30 January 2017
Tim Gardner

Tim Gardner

Senior Policy Fellow
Health Foundation

The other night I was just minutes from home when an ambulance shot past, sirens blazing and blue lights flashing.

My first thought was to hope the person the ambulance crew were racing to help – clearly someone in my community, possibly someone I know and care about – would be ok. My second was to reflect on the enormity of the task faced by ambulance services in delivering potentially life-saving care to everyone who needs it around the clock, 365 days a year.

So the National Audit Office’s recent report, published just a few hours later, put a timely spotlight on the growing pressures on ambulance services across the country.

This rightly highlights a rapid growth in demand for ambulance services: since 2011/12, the number of ambulance calls and NHS 111 transfers has grown by an average of more than 5% per year, reaching 10.7 million in 2015/16.

Funding for ambulance services also increased between 2011/12 and 2015/16, by around 16%, but only by just over half of the 30% growth in activity over the same period. And budgets are set to get even tighter in the near future.

With funding having failed to keep pace with demand, it may be unsurprising that ambulance response time targets for people with life threatening conditions now haven’t been achieved at national level for some time, though that doesn’t make it any less of a concern.

Perhaps more of a surprise is that, despite the inevitable focus on performance against the national targets, ambulance services have managed to make notable progress in improving some other important aspects of quality.

The NAO echoes our latest QualityWatch annual statement, which found substantial improvements in call handling from 2011/12 to 2015/16. More people got through to the ambulance service promptly on the phone, while twice as many had problems that were resolved with telephone advice. And that advice seems to have been effective, given the seven percentage point drop in the number who got back in touch within 24 hours.

The number of calls that resulted in an ambulance journey to an A&E department also fell by half a million, as a greater proportion of patients received treatment – from ambulance staff, at a minor-injury unit or in primary care – that meant they didn’t need to go to hospital. These are impressive improvements, not least because hospitals are themselves under enormous pressure.

Now that winter is well and truly here, it’s almost impossible to miss the headlines about the pressures being experienced by acute hospitals. What tends to get less attention is the impact this has on ambulance services. The NAO helpfully shines a light on this, highlighting that in 2015/16 alone delays in handing over patients at A&E departments accounted for approximately 500,000 lost ambulance hours.

However, ambulance staffing is an important area that the NAO could and arguably should have emphasised more.

The report does acknowledge problems with the recruitment and retention of ambulance staff, noting that sickness absence rates are higher than other NHS trusts and how reducing absence – particularly at ambulance trusts with the highest rates - could provide substantial extra resource for patient care. But it could go further in exploiting the hugely rich source of data offered by the annual NHS staff survey.

Fortunately, analysis undertaken by QualityWatch shows ambulance trusts stand out in a number of other important areas.

Our indicators show that a greater proportion of ambulance trust staff consistently report having worked extra hours than other NHS staff, and receiving less support from their immediate managers. The proportion of ambulance staff experiencing violence from patients or relatives is also consistently much higher than other types of trust.

What I find really concerning is work-related stress. Around one in two ambulance trust employees report having been made ill in the last 12 months due to work-related stress, compared to one in three for all NHS staff. But this doesn’t seem to be inevitable: until about 4-5 years ago, ambulance trusts were very similar to other trusts on this measure and something quite important seems to have changed since then.

I suspect there aren’t many easy answers, but we still need to ask the question: what can be done to look after the dedicated professionals who staff our ambulance services as well as they look after us?

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