Northern Ambulance Alliance: New model for emergency services collaboration?

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Professor Paresh Wankhade (Business School) analyses the latest announcements about ambulance alliance and its implications:

Interoperability between the emergency services (the police, ambulance and fire) is an important but highly contested topic of research. The governance of these ‘blue lights’ in England is complex given these services come under different departments and are structured differently largely as a result of the relatively ad-hoc nature of their historical development. Currently there are 11 ambulance trusts, 44 police forces and 55 fire and rescue authorities in England.

Collaboration between emergency services is neither novel nor new. Many emergency services are already working with each other, and other public bodies to provide better services while improving efficiencies. In September 2015  the Government published the consultation document ‘Enabling closer working between the Emergency Services’ aimed at promoting better coordination of emergency services in England.  In January 2016, the government published the ‘Summary of consultation responses and next steps’ to the Consultation intending to legislate to:

  • Introduce a high level duty to collaborate on all three emergency services, to improve efficiency or effectiveness;
  • Enable Police and Crime Commissioners (PCCs) to take on the functions of fire and rescue authorities (FRAs), where a local case is made;
  • Where a PCC takes on the responsibilities of their local FRA, further enabling him or her to create a single employer for police and fire personnel;
  • In areas where a PCC has not become responsible for fire and rescue services, enabling them to have representation on their local FRA with voting rights, where the local FRA agrees; and
  • Abolish the London Fire and Emergency Planning Authority and give the Mayor of London direct responsibility for the fire and rescue service in London.

The proposed governance arrangements contained within the consultation document present a number of challenges and has received mixed responses, and the consequent legislation was rushed through in the Parliament. Some of the proposals in the latest consultation are not original. In 2013, the government commissioned report  Facing The Future  led by Sir Ken Knight, former government Fire and Rescue advisor, had reviewed the efficiencies and operations in the fire and rescue authorities in England. The report had further proposed the merging of fire and rescue services with the possibility of the PCCs taking on the role of fire and rescue authority after due evaluation.

The Association of Ambulance Chief Executives (AACE) has welcomed the intention of the Government backing to keep ambulance services as part of the NHS, while reaffirming its support for closer collaboration and more innovative blue light working between the three emergency services. The Keogh Review and the NHS Five Year Forward View also acknowledge the role and contribution of the ambulance services to the Government’s urgent and emergency care strategy. The overall attendance of fire services incidents has shown a decline of more than 40% over the last decade. Recorded crimes (other than fraud) are showing a downward trajectory since its peak in 2003-04. But ambulance demand has shown a steady increase of almost 10% over the last five years.

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While their position within the blue-light architecture is still being decided, the latest announcement by the North East, North West and Yorkshire Ambulance Service Trusts to launch the ‘Northern Ambulance Alliance’ to improve efficiency gains (Highlighted by the Carter Efficiency Review, 2016), presents opportunities for exploring new innovative organisational forms and management structures, to bring about a new model for regional collaboration in absence of a national initiative.

A statement issued by the new NAA clarifies that the move is not a merger, but ‘an attempt by all three organisations to work closer together to standardise care, identify savings through collaborative procurement, and be better placed to tackle the fast moving change agenda.’ The move opens greater opportunities to access new, modernisation funding streams such as the transformational funding collectively, while allowing greater synergy for working with other blue light partners. It has been also stated that the three trusts remain completely separate entities and will be regulated independently.

The alliance has been quick to dismiss the fears about potential amalgamation and job losses but questions have already been raised including:

  • Implications for future joint appointments and re-categorisation of new roles and responsibilities;
  • Whether staff will be rostered to work within the geographical boundaries of the other trusts in the Alliance
  • The claim to improve quality and service delivery for all patients in the North of England remains to proven;
  • Whether performance and quality standards will be assessed and monitored collectively across the North of England in future; and
  • Importantly, the impact on devolution schemes which are at different stages in the North, remains unclear.

This new model can help drive regional collaboration and blue light interoperability but concerns about potential job losses, its impact on patient safety and service delivery will have to be quickly addressed to give it any meaningful chance of success and building a sense of confidence in the proposed Alliance.

