Select committee inquiry
Ambulance Services Study inquiry
Closed
What the inquiry looked at
“Ambulance services are finding it increasingly difficult to cope with rising demand for urgent and emergency services, according to the National Audit Office. Demand for ambulance services continues to grow rapidly. Contributing factors may include the increasing numbers of elderly patients with multiple conditions, an increasing number of alcohol- and mental health-driven issues, the availability of primary care services in the community and how patients seek help. Between 2009–10 and 2015–16, the number of ambulance calls and NHS 111 transfers increased from 7.9 million to 10.7 million. Increased funding for these services has not matched rising demand, and future settlements are likely to be tougher. Introducing new models of care, such as resolving calls over the phone by providing advice to callers, has helped but there are signs of stress, including worsening performance against response time targets. In 2015–16, only one ambulance trust met the three response time targets. National Audit Office report The National Audit Office's report , however found a general consensus that commissioners, regulators and providers place too much focus on response times. The majority of patients currently coded as Red 2 do not derive clinical benefit from the arrival of an ambulance within 8 minutes, but the 8-minute target has led to a range of behaviours which undermine efficiency, such as dispatching resources before it has been determined what the problem is, whether an ambulance is required; and dispatching multiple ambulances to the same patient and then standing down the vehicles least likely to arrive first. In 2015–16, around 500,000 ambulance hours were lost due to turnaround at accident and emergency departments taking more than 30 minutes, which equates to 41,000 12-hour ambulance shifts. Transferring the care of a patient from an ambulance to an accident and emergency department is expected to take no longer than 15 minutes, with a further 15 minutes to prepare the ambulance for the next call. In addition, most ambulance trusts are struggling to recruit and retain the staff they need. The NAO report also found that each of the 10 ambulance trusts in England has developed its own operating framework, with differences in workforce mix, fleet mix and estate. These differences have contributed to variations and inefficiencies in performance. For example, across ambulance trusts in 2015-16, the proportion of incidents where one or more vehicles were stood down after mobilisation varied from 4% to 46% and the proportion of call handled over the phone varied from 5% to 15%.”
The committee's words, from the inquiry page on parliament.uk ↗.
What it found
In the committee's words, from the summary of 62nd Report - NHS ambulance services ↗
Ambulance services provide a valuable, life-saving service that is held in high regard and plays a vital role in the entire urgent and emergency care system. Since this Committee last examined ambulance services in 2011: funding increases for the urgent and emergency services provided by ambulance trusts have not kept up with increasing demand; ambulance trusts increasingly struggle to meet response-time targets, despite focussing on these targets to the detriment of wider performance; and significant variations between trusts, in both operational and financial performance, persist or have got worse as insufficient work has been done to understand and reduce variation.
Action is being taken by NHS England, NHS Improvement and ambulance trusts to address the performance and long-term sustainability of the ambulance services but it has taken too long to begin addressing the issues identified by this Committee in 2011.
We recognise ambulance services and national bodies are inherently reliant on the rest of the health system to deliver new care models and services outside of hospital in order to support a more sustainable ambulance service.
What the government said
No government response is linked to this report.
How the inquiry ran
Each dot is a dated item listed on this page, from the inquiry's opening on 21 February 2017 to its close on 4 January 2018.
- Oral evidence 20 Mar 2017
- Report 27 Apr 2017
What it recommended 4 recommendations · 20 conclusions
1Ambulance trusts have organised themselves to meet response-time targets, at the expense of providing the...
Concluded (the committee's words)
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.
2Despite this Committee identifying significant variations in ambulance service performance and efficiency in 2011, the...
Recommended (the committee's words)
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. 6 NHS ambulance services
3Various ambulance service improvement programmes are now underway, but this has taken too long to...
Recommended (the committee's words)
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.
4To deliver new ways of working, ambulance services will need a different mix of skills...
Concluded (the committee's words)
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.
5Ambulance services have struggled to recruit and retain staff, and staff shortages are exacerbated by...
Recommended (the committee's words)
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 NHS ambulance services 7 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.
6Many patients are waiting too long to be transferred from an ambulance to hospital care,...
Recommended (the committee's words)
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.
