Key points
- The ambulance sector has made a significant and highly-valued contribution to the COVID-19 pandemic health response across the country. During the first wave, ambulance services received additional funding to enable them to increase capacity to address the challenges they were faced with. This meant the service was able to respond rapidly and effectively.
- Ambulance service provision has historically been under-funded, with financial settlements not keeping up with ever-increasing demand faced by the sector. This has an inevitable negative impact on patient experience and clinical outcomes, as well as the mental health and wellbeing of ambulance service staff. The latest independent demand and capacity review modelling commissioned for ambulance trusts in England forecasts an annual funding gap of £237.5 m.1
- Learning from COVID-19 strongly highlights the need for ambulance services to be adequately funded on a recurrent basis, so that their capacity to respond safely to predicted demand can be fully and appropriately resourced with the necessary skill mix all year round. The Association of Ambulance Chief Executives (AACE) and NHS Providers are clear that this must be reflected within the COVID-19 support package that will be set out in the government’s forthcoming spending review and in future commissioning to keep up with demand.
Introduction
The government recently announced that it will conduct a one-year spending review on 25 November 2020, rather than the previously planned comprehensive spending review. While the government intends to include multi-year NHS resource settlements as part of the review, it is unclear how far-reaching these commitments will be.
The government has also signalled its intention to include provision within the spending review for “enhanced support for public services to continue the fight against the virus alongside delivering first class frontline services”. As evident during the first wave of the pandemic, there is a need for this enhanced support to include dedicated funding for ambulance services.
Ambulance trusts received additional funding in the initial COVID-19 response to enable them to increase capacity and meet demand. The sector has made a significant and highly valued contribution to the pandemic health response across all health systems. Alongside this, and despite the new challenges they were faced with, ambulance services were successful in meeting national targets and standards for the first time in the last decade. The relationship between demand, capacity and performance is complex but it is likely that meeting the standards was made more possible due to a closer alignment between capacity and demand during this period.
As highlighted by NHS Providers in our submission to the spending review, the health and care system is facing longstanding pressures which pre-date the COVID-19 pandemic and have arisen from a lack of sufficient investment to meet growing demand for services and to recruit and retain enough staff.
This short briefing, jointly developed by AACE and NHS Providers, highlights the need for a specific focus on ambulance service funding as part of the government’s planned COVID-19 support package within the spending review.
Demand and capacity planning
The ambulance service plays a fundamental and pivotal role in the delivery of urgent and emergency care with approaches such as hear and treat and see and treat contributing to reductions in ED admissions. Traditionally the sector’s focus has been on delivery of 999 services but now encompasses urgent care with 111, clinical assessment services (CAS) and patient transport services (PTS) integral to many ambulance trusts’ provision. 999 service provision has historically been under-funded with financial settlements not keeping up with ever-increasing demand faced by the sector.
Ambulance services now routinely undertake sophisticated demand and capacity reviews (DCRs) for 999 frontline and control room requirements with resource needs projected forward for three to four years. The process builds in allowance for expected increases in productivity through identified efficiency measures. This modelling is usually procured from independent external experts often in collaboration with commissioners and other external stakeholders. The level of resources needed to meet national ambulance service standards, as identified through these DCRs, however, generally remains under-funded across trusts, and this has an inevitable negative impact upon patient experience and clinical outcomes, as well as the mental health and wellbeing of ambulance service staff. The cumulative effect of the shortfall in funding very often leads over time to significant gaps in capacity and difficulties in meeting increasing demand.
Responding to the COVID-19 pandemic
During the first wave of the COVID-19 pandemic, ambulance services received additional funding to enable them to increase capacity (workforce and assets) to address the demand increases experienced. Some of the additional capacity was brought in through mutual aid from partners such as St John Ambulance and fire and rescue services. Ambulance services themselves curtailed much of their normal activity (including cancellation of non-mandatory training and cessation of secondments) to place all operational staff (including operational managers) on frontline duties and focus all available resources on the response to COVID-19. This was, of course, unsustainable in the longer term and, in the second quarter of the financial year (Q2), services had to withdraw these additional frontline resources and return them to business as usual (BAU) duties. With the re-emergence of COVID-19 pressures associated with the second wave of the pandemic, ambulance trusts have again curtailed all developmental activities and are once again returning all operational staff to front line duties and calling on support from private and voluntary resources and, at times, mutual aid.
