18.11.15
‘Out of date’ ambulance services tied to targets that create ‘perverse’ behaviours
Ambulance service provision is “out of date” and the current response targets can create “perverse” behaviours, according to the NHS Clinical Commissioners’ National Ambulance Commissioners Network (NACN).
Its ‘Developing an ambulance commissioning strategy: Five Year Forward View and beyond’ report calls for a refocus on commissioning and provider systems that support non-conveyance and provision of the right care closer to home as its principal aim for most patients.
Currently, there are 11 ambulance trusts in England and while CCGs are responsible for commissioning their services, the commissioning arrangements are based on a collaborative commissioning model.
Most contracts for emergency ambulance provision are negotiated on a regional basis by a lead CCG under collaborative commissioning arrangements, using either a block contract or cost and volume contract for a one-year duration, designed to deliver national performance standards at a regional level.
But the NACN report stated that ambulance commissioners and providers acknowledge that the current model of ambulance service provision and commissioning is out of date.
It added that “traditional transactional and competitive behaviours”, with antagonistic attitudes between providers and commissioners, will not deliver the ambitions contained in the Urgent and Emergency Care Review.
Therefore, system-wide changes to the payment mechanism and how these will be played in to system-wide savings will need to be developed along with a model of risk and reward sharing among providers and commissioners.
Jane Hawkard, chair of the NACN and chief officer of NHS East Riding of Yorkshire CCG, said: “With the recent publication of the Urgent and Emergency Care Review, there is a real opportunity to seize the moment and to move at pace to make changes to the way in which ambulance services are commissioned and provided to the benefit of patients.”
She added that the NACN hopes the report will “support us all” in providing the public with a “sustainable modern, fit-for-purpose service that delivers high-quality care”.
It was noted that ambulance providers are monitored against three national standards: Red 1, Red 2 and A19, which require either an eight-minute or 19-minute response irrespective of clinical condition at a regional level.
However, the result is a response model designed to ‘stop the clock’ and potentially inefficient use of scarce resources.
Ambulance trusts are performance managed against these targets cumulatively, on an annual basis across their regional contract. But the NACN stated that the need to achieve these targets creates some “perverse behaviour”, such as multiple vehicles being dispatched to a single incident, often to be ‘stood down’ before arrival.
The organisation has called for a shift away from time-based targets for the majority of responses, to ones focused around patient and clinician experience and patient outcomes.
Additionally, NACN wants to see a focus on an improved triage that will be consistent, systematic and focused on the right response for the patient, and a workforce and training plan developed with commissioners that supports the shift to new models of care which are realistic in terms of timescales.