Vital support for the emergency services

The speakers’ panel at the annual Independent Ambulance Conference earlier this year was loaded with some of the most influential leading figures from the National Health Service. That in itself was significant, but one moment in particular will prove to be especially relevant in the future.
As delegates remarked afterwards it was clearly a deliberate comment from one of the speakers, a senior NHS commissioner in London, who had said: “Don’t wait for the ambulance trusts to come to you…go to them now and tell them what you can do for them….they need your help…partnerships are likely and relationships are key.”
Those words were poignant for the ambulance industry. The companies which, just a few short years ago, were being branded ‘cowboys’ and described in Parliament as the ‘back door’ to privatisation of the NHS, were at long last being officially invited to come in from the cold.
In reality they confirmed what most healthcare observers already knew but rarely mentioned in public, that for the past few years, the NHS ambulance trusts were relying increasingly on private companies for help as they struggled daily to meet the ever growing demands on their emergency services.

Growing importance
In the wake of financial pressures, some of the trusts have given up providing non-emergency patient transport services and it is now estimated that well over half of all NHS hospital transfers are carried out by private ambulance providers; even more significant is the fact that the companies’ resources are increasingly being called in for emergency duty.
Healthcare industry observers are predicting that this is just the start of a complete transformation of the ambulance service in England over the next five years when the independents will become fully engaged in carrying out both emergency and non-emergency work.
These views were strongly echoed by other speakers at the IAA conference. Professor Jonathan Benger, National Clinical Director for Urgent Care, NHS England, who is a key member of the Keogh Review, made the point that the new system of emergency and urgent care services will see an increased provision of care over the phone, at scene and in the community, with transport to A&E the exception rather than the rule. This will require an increase in community provision, free flow of information, joined up work with social care, enhanced clinical support and workforce development.

Delegates were pleasantly surprised to hear his prediction that a range of new opportunities will exist for independent ambulance services in the new system, ranging from the support of new models of care to urgent transportation to transfer and retrieval for the most seriously ill and injured patients.
Benger added: “There is an appetite for change within Government and all those engaged in the review. Ambulance services are central to the changes which will be radical and there will be a pivotal role for the independent ambulance sector.”

Keogh task force
Such is the growing respect for independent ambulance providers that the IAA is represented on the Keogh Review Task Force, sitting alongside the three statutory emergency services – police, fire and ambulance – to chart the future development of emergency and urgent care services.
It is the independent ambulance sector’s first opportunity to be directly involved in the future development of the nation’s healthcare services, a far cry from the days when irrevocable decisions were taken without any reference to them or recognition of the impact of such decisions on their businesses.
This change of fortune reflects the changes that are coming about across the whole NHS landscape. It has come about as a result of the Government decision in April 2011 to bring ambulance companies within the regulatory scope of the Care Quality Commission.
Since then both the public and private ambulance services had for the first time a level playing field on which to operate – they have been legally required by the CQC to meet the same standards of patient transport services, face the same regime of unannounced compliance inspections and the same legal enforcement action for those companies which are continuously non-compliant.

As with the Keogh Review, the IAA plays an important role in shaping the future compliance regime for ambulance services. The Association’s representatives sit with AACE, the national policy body for the 10 ambulance trusts, St John Ambulance, the British Red Cross, and various NHS organisations, as members of the CQC Ambulance Advisory Group which has been established to propose how the new regime should operate when it is introduced in 2015.
Details of the new regime are still being fine-tuned but it is already self-evident that all three ambulance providers will face tougher and more frequent unannounced visits by teams of CQC inspectors from next January.
From the start of regulations, the IAA has been a strong advocate of continuously raising the performance bar and of more robust inspections in order to ensure that all registered providers perform to the highest level of safety and care for patient. This lobbying appears to have paid dividends as the CQC has indicated it will respond positively to proposals to make it more difficult for companies to be registered in the first place and then meet all the criteria for delivering high quality patient transport services.

Under the CQC plans the inspectors will carry out test inspections starting this autumn and providers will be assessed on 5 key questions: are they safe, effective, caring, responsive and well-led.
To answer these questions the inspectors will increase the frequency of their unannounced visits to check ambulances inside and out, review personnel employment and training files, analyse operational records, talk with employees, customers and patients, and question managements on their corporate culture.
IAA members will support the new robust regime and will co-operate fully with the inspectors; equally they expect that the inspections will be carried out constructively and that the reporting of the findings will be fair and transparent.
The inspection reports will be published on the CQC website and to help people compare the services of NHS ambulance trusts, independent companies and voluntary organisations, each will include a rating outstanding; good; requires improvement and inadequate.
The CQC will have legal enforcement powers to require providers to improve, making sure those responsible for poor care are held accountable for it. In addition the IAA will itself take strong action, including suspension and expulsion, against any member which seriously breaches the CQC compliance rules.

Working with the NHS
The introduction of regulations prompted the private ambulance providers to form the IAA to work with all the NHS and all the regulatory bodies, not oppose it – as had been practised by other ambulance organisations who were strong advocates of self-regulation.
From the outset, the IAA actively sought the support of ambulance industry manufacturers and suppliers of equipment and specialist services who would be willing to offer members valuable business benefits and advice.
Today the group of IAA Business Affiliates comprise some of the most important companies serving both the NHS and independent ambulance sector in information technology, vehicle manufacture, specialist ambulance building, automotive products, engineering, and insurance, business & financial services.
Campaigning on behalf of members is a priority activity for the IAA and issues it has taken up include: local authority bans on private ambulances from using bus lanes; a new NHS commissioning model smaller and specialist contracts; ‘secondary employment’ of NHS personnel by private companies; and changes in EU public contract procurement directives.

Current duties
The IAA is presently working with the CQC on its new registration fee structure and compliance regime for ambulance services; it is engaged in discussions with the Department of Transport seeking members’ exemption  from the speed limit regulations and is also part of the Keogh Review task force developing a new look for emergency and urgent care services.
One expected lobbying success is likely to be a change in the law to close a loophole which allows ambulance companies, which are not registered by the CQC, to provide support services at sports events, concerts, and the like. The Department of Health, which is responsible for drafting legislation, has indicated that there will be changes – but not before the next general election in May 2015.
For now, however, the IAA’s most important achievement has been gaining genuine recognition by the healthcare establishment, regulators and policymakers that the patient transport services provided by private ambulance companies are equal to those of the NHS ambulance trusts, in terms of safety and caring; they are also starting to realise that the private sector makes a vital contribution to the nation’s healthcare economy, that it has substantial resources in qualified people and a substantial ambulance park, and that it has a growing influence on healthcare services.
Now in its third year, the IAA would be justified in looking to the future with a sense of optimism, provided it does not become complacent in the flush of its early achievements. The journey ahead will be a continuous set of challenges – social, economic and political. But its main concern will be the well-being of its customer – the NHS.

Further information