Oral evidence: Ambulance Services Study, HC 1035
Oral evidence, 20 March 2017.
Witnesses
Chris Wormald, Professor Keith Willett, Rod Barnes and Miles Scott.
Chair
Good afternoon. Welcome to the Public Accounts Committee on Monday 20 March 2017. We are here to look at ambulance services, on the back of a study by the National Audit Office that followed up from a Public Accounts Committee Report in 2011 when we last looked at this. It is of particular interest to Mr Richard Bacon, who is the deputy Chair of the Committee, because he has had such challenges in his area. We encouraged the NAO to do the Report without, I have to say, any resistance from them. Our witnesses today are, from my left to right, Professor Keith Willett, who is the medical director for acute care at NHS England. Welcome, Professor Willett. I think this is the first time you have appeared before the Committee.
Professor Willett
No, there was a time before.
Chair
Forgive me; I should have remembered that. Chris Wormald, who is a regular visitor to the Committee, is permanent secretary at the Department of Health. Rod Barnes is the chief executive of the Yorkshire Ambulance Service NHS Trust, but I think he also speaks for the chief executives of the other nine English ambulance services, other than the Isle of Wight. I should say that the Report covers 10 ambulance services in England but not the Isle of Wight, which has a slightly different arrangement, so we are not covering it today; apologies to residents of the Isle of Wight. Miles Scott is the improvement director at NHS Improvement. Our hashtag today is #ambulances. I will hand straight to the deputy Chair, Richard Bacon, to kick off.
Mr Bacon
Professor Willett, perhaps I can start by asking you, and then I might come to one or two others to answer the same question. Do targets help, or do they make things worse?
Professor Willett
I think targets can be very beneficial. As David Nicholson indicated last time the Committee looked at ambulances in 2011, when you are a long way from something, a target helps to move the service towards it. However, they can be rather blunt instruments and tend to be quite narrow. As a result of that, as you get closer to them, and as the performance gets in that park, they can start to distort. There is a plus and a minus to targets. From my perspective as a clinician, targets need to be clinically credible and they need to be sensitive. They need to be doing what you want for—in the ambulances’ case—the sickest patients, but not at the expense of those patients who clearly have a need, but which may not be of the same priority.
Mr Bacon
Mr Barnes, do targets help or do they make things worse?
Rod Barnes
I think they generally help. There has been a view in the ambulance sector for a number of years now that the current Red 1/Red 2 category response times put too high a proportion of patients in the highest category of call. That, in itself, can lead—
Mr Bacon
In other words, in Red 1?
Rod Barnes
Particularly in Red 2.
Chair
Perhaps it would be helpful to be clear what Red 1 and Red 2 are. We have read the Report and know this, but for those who might not.
Mr Bacon
Can you just say for the record what Red 1 and Red 2 are?
Rod Barnes
Red 1 is the highest clinical urgency of call, such as for patients having cardiac arrest. The Red 2 category can include patients having strokes or heart attacks, but there are also an awful lot of other categories of patients that fall into Red 2. In terms of a typical ambulance patient workload, for want of a better term, close to 50% of calls coming in to 999 would fall into the Red 1 or Red 2 categorisations.
Mr Bacon
Your statement a moment ago was that there is a widespread view in the ambulance service, which has been growing for some years, that—I think you used the phrase—“too high a proportion” of the totality ends up in the highest category. I thought that is what you said, which is why I asked whether you meant Red 1.
Rod Barnes
Apologies. I would classify Red 1 and Red 2 together as the—
Mr Bacon
I see. So “too high a proportion” of the totality of calls ends up being triaged into Red 1 or Red 2?
Rod Barnes
That’s correct. That view is certainly shared by clinicians in the service. Clinicians are responding under blue light conditions for patients who ultimately, on clinical grounds, do not need a response in eight minutes. That is actually diverting resources away from perhaps higher priority patients, based on their condition.
Mr Bacon
Mr Scott, do targets help or do they make things worse?
Miles Scott
I think, with the caveats that were particularly pointed out by Professor Willett, I would say they help. They help to concentrate the mind. I am sure we will talk a lot this afternoon about the impact of targets on ambulance services themselves. The comment I would make is that they help to concentrate not just the minds of people like Rod, to my right, but those of the wider service. I think services like ambulance services easily disappear from view if one is not careful because of the public emphasis on hospitals and acute care. So long as the targets are clinically relevant, well-constructed and so on, as Professor Willett said, I think it is a very helpful way of having a public dialogue around important services such as the ambulance service.
Mr Bacon
Mr Wormald, I wouldn’t say you are itching to get in, but you should have an opportunity to answer the question as well.
Chris Wormald
Thank you. I think the devil is in the detail. A target is a proxy for a set of behaviours that we are trying to incentivise a set of people to undertake. I suspect the point of your question is whether the ambulance targets do that and incentivise the behaviours we want to see, rather than the ones we don’t.
Mr Bacon
Quite. Do they incentivise behaviours that we don’t want to see? My own trust, the East of England trust, is quite big and covers a very large area of the counties of the east of England. We had 15 paramedics from East of England together with the Minister in a room along this corridor—it may well have been this one—explaining to the Minister what was wrong. One of the things they said was that the targets incentivised the wrong behaviour, so that a crew could be out in either an ambulance or a rapid response vehicle and move from one location where they had been told to go to another, and before they got there, being reinstructed to go to a third and then a fourth, so that they sometimes spent half the day going from pillar to post and not actually reaching a patient. They were doing seven sides of an octagon without ever actually doing anything. Any system that could create those sorts of behaviours has plainly got something wrong with it, has it not?
Chris Wormald
The kinds of issues you are pointing to is why Professor Willett has been leading a very large programme on what we might do with the ambulance response performance framework, which I am sure he will describe. We discussed with the Committee before the need for some balance to be struck between consistency of targets and the public understanding of targets—we don’t want to change the framework all the time—and needing to update them for the reasons that you say. As I have said, this is a live debate at the moment, and Professor Willett has been leading a large programme to look at whether there is a better way of doing this.
Mr Bacon
Professor Willett, you look like you want to come in, so I will keep this short. It seems to me that, several years after it seemed quite fragile, it still seems quite fragile. I remember Mr Anthony Marsh, who is the chief executive of the West Midlands service, coming into East of England as an interim, temporary chief executive. It got so bad that we had a debate in Westminster Hall, and Anthony Marsh wrote a report questioning whether the board knew what they were doing and why they were there. I saw him give evidence in a House of Lords Committee Room down the corridor, in which he sat next to the Minister and said, “If it is a choice between meeting these targets”—he meant the existing ones that we have now; the eight minutes and the 19 minutes—“and providing an effective service, I am going to provide an effective service”. He said this with the Minister sitting next to him. That was some time ago. I do not feel that we have got to a new point yet, where we can say, “Aha. Things are better because”, and then complete that sentence.
Chris Wormald
We have been trialling for over a year. Actually, Anthony both hits the target and provides quality.
Mr Bacon
I know, and one of the interesting bits of data on this is how consistently West Midlands is better than most of the others. We might get into why.
Chris Wormald
Of course, as well as the targets, one of the very big things that has been added to the mix since this Committee last discussed it is the CQC regime around ambulances, which, from 2013, has been looking at a much wider basket of things concerning whether a trust is well run or not. That is the other thing we have to say about targets: they are but one part of the picture here. The story that the CQC tells across the ambulance service is at least as important as the targets and they, of course, look at the actual quality of care delivered as well as the things that the target regime covers. But we do not fundamentally disagree with you that all this needs looking at, which is why we have—
Professor Willett
On the ambulance response programme, we are confident, I think, in saying that it is the largest prospective trial of a system change in any ambulance service in the world.
