Ambulance services are finding it increasingly difficult to cope with rising demand for urgent and emergency services, according to the National Audit Office.

Demand for ambulance services continues to grow rapidly. Contributing factors may include the increasing numbers of elderly patients with multiple conditions, an increasing number of alcohol- and mental health-driven issues, the availability of primary care services in the community and how patients seek help. Between 2009-10 and 2015-16, the number of ambulance calls and NHS 111 transfers increased from 7.9 million to 10.7 million. Increased funding for these services has not matched rising demand, and future settlements are likely to be tougher.

Introducing new models of care, such as resolving calls over the phone by providing advice to callers, has helped but there are signs of stress, including worsening performance against response time targets. In 2015-16, only one ambulance trust met the three response time targets. Today’s report, however found a general consensus that commissioners, regulators and providers place too much focus on response times. The majority of patients currently coded as Red 2 do not derive clinical benefit from the arrival of an ambulance within 8 minutes, but the 8-minute target has led to a range of behaviours which undermine efficiency, such as dispatching resources before it has been determined what the problem is, whether an ambulance is required; and dispatching multiple ambulances to the same patient and then standing down the vehicles least likely to arrive first.

In 2015-16, around 500,000 ambulance hours were lost due to turnaround at accident and emergency departments taking more than 30 minutes, which equates to 41,000 12-hour ambulance shifts. Transferring the care of a patient from an ambulance to an accident and emergency department is expected to take no longer than 15 minutes, with a further 15 minutes to prepare the ambulance for the next call. In addition, most ambulance trusts are struggling to recruit and retain the staff they need.

Today’s report also found that each of the 10 ambulance trusts in England has developed its own operating framework, with differences in workforce mix, fleet mix and estate. These differences have contributed to variations and inefficiencies in performance. For example, across ambulance trusts in 2015-16, the proportion of incidents where one or more vehicles were stood down after mobilisation varied from 4% to 46% and the proportion of call handled over the phone varied from 5% to 15%.

According to the NAO, ambulance services are finding it challenging to engage with the wider health sector due to the growing number of stakeholders that trusts are required to work with. In addition, the wider system does not always make good use of the ambulance services’ experience or recognise the impact that changes to other local services have on the ambulance services.

“Ambulance services are a vital part of the health service but much of their ability to work better greatly depends on other parts of the health system. Until clinical commissioning groups see ambulance services as an integral part of that system it is difficult to see how they will become sustainable and secure consistent value for money across the country”

Amyas Morse, head of the National Audit Office

Read the full report

NHS Ambulance Services

Notes for editors

£1.78bn The cost of urgent and emergency ambulance services provided by NHS ambulance trusts in England in 2015-16 10.7m Calls and NHS 111 transfers to the ambulance service in England, in 2015-16 6.6m Incidents resulting in a face-to-face attendance by the ambulance service in England in 2015-16 72.5% Of the most serious (Red 1) calls responded to within 8 minutes in 2015-16, against a target of 75% 10.4 percentage points Difference between the proportion of Red 1 calls responded to within 8 minutes, at the best- and worst-performing trusts in England 2015-16 5.2% Average annual growth rate in demand (calls and NHS 111 transfers) for ambulance services since 2011-12 500,000 Ambulance hours lost due to delayed transfers of care at hospitals in 2015-16 52% Of patients taken by ambulance to hospital who were then admitted in 2015-16, compared with 48% in 2007-08 4% to 46% Variation in the percentage of incidents in which an ambulance was deployed and later stood down, across trusts in 2015-16
  1. Press notices and reports are available from the date of publication on the NAO website. Hard copies can be obtained by using the relevant links on our website.
  2. The National Audit Office scrutinises public spending for Parliament and is independent of government. The Comptroller and Auditor General (C&AG), Sir Amyas Morse KCB, is an Officer of the House of Commons and leads the NAO, which employs some 785 people. The C&AG certifies the accounts of all government departments and many other public sector bodies. He has statutory authority to examine and report to Parliament on whether departments and the bodies they fund have used their resources efficiently, effectively, and with economy. Our studies evaluate the value for money of public spending, nationally and locally. Our recommendations and reports on good practice help government improve public services, and our work led to audited savings of £1.21 billion in 2015.
  3. Until recently all English ambulance trusts had three national response time targets:
  • Red 1 calls:  an emergency response arriving at the scene within 8 minutes in 75% of cases (clock starts as soon as the call is connected)
  • Red 2 calls: an emergency response arriving at the scene within 8 minutes in 75% of cases (clock starts up to 60 seconds after the call is connected)
  • Red 1 and 2 calls: where onward transport is required, a vehicle capable of conveying the patient arriving on the scene within 19 minutes in 95% of cases.

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