In May to July of 2020/21, at the height of the initial wave of COVID-19, all national ambulance service targets were met by the sector for the first time since their introduction in 2017. It is important to note that the relationship between demand, capacity and performance is complex and that the total number of incidents was actually lower than the same time last year during this period. Ambulance trusts were, however, faced with new capacity pressures caused by the pandemic, relating to infection and prevention control, social distancing measures and workforce absence. It is likely that meeting the standards was made more possible at this time due to a closer alignment between capacity and demand. The picture then began to change in Q2, as demand increased, services had to return staff to BAU functions some mutual aid was stood down.
The ambulance sector has demonstrated its ability to respond highly effectively to a national level 4 emergency and was commended for its contribution and coordination of health response across their regions during the first wave of the pandemic. This included the establishment of the National COVID-19 Response Service (CRS) for 111 by South Central Ambulance Service. National coordination of operational response was achieved through the National Ambulance Coordination Centre and the national strategic ambulance advisor. For the first time in the last decade, the level of available capacity was sufficient for all English ambulance services to meet national targets and standards.
Funding to meet current demand
The matching of capacity with demand needs to become the norm, with historic underfunding addressed and capacity requirements met on a recurrent basis. This will result in a consistent standard of high-quality care being provided for all ambulance service patients with a beneficial impact upon employee mental health and wellbeing.
Across the sector in England, the gap in annual funding of ambulance services against forecasted resourcing requirements to meet national standards currently sits at £237.5m.( This figure has been determined through AACE requesting identified gaps in current operational funding through trusts’ demand and capacity reviews; it does not include any other current or future potential cost pressures faced by ambulance services. For each of the ten English ambulance services, this total gap of £237.5m equates to a range of under £10m in some trusts to in excess of £60m in others).
During the initial COVID-19 response, an additional 614 double crewed ambulances were resourced in the English ambulance trusts. This would equate to approximately 7,368 responses to patients per 24 hours. This additional resourcing has now reduced, while demand is again on the increase as winter approaches along with a second wave of COVID-19 transmission.; Ambulance services are working hard to maintain resourcing levels while stopping other key trust functions as they did during the first wave of the pandemic.
Furthermore, responding to people who need an ambulance is being severely hampered by patients having to wait in ambulances outside emergency departments (EDs). In Q1 2020/21, in the height of the pandemic, handover delays reduced significantly - an average of 27,164 hours were lost each month for handovers over the 15-minute standard. The trend is now increasing again to reach similar figures to those seen in Q2 last year (c.40,000 hours lost in September 2020. Figures obtained by collated returns from all English ambulance services related to handover delays).
The delays are exacerbated by capacity pressures across the health system – for example, hospitals are endeavouring to recover services and manage non-COVID demand while COVID-19 cases increase. Ensuring COVID and non-COVID patients are kept safe and separate has reduced NHS capacity by 10 to 30%, depending on the trust concerned, and trusts in areas with higher rates of COVID are understandably seeing increases in sickness absence. Patients waiting in ambulances outside EDs is unacceptable and a major indication of enduring capacity pressures within hospitals, presenting significant risk to the safety of patients waiting in the ambulance and for those waiting for a response in the community.
Conclusion
Learning from COVID-19 strongly highlights the need for ambulance services to be adequately funded on a recurrent basis, so that their capacity to respond safely to predicted demand can be fully and appropriately resourced with the necessary skill mix all year round. AACE and NHS Providers are clear that this must be reflected within the COVID-19 support package that will be set out in the forthcoming spending review.