Mr Bacon
How long has it been running so far?
Professor Willett
We are now into about 18 months and we have looked at and followed through to outcome 10 million ambulance calls.
Mr Bacon
So you have big data.
Professor Willett
So 10 million ambulance calls, and we have looked at them with more than 30 measures. This is looking not just at the target—the crude performance level—it is looking at 30 measures that include things like the performance of the ambulance service, efficiency of utilisation of the assets of the ambulance service, clinical outcomes for patients and the experience of staff working in the different systems. The ambulance response programme we will discuss, I am sure, at whatever point the Committee chooses this afternoon, but in essence it takes the issues. Perhaps I could just explain, because it is not quite as straightforward as, “You have a target and therefore it either doesn’t work or does work”. The issue in the system is that currently the ambulance services have a 75% target for eight-minute response to those calls in categories Red 1 and Red 2. For those patients in category Red 2, the ambulance service has 60 seconds from the point at which the call is connected to them to come to a decision about the right thing to send.
Mr Bacon
And then the clock starts.
Professor Willett
The call handler is taking the information from the patient—perhaps an old lady downstairs and a poorly husband upstairs—and in 60 seconds you have to get an awful lot of information across to come up with something that says, “This is what we think is wrong with the patient and this is what they need”. At the end of 60 seconds, while the call handler is still taking that call, the dispatch desk has no choice but to discharge an ambulance on blue lights and sirens. Many of you will have experienced driving along the road and pulling over to allow an ambulance to pass you with blue lights on, only to find 400 yards down the road that it has pulled over and stopped and you think, “What was all that about?”
Mr Bacon
Back to my point about effectiveness—
Professor Willett
One in four ambulances that are currently dispatched on blue lights and sirens does not get to the scene because it is stood down beforehand. That is immensely frustrating and highly efficient and many ambulances—
Mr Bacon
Sorry, did you say highly inefficient?
Professor Willett
Inefficient, yes, and frustrating for the crews. That ambulance may well have been going to treat a lady who had been on the floor for a couple of hours, who did not have the same priority as perhaps what was possible in that 60 seconds that had not been determined. So that creates enormous inefficiency—
Mr Bacon
Yes, back to my original question: are targets helping, or are they making things worse? Your own description, just then—
Professor Willett
When you have headroom in the system, and the system is not under immense pressure, you can afford targets to be blunt and still respond without detriment to patients who have a lower priority, but, as the Report clearly shows, demand has increased in terms of callers by 30%—
Mr Bacon
Hang on, can I just stop you there? Let’s imagine that you have headroom in the system—I realise that you don’t. What you are saying is that if you have headroom you can afford to have one in four of your ambulances set off and then stood down.
Professor Willett
Yes—
Mr Bacon
Right, well most taxpayers would say, “No, you can’t”. What you ought to have is an efficient and effective response regarding each ambulance that starts off, or each vehicle that starts off—it doesn’t have to be an ambulance; it could be a rapid response vehicle, and it might be a RRV that was differently configured so that it was capable of putting somebody on a stretcher if required, but we don’t have that at the moment. Why would you accept a model in which it was okay to have one in four journeys started and then stood down? To the lay person, that sounds extraordinarily inefficient, even if you have got headroom.
Professor Willett
Because at that point, when it is dispatched, the clinical knowledge about the patient puts them into a life-threatening or serious category, and therefore the ambulance service’s clinicians and dispatchers have an absolute priority to get something to that patient as soon as possible. In an urban area, with traffic difficulties and ambulances at different distances, you do not know who is going to get there first. If it is in that category, the ambulance service has always tried to get something there quickly, and they will therefore often put out multiple vehicles to try to do that.
Mr Bacon
Back to your 60 seconds, what you are saying is that in the ambulance response programme, you are measuring or finessing that 60 seconds and seeing what a better time is, whether it is 180 seconds or—
Professor Willett
It would be much more than that, I suggest. There are three parts to the ambulance response programme that we have now piloted and tried right up to the complete set of three being in ambulance services over the past 18 months, with the Secretary of State’s permission. The first thing is something called “dispatch on disposition”. It is a silly term, but what it means is that rather than just giving them 60 seconds—we know from looking at this that the length of time it takes to make the right decision is often more than 60 seconds—we have trialled longer periods in order for them to come to the right decision. That is part of this big study that is independently being scrutinised by the University of Sheffield through its centre for urgent and emergency care.
Mr Bacon
I am sorry to move you on, but we have a lot of ground to cover. After 18 months and 10 million data points, do you have enough information?
Professor Willett
We do. Their report will be coming to us very shortly, and we would hope for it to be published in the next month.
Mr Bacon
But are you expecting that it will probably be 180 seconds?
Professor Willett
We are expecting them to indicate that additional time is appropriate. It looks like an additional 180 seconds is what is appropriate. That is the first thing.
Chair
Can we just be clear? This report will be published, you think, in a month.
Professor Willett
In the next month, we expect.
Chair
When will you make decisions and how long will it take to get those decisions into the system?
Professor Willett
We will need to look at that report and fully evaluate it—
Chair
How long?
Professor Willett
Then we will need to take that to the Government.
Mr Bacon
The report will be published during April 2017, and then you will need to think about it internally.
Professor Willett
No, we will have done the thinking by that time, because we have been working with this—
Chair
We do not need very long answers. In April, it will be published and will go to Ministers with advice. It does not need any primary legislation, does it, Mr Wormald?
Chris Wormald
There were some changes in this that will require secondary legislation, because it is set out in regulation.
Chair
Secondary, okay. That is quite easy when the Government have a majority.
Chris Wormald
What we are expecting is that the Secretary of State will need to receive formal advice from NHS England.
Chair
Roughly, what is the timetable, Mr Wormald?
Chris Wormald
We are expecting that advice in the next six weeks and a decision soon after that.
Chair
By the end of the year?
Chris Wormald
Certainly, yes.
Chair
Just to be clear, Professor Willett, if one of us called an ambulance in an emergency now, how long—is the 180 seconds in addition to the 60?
Professor Willett
Yes, it is in addition.
Chair
So it is up to four minutes.
Professor Willett
The average length of time for them to reach what we call the correct disposition is only 60 seconds more than the 60 they already had.
Chair
So two minutes.
Professor Willett
Yes. The evidence to date is that that does not change the actual response, interestingly. It means that fewer ambulances are riding out on blues and twos, as we call it—with sirens—so ambulance crews are much more likely to know, at the end of that blue-light request they have been given, that they are going to find something that really—
Mr Bacon
To what extent—this may seem unfair, because I know you have your data points and you have been looking at this very hard—are you just moving the goalposts because you are not achieving the targets?
Professor Willett
That doesn’t interest me; I am a clinician. The whole concept of the ambulance response programme has come from the ambulance clinicians. It did not come from us. It came from Anthony Marsh, who is the chief executive of the Association of Ambulance Chief Executives, who came from the medical directors of the ambulance services. Those are the people who gave us the advice that we initially took, and we then took that advice to the Secretary of State.
Mr Bacon
What is causing the increase in demand for ambulance services?
Professor Willett
We have the same demands as there are in the rest of the healthcare system. We have an ageing population. The average age of patients is much older and they have multiple co-morbidities. We have more patients in general in society in that age group who are more frail, and relatively small events cause quite significant changes in dependency. Ambulance service demand has increased at about twice the rate of A&E attendances or hospital admissions—
Mr Bacon
Which themselves have gone up quite steeply.
