Paresh Wankhade, Professor of Leadership and Management and Emergency Services Management Expert discusses the issues the Ambulance Service faces as winter approaches in his latest Comment blog:
With each passing year, the winter crisis puts a massive strain on the NHS ambulance resources with huge bottlenecks in the transfer of patients into the hospital Accident and Emergency (A&E) wards. In 2017, media carried several reports which highlighted delays on the part of ambulance crews arriving at the scene, including deaths of the patient waiting for an ambulance. Some of these arguments have been well rehearsed and have also prompted emotional debates and the cries of “52 weeks of the year crisis” in the Parliament. I have highlighted four issues which in my view are the key flash points for ambulance services to deal with such recurrent crisis.
Address the funding-demand gap
The sustainability of an underfunded and overstretched ambulance services is though well recognised, but remains unresolved. The National Audit Office reported that between 2009-10 and 2015-16, the number of ambulance calls and NHS 111 transfers increased from 7.9 million to 10.7 million (average year-on-year increase of 5.2 per cent), and income for NHS ambulance trusts’ urgent and emergency care activity increased by 16 per cent from £1.53bn to £1.78bn between 2011-12 and 2015-16, but ambulance activity over this period (NHS ambulance calls and NHS 111 transfers) rose by a massive 30 per cent. This is accompanied by significant shifts in the demand with only 10 per cent of 999 callers having a life threatening emergency despite the average annual increase of five to six per cent in ambulance demand. Doing even ‘same with less’ is proving difficult for ambulance trusts, something I have argued in my recent piece.
Move away from response time targets
Response time targets have been historically used to measure ambulance performance. Since July 2017, performance of NHS ambulance trusts is being benchmarked against four new national standards, based upon patient’s condition, now enshrined in the NHS Constitution. However, during May-September 2018, ambulance services in England failed to meet all the standards. A recent Parliamentary Report concluded that ‘ambulance trusts have organised themselves to meet response-time targets, at the expense of providing the most appropriate response for patients’ (p.5). Another view that ‘commissioners, regulators and providers still place too much focus on meeting response times” reported in the National Audit Report (p.8) is deeply worrying.
Our research points to similar conclusions. We have systematically documented a range of unintended consequences of response time targets used by the ambulance services. We have also explored the relationship between cultures, performance measures, and organisational change to understand how organisational culture is perpetuated and found the targets to be a significant factor impeding the process of change. Ambulance services have embarked on the drive for ‘professionalisation’ but our latest research suggests that as ambulance work continues to intensify, ‘issues around dignity, staff retention and the meaning of work are becoming ever more challenging’.
Introduce fines/penalty for hospital delays
Ambulance handover delays to hospital A&E departments can have serious implications for patient safety and reduce available ambulance resources. The 30 minute cycle (handover and readiness for next call) is proving difficult to resolve. NAO figures suggest that in 2015-16, only 58 per cent of hospital transfers met the 15-minute expectation in 58 per cent of cases as against 80 per cent in 2010-11, and only 65 per cent of ambulance crews were then ready for another call within 15 minutes. There are inconsistencies on the part of commissioners to penalise hospitals that do not adhere to the guidance of 15-minute transfers in absence of a fining regime. A quality indicator for measuring hospital performance in meeting the transfer-time target has not yet materialised, notwithstanding the recommendations of the Committee of Public Accounts.
Improve efficiency and productivity
The Carter Efficiency Review, published last month, highlighted concerns about huge variations in the delivery of ambulance services. It suggested potential savings of £300m a year by cutting unnecessary ambulance transfers, along with further £200m through use of more efficient models of operations and procurement. But the review also raised fundamental questions over the need for significant investment in the ambulance sector. The shortage and retention of paramedic staff coupled with high sickness absence rates continue to be a problem, an issue highlighted in the draft NHS Workforce Strategy. However, the review raises the clear need for investment since one of the recommendations to reduce high conveyance rates is likely to have cost implications. This will also require high quality staff engagement.
There are no easy fixes and addressing the winter pressures will necessitate strong and visionary leadership by ambulance chiefs and cooperation from other health care partners, in a political climate dominated by Brexit. A ‘whole systems’ approach is crucial to deal with this crisis. The Dalton Review called for successful leaders to act as a ‘systems architect’ to use their entrepreneur skills to explore innovative organisational models, as set out under the NHS Five Year Forward View. The Carter Review necessitates ambulance leaders to make right business and spending decisions which will impact the NHS. Devising an effective public education campaign to minimise misuse of ambulance resources and managing public expectation, will be a good starting point.