Ambulance service at creaking point

Adobe SparkRecent figures published by NHS England reveal the ambulance service is continuing to fail to meet Government standards for responding to Category A (Red 1 and Red 2) calls. The figures for March 2016 showed only 66.5% of Red 1 calls were responded to within 8 minutes, while 72.3% of Red 2 calls received a response within the same timeframe (NHS England, 2016). This is compared to 73.4% and 69.6%, respectively for the same period in 2015. It marks 10 months that services in England as a whole have failed to meet the Government target of 75% for Red 1 Calls. The response to Red 2 calls is the lowest proportion recorded since the data collection began in June 2012. However, it must be highlighted that Red 2 data from February 2015 onwards are not completely comparable across England due to the introduction of Dispatch on Disposition, allowing up to two additional minutes for triage to identify the clinical situation and take appropriate action.

It has been a tough year for ambulance services, with London Ambulance Service NHS Trust being placed under special measures by the Care Quality Commission (CQC) in November 2015 and East Midlands Ambulance Service NHS Trust being recently rated inadequate by the CQC for safety due to insufficient staff numbers and a consensus that the skill mix of staff deployed was not always safe (CQC, 2016).

The fact of the matter is that demand for ambulance services continues to rise and services are struggling to keep up. The ambulance service in England received 861 853 phone calls in March 2016, compared to 694 188 in March 2015 (NHS England, 2015; 2016), a rise of 24%. However, Trusts have not been able to increase their numbers of staff to meet this demand. This creates greater work pressures and stress for existing employees, brought on by longer working hours and missed meal breaks. The result? High staff attrition within Trusts. Those that remain will no doubt be questioning whether this is sustainable. With staff currently being balloted by unions over industrial action on pay, the possibility of a crisis within the ambulance service cannot be dismissed as hearsay.

If this is to be avoided, a number of things have to change. Trusts must ensure front-line vacancies are filled and staff do not leave. This can only be done by fostering a work environment in which staff are happy to remain. The over triage of patients must be minimised so that appropriate resources are dispatched. And, where possible, patients’ needs must be addressed at the point of contact and unnecessary transfers to hospital must be avoided. If the ambulance service carries on as it is, it is difficult to see how it will continue to operate in 10 years’ time. By focusing on employee welfare, this crisis may be averted.


Care Quality Commission (2015) London Ambulance Service NHS Trust Quality Report, 27 November 2015. (accessed 26 May 2016)

Care Quality Commission (2016) East Midlands Ambulance Service NHS Trust Quality Report, 10 May 2016. (accessed 26 May 2016)

NHS England (2015) Ambulance Quality Indicators Data 2014–15. (accessed 26 May 2016)

NHS England (2016) Ambulance Quality Indicators Data 2015–16. (accessed 26 May 2016)

Taken from Journal of Paramedic Practice, published 27 May 2016.

Special measures for struggling services

In November of last year, London Ambulance Service NHS Trust (LAS) became the first ambulance Trust to be placed under special measures following an inspection of the service by the Care Quality Commission (CQC) in June 2015. The overall rating given by England’s chief inspector of hospitals, Prof Sir Mike Richards, was that the service was inadequate, and it was acknowledged that improvements were needed on safety, effectiveness, responsiveness and leadership (CQC, 2015b).

Of the key findings, it was noted that LAS had a high number of front-line vacancies, with some employees saying that there were not enough appropriately trained staff to ensure that patients were consistently safe and received the right level of care (CQC, 2015a). As a result of staff working long hours, many reported feeling high levels of stress and fatigue. Additionally, while the CQC recognised that staff were ‘overwhelmingly dedicated, hardworking and compassionate,’ they revealed that ‘some reported a culture of harassment and bullying’ (CQC, 2015a). It was highlighted how until March 2014, LAS was consistently the best performing service in the country to category A calls. However, since then there has been a substantial decline in performance, and the target time of 75% of calls being responded to within 8 minutes has not been met. This is something that has been affecting ambulance services across England, although LAS response times for Red 1 and Red 2 category A calls were reported as being the worst in the country. Serious concerns were also identified about the service’s Hazardous Area Response Team (HART) capability due to an insufficient number of paramedics. The result was the feeling that there was not a safe system of working where an effective HART response could be utilised (CQC, 2015b).

The decision to place LAS under special measures is a considerable blow, not just to the service, but to all members of ambulance Trusts. Fundamentally it highlights the CQC’s belief that LAS is unable to provide the level of care expected of it. This is despite the dedication and commitment that is clearly apparent in front-line staff, alluded to in the report. But while it is easy to consider the negative connotations of the CQC’s report, it is important to remember that one of the key reasons why services are placed under special measures is to ensure they get the support they need to improve. External partners such as the NHS Trust Development Authority and NHS England will give LAS access to a package of additional resources and support.

Ambulance services throughout the country are struggling to deal with increasing pressures, a national shortage of paramedics and insufficient funding. It is hoped that other ambulance services will not suffer similar findings from the CQC, but it should be reassuring to know that there is a system in place to offer support to services that are unable to make improvements required of them on their own.