Professor Willett
Hospitals are going up 2% or 3% and ambulances in the region of 5% or 6% year on year—
Mr Bacon
To what extent is it due to the increase in the population of the country? We are 5.3 million people more than we were in 2004.
Professor Willett
No, it is independent of that. This is a healthcare need. We also have a society that behaves differently. We have a bit of a “right now” society, with people expecting immediacy and seeking help.
Mr Bacon
I can see Mr Kwarteng coming in. I think he is interested in the fact that you do not think the population increase has anything to do with it.
Kwasi Kwarteng
The airy way in which he said that an increase in the population of 5 million people, which is almost 10%, in 12 years has nothing to do with it—
Professor Willett
No, it doesn’t have nothing to do with it. I’m sorry. I didn’t mean that it had nothing to do with it. Clearly there is proportional increase with that, but the demand that we see increasing in healthcare is over and above just a population number. It is the fact that we have an ageing population. I will give you some idea, 10 years ago, in the last few years of life people would go into hospital on average once or twice and now they will be in hospital three or four times. People are surviving illnesses and events that they would not previously have survived. Medicine has moved on. There is a distinct improvement in that. That is great, but the consequence is that the demand, particularly in the older population, has increased—
Kwasi Kwarteng
I hear civil servants dismiss this all the time, and constituents are acutely aware of it and talk about it all the time—
Chris Wormald
Very clearly, one element of the increased demand on health is demographic. I think that what Professor Willett is saying, which we would agree with, is that the bigger proportion of that demographic is the ageing of the population as opposed to the total size. An extra young, fit person does not add much to our demand, whereas the ageing population adds a lot. Clearly, any demographic change will add to our challenge, but it is more in the ageing population.
Mr Bacon
What can be done to manage this increasing demand before it reaches the ambulance service?
Professor Willett
Well that is part of what the urgent and emergency care review is doing, which I am leading on for Sir Bruce Keogh, the medical director of the NHS. We know that in terms of addressing the demand in the system we have to do something with every single element. We have to do something around self-care. We have to do something about members of the public seeking medical advice that does not require them to end up going to hospital. The 111 service is being transformed from what it is currently, which is a service that was very much about giving advice and directing people, to one that is going to have much more clinical involvement, with clinical advice behind it. That is the transition over the next two or three years. Patients phoning 111 will be put through and be able to speak a clinician, if that is appropriate, so they can get more accurate advice, do not need to be referred to A&E, do not need to have an ambulance called by the 111 service in many cases, and can get the closure of the consultation, if you like, on the phone, or in some way other than by transfer to hospital—in the community.
Mrs Trevelyan
On that, you have not mentioned the algorithm that is used by staff when triaging people, and how that has continually increased a drive towards calling out the ambulance, along with—
Professor Willett
Do you mean in the ambulance service or in 111?
Mrs Trevelyan
In the ambulance service, so that you are seeing this increased “hit the blue button” phenomenon.
Professor Willett
There are two computer-aided dispatch softwares used in the ambulance service. Five services use something called AMPDS and five use NHS Pathways. They are both well-established systems in the ambulance service, and the second part of the ambulance response programme, in addition to the dispatch on disposition extra time, is that we have built in at the front of them questions that increase the sensitivity to identify the highest risk patients first. The three objectives, if you like, of the ambulance response programme are that we need to focus on the sickest to make sure they are getting what they need, we need to provide the best—not just necessarily the fastest—thing for the rest, and we need to make sure that there are not very long delays and bring in that tail that has been talked about, particularly in rural areas.
Mrs Trevelyan
In order to assess that, are you driving an increase in the qualifications of staff? That went the other way for several years, leading to a reliance on the computer decision-making rather than applying—
Professor Willett
Are you talking about 111 again here or the ambulance service?
Mrs Trevelyan
Within both.
Professor Willett
The programme for call handlers is there. The algorithm is written by clinicians. It is a clinically based algorithm. The colleges wrote the algorithm. What we need to do is where—
Mrs Trevelyan
There is a very strong protection—
Professor Willett
Yes, because when it was designed it was not expected to have clinical input. What we are now doing is putting in a clinical advisory service that sits behind that, so that at a much earlier point in the conversation with the call handler if it is clearly a complex case, or a sick young child, or something like that, they will step out of the algorithm and pass that case to a clinician for management. That is where we are going with the system and that will apply to the 111 service.
Bridget Phillipson
On 111 and its predecessors, what has been the history of direct clinician involvement in call responses? How have the changes taken effect?
Professor Willett
Do you want to go back to NHS Direct?
Bridget Phillipson
Yes.
Professor Willett
NHS Direct was a service that was not an urgent call-line service; it was a general helpline service. So it got everybody phoning up about everything. It peaked at about four million or five million calls. It did put about three quarters—
Chair
Is that per annum?
Professor Willett
Yes. It put more calls through to a clinical adviser—nurses—but the problem there was that the system became overloaded and although it only got four million or five million callers at its peak, the callback times became so long that people were just going off and doing other things, such as going to A&E or calling an ambulance. That’s why the 111 system was designed. The 111 system has become very popular, despite what might be reported in the media. We now have over 14 million people calling 111 each year: 11% of them are issued an ambulance; 8% are sent to A&E; and the rest are managed in alternative ways. It is acting as a significant buffer, but again it is an indication of the increase in demand in society for health care, particularly of the “We want to know now, we want a response now” sort. We know that if people can’t access primary care or care in the community, many of them will seek care elsewhere.
Bridget Phillipson
This may be for Mr Wormald. Was it a mistake to have reduced clinician involvement in some of this decision making? Could we have foreseen that some of the problems that have arisen under 111 could have been prevented?
Chris Wormald
I’m not sure I can answer that question, because I wasn’t there at the time, but certainly NHS 111 has always had a bigger clinical involvement, and that was clearly a conscious decision of Government to do that. I couldn’t tell you about the decision making previously—
Chair
Ms Phillipson’s point is an important one that this Committee raises about cost shunting; you make a decision somewhere else and it causes pressure on the system. On that point, I will bring back Richard Bacon.
Mr Bacon
Given this rising demand that we’ve been talking about, Professor Willett, to what extent do you think the ambulance service has enough funding to deliver the required level of service?
Professor Willett
We have to live within the funding envelope we’ve been given. What the ambulance response programme is doing is making sure that we have the highest level of system efficiency. The third part of the ambulance response programme is very much addressing that. At the moment, if I can just complete the ARP description, at the end of the call you reach a code, based on the symptoms or the story given by the patient, which indicates what they think is likely to be wrong with the patient. In AMPDS, that is about 2,000-plus codes—
Mr Bacon
Can you just tell us what that is?
Professor Willett
It’s the advanced medical priority dispatch system. It’s just a system of prioritising calls. It’s the same as Pathways, but an alternative version. At the end of that call, a patient could get one of more than 2,000 codes in AMPDS; there are over 4,000 codes in Pathways. What you have in terms of a Red 1, Red 2 or Green response currently was a best guess by clinicians, looking at the case and saying, “This patient’s got this amount of bleeding”, and so on. “Therefore, I think it could be this or it could be that, and we probably should put it in that category”. What we did at the start of the ambulance response programme was to take a million calls. We did not look to say, “What did we give them?”, but, “When we got there, what did it turn out to be? What was the outcome of that call?”, so we knew if that response was appropriate. Now we have an evidence base behind what we send to a patient. So, rather than someone saying, “This is what we think you might need”, it is a case of saying, “That code normally requires”, and we send that. Both that and the dispatch on disposition, on the evidence that we have collected so far—we anticipate that evidence being set out in the Report—free up literally thousands of occasions when ambulances could be released into the system that otherwise would be directed elsewhere.