Emergency services collaboration: role and future of the ambulance services?

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Collaboration between emergency services is neither novel nor new. Many emergency services are already working with each other and other public bodies to provide better services while improving efficiencies. It was however argued that the present levels of coordination and collaboration are uneven and not as well developed as they might be. In September 2015, the UK Government published the consultation document ‘Enabling closer working between the Emergency Services’ aimed at promoting better coordination of emergency services in England. Early this year, the responsibility for fire and rescue policy was transferred to the Home Office from the Department of Communities and Local Government (DCLG). The Government also published its response to the consultation in January 2016. The Summary of consultation responses and next steps sets out legislative proposals to:

  • introduce a high level duty to collaborate on all three emergency services, to improve efficiency or effectiveness;
  • enable Police and Crime Commissioners (PCCs) to take on the functions of fire and rescue authorities (FRAs), where a local case is made;
  • where a PCC takes on the responsibilities of their local FRA, further enabling him or her to create a single employer for police and fire personnel;
  • in areas where a PCC has not become responsible for fire and rescue services, enabling them to have representation on their local FRA with voting rights, where the local FRA agrees; and
  • abolish the London Fire and Emergency Planning Authority and give the Mayor of London direct responsibility for the fire and rescue service in London.

The latest consultation response assumes both the desirability of PCCs taking over the leadership of fire services and the ‘single employer’ form of merger to promote greater efficiencies. Arguments for and against the proposals to bring together the fire and police services under the remit of PCCs have been well rehearsed in the media. The consultation response does not specify the exact nature of collaboration between the ambulance services and the police and fire services. Other than suggesting a legal duty to collaborate, the role and responsibility of the NHS ambulance trusts in determining their legal duty remains unclear and has not attracted much attention and scrutiny.

The Association of Ambulance Chief Executives (AACE) has welcomed the intention of the Government backing to keep ambulance services as part of the NHS, while reaffirming its support for closer collaboration and more innovative blue light working between the three emergency services. The Keogh Review and the NHS Five Year Forward View also acknowledge the role and contribution of the ambulance services to the Government’s urgent and emergency care strategy. This view was also echoed by several speakers at the recent Ambulance Leadership Forum 2016.

Whether ambulance services see their future as part of NHS or whether there is a drive to integrate-fully or partially with other emergency services, there will always be the need for two functions currently provided by the ambulance services namely, (i) a means of supported transport of patients in the community to services provided in health care facilities and (ii) responsive, professional, timely outreaching emergency diagnosis and management service. These are the core of current ambulance services and will be the core of any future service(s). What is likely to change is the means of delivery and the professionals that delivers the service. Technology will enable better remote triage; increasingly skilled practitioners will use better decision support mechanisms to deliver more sophisticated heath care.

There is however a significant change in the profile for demand for the ambulance services as compared to the police and fire services. The overall attendance of fire services incidents has shown a decline of more than 40% over the last decade. Recorded crimes (other than fraud) are showing a downward trajectory since its peak in 2003-04. But ambulance demand has shown a steady increase of almost 10% over the last five years. Ambulance services are also no more the sole employer(s) of the paramedics, many of whom now work outside the NHS ambulance settings such as the GP surgeries, out-of-care facilities and with private ambulance providers. With a shortage of paramedic staff, managing such levels of demand and quality of patient care is clearly unstainable and it is no secret that ambulance services across the country are struggling to cope up with increased activity and meet their performance targets.

This is a changeable moment for the ambulance services. Steady rise in 999 demand and shrinking budgets are seen by many as two of the key challenges which are unlikely to go away in the near future. While their position within the blue-light architecture is still being decided, it presents opportunities for exploring new innovative organisational forms and management structures to bring about real reforms and transformational change. There has never been a greater need for an open and honest conversation between the ambulance leaders, policy makers and other stakeholders to debate the role and future of the ambulance services we all love and care about.

Interoperability between Emergency Services: A Missed Opportunity?