7Ambulance services are pivotal to the wider health system but it is not clear how...
Concluded (the committee's words)
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. 8 NHS ambulance services 1 Performance
8Each ambulance trust has developed its own operating framework, which has contributed to these variations.
Concluded (the committee's words)
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 8 Qq16–21; C&AG’s Report, para 3.4 9 Qq7, 105–107 10 Qq21, 40, 57, 108; C&AG’s Report, para 3.5 11 Qq177–180 12 Qq176–177; Committee of Public Accounts, Forty-sixth Report of Session 2011–12, Transforming NHS ambulance services, HC 1353, summary; paras 4–7 13 Qq136, 151; C&AG’s Report, paras, 3.3, 3.6, 3.8, Figure 4, Figure 13, 10 NHS ambulance services 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.14
9In addition, ambulance services are not commissioned consistently across England, with differences in how trusts...
Concluded (the committee's words)
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.15
10In moving to standard operating and commissioning framework, there is a risk of imposing a...
Concluded (the committee's words)
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.16 Improvement programmes since the previous Committee’s report in 2011
11Many of the key issues discussed at our evidence session, and in the accompanying National...
Concluded (the committee's words)
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.17 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 2016.18 14 Qq65–66, 70; C&AG’s Report, para 3.4, 3.6 15 Qq70–71, 81, 136; C&AG’s Report, paras 1.15 16 Qq158–165 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, C&AG’s Report (2017), paras 1.6, 1.14, 3.5 NHS ambulance services 11 2 New ways of working Adopting new ways of working
12The Urgent and Emergency Care Review and likely changes from the Ambulance Response Programme will...
Concluded (the committee's words)
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 30.19 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.20
13NHS England and NHS improvement told us that Health Education England had set up a...
Concluded (the committee's words)
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.21
14In addition to increased number of paramedics, from 31 December 2016, in recognition of the...
Concluded (the committee's words)
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).22 Until 2018–19, funding to cover these costs will be provided by NHS England (one-third) and the Department (two-thirds).23 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.24 Workforce challenges
15Most ambulance trusts are struggling to recruit the staff they need and then retain them.
Concluded (the committee's words)
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.25 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 19 Qq39–40, 60–65, 167; C&AG’s Report, paras 1.6–1.7 20 Qq49–54, 67–68 21 Qq60, 67–68, 89–90, 97–100, 127, 130; C&AG’s Report, para 1.19–1.20 22 Qq97, 100–103, 186; C&AG’s Report, para 1.13 23 Qq97 24 Qq97–103; C&AG’s Report, para 1.13 25 Qq89–96; C&AG’s Report, para 1.17–1.18; Department of Health (ASS 05) 12 NHS ambulance services 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.26 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.27
16Staff shortages are made worse by high sickness absence rates in some trusts.
Concluded (the committee's words)
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%.28
17NHS England, NHS Improvement and the Chief Executive of Yorkshire Ambulance Service told us that...
Concluded (the committee's words)
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.29 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.30 26 Qq155, 159, 217–219; University of Manchester (ASS 03) 27 Qq185, 209–211; C&AG’s Report, para 1.18 28 Qq137, 140, 152; C&AG’s Report, para 1.21, Figure 6 29 Qq108–109, 154–156, 158–159 30 Qq156–157 NHS ambulance services 13 3 The ambulance service within the wider sector Transfer of ambulance patients to hospital care
18When an ambulance conveys a patient to hospital, transferring the care of that patient from...
Concluded (the committee's words)
When an ambulance conveys a patient to hospital, transferring the care of that patient from the ambulance to the hospital emergency department should take no longer than 15 minutes. Each failure to meet the 15-minute standard results in a poor experience for the patient waiting in the ambulance, and a delay in an ambulance crew being available for a new emergency call. However, just 58% of patient transfers were completed within 15 minutes in 2015–16, compared to 80% in 2010–11.31
19NHS England told us that ambulances not being able to transfer patients to hospital care...