Mr Bacon
Can you just remind us what a fully kitted-out box ambulance costs?
Professor Willett
I’ll have to go to my chief executive colleague, because I’m afraid that I don’t buy them.
Mr Bacon
Mr Barnes?
Rod Barnes
It depends on whether you go for a van conversion or a box body.
Mr Bacon
I understand that there are two benchmarks.
Rod Barnes
If you use a figure of about £120,000, including the equipment in it—
Mr Bacon
Mr White, didn’t you say £99,000 and £135,000, depending?
Robert White
The box conversion is about £135,000, and the smaller, narrower vehicle is somewhere around £90,000 to £95,000.
Mr Bacon
And how much does a rapid-response vehicle cost? Those are these little Land Rover Freelanders, aren’t they? Small four-wheel drives.
Rod Barnes
Yes. Skoda Scouts are probably the most common ones—it is an estate car. Off the top of my head, probably about £50,000.
Mr Bacon
£50,000?
Rod Barnes
Maybe slightly less than that.
Mr Bacon
But they are not long enough to have a stretcher in, are they?
Rod Barnes
No.
Mr Bacon
So you can’t actually take a patient to hospital in them.
Rod Barnes
They are not normally used for conveyance. On occasion, if you have got a less critically ill patient who is walking, a paramedic will use them to convey people to hospital.
Mr Bacon
We occasionally have police cars used to convey people to hospital because there is no ambulance available. That’s probably not ideal either, but it happens. What I am curious about is why we don’t have a vehicle that has a long enough wheel base and is significantly cheaper than the ambulances that Mr White and you were talking about. Short of a motorbike, surely every vehicle that attends ought to be capable of conveying somebody to hospital. Wouldn’t that be a better use of the available resources? You would have more vehicles in use for conveying.
Professor Willett
Part of the ambulance response programme is about looking at the codes and categories. There are patients who require conveyance, and that means it has got to be two people to move the patient on a stretcher and a vehicle big enough. You can’t do that in most cars, and very few countries have even tried that, apart from some developing countries. In the new categories, it is important that we send to the patient both the right clinician and the right vehicle. For instance, if you have had an epileptic fit and are known to be epileptic, what you want is somebody who can get to you quickly, can be with you and can get you out of that fit medically if they need to. The chances of you needing to be conveyed to hospital as an epileptic who has fits regularly is very low. You want a rapid response vehicle with an experienced clinician. If you have had a stroke, there is no point in a very experienced clinician turning up on a motorbike. What you need is two lesser paramedics who can do the basics but can get there promptly with a double-crewed ambulance that can convey you to a stroke centre very promptly. It is about matching—
Mr Bacon
I have been present when somebody had an epileptic fit. A rapid response vehicle attended, and they were dealt with on the spot and were given oxygen and all the rest of it. My point is that in those circumstances, where it turns out that somebody needs conveying to hospital, if they are being conveyed in police vehicles because there is nothing else available, as happens, wouldn’t it be better to configure and have available a vehicle that doesn’t exist at the moment, which would be significantly cheaper than a full-box ambulance at £135,000 but would enable you to be more flexible?
Professor Willett
That is not a model that is being used internationally. I imagine it is because the vehicles are just not big enough, but I would defer to other colleagues.
Miles Scott
If a patient needs to be transferred to hospital, they need to be transferred in a proper ambulance. We need to make sure we can send a proper ambulance to those patients, as opposed to—
Mr Bacon
As opposed to a police car, which is what is happening at the moment.
Miles Scott
Exactly. Inventing a third vehicle is not going to address the core issue. The core issue is exactly the one you point to, which is the lack of availability of an appropriate ambulance.
Mr Bacon
In the east of England, part of the problem was physically not having enough vehicles. In fact, when Mr Marsh was in charge, he commissioned some extra vehicles, but whatever the optimal number of vehicles was, they didn’t even have that. To what extent, across the ambulance estate—Mr Barnes, this is probably for you, as you represent all the services—do all the services across the country have what they say is the number of vehicles they need? Whether there are enough crews at any one time is of course a separate question, but this is about the actual vehicles. I know the services are configured differently—some have more ambulances, and some have more rapid-response vehicles—but to what extent do they say they have the right number of vehicles, or is there a shortage?
Rod Barnes
The services that are going through the ambulance response pilot are currently modifying their fleet of vehicles to fit with the ambulance response programme. The outcome for us—I am speaking for Yorkshire—is that we have seen, as a response to the changing dispatch model, a requirement for more double-crewed ambulances and fewer rapid-response vehicles. We are in the process—I understand that the other two organisations are going through a similar process—of reducing the number of rapid response vehicles and increasing the number of double-crewed ambulances. We are broadly there in terms of having the right number of ambulances—
Mr Bacon
Broadly there, but not quite there yet?
Rod Barnes
I would say that there will probably be a requirement to increase the fleet slightly.
Mr Bacon
By how much?
Rod Barnes
At a rough estimate, I would probably say about 20 to 30 vehicles.
Mr Bacon
Across the country?
Rod Barnes
Across our trust—across Yorkshire.
Mr Bacon
Twenty to 30 vehicles across Yorkshire? What about the rest of the country? How many vehicles short are we across the country, Professor Willett?
Professor Willett
We don’t know if we are short. At the moment, what has happened, because the focus has been on the eight minutes 75% target, is that we have seen quite a lot of ambulance services, particularly those in rural areas, moving a lot of their fleet towards rapid response vehicles—and in urban areas, motorcycles. That is because they are trying to stop the clock to meet the target, but they are actually missing the point, which is that the patient might need a double-crewed ambulance. With the ambulance response programme, the sites that have got the full work-up, which includes Yorkshire at the moment, are seeing that they need fewer rapid response vehicles and more double-crewed ambulances. The question, as we go through this transition and if the recommendations are accepted, is whether the ambulance fleets will shift to having the right mix. At the moment the mix is distorted by the target. Once we have done that, we will be able to have an estimate as to what the total number of—
Mr Bacon
I am aware of all of what you say—that there has been a shift towards rapid response vehicles, driven to some extent by the need to meet the targets—so back to my first question, are targets helping or making things worse? I am still persuaded that targets are making things worse, but that is only my opinion—what do I know? But I am slightly surprised that you still do not know what the optimum number of ambulances is somewhere between three and five years after this first became a quite obvious crisis—I dislike using the word “crisis”, but certainly in the east of England it became a crisis. We are now told by Mr Barnes that you are 20 to 30 ambulances short in Yorkshire, and you cannot tell us how many ambulances you are short across the whole of England.
Professor Willett
I can’t, and I would say that what has happened over the last few years has not just been that the fleets have changed, in terms of their proportion, but ambulance services have different uprating models. They have been trying to do things differently depending on their rurality, their deprivation or the calls on them—
Mr Bacon
Did you say “rurality” or “morality”?
