much greater problem in some trusts, with sickness absence rates ranging from 3.7% to 6.7%.
17.NHS England, NHS Improvement and the Chief Executive of Yorkshire Ambulance Service told us that a number of initiatives were planned, or in train, to improve workforce morale, and thereby improve the retention of staff. These included providing: a new career framework for paramedics; greater support for newly qualified paramedics when they attend a patient; greater support for staff suffering from issues like post-traumatic stress disorder; and nationally consistent learning programmes. However, at present there is no programme to support the development of ambulance workers below the level of paramedic. NHS England told us that they believed Health Education England were planning to develop such a programme, but that it was dependent on funding.
19 Qq39–40, 60–65, 167; , paras 1.6–1.7
20 Qq49–54, 67–68
21 Qq60, 67–68, 89–90, 97–100, 127, 130; , para 1.19–1.20
22 Qq97, 100–103, 186; , para 1.13
24 Qq97–103; , para 1.13
25 Qq89–96; , para 1.17–1.18; Department of Health (ASS 05)
26 Qq155, 159, 217–219; University of Manchester (ASS 03)
27 Qq185, 209–211; , para 1.18
28 Qq137, 140, 152; , para 1.21, Figure 6
29 Qq108–109, 154–156, 158–159
25 April 2017