With the comprehensive spending review (CSR) approaching at the end of the month, NHS Providers recently published its submission on behalf of NHS trusts and foundation trusts, setting out the urgent investment the NHS needs to live with the long term impact of COVID-19, build resilience and transform services.
In a series of blogs, we are exploring some of the specific funding needs across the different parts of our membership.
The recently announced settlement of an additional £15.8bn in NHS revenue over the next three years is welcome, especially at this time of constrained public spending. But we estimate that it still leaves a shortfall of more than £3bn for the next financial year, with a continuing funding gap into the future. The picture for the ambulance sector specifically, including the all-important capital allocation for the NHS, is as yet unclear. At this critical juncture, the government must take a holistic view of investment, recognising the vital role of ambulance services in supporting care backlog recovery and transforming services. As ambulance trust leaders turn to the immediate task of navigating winter, and further ahead at the likely demand pressures over the three year CSR period, they have four key funding concerns:
- The demand and capacity mismatch shows no sign of easing
As highlighted in last week's NHS planning guidance, there has been sustained pressure on urgent and emergency care (UEC) services over the summer due to increased demand and ongoing capacity constraints. NHS staff are bracing themselves for worse to come over the winter period. The ambulance sector has had a welcome injection of funding to bolster staff numbers ahead of winter but it's unclear whether similar support will be allocated for the longer term.
There are still a lot of vacancies across the sector and trust leaders have voiced ongoing concerns about levels of burnout among staff. Even before COVID-19, there was a severe mismatch between demand and funding across the NHS as a whole, with the ambulance sector requiring around £250m of additional support. It is unclear how far the recently announced funding settlement will go towards addressing this mismatch. Plus the NHS desperately needs a multi-year workforce plan to support and grow the workforce.
- The costs of COVID-19 will be with us for a long time
NHS Providers and the NHS Confederation recently published a report which set out how COVID-19 has increased the NHS' day-to-day running costs for the long term. Factors such as infection prevention and control measures, increased staff absence rates, expanding services to deal with increased demand, and providing much more personal protective equipment for staff, will be with us for the duration of the three-year period likely to be covered by the CSR.
The ambulance sector has had to increase call centre space due to social distancing, undertake enhanced cleaning of vehicles and stations and increase the capacity of patient transport services as more patients have needed to travel alone. This is further compounded by lost productivity due to staff absences and the impact on system flow across UEC, for example in relation to ambulance handovers. On average, ambulance trusts have seen an estimated 6.94% increase in recurrent annual costs as a result of COVID-19.
- Ambulance trusts will play an important role in tackling the care backlog
Ambulance services are seeing the impact of pent-up demand due to COVID-19. There are many different factors at play here, including more people requiring support for health issues that have deteriorated over the course of the pandemic, and mounting pressures across the whole health and care system meaning more people are turning to emergency services. The ambulance sector also has a key role to play in elective recovery through the provision of non-emergency patient transport services (PTS).
These services ensure that patients arrive on time for their appointments and that, when being discharged, they can return home quickly, supporting the smooth-running of elective care pathways. 60% of ambulance trust respondents to a recent NHS Providers survey said they anticipated PTS demand to increase significantly as the NHS steps up elective activity. The task faced by integrated care systems and providers in recovering the care backlog over the next two to three years will require sufficient funding being available across the ambulance sector. Effective use of resources across the health service as a whole is also reliant on having sufficient capacity for NHS 111 and 999 services, as highlighted in NHS England and NHS Improvement's recently published UEC recovery 10 point action plan.
- We risk missing the opportunity to transform services
The COVID-19 pandemic has highlighted the need to deliver services differently in order to reduce pressure on hospital services. We have seen the key role of ambulance trusts in this endeavour, for example through paramedic referral to same day emergency care initiatives and using alternative care pathways and digital tools to safely reduce avoidable conveyance to emergency departments.
The latest figures show that 52.7% of incidents resulted in journeys to A&E, with the remaining 47.3% treated and discharged on scene, provided with telephone advice or transported to other suitable destinations. There is scope to do more if sufficient capital and revenue investment is made, for example in expanding clinical assessment services and the digital infrastructure required to improve resilience and responsiveness. As highlighted in NHS Providers' recent capital briefing, additional capital investment is also needed to support the NHS' ambition to become 'net zero' by 2040, for example by extending the use of zero-emission ambulances.
The additional revenue for the NHS is welcome but tackling the care backlog and transforming care effectively will require a holistic view of investment. It is therefore vital that the government takes the issues set out above fully into account in its CSR decision-making and agrees a settlement that provides the ambulance service with what it needs to meet growing demand, manage the ongoing costs of COVID-19, support care backlog recovery and transform services in the best interests of patients.