Professor Willett
Rurality, I hope—I would certainly correct the minute if it was “morality”. They have developed not only different fleet proportions, but different proportions of paramedics, advanced paramedics and technicians, so there is a whole variety. We have got different operating models and different proportions of personnel so it is not as simple—
Mr Bacon
No. I realise that, but I and many of us find it puzzling. I understand that there are different staffing models, different vehicle configurations and different operating models used, but why is there so little consistency in the way ambulance services are commissioned across the country? Plainly you have rural, urban and suburban—there are different mixes that might mean different needs to some extent—but it is not that complicated. There ought to be a model or a variation of one or two on a model that would work in most cases. You do not yet seem to be anywhere near reaching that, do you?
Professor Willett
We are just about to go to that, and I will pass to Miles at this point. Having now got all the information and really understood to a level that we have never understood before, Miles has been leading the work on the ambulance transformation work, which is about the workstreams and looking at getting the right skill mix, the right financial sustainability, the right commissioning model and the right operating models. Because we have brought all the ambulance services together under the ARP, we now have all the ambulance services talking in a way that has perhaps never happened before.
Miles Scott
I can just tie up one slight loose end on the number of vehicles. We can be quite confident in saying that none of the reviews that has been undertaken into ambulance services, whether through the CQC, our own work or Professor Willett’s work, has identified the number of vehicles as a bottleneck or a rate-limiting step. The number of vehicles is appropriate to the model of service that people are operating currently. The issue is whether that model of service is correct. Then, as Keith says, should we shift to—
Chair
This is expensive capital expenditure, then you have the crews to put in them, so there is an importance, as Mr Bacon is trying to highlight, to having a sense of how many we will need.
Miles Scott
Exactly, so we need to have the right number. I am saying that none of the reviews we have done has identified that there are paramedics sitting around waiting for a job because they can’t get into an ambulance. I just wanted to reassure you on that point. In terms of the commissioning point—
Chair
I’m sorry, but I don’t think that was quite the point Mr Bacon was making. He was not suggesting there were paramedics wondering whether they would get a job. We know there is an issue about workforce, which we will come on to. You have an expensive bit of kit—the ambulance. If you need 20 or 30 in Yorkshire, there is an impact on your budget, Mr Barnes. How are you going to fund 20 or 30 ambulances and get the people to crew them up? Some of them would come from rapid response, from what you are saying, but would you have an additional recruitment problem?
Rod Barnes
At the moment, each ambulance service carries spare capacity of vehicles, in terms of day-to-day planned maintenance. We are managing the situation with that spare capacity over time, from where we are at the moment in the pilot, and after we would need to make a slight increase to the size of the fleet.
Chair
So there is no budget crisis because of the need for new ambulances?
Rod Barnes
We will be reducing the number of rapid response vehicles, which will free up—
Mr Bacon
—more money to spend on ambulances. Mr Scott, my real point was this: given that it hopefully should not be rocket science to figure out what a good operating model looks like, why is there so much inconsistency across the country in the way in which ambulance services are commissioned?
Miles Scott
I agree with you that we need to get to a more consistent position across the country. There is a mixture of reasons why the commissioning and operating models are so different. Some of those reasons are happenstance, and some are good reasons to do with geography, demography and so on. We have never had a national ambulance service. The ambulance services that we have currently have come up from county ambulance services and so on, so there has been a coming together of ambulance services, rather than a fracturing. It is important for the Committee to understand that.
Chair
We do know that. Can you get to the point?
Miles Scott
Yes, absolutely. We will be recommending a consistent framework for commissioning of ambulance services that will be consistent across the country.
Mr Bacon
That is something you are going to be recommending in the report coming out in April 2017?
Miles Scott
This is not part of Professor Willett’s report. This is—
Mr Bacon
Another piece of work?
Miles Scott
Yes, exactly.
Mr Bacon
In what report is that recommendation coming and when?
Miles Scott
We will be signing off the scope for that piece of work next month.
Mr Bacon
It hasn’t been done yet?
Miles Scott
No. We will be signing off the scope for that piece of work next month and would expect to put—
Mr Bacon
In April 2017 you will be signing off the scope?
Miles Scott
Yes, and we would expect—
Mr Bacon
How long will the work take?
Miles Scott
Within six months we would put recommendations to—
Mr Bacon
Right, so in October 2017 you expect to put recommendations to whom?
Miles Scott
To NHS England primarily, but also to NHS Improvement.
Mr Bacon
Who will then agree with them or not. If they agree, will they then recommend them to Ministers?
Miles Scott
Exactly. That will be the basis for commissioning ambulance services going forward.
Mr Bacon
How long will it take from the time NHS England has made the recommendation to Ministers for that to become the standard reference point and operating model that people use?
Miles Scott
From that point, the commissioning would be on a consistent basis. Essentially, you would work into the beginning of the following financial year.
Mr Bacon
In other words, from 1 April 2018, you would expect to have a consistent commissioning model for ambulance services across England?
Miles Scott
Yes.
Chris Wormald
Can I add something?
Mr Bacon
Caveat, Mr Wormald.
Chris Wormald
No, it wasn’t going to be a caveat.
Mr Bacon
You can back-pedal now if you want.
Chris Wormald
I might not speak at all. What we are aiming for is a national framework that allows for local variability. It is not a single framework we are aiming for, for the reasons you say. The other thing I wanted to clarify is that thing you said it then comes to Ministers. I don’t think there is a ministerial decision in that bit. That is entirely the operational commissioning process.
Mr Bacon
Perhaps this is for you, Professor Willett. What impact has stopping fines against hospitals that delayed the transfer of patients had on performance?
Professor Willett
Within the NHS standard contract, which ambulance service lead commissioners use for the ambulance services, there are sanctions or penalties for—
Chair
We know that. What has the impact been on performance?
Professor Willett
The sanctions were suspended under specific conditions only—it was not blanket. It was for those ambulance services that were accepting control totals. The reason is that, as part of the STP and the control totals, if you are accepting the control total, you already have built in there a financial control, but if you had the sanctions as well, it would essentially be double jeopardy for the ambulance services, so you would not have both. Obviously, with the drive, as we have discussed, around the ambulance service, the demand is across the whole system, and in many ways it is inappropriate to penalise just one part of the system for a system-wide problem. In addition, we know that, in fact, for most—
Chair
Sorry. We do know the history of this. Forgive me for interrupting you, but Mr Bacon asked what the impact of that is.
Professor Willett
Perhaps NHS Improvement would like to clarify their operational view of it, but I do not think there has been an impact, for the reason that most CCGs were either not invoking the fines or they were disappearing at year-end settlements anyway because they were relatively small. They were a useful discussion tool.
Chair
So there has been no impact? That’s fine. That has answered the question. Mr Scott?
Miles Scott
I wanted simply to say that handover delay is a very important issue that we have to address—the rise in handover delays happened when fining was in place. We do not believe that the fact of the fines actually—
Mr Bacon
Fair enough. What incentives need to be put in place to reduce turnaround times?
Miles Scott
It is largely about good practice within hospitals and across the whole system. The incidence of delays is very closely connected to the pressure on the hospitals and the flow within the hospitals—their ability to offload the patients into the department. With Professor Willett’s input, we have provided new clinical advice to hospitals to help them to make the decision to take the patients more promptly, and we are beginning to see some improvement in the incidence of delays. But this is a major priority for us, with both the hospital trusts and the ambulance trusts. We have two national champions helping to take that forward.
Mr Bacon
Mr Wormald, we on this Committee recommended five years ago that a quality indicator be developed for hospital transfer times. Why has that recommendation not been implemented?
Chris Wormald
To be perfectly honest, we haven’t been in the right place on this. A number of things were done and—this is quoted in the National Audit Office Report—a lot of management and operational data were created, so NHS trusts can now monitor their own performance, but we did not go for a published indicator. We are looking at that again—that is one of the things that Miles Scott is looking at—but as I say, I do not think we have been in the right place on this.