Concluded (the committee's words)
NHS England told us that ambulances not being able to transfer patients to hospital care quickly enough is one of their most serious concerns across the urgent and emergency care system, because, unlike patients already in a hospital or in an ambulance, patients in the community waiting for an ambulance are at greater risk as they are not being cared for by medical staff. NHS England and NHS Improvement told us that, to address this issue, much firmer performance management of the system was taking place. This requires hospital trust executives, such as the medical director, to engage with the ambulance service during periods when the hospital is missing the patient transfer-time target. Another key approach in preventing delayed patient transfers is to ensure that patients can be moved from the hospital emergency department onto wards, and then out of the hospital and into appropriate social care in a timely fashion. NHS England told us local Sustainability and Transformation Plans will bring together local authorities and the healthcare system, to avoid blockages of patient movement in the system.32
20After the patient has been handed over, ambulance crews are expected to make their vehicle...
Concluded (the committee's words)
After the patient has been handed over, ambulance crews are expected to make their vehicle ready for the next call within another 15 minutes. In 2015–16, this was achieved in just 65% of cases, with wide variation in the performance of individual ambulance trusts. Collectively, hospital delays in accepting care of the patient, and ambulance delays in preparing their vehicle, meant almost half a million ambulance hours were lost in 2015– 16, NHS Improvement told us they are focussing their efforts on patient transfers as this is where most of the time is lost.33
21In 2011, the previous Committee recommended that a quality indicator should be developed for hospital...
Concluded (the committee's words)
In 2011, the previous Committee recommended that a quality indicator should be developed for hospital performance in meeting the transfer-time target; this has not happened. The Department and NHS Improvement told us that data was being used operationally, but that NHS Improvement was working through the detail of how this data could be incorporated into official statistics.34 Integrating ambulance services into the wider health system
22The Urgent and Emergency Care Review sets out NHS England’s ambition to integrate urgent and...
Concluded (the committee's words)
The Urgent and Emergency Care Review sets out NHS England’s ambition to integrate urgent and emergency care systems and provide care as close to home as possible. To help deliver this ambition, NHS England established 23 urgent and emergency care networks, 31 C&AG’s Report, para 1.22–1.23 32 Qq86, 113–116, 121–122, 217 33 Qq117–119; C&AG’s Report, para 1.23–1.24, Figure 7 34 Qq87–88, 123; C&AG’s Report, para 1.26 14 NHS ambulance services to provide strategic oversight at a regional level. These networks are expected to include at least one ambulance trust and are supported at an operational level by Accident and Emergency Care Delivery Boards.35 NHS England has also introduced 44 Sustainability and Transformation Plan ‘footprints’, each of these has produced a plan setting out how local services will change and improve over the next five years, to meet rising demand within the resources available.36 NHS England has produced guidance to support the development of these Sustainability and Transformation Plans, and has asked urgent and emergency care networks to provide expert advice to them on urgent and emergency care.37
23Effective collaboration is key to ensuring that all urgent and emergency services are connected and...
Concluded (the committee's words)
Effective collaboration is key to ensuring that all urgent and emergency services are connected and integrated. Ambulance services find it challenging to engage effectively with all their stakeholders. The Chief Executive of Yorkshire Ambulance Service told us that his trust deals with 20 clinical commissioning groups, about 15 accident and emergency delivery boards and four Sustainability and Transformation Plans systems. It is not always there for the day-to-day planning discussions with all its stakeholders, which means it is “playing catch-up”.38
24It remains unclear how locally driven Sustainability and Transformation Plans will fit with the national...
Concluded (the committee's words)
It remains unclear how locally driven Sustainability and Transformation Plans will fit with the national aim of connecting and integrating all urgent and emergency care services and getting a more consistent service offer across regions. Moreover, plans are being taken forward in different ways across the country, and ambulance services have been insufficiently involved with local planning, meaning it is not clear how the ambulance service will be integrated into the wider health system.39 35 C&AG’s Report, para 1.6, 3.12, 3.14 36 Qq116, 138; C&AG’s Report, para 3.12, 3.14 37 Q137; C&AG’s Report, para 3.14 38 Q126; C&AG’s Report, para 3.13–3.15 39 Qq126–130, 167–173; C&AG’s Report, para 3.14 NHS ambulance services 15
Evidence
Oral evidence sessions 1
- 20 Mar 2017No witnesses recordedparliament.uk ↗