• Audit

In June the National Audit Office published a 48-page document called ‘Transforming NHS Ambulance Services’. It is forthright and clear in what it has to say and, depending on your perspective, it offers either a threat or an opportunity for ambulance services to respond.1

A contemporaneous press release indicates that the report is being taken seriously by the Public Accounts Committee, itself part of the National Audit Office; it wants to explore with the Department of Health (DH) how ambulance services intend to achieve efficiency savings without damaging the quality of the services they provide (with the context that the number of emergency calls has been increasing at a rate of 4% a year), and how it intends to achieve better integration of ambulance services with other parts of the emergency care system. Ominously, perhaps, if you are a senior DH official, the Committee looks forward to exploring these vital issues with senior officials when they come before it.

So what does ‘Transforming NHS Ambulance Services’ have to say for itself? There is a lot in it to digest; here are a few selected highlights from the summary:

• In England in 2009–10 the cost of ambulance services was £1.9 billion, of which around £1.5 billion was for urgent and emergency services.

• 7.9 million emergency ‘999’ calls were received, leading to 6.4 million ambulance incidents and 4.7 million emergency or urgent journeys.

• The number of emergency or urgent calls has increased by 4% a year since 2007–8.

• The services are pivotal to the performance of the entire urgent and emergency care system.

• Performance over the last decade has been driven by response time targets and not outcomes.

• The services must achieve a minimum of 4% efficiency savings in its budget (around £75 million per year).

• The cost per call across services ranges from £144 to £216 and the cost per incident from £176 to £251.

• Advanced practitioners are used in different ways by different services and often in ways that do not make full use of their skills.

• The services now handles the increased telephone calls by providing advice (hear and treat), treating patients at the scene (see and treat) and moving patients to a wider range of destinations; the percentage of calls treated in these ways varies considerably between services.

• Overtime costs nearly £80 million per year; high sickness rates contribute to poor resource usage; reliance on overtime and sickness rates for staff varies by 60% between services.

• There is scope for standardisation and efficiency as evidenced by variations between services in costs per call, the way resources are deployed to meet demand, the take-up of different approaches to call responses and reliance on overtime.

• The services must take more opportunities to learn from each other.

• Over one-fifth of patient handovers at A&E departments take longer than the 15 min recommended. If ambulances are queuing outside hospitals, they are not available to respond to other calls. There is scope to reduce the time taken by ambulance crews from patient handover at the hospital to being available for their next job.

• The ability to improve performance is limited by a lack of data on patient outcomes and a lack of comparative information that can be used to benchmark performance.

• The services provide a life-saving service to some patients, is highly regarded by the public and rightly remains committed to providing a rapid response to urgent and emergency calls at a time of steadily growing call volumes; but, until April 2011, the DH's emphasis on response time as a measure of performance rather than on a more rounded view of clinical outcomes meant that the incentive structure did not encourage resource optimisation.

• The DH (and in future the NHS Commissioning Board) must bring about a better service model by ensuring that existing specialist knowledge of ambulance commissioning is not lost. These arrangements should operate in an overarching urgent and emergency care strategy to encourage integrated and consistent services.

• Commissioners must ensure that work to develop local directories of services continues at pace and that alternative destinations to A&E departments are available.

• The new measures and performance regime must be carefully thought through to deliver the right balance to preserve rapidity of response, but only as one element of a more rounded response model.

• The DH needs to establish how the ‘call connect’ process during call initiation can be adjusted to allow more flexibility.

As the report says, achieving efficiencies across the ambulance service will require strong leadership and the greatest challenge for the service over the next 4 years will be to improve efficiency in their resource bases while managing demand in a different way.

The gauntlet has been thrown down. Good luck.