Mr Bacon
Mr Scott, is that part of your report, or is that yet another report?
Miles Scott
No, we are using the data operationally. We have to agree the basis on which they are incorporated into official and published statistics. It is as simple as that.
Mr Bacon
What is the shortage of paramedics now? A shortage of paramedics has developed. What is the gap between what you have and what you need?
Miles Scott
Currently, vacancies are running at about 5%, so the big workforce challenge is less the current vacancies and more the number of paramedics that we are going to need going forward to accommodate the kinds of new models of care that Professor Willett talked about earlier in the session.
Mr Bacon
What are you doing to overcome that shortfall?
Miles Scott
Over the period since the last NAO Report, Health Education England have more than doubled the number of paramedic trainees. I know in your own patch there has been some bumpiness about the introduction of that with the local universities, but that is now in train and the number of trained ambulance personnel—both paramedics and technicians—actually increased significantly during the course of 2016. Over the last three years, the number of trained ambulance personnel was pretty flat for a couple of years and then significantly increased over the last 12 months.
Chair
So you have been growing our own. What about immigration? Is it on the shortage occupation list?
Miles Scott
It is on the shortage occupation list, but there are not many other countries that have training for paramedics that has equivalence in the UK—not many other European countries in particular.
Chair
Which countries do?
Miles Scott
Primarily Australia and New Zealand. The London Ambulance Service in particular has very successfully recruited nearly 200 paramedics from Australia and New Zealand.
Chair
How long does it take to train to be a paramedic?
Miles Scott
Three years.
Chris Wormald
Can I just clarify—
Chair
Another caveat.
Chris Wormald
No. I think the vacancy rate is 5% over the natural rate, so the total vacancy rate is 10%. You would expect a level of 5% in any organisation, and we have an excess 5%, so I think the number quoted in the NAO Report is nearer 10%.
Chair
Well caught, Mr Wormald.
Chris Wormald
See, that wasn’t a caveat.
Mr Bacon
No, you were making it worse. It is good to know we have clarity and honesty from the Permanent Secretary.
Miles Scott
It might be helpful if we could confirm with the Committee afterwards the latest workforce statistics.
Mr Bacon
Yes, it would be good if you could to write to us with that.
Chair
It would be helpful to have the vacancy rate for each trust as well, because it may be attractive for New Zealanders and Australians to come and work in London, but they may not want to go and work in—
Miles Scott
Yes, we will provide you with that.
Mr Bacon
And the total expenditure on agencies by each trust in the last two years as well, if you wouldn’t mind.
Miles Scott
We can absolutely get you that figure.
Mr Bacon
This is probably for you, Professor Willett. Given the extra costs of the pay uplift, are those ambulance trusts going to be able to afford to recruit all these extra paramedics?
Professor Willett
The paramedic shift is obviously wider than that, because we are bringing a graduate paramedic programme into the country. We are training about 1,750 learners in the system this year. That will be the same—Health Education England will be bringing those into the system over the next three years to address the shortfall in paramedics. There has also recently been the band 5 to band 6 change for paramedics, as part of NHS Employers’ and Department’s settlement for paramedics. That encompasses the recognition of the paramedics’ significant skillset that has changed over the years. They have now been rebanded within “Agenda for Change”. That is being funded one third by NHS England and two thirds by the Department.
Rod Barnes
Certainly within our own service, we have had to find savings in other parts of the organisation to reinvest in frontline staff.
Chair
Such as?
Rod Barnes
We are looking at doing things more efficiently in back office functions like fleet, IT, estate and rationalising some of the legacy estate that the organisation has.
Chair
Was that done in time? Obviously, the uplift came. Were you planning for those efficiencies? It takes a while to change backroom, IT systems and other things like that.
Rod Barnes
Yes, and like most provider organisations, we have a three-to-five-year cost improvement programme that looks out ahead at various degrees of fitness to go live with.
Chair
Sorry, just to be clear: did you have three to five years to plan for the uplift in salaries? That was not quite clear.
Chris Wormald
This is why DH and the NHSE provided separate money for the first few years of the uplift. We are funding until 2018-19.
Chair
And you are funding the actual costs of every member of staff who has gone up from 5 to 6?
Chris Wormald
Of the rebanding? At that point, it goes into the general commissioning system, which gives people time to have made the transition.
Chair
Mr Barnes, is that enough of a cushion for you and your colleagues around the country to cover the cost?
Rod Barnes
It is.
Chair
So you don’t have any worries in that respect?
Rod Barnes
Clearly, once we get past ’17-’18 and the responsibility to fund the increase goes back to local commissioning organisations, the expectation is that the funding will come from efficiencies in the sector that are driven out by having enhanced clinical skills.
Chris Wormald
It should be said that there is one trust—West Midlands—that is our outstanding trust and has done this rebanding already within its existing resources, so we know that it is—
Mr Bacon
I’m sorry; say that again.
Chris Wormald
It has done the rebanding already within its existing resources. That is our outstanding trust, so we know that this is a possible model, but we have given people some—
Mr Bacon
You just need to clone Mr Marsh. I was about to put in a plug for the Genome Analysis Centre but I don’t think I will—it is in my constituency. Green calls represent half of all the calls, so why isn’t there a target for them? Would it be a good idea to have a target? I have my own views. You can see why people might ask why there isn’t a target for Green calls.
Professor Willett
That is a real issue. As we have understood more and more with the ambulance response programme, there is clearly a disadvantage to the patients in that Green call category. Standards are set, but they are set locally by the lead CCGs as part of the commissioning arrangement. They are not nationally reported but they are locally reported. It is usually 30 minutes or 40 minutes—something of that order is the target set for those.
Mr Bacon
Will there be a new set of clinical codes and performance standards for Green calls?
Professor Willett
What we have to do is to make sure that Green calls are not forgotten and, most importantly, that we pull that in, as we call it, the long tail in the Green calls—patients who, in times of surge and real busyness, are disadvantaged.
Mr Bacon
The tail breaches, you mean?
Professor Willett
The tail breaches. We will be looking very much for that to be one of the products of the ambulance response programme.
Mr Bacon
Oh, right; good. So that is one of the outcomes you are expecting from it?
Professor Willett
That is what we would anticipate, yes.
Mr Bacon
Given that the data are not collected consistently, how useful are national indicators anyway?
Professor Willett
If they are national, I think they need to be nationally reported. As part of the fourth part of the ambulance response programme, now you have nicely walked me to it, is to actually look at all of the quality indicators. Now we understand the optimal configurations—we are working towards a very different way of operating and using our staff and our vehicles, and adjusting the calls—we need to look at the right measures that actually indicate whether the services are working properly in terms of safety, in terms of efficiency within the system, in terms of clinical outcomes. Also, very importantly, we have learned this from the ambulance response programme—what the staff think of it. Throughout the NHS—it doesn’t matter where we go—the staff are the people who know whether the system is working well or not, and we have learned a lot from them. On the ambulance response programme, the surveys we have done of staff to date—we will see what the final report says, but frontline staff in vehicles are recording far fewer unnecessary blue-light calls. Obviously they are driving at risk to themselves and the public. The call handlers and the dispatchers are having a lot less stress. I was in the Yorkshire Ambulance Service operating room not long ago, and the common comment on the services that are now working the new system is that the whole control rooms are just quieter. There is not the same level of chaotic intensity, if you like, that was being driven by everybody trying to get something that they had not got.
