Ambulance trusts are uniquely placed to play a pivotal role in managing the long term impact of COVID-19, transforming services and the delivery of the long term plan. They make a particular contribution through their role as care navigators in driving integrated care, deploying innovative workforce models and enhancing patient care using digital approaches. This will result in more patients being managed in the right place at the right time. With appropriate support, recognition and investment, there is potential for the sector to do even more across and within integrated care systems (ICSs).
The ambulance service continues to face intense pressures. In June 2021, category one incidents increased by 8.1% compared to the previous month. Compared to two years ago, before the pandemic, category one incidents have increased by 27.2% and overall activity has increased by 11.3%. The sector is proving resilient in the face of these increasing pressures, including rising demand for services outpacing funding increases and workforce capacity, and the knock-on impact of very pressured primary and social care services.
Trusts are rightly adapting the way they work to meet the increasing demand, in line with the long term plan’s vision, but they need parity in investment if this is to be sustained. Prior to the pandemic it had been identified that the sector needed some £250m of additional funding to deal with increasing demand and eliminate historic underfunding for some trusts. While they have proven to be resilient and innovative throughout the pandemic, these underlying funding issues remain and must ultimately be addressed if ambulance trusts are to fully realise their potential.
As part of the evolving policy landscape relating to ICSs, ambulance trusts must be involved in regional, ICS and place-level decision making about service design, including defining what single point of access means in practice and over what size footprint. AACE has developed a blueprint model which sets out this joined-up approach in more detail.
Without this, we risk fragmenting services and duplicating resources through multiple points of access within regions. It is vital that this is recognised as part of the ongoing work to agree how ICSs will function as statutory bodies as of April 2022. AACE is currently engaging with NHS England and NHS Improvement and ICS leaders to explore the concept of a single regional commissioning board with oversight for ambulance services working across multiple ICSs.
Learning from the COVID-19 response has shown that there are opportunities to improve productivity and efficiency when aspects of service provision can be done collaboratively, at scale, across ICS and multi-ICS footprints. Ambulance trusts are well-placed to participate in, and lead, provider collaboratives at system level where it makes sense to do so.
Trusts have highlighted the benefits of provider collaboration and partnership working as particularly relevant for the ambulance sector, where demand can be so significantly impacted by wider system issues. Ambulance trusts are already engaged in system working to varying degrees, and all are keen to realise the full value of their contribution in UEC provision and population health management.
Integrated care
The NHS is clear on its ambition to provide patients with the care they need as close to home as possible and reduce pressure on hospital services through reforming how urgent care is organised and delivered. Ambulance trusts already deploy 'hear and treat' and 'see and treat' response models, which have been particularly relevant during the pandemic in keeping people out of hospital wherever possible. Many ambulance trusts are working in partnership with other providers and commissioners in their region to deliver integrated services, with the clinical assessment service (CAS) model forming a central part of this. This means that resources are not duplicated and patient flow is streamlined, leading to a better patient experience.
The ambulance sector’s full potential to support elective recovery and measures to tackle the care backlog should be realised. Non-emergency patient transport services (PTS), some of which are provided directly or coordinated by ambulance trusts, support the smooth-running of the healthcare system. These services ensure that patients arrive on time for their appointments and that, when being discharged, they can return home quickly. The move to system-working provides an opportunity for larger system-wide PTS contracting or coordination, which will play a key role in patient flow and tackling the care backlog through efficient use of resources across systems and regions. It will also help to tackle health inequalities by supporting patients who need help to access care.
Innovative workforce models
Ambulance trusts are making changes to training and working practices so that paramedics can develop and learn alongside other types of healthcare professionals and therefore be deployed differently, leading to a reduction in hospital conveyance rates. One such model is rotational working, whereby specialist and advanced paramedic practitioners rotate between clinical settings across systems, using their advanced clinical assessment skills to help provide the right response the first time.
Wider use of the model could have a positive impact on patient experience and workforce retention – this is particularly relevant to the development of paramedic roles within primary care networks. The paramedic workforce is scarce however, and the recruitment and positioning of these skillsets need to be considered within ICS multi-professional workforce planning so that the ambulance workforce is not further depleted, especially of the most experienced paramedics.
The long term plan made welcome commitments to build the capability of ambulance staff to respond to patients presenting with mental health issues. This commitment must be adequately resourced in order to increase capacity in the system as the number of people requiring mental health support continues to rise.
Mental health expertise within the ambulance workforce is particularly important given that emergency departments (EDs) are not always the most appropriate place for people in a mental health crisis. Adapting response models and working closely with community mental health teams to avoid unnecessary conveyance to hospital for people with mental ill health is, therefore, an important current focus for ambulance trusts.
Digital transformation
The response to COVID-19 has accelerated digital ways of working, leading to: better sharing of medical records and therefore faster clinical decision making, greater collaboration between services, including use of video consultation to enable paramedics to provide care remotely, reducing unnecessary admissions and virus transmissions, and wider use of innovative ways of working, such as 111 First, to ensure seamless clinical handover for patients who need to visit ED. For ambulance trusts covering several ICSs and working with every part of the health and care sector, the gains from digital transformation will be significant: better service coordination, a reduction in avoidable waits and better response times.
Key asks of government and national bodies
With the right measures and investment in place, the ambulance sector’s role in supporting COVID recovery and delivering the long term plan can be developed to its full potential, to the benefit of the whole health and care system and the patients it serves. AACE and NHS Providers are therefore calling for:
- Policy alignment, ensuring the voice of the ambulance sector is involved in strategic decision-making at national, regional, ICS and place level. This includes: continued meaningful engagement with the sector on evolving ICS guidance and joined-up workforce planning, wider promotion of the rotational paramedic model in a measured way, and involvement of the sector in policy developments for primary care and social care which impact UEC.
- Greater recognition of the ambulance sector’s role as providers of UEC, with many care episodes being concluded, either on-scene or over the phone, without the need for onward referral, and as care navigators, ensuring people are treated in the right place at the right time. This includes: recognising the service’s role in integrating UEC provision across larger footprints, whilst supporting local, place-based care, acknowledging the unique insight of ambulance trusts on the impact of service reconfigurations and scaling up best practice across a region, and understanding the important contribution of the paramedic workforce in the next iteration of the NHS People Plan.
- Whole system investment to build on learning from the pandemic, to match the ambition set out in the long term plan, and to address historic underfunding, in the form of: dedicated mental health funding reaching the services that need it most, a long term, fully costed and funded, workforce plan in the next comprehensive spending review (CSR) that takes into account the needs of the ambulance sector, a multi-year NHS capital settlement in the CSR, in line with NHS Providers' #RebuildOurNHS campaign asks, to unlock capital investment to support further digital transformation and specific fleet requirements.