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Single commissioning framework can ‘level the playing field’ for strained ambulances

NHS ambulance trusts should be not tied together by a single national standard operating framework, but instead by a standard commissioning framework that reflects the range of services they provide, the head of the Association of Ambulance Chief Executives (AACE) has said.

Martin Flaherty, AACE’s managing director, broadly welcomed a report by the National Audit Office (NAO) on ambulance service sustainability, published yesterday. He stated that the auditor helped underline several prominent issues in the ambulance sector, such as an ever-growing demand for services but insufficient funding injections.

But he dismissed the report’s suggestion that the use of different operating frameworks across ambulance trusts is contributing to variations in their performance. While the NAO argued that NHS England, NHS Improvement (NHSI) and English ambulance trusts should partner up to define an “optimal operating framework”, Flaherty said this could be difficult to implement due to regional variations in health economies.

NHS England has put in place an urgent and emergency care strategy that aims to integrate all emergency care services and provide care closer to home, but ambulance trust take-up of this has been patchy.

“Each trust has developed its own operating framework which is contributing to variations and inefficiencies in performance,” said the NAO. “Key operating framework variables include workforce mix, fleet mix and estate.”

AACE’s boss, however, claimed that these issues could be better addressed by improvements in the way ambulance services are commissioned. In practice, this would mean developing a “standard, collaborative commissioning framework” capable of reflecting the range of services the ambulance sector provides – for example, giving clinical advice by phone, treating on scene, referring to other services or conveying to hospitals.

“This would mean all trusts are commissioned and monitored in the same way, which does not happen at present,” continued Flaherty. “This framework would better inform the development of the optimal operating framework to meet local requirements across the multiple STPs in each ambulance region.

“This would level the playing field for all ambulance trusts and help the sector measure performance and outcomes in a uniform way, while improving health and care services for local people.”

In its statement, AACE also emphasised one key area left unaddressed by the NAO report: the “issue of how ambulance trusts can be effectively and efficiently engaged within the multiple and complex commissioning and planning structures in their regions”.

“Changes in the way ambulance services are commissioned and operate, to transform the delivery of out-of-hospital urgent care, are essential if our ever-increasing numbers of patients are to receive the right care, in the right place, at the right time – the fundamental aims of the Five Year Forward View and the Urgent and Emergency Care Review,” added Flaherty.

“Such changes and aspirations are being embraced and attempted by the sector, but they cannot be achieved in isolation, without the tangible support of NHS England, NHSI, commissioning bodies and colleagues in other sectors.”

Elsewhere, Flaherty praised the auditor’s report for recognising the “rapid and sustained increase in demand” for ambulance services, which “has not been matched by proportionate increases in funding and therefore resourcing”. He stressed that this is an issue which “needs to be addressed urgently”.

Recognising the experience of ambulance trusts

As previously reported by NHE, the main headline from the NAO report, amongst other things, included the fact that the wider health sector does not currently use ambulance services’ experience sufficiently, or recognises how they are impacted by changes to local services.

“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,” Amyas Morse, the auditor’s boss, said yesterday.

But Yvonne Rispin, chair of the NHS Clinical Commissioners (NHSCC) National Ambulance Commissioners Network, said CCGs “do see ambulance services as an integral part of the health system”, adding that their role is to work in collaboration to find solutions for the “immense challenges that we are all facing across health and care”.

Although the CQC has recently rated the first-ever ambulance trust as ‘outstanding’, many find themselves in a troubling position as A&E demand continues to swell – especially during winter months.


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