Mr Bacon
I thought you were going to say, for a moment, “being driven by the target”, which goes back to my first question.
Professor Willett
No, not to you, Mr Bacon. Also, they are reporting there are fewer times when they miss meal breaks. Shift finishes are better. The unions have been involved. The staff have been involved very much with the ambulance response programme. We have taken a strong steer from that.
Mr Bacon
Should there be national indicators for things like trauma?
Professor Willett
I do not think we should have them for trauma—I am a trauma surgeon, so I can say that. We have a set of measures in trauma. I will come back to trauma, but for things like stroke and heart attack we already have them. You are right that we should consider those at the national level, but there are other things that we could include. The trouble with trauma is that it is very heterogeneous. Someone can have a head injury, someone else can have a chest injury, someone else can have a crushed pelvis or an amputated leg, or someone can have all of those, so actually setting an individual target for that is quite difficult. We have a very good system in place already for major trauma.
Bridget Phillipson
The North East Ambulance Service Trust tells me that, just in terms of Green calls, they have a system whereby with a Green 3 case, if the patient waits more than an hour their case is upgraded to a Green 2 emergency response—for a within-30-minutes response. Is that kind of protocol in operation in other trusts around the country? Is that a standard protocol?
Professor Willett
For the Green calls, the commonest effective intervention that has been introduced across the ambulance services is actually putting clinical advice into that call, because many of those calls perhaps do not need to be conveyed to hospital. When the ambulance eventually gets there, it may be something that can be managed in the community like urgent care support arrival, or it can be something done there. So clinical advice is the commonest new model, which we are strongly supporting. Obviously the graduate paramedic programme supports that. The idea of raising patients up categories makes sense in principle—the difficulty is if you haven’t got assets to send it does not change anything. Usually the reason for the long delay in Green is because everyone is running trying to get to Red.
Bridget Phillipson
That is certainly the response that I have had from the trust, with a number of cases, but that has also gone hand in hand with regular clinical updates. Patients who are waiting for an ambulance will have been given regular updates. However, despite that, they are still having to wait longer, and they have had to introduce a new protocol to try and deal with it.
Professor Willett
From the ambulance response programme, the solution is to free up those vehicles that are currently running around all together not getting to scenes. If we can free up those ambulances—and we anticipate literally freeing up thousands of ambulance occasions each week, both as a result of giving them more time and the code set—that combination will be the best solution for those patients.
Bridget Phillipson
The biggest factor that we hear locally is around waits at hospitals—particularly at two or three major hospital centres. I appreciate this is not necessarily an easy response to give, but how do we sort that?
Professor Willett
From a clinical point of view I would agree. Ambulances not being able to offload patients is one of my most serious concerns in the system currently. I do not think the patients in the ambulances are at particular risk, because they often have two paramedics with them. They are probably better staffed than intensive care, at a 2:1 ratio, but that vehicle and that crew is locked, and actually we know where the demand in the system is out there. That is a very serious one. Myself and others have written out to the system. We saw this building. It happens every winter to some extent, but we saw it building in the autumn and particularly into December and wrote out to the system at that point and made it clear that this needed to be looked at. We started to get some behaviours going on as well that we were not very happy with, so part of that programme has been taken over by Miles. Having put out the recommendations about what we should do about turnaround in hospitals, there is now a programme of escalation going on and much firmer performance management of the system.
Bridget Phillipson
Could you just clarify for me what the organisational response is when an ambulance identifies a particular problem in the system with a given hospital or hospitals within an area that causes significant delays to the handing over of patients, therefore putting pressure on the ambulance service in deploying resources? What is the organisational response to managing that and improving it?
Professor Willett
In the current structure, both the ambulance service and the acute trust will be represented on what is called the A&E delivery board, which used to be the system resilience groups. That would be the forum for those system-wide pressures to be discussed and for the acute trust to understand. More recently we have escalated that. Now, if the ambulance service is aware of delays building up at a hospital, there will be direct contact with the executive of the hospital to make them aware. We will task the medical director of the hospital—the executive of the hospital—to work with the ambulance service, and then on a real-time basis to resolve that issue, rather than it being something that is done perhaps in the cold light of day a few days after the issue.
Bridget Phillipson
But hospitals will already know they have a problem and will want to deal with it. They presumably say, “We know it’s a problem, but there are other factors here that we have no control over.”
Professor Willett
That’s right. That is why it has to be a system-wide problem at the end of the day, which is why it is the A&E delivery board where you have representatives there, and, for the STPs of the future, you will have local authority representatives, the ambulance service and the community sector. You will have everybody represented. It is this problem that the hospitals are congested currently with all the issues in the media that I am sure we have all discussed.
Mr Bacon
Yes, we have.
Professor Willett
And it backs right through. The last point of back-up appears to be ambulances that cannot hand patients over to the care of the A&E department, because the department has nowhere to put them. They cannot move patients out, so the hospital cannot move patients in.
Bridget Phillipson
It just feels like we are talking about the problems within the system. We seem to be able to identify where the problems are. Doing something about it seems a lot more difficult.
Chair
You have just described a lot of people meeting.
Mr Bacon
We have had exactly this discussion on delayed discharges, which the Committee has looked at a number of times. Northumbria NHS Trust, which runs and organises adult social services in Northumbria, has zero delayed discharges. They have had 51 visitors from different parts of the country. It was Mr Stevens or Mr Rouse from DCLG who said you have to have a situation where the whole system owns the whole problem. You have said something very similar. Why is that understanding not more widespread?
Professor Willett
That is one of the main reasons behind the sustainability and transformation plans being generated. In some places that is the first time you have had local authorities working with the health providers and commissioners all coming together to take a local population view about the pressures in the system and helping each other out. That is what the STPs are all about. It is a joint management structure where you bring executives together to drive that.
Mr Bacon
I have one more question for Mr Barnes. Once the handing over is done and once any delay in the hospital has been dealt with, ambulance crews are supposed to have 15 minutes to make ready for the next call, but many ambulance trusts are not meeting that separate requirement. Why is that?
Rod Barnes
It can depend on peaks in demand.
Mr Bacon
In terms of what demand?
Rod Barnes
Let us consider an average 12-hour ambulance shift. If it is a particularly busy day and the crew have treated one patient after another, there can be times where in that 15-minute slot the crew might either take a break for a cup of coffee, depending on the nature of what is wrong with the patient, or they might take additional time to discuss the case and what happened during the incident. It is an area where I would say there has been quite an improvement over the last few years. There has been an increased focus on the amount of time that crews take to wrap up, which is what we call it, the 15-minute slot with patients. There is a bit more that we can do. A lot of trusts have implemented welfare calls with crews. If they have not come clear within 15 minutes, the control room will call the crews directly to check whether anything can be done to help.
Miles Scott
I was going to make the point that, although the absolute instance of it taking more than 15 minutes for the ambulance crew to turn their vehicle around is significant, the number of minutes over 15 minutes is usually much less. That is why, when the NAO looked at the two components of this—15 minutes for the hospital to accept the patient and 15 minutes for the ambulance crew to turn the ambulance around—they focused on the hospital bit, because that is where the time is being eaten up. Those delays can run into an hour, or several hours even, whereas the delays against the 15-minute stand for the ambulance crews tend to be a number of minutes.
Chair
It sounds like a bit of a meaningless target.
Robert White
I wanted to point out the variation in turnaround times on page 22 of the Report. While I think some of the responses for why there might be a delay were reasonable, what is not explained is why some trusts seem to be able to turn them around in 15 minutes and others are not.
