Why ambulance services can’t afford to be last on the scene when it comes to collaboration
Nathan East of national law firm Weightmans explains why the ambulance service should embrace collaboration.
This article first appeared in Emergency Services Times on 19 January 2019
The ambulance service should embrace collaboration to tackle increasing demand and financial pressure.
Ambulance Trusts sit in a complicated position. As an emergency service that’s also part of the NHS, they must contend with a multitude of different NHS policy initiatives – the latest of which is presented by the NHS 10-year plan.
And while the policy pull of the NHS must be heeded, it sometimes stops Ambulance Trusts from fulfilling their role as an emergency service. In terms of demand, Trusts have a lot in common with the police and fire-and-rescue services, but policies for integration are not being maximised to the same extent.
The Policing and Crime Act 2017 introduced a new duty for the emergency services, to work together wherever possible to improve efficiency and effectiveness.
For Police and Fire services, collaboration has become a core way of working, sharing resources, combining non-operational support teams such as estates and HR and combining their buying power to make procurement savings.
In May it was announced police forces have saved £273m in three years on equipment costs proactively through the Collaborative Law Enforcement Programme (CLEP).
However, it is fair to say that there has been very significantly less involvement in this collaboration from ambulance services. This is a great shame as there are many areas where they could be collaborating with other services more effectively.
There are, however, several reasons that ambulance services have struggled to collaborate effectively but with an effective strategy these can be overcome.
One of the biggest barriers is the large geographic areas covered by individual ambulance services. There are just 11 of these organisations across England and Wales, compared with 46 fire and rescue services and 43 police forces.
This means that any ambulance service that chooses to collaborate with other organisations will automatically need to fragment the way it delivers services, which makes it harder to operate locally with Police and Fire partners.
Ambulance services can tackle this challenge, by putting the resources in place to co-ordinate collaboration at a more local and regional level.
The NHS 10-year plan indicated a new national framework will be introduced to help ambulance services overcome the fragmentation they have experienced through improvements in local commissioning. This will assist, but only if the framework is cognisant of the context in which Ambulance Trusts operate alongside the other emergency services.
Lack of standardisation
Lord Carter’s review of ambulance services released in September 2018 identifies an absence of coordinated procurement between services as one of the key areas of inefficiency that needs to be addressed.
In terms of fleet management, for example, the services use a range of different vehicle suppliers, with no consistency in the make or model used or how it is fitted out.
The Carter review recommends that co-ordinating efforts and procuring fleets through a single supplier could deliver substantial savings.
However, there are also significant challenges here, chief among which is a lack of alignment in procurement cycles. Many services have 10-year agreements with suppliers that are mid-way through their terms, so aligning these would be a significant project requiring co-ordination on a national scale.
However, there are many examples of police and fire services making joint procurement work to achieve savings. Ambulance services should try and exploit opportunities to jointly procure with fire and police organisations.
We are also seeing an increase in the amount of fleet maintenance co-ordination and co-location between regional emergency services, and this is also something ambulance trusts should be considering across the board.
Collaboration with urgent care
One of the most striking statistics in Lord Carter’s report was that only 10 per cent of the call-outs attended by the ambulance service fall into the emergency category.
This means that a huge proportion of the service’s time is being consumed in providing a service for those who – although they may need urgent care – do not require a paramedic.
To reduce this drain on resources, ambulance services need to develop a coherent vision for urgent care redesign and delivery.
This will be particularly important as the NHS works through its Five-Year Forward View and 10-year plan, a major priority of which is reducing patients’ dependence on hospital care through an increased focus on prevention and primary care. But the governance of any projects aiming to deliver this also needs a stronger voice from Trusts.
For example, the development of a single multidisciplinary Clinical Assessment Service (CAS) within an integrated NHS 111, ambulance dispatch and GP out of hours services, as proposed in the 10 Year plan, could help on this front, but Ambulance Trusts must play an active role in its development if the model is going to works to their advantage.
Making collaboration work
There are some key ground rules when it comes to creating a successful collaborative relationship, whether this is with other emergency services or urgent care providers.
Ambulance services must be clear from the outset what the roles and responsibilities will be in any given scenario.
They need to ensure they have effective contracts and governance in place to make sure these collaborations can work effectively.
Too often the arrangements underpinning collaborations are dealt with in simple agreements which lack accountability and key performance indicators and the ability to enforce obligations on collaborating parties.
This can lead to ineffective leadership and a lack of clarity on responsibilities and protocols when things don’t go according to plan. Failings in collaborative systems often stem from a lack of clear objectives and expected outcomes, so these need to be in place from the start.
In practical terms, the first step is to harmonise objectives between the two collaborating parties. Any issues that might cause disputes must be identified at an early stage and early-warning systems designed to build more resilience into the system.
Most police forces and fire and rescue services have a designated collaboration lead who sits on the board, but this is not the case for every ambulance service.
This is a critical role, as co-working and cross-service collaboration is unlikely to succeed without a central conduit through which it is co-ordinated and monitored. Senior representation is also essential in terms of risk management and identifying new opportunities.
Given the arguably more complex challenge they face in making partnerships work, this needs to be addressed urgently by the service.
Overall, it’s important for them to have a clear vision of what their pressure points are and what they want to achieve from the collaboration projects.
Too often, there is a degree of tokenism and too little detailed consideration of the true objectives of collaboration. Without a detailed understanding of how it addresses the main challenges, no collaboration project will be successful.
Ultimately, the aim isn’t to tick regulatory boxes, but to address the real fundamental challenges that services are facing, to deliver a better service to the public.
Nathan East is a partner at national law firm Weightmans’ public bodies practice. He has experience advising on a public-sector projects, commercial partnerships and joint ventures.