Commissioning

NAO: Ambulance sustainability unlikely until CCGs see its importance

Ambulance services are struggling to cope with rising demand for urgent and emergency services, the National Audit Office (NAO) has stated.

The NAO found that demand for ambulances is growing rapidly due to increasing numbers of elderly patients, growing alcohol and mental health issues and a difficulty in accessing GP services, with 10.7 million ambulance calls and NHS 111 transfers logged in 2015-16.

The spending watchdog warned that the wider health sector does not currently use ambulance services’ experience sufficiently or recognise how they are impacted by changes to local services.

Amyas Morse, head of the National Audit Office, said today: “Ambulance services are a vital part of the health service but much of their ability to work better greatly depends on other parts of the health system.

“Until CCGs see ambulance services as an integral part of that system it is difficult to see how they will become sustainable and secure consistent value for money across the country.”

The NAO found that while demand for ambulances has risen, funding has not with NHS England boss Simon Stevens noting that future financial settlements are likely to be even tighter.

This has led to ambulances performing worse against key targets with only one ambulance trust – West Midlands Ambulance Service, rated Outstanding by the CQC earlier this week  – meeting response time targets last year, despite new models of care which are helping to stem the tide.

The watchdog noted wild variation in performance between ambulance services due to each having their own operating framework, with a 10.4 percentage point swing between the best and worst performing trusts in responding to the most urgent ‘Red 1’ calls within the eight minute target.

However, the NAO said that commissioners and regulators place “too much focus” on time targets which have no clinical benefit to patients, also highlighting other issues afflicting ambulance services such as inefficient transfers of care at A&E departments and a struggle to recruit and retain staff.

Yvonne Rispin, chair of the NHS Clinical Commissioners National Ambulance Commissioners Network (NACN), said that ambulance services are a “vital component” of the NHS and CCGs are working hard with trusts and other bodies to find solutions to ongoing issues, such as linking the performance of services to patient outcomes rather than solely time-based targets.

“Our role as commissioners is to work in collaboration to find solutions to the immense challenges that we are all facing across health and care, and the NAO report clearly demonstrates the pressures facing the ambulance service, many of which are as a result of those wider challenges,” Rispin said.

Other commentators saw wasted ambulance hours queueing outside A&E as mere symptoms of a systemic problem, urging the government to invest in social care and reduce the number of patients unnecessarily kept in hospital.

“The answers to improving performance don’t just sit with ambulance services,” said Phil McCarvill, deputy director of analysis for the NHS Confederation. “If we are to relieve the current pressures on ambulance services, we also need to see the right balance of resources going into community, primary care and social care."

RCP registrar Dr Andrew Goddard added that the new report is “yet more evidence of the increasing strain the NHS is under at present, as we outlined in our letter to the Prime Minister two weeks ago”. 

“Any physician will recognise the situations described by the NAO – the inadequacy of social care provision has led to beds being filled by patients who are medically well but unable to be transferred to more appropriate care for their needs,” he said. “This has a knock-on effect throughout the hospital, with the A&E dept eventually unable to find any beds to transfer their patients into, leading to trolley waits and use of inappropriate care rooms – our hospitals are desperate.” 

But Prof Keith Willett, of NHS England, admitted the ambulance service is facing significant pressures, “partly because too many ambulances are dispatched to simply hit targets, rather than attend those patients most in need, with 25% of dispatched blue light vehicles being stood down before they reach the scene”.

“That is why we're carefully testing a change to the way in which ambulance services can respond,” he said.

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