Mr Bacon
There is a big variation, isn’t there? Is that due to cultural behaviours?
Miles Scott
I accept that there is a big variation. I would simply say that, when looking at our operational response to this, we absolutely chose to focus on the hospital handover element of it, because our understanding of the data is that the significant delays are very much in the hospital end of it. I think we have resolved that. We can get into why it is there is this apparent variation, but our understanding of the issue that is having an impact on the system is that it is highly focused on the hospital handover bit.
Chair
Is it that clinicians and others in hospitals do not appreciate the need to get that ambulance out again quickly?
Miles Scott
No, not at all. As Professor Willett said, we are talking about hospitals that this winter have been typically over 95% occupied. Those are historically incredibly high levels of occupancy.
Chair
Is it primarily shortage of beds, then?
Miles Scott
Yes, it is the ability to get patients into the hospital. If you put yourselves in the shoes of a medical director who is responsible for safety in a hospital on a given day, the safety they can see is the safety of patients in the hospital. So they can see how full their hospital is. What they cannot see is—
Chair
The queue of ambulances outside.
Miles Scott
Well, they can see that, too, but in the queue of ambulances they can see you have got trained clinical staff—almost like an intensive care bed, as Professor Willett said. What they cannot see is the patients in the community waiting for an ambulance to arrive. That is why I think the key intervention was Professor Willett and Kathy McLean communicating with medical directors to say, “Look, our concern across the whole of the system is that the biggest clinical risk is lying outside of hospital. That is why we want you to accept the increased pressure in the short term of taking these patients straight into the hospital, even though you are at these very high levels of bed occupancy.”
Chris Wormald
The important thing in dealing with this is exactly the same set of measures as in dealing with A&E more generally. So when Simon Stevens and Jim Mackey wrote to the system on 9 March, they were talking about how we free up large numbers of beds and how we free up A&E. That should also be the set of measures that allows us to deal with this challenge. As I say, it is that system response.
Philip Boswell
This is probably directed at Mr Scott. It is in relation to metrics, KPIs and so on: the expected performance targets that colleagues have covered. In terms of the queues of ambulances outside, who is measuring or reporting the impact on the service from a countrywide perspective? Is it the delivery boards? Who collates that? How can we get this data?
Miles Scott
I think we covered this just before you were able to arrive, Mr Boswell. We are collecting those data and using that information operationally at the moment. We are just working through the detail of how we can incorporate that into official statistics.
Chair
It is partly to do with national statistics rules, isn’t it? But next time you are in front of us, we will have that data—that is the key point.
Anne Marie Morris
You are painting a picture that on one level is encouraging, because you are clearly addressing many of the problems that the NAO and others have identified. That is the good news. But I am concerned about the deliverability of it, at the end of the day. Professor Willett, do you agree that in terms of the jigsaw puzzle that is health and social care, the ambulance piece is pretty mission-critical, because it determines so much of the entry into A&E, which is one of the most expensive bits of the system? Looking at the figures for 2015-16, it seemed to me as if the ambulance service was responsible for something like 20% of the entries into the A&E system, and therefore it was kind of pivotal.
Professor Willett
Yes, I agree, and actually I would take things one step further by saying that there is no better vantage point of the whole urgent health and social care system than the ambulance service. That service touches just about every part of the NHS. They know the general practices, the care homes, the community providers and the hospitals; they touch all parts of the system. So they are in a very good place. From my time in urgent emergency care—that has been my career—I think there is still a significant under-appreciation by the health system leaders and by the commissioners, not only of the pivotal role of the ambulance services but of their pivotal position to lead transformation. They are a relatively small player in terms of activity, finance and workforce, but actually they are in an absolutely pivotal position. That is—
Anne Marie Morris
So you agree with me?
Professor Willett
I agree with you.
Anne Marie Morris
Right. Mr Barnes, given how pivotal the ambulance system is, why is it that it is so little engaged in the overall change programme and the STPs? I appreciate that you have a challenge of 10 ambulance trusts and an awful lot of other organisations, never mind the total number of STPs and clinical commissioning groups. However, given the importance of the service, isn’t there some learning to be had, or something that needs to be addressed in this new, future way forward, if we are to make sure that we are actually spending the right amount in the right place and getting value for money across the whole of health and social care? What is your perception of the engagement and involvement of the ambulance service in this huge change programme that is going on, and what more could be done to ensure that the service is properly engaged and consulted?
Rod Barnes
You are right to flag up the challenges for ambulance services. Within Yorkshire, and I think we are fairly typical, we deal with 20 different CCGs, probably about 15 A&E delivery boards and four STP systems. It is a huge challenge for groups of organisations meeting at a local level, whether or not that is in a CCG footprint, and meeting day in and day out. While we can and do send representatives to meetings periodically, we are not there always for the day-to-day discussions, which means that quite often we don’t come to the forefront of all the planning discussions and we are playing catch-up. Also, I think some of that is history. Again, going back in time, ambulance commissioning was probably seen as less glamorous and as second-tier, and it didn’t necessarily get the key individuals within commissioning organisations to the table in the way that the core large acute organisations did.
Anne Marie Morris
How are we going to change that in the future? You are right about the history. I think there was an earlier question from one of my colleagues and you talked about this new world, and it was all going to be all right, and my concern is that I am not sure that by 2018 we will be in a shape to have this model. You talked about developing a standard operating framework. Well, if the ambulance service is not as engaged as it should be, how will you develop one? My concern is that you will try to do what’s been done to the STPs. You say that you’ve got to do it, but it’s got to be within the same amount of money that you are spending already, and actually there is very little room for manoeuvre. Your challenge is that, with the ambulances, you have got so many different configurations and frameworks that I would have thought it’s almost impossible to come up with one ideal framework.
Rod Barnes
I will possibly hand over to Miles in a second. I have been quite encouraged. About two years ago, I was quite depressed at just the fragmentation within the health service from an ambulance perspective, and I have been quite encouraged by the coherence of what’s come together through the urgent and emergency care review, and the way that’s led through to the work on the ambulance response programme. Also—
Anne Marie Morris
How are they interconnected? There is a lot of talking, as my colleagues said, but nobody is saying, “This piece of work is linked to that piece of work, and this is the overarching piece.” We have got so many ways of looking at the NHS care world, but the average punter and even colleagues around the table remain confused about what the priority is. You almost want to see some sort of pyramid structure—some structure where something dominates, whether or not it is the STPs, and everything else falls into line. At the moment, it is a bit like wobbly jelly that hasn’t set.
Rod Barnes
Certainly, from the groups that I am involved in, I think that clarity is starting to emerge. The work that Miles is leading on through the sustainability review and the review of the commissioning framework is very much a key element of that.
Anne Marie Morris
So Mr Scott, how are we going to get to a position where there is some structure that people who are working in the NHS and the care world understand, that we understand, and that the average man in the street understands?
Miles Scott
That is a very important question. As Professor Willett said, right at the outset the ambulance response programme has been inspired by and has engaged with all 10 ambulance services in England. The ambulance services have all worked together with Professor Willett and his team on the ambulance response programme. If you look at the changes that are required across the whole of the urgent and emergency care system, to a large extent the ambulance service component is going to be plugged through the ambulance response programme. It is going to be about the changes that we talked about—a greater use of “see and treat” and “hear and treat” models, and so on. For that to be sufficient, it will also require the other elements of the urgent emergency care review, in terms of flow through hospitals, discharge and alternative primary care.