GP consortia are to have a lead role in commissioning ambulance services under the NHS reforms published in the Department of Health's (DH) recent Health and Social Care Bill (Nutfield Trust, 2011). The abolishment of the primary care trusts means that moneys for commissioning the service will fall directly into the hands of GPs, with the NHS commissioning board merely having a supervisory role.
At the same time, ambulance trusts are required to become foundation trusts by the time the changes set out in the bill are implemented. However, nothing fixed has yet been established over how consortia will liaise with ambulance trusts over the commissioning process, although the Department of Health has confirmed that it is likely to be through a lead commissioning arrangement, with one consortia taking the lead in ambulance commissioning on behalf of a group of consortia.
The idea underpinning these commissioning proposals is that services should be locally-led. Under these reforms, local authorities will also be involved in the commissioning process whereby they will have a responsibility for public health and will need to map out the demographics of the population, passing this information on to GPs to aid them in the commissioning decision-making process.
According to the Ambulance Service Network (ASN) and the National Ambulance Commissioning Group (2010), ambulance services cost approximately £1.5 billion each year but have an impact on around £20 billion of NHS spend on emergency and urgent care, therefore it is essential that future commissioning models for ambulance services are right. The NHS has said that in the last 5 years, the number of ambulance 999 calls have risen by a third.
However, ambulance services do far more than simply respond to emergencies and take people to A&E. They are a mobile clinical delivery service that offers a range of innovative services that GPs will be interested in.
Ambulance trusts offer these services as part of a combined response with the rest of the NHS, and according to the NHS Confederation, the absolute key challenge, therefore, is to get that message across to commissioners.
‘Ambulance services do far more than simply respond to emergencies and take people to A&E’
The ASN has said that what needs to be developed is a framework for offering services which need to be arranged and commissioned at a regional level. For example, a recent report by the ASN assembled the international evidence on trauma care and it is clear these services need to be arranged at a regional or ‘beyond local’ level (Ambulance Service Network and the National Ambulance Commissioning Group, 2010). It is important that GP consortia maintain existing networks and, where necessary, the networks enhanced.
Collaborative commissioning models
Health Minister Simon Burns has said:
‘Ambulance services will be commissioned through GP consortia at local level. What I think will develop is that, just as ambulance services are currently commissioned for geographical areas in England through one PCT, the consortia will appoint lead consortia to commission services for that area.’
This echoes recent recommendations from the ASN (2010), which has said that there is a need for a single point of access so that patients are consistently assessed and prioritised and receive appropriate service response. They also suggest that real-time information and data about emergency and urgent care services and patients’ health records should be shared seamlessly between different parts of the health and social care system.
Suggestions
There have been several commissioning models suggested that consortia could adopt, however, it is the federation and lead consortium model that the Department of Health has suggested as the most appropriate contender for commissioning ambulance services.
In this model, a number of consortia across a region would join together as a group or federation and elect and appoint a lead consortium to undertake agreed functions on behalf of the group.
However, other models have been suggested. For example, the South East Coast Ambulance Service NHS Trust (SECAmb) has proposed a commissioning outcomes framework centred around patient pathway, as opposed to sector as a way of realizing significant efficiency savings (2010).
In their model, for example, commissioning of stroke pathway would ensure services respond quickly and are supported to bypass to specialist stroke centres, thereby reducing risk of long-term disability for patients and therefore reducing the length and cost of long-term rehabilitation for the NHS (SECAmb, 2010).
However, the Royal College of General Practitioners is skeptical that GP-led commissioning of NHS services will work to the benefit of the population and are concerned that plans for free choice of GP practice and the abolition of practice boundaries will lead to an greater need for local emergency services and hospital A&E admissions, thereby putting further strain on already overwhelmed services; and that the new legislation will lead to a postcode lottery and greater health inequalities, particularly in rural areas (General Practitioners Committee, 2010).
Key challenges
The Nuffield Trust (2011) has expressed concerns that in their early years, GP commissioning consortia will be underdeveloped as commissioners are subject to the same pressures as primary care trusts (PCTs) but with significantly reduced management resources.