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Professor Paresh Wankhade (Business School) analyses the latest Interoperability proposals offered by the government:

The governance of the emergency services in England is complex and the three main emergency services (ambulance, police, and fire & rescue) are structured differently, largely as a result of the relatively ad-hoc nature of their historical development. In September 2015, the UK Government published the consultation document ‘Enabling closer working between the Emergency Services’ aimed at promoting better coordination of emergency services in England. The government argued that the present levels of coordination and collaboration are uneven and not as well developed as they might be.

Earlier this month it was formally announced that fire and rescue services will be transferred to the Home Office from the Department of Communities and Local Government. However the Chief Fire Officers Association has sought clarity on issues pertaining to transitioning policy, provisions to meet national emergencies, in-depth risk assessment framework and sustainable budgeting principles to separate fire budgets from police and other Home Office Budgets.

This week the government published the ‘Summary of consultation responses and next steps’ to the Consultation after receiving over 300 responses. The Government intends to legislate to:

  • Introduce a high level duty to collaborate on all three emergency services, to improve efficiency or effectiveness;
  • Enable Police and Crime Commissioners (PCCs) to take on the functions of fire and rescue authorities (FRAs), where a local case is made;
  • Where a PCC takes on the responsibilities of their local FRA, further enabling him or her to create a single employer for police and fire personnel;
  • In areas where a PCC has not become responsible for fire and rescue services, enabling them to have representation on their local FRA with voting rights, where the local FRA agrees; and
  • Abolish the London Fire and Emergency Planning Authority and give the Mayor of London direct responsibility for the fire and rescue service in London.

The proposed governance arrangements contained within the consultation document present a number of challenges and has received mixed responses. The Local Government Association (LGA) raised concerns in their response to the consultation document. It contended that the changes would be a distraction from existing patterns of cooperation and could indeed undermine existing arrangements where the boundaries between the fire & rescue services and PCCs are not coterminous. Government’s proposals to allow PCCs to take responsibility for their local fire and rescue services was dubbed as ‘dangerous’ by the Fire Brigades Union (FBU).

It is worth noting that some of the proposals in the latest consultation are not original. In 2013, the government commissioned report ‘Facing The Future’ led by Sir Ken Knight, former government Fire and Rescue advisor (and Visiting Professor at Edge Hill Business School) had reviewed the efficiencies and operations in the fire and rescue authorities in England. The report had further proposed the merging of fire and rescue services with the possibility of the PCCs taking on the role of fire and rescue authority after due evaluation.

The latest consultation response assumes both the desirability of PCCs taking over the leadership of fire services and the ‘single employer’ form of merger to promote greater efficiencies. There are concerns that that giving a wide range of powers to a single individual will necessarily provide greater benefits than having an elected body with those powers. The merger process can have its own unintended consequences and there is enough academic evidence to suggest that such a process is likely to have an adverse impact on individual staff and organisational capacity to deliver intended benefits. Moreover, the requirement and mechanisms for the PCCs to have access to an informed, independent assessment of the operational performance of the fire services remain to be finalised.

The proposals while suggesting a legal duty to collaborate, do not clarify what would constitute evidence of a failure to collaborate, who would be allowed to institute proceedings should this allegedly happen and what would be the penalty for non-compliance. The role and responsibility of the NHS ambulance trusts in determining their legal duty remains unclear and efforts should be made to reflect their role within these proposals and in future legislative changes including possible impact on the governance of the ambulance services.

One key pubic message emerging is that the government wants the police, fire and ambulance services in England to share control rooms to improve their response to 999 calls. But this is already happening in many parts of the country (such as in Bootle in Merseyside) without a formal merger/integration. The long standing question of addressing the issue of different professional cultures in the three emergency services remains unattended in these proposals. Lack of specific proposals to improve strategic leadership across these organisations in brining transformational change can seriously hamper bringing real change in attitudes and culture(s) within the blue-light services.   There is a danger that the current process may lead to a ritualistic compliance and perverse consequences.

The consultation process was the first real opportunity to look into the important question of improving interoperability between the three main emergency services. By limiting the scope of the consultation to seek views on the proposed integration of police and fire & rescue services and giving power to PCCs to take on the functions of the fire rescue authorities, a golden opportunity has been lost for having an honest and frank discussion about the future of our emergency services.