Care Quality Commission (2015a) Chief Inspector of Hospitals recommends London Ambulance Service NHS Trust is placed into special measures. CQC, London. (accessed 4 January 2015)

Care Quality Commission (2015b) London Ambulance Service NHS Trust Quality Report. CQC, London. (accessed 4 January 2016)

Taken from Journal of Paramedic Practice, published 8 January 2016.

CQC publishes guidance on how health and care providers can meet the Government’s new care regulations

The Care Quality Commission (CQC) has published guidance on how the 46,000 health and adult social care providers and services across England can meet the Government’s new care regulations.

The new care regulations—called the fundamental standards—will take effect from April, and follow a public consultation that took place last summer to get people’s views. The CQC has also published what people told them and what has changed in response to their comments.

A key part of the enforcement policy is the ability for the CQC to prosecute providers for poor care without having to issue a warning notice first. Up until now, CQC has had to follow a staged process of enforcement, starting at the bottom of the scale, and so the new policy will allow CQC to act quickly in response to the seriousness of the concern.

Commenting on the regulations guidance and new enforcement policy, David Behan, chief executive of the Care Quality Commission, said:

‘We now inspect services against the five key questions that matter most to people who use them: are they safe, caring, effective, responsive to people’s needs, and well-led? This helps our inspection teams to identify good care.

‘When our inspection teams identify poor care, this guidance will help us to determine whether there is a breach in the new regulations and if so, what action to take. In some cases, this will mean we will use our powers to prosecute. We hope this helps providers in their preparations for April and to make sure that their services do not fall below acceptable levels of quality.’

Further guidance will follow in March, including how care homes, general practices, dental surgeries, private hospitals and other services can meet the ‘duty of candour’ and ‘fit and proper person’ requirements for directors. These will oblige providers to be open and honest when things go wrong and hold directors to account when care fails people.

Taken from Journal of Paramedic Practice, published 17 February 2015.

CQC outlines priorities for improving monitoring, inspection and regulation of ambulance services

The Care Quality Commission (CQC) has published a signposting document outlining initial thoughts on how it intends to regulate ambulance services in England.

A fresh start for the regulation of ambulance services builds on the new vision and direction set out for the CQC in its strategy for 2013–2016, Raising standards, putting people first, and the changes proposed in the way health and social care services are regulated in the consultation document, A new start.

These changes were developed through engagement with the public, CQC staff, providers and key organisations.
The document sets out the CQC’s priorities on how it monitors, inspects and regulates ambulance services.

It also sets out the conversation the CQC wants to have with all its stakeholders in the ambulance service, including the people who use services, their families and carers, in order that it can develop a new approach which places matters important to patients at its heart.

As part of the new operating model that the CQC will use, it has set out a number of principles that will help guide how the CQC will inspect and regulate all care services. These include: the way the CQC register those that apply to provide services; the standards that those services meet; how the CQC uses data, evidence and information to monitor services; the specialists used to carry out inspections; how the public are given information on judgements about poor care quality, including a rating to help people compare services; and the action to require providers to improve, making sure those responsible for poor care are held accountable.

While these principles will guide the regulation of ambulance services, the detail of how the CQC will do this will be specific to the sector.

Five key questions will be asked of all services, to establish whether patients are receiving the necessary level of care: are they safe? Are they effective? Are they caring? Are they responsive? Are they well-led?

New inspection methodologies for the ambulance sector will begin in July. This will be followed by further inspections from October, to help refine the inspection methodologies and provide a meaningful system of inspections.

Taken from Journal of Paramedic Practice, published 28 April 2014.

East Anglia Ambulance Service under Fire

A damning report has revealed Suffolk, Norfolk and Cambridgeshire Ambulance Services have failed to meet response targets every month of the last financial year.

National standards require emergency services to reach targets of 75% of most urgent cases in eight minutes and 95% of incidents in 19 minutes.

Ambulance bosses have claimed the failing of these two key targets by the East Anglia Ambulance Service is due to high staff sickness rates, an increase in calls this winter and hospital handover delays.

Suffolk MP and health minister, Dan Poulter, said the findings were ‘hugely disappointing but sadly unsurprising.’

He added: ‘These figures are a sobering reminder of the complete failure of leadership within the ambulance service to face up to the challenge of providing high quality and speedy ambulance cover for Suffolk.’

In an attempt to ease pressure on the service, 15 new ambulances have been introduced to the East of England Ambulance Service Trust.

However, due to a lack of paramedics willing to work overtime, so far the extra vehicles have been unable to be put to proper use.

It is hoped that performance will improve following the planned recruitment of 75 new paramedics and 124 care assistants by the Trust.

The Care Quality Commission (CQC) has found the Trust non-compliant when it comes to the care and welfare of patients, and the results of a full investigation into the Trust are due to be published next month.

Taken from Journal of Paramedic Practice, published 14 Mar 2013.