There are concerns that commissioning will suffer as a result, and the government are being called upon to consider carefully how GP consortia can be provided with high-calibre management and analytical support, and how to address both the risks of loss of financial control by GP consortia in the early years and the handling of financial risk. In addition, the systems for assessing independently whether GP consortia are sufficiently prepared to assume budget responsibility and achieve value for money are as yet unclear.
With the large sums of money involved, it is crucial that these arrangements are robust. The ASN has called for a system of funding that incentivizes services to treat patients in the most appropriate location for their clinical need—in specialist centres where necessary and in local communities or people's homes where possible— and suggest that that appropriately trained and skilled ambulance service staff should work in multi-disciplinary teams across a variety of setting and be able to take care to the patient as well as taking the patient into hospital or other place of care, with a range of services across primary, secondary and community care available.
They also suggest that patient outcomes and experience should be adopted as measure of success (Ambulance Service Network and the National Commissioning Group, 2010).
The new commissioning arrangements will face other key challenges. Clarity over resolution of disputes with other providers, for example, and the issue of delays in handovers between ambulance and acute trusts, is still to be determined.
Accountability
Ambulance trusts will be held accountable for their performance according to the outcomes they achieve. Backed up by the Care Quality Commission, contracts arranged through lead GP consortia will be the principal means for ensuring adequate high quality services (South East Coast Ambulance Service NHS Trust, 2010).
More generally however, the accountability arrangements in the health reforms are one of the main source of concern across the NHS. The mechanics of who makes sure services are of high standards and outcomes achieved, and what happens when things go wrong, is a fundamental but vital issue.
The issue of ‘any wiling provider’ at the head of the government's health reforms, has been met with disapproval in many sections of the NHS, however, the ASN has expressed that the urgent care service reform, particularly the NHS 111 numbers, is seen as a major opportunity of delivering high quality care to patients as part of a combined NHS response in an area where demand is growing year on year; and which urgently needs action if it is not to overwhelm other sources of efficiency gains.
Ambulance foundation trusts
Under the new legislation, ambulance trusts are required to achieve foundation trust status. Foundation trusts are tailored to the needs of the local population, and are given much more financial and operational freedom than other NHS trusts. Foundation trusts are fundamental to the government's plan of de-centralisation of services.
Of the current 12 ambulance services in England, just two have recently achieved foundation trust status —the South East Coast and the South Western Ambulance Service Trusts. As foundation trusts, ambulance trusts will still need to meet national standards and will be regularly inspected, but they will have more freedom to develop services based on the needs of local people. Health Minister Simon Burns said:
‘These are the first ambulance trusts to achieve foundation status. They will now benefit from a range of freedoms and will be able to better meet the needs of local patients as a result.’
According to the General Practitioners Committee, consortia will be in shadow form until 2012/13, and until then they are expected to focus on working out exactly what it is they need to do before considering how to do it or embarking upon the actual process of commissioning (Ambulance Service Network and the National Ambulance Commissioning Group, 2010). Strategic Health Authorities are to be abolished by 2012/13, and primary care trusts will be abolished by 2013/14. The PCT will remain the legally accountable body until it has been abolished. According to Niall Smith, ASN spokesman:
‘While we need to be level headed about the size of the challenges ahead, even for the trusts relatively ‘untouched’ by the current re-organizations, we also need to recognize there are long-term opportunities ahead that will benefit patients and develop truly modern ambulance services.’
The NHS Confederation has also expressed concern at the reforms’ emphasis on ‘any willing provider’. Whilst the NHS Confederation acknowledges the benefits that competition can bring to the services, they question the appropriateness of this policy to complex care pathways (NHS Confederation, 2011).
Conclusion
There is much uncertainty over how the reform of the NHS is going to affect service delivery and patient outcomes. While ambulance services will remain relatively untouched and will retain much of their autonomy, they play such a pivotal role in the healthcare system that it is unlikely that they will not be affected by any knock-on effect from other parts of the system trying to find their own feet within the new system.