hfmabriefing Contributing to the debate on NHS finance November 2008 PBR for ambulance services A review of the issues involved in introducing payment by results for ambulance services in England and the tariff options currently being piloted Foreword Payment by results is now an established part of part of NHS spend. But the case for an emergency the NHS funding system in England. Having first services tariff is just as compelling as it was for acute been introduced on a limited basis in 2003/04, it services. It could improve transparency, incentivise now covers some £25bn of services, typically better cost-effectiveness and underpin new roles for accounting for more than one third of a primary ambulance services that would improve patient care trust’s expenditure and around 60% of an acute pathways and relieve the pressure on accident and trust’s income. emergency departments. Reviews suggest it has improved the transparency Progress is being made. The Department of Health and fairness of the payment system and contributed has identified urgent and emergency care, including to an increase in day cases and a reduction in ambulances, as one of five priority areas for length of stay. And with the system now embedded, development within payment by results. And a there are moves to refine it, providing a greater number of pilot sites are trialling different link with service quality and outcomes, rather than approaches to local tariffs. just activity. However, there remains no timetable for the Payment by results has come a long way. But with introduction of a national tariff for ambulance such good coverage now within the acute sector, it services. This briefing aims to support the current should be remembered that many areas of the NHS development work by rehearsing the arguments for remain a tariff-free zone. Mental health, community an ambulance service tariff and highlighting the provision and ambulance services are three areas issues that need to be resolved and the potential where links between the work undertaken and the benefits for the NHS as a whole. amount paid remain weak. It would be particularly easy to overlook ambulance Andy Hardy, chairman of HFMA Payment by services. In overall terms, they represent only a tiny Results Group Acknowledgements Written by Steve Brown, HFMA head of policy, with support from: Keith Wood, finance director, West Midlands Ambulance Service; Vicky Clarke, finance manager, London Ambulance Service; and Alan Boyes PBR project accountant North East Ambulance Service the voice of healthcare finance... Introduction undertaken – the numbers of patients transported and treated, the types of incidents and patient CONTENTS Ambulance services have changed dramatically over problems or the numbers of calls received – and the the last 15 years. No longer simply emergency money paid to ambulance trusts. Funding remains Introduction 3 transport services, ambulance trusts have on a historic basis. This means that any funding increasingly been moving into the realms of inequities introduced in former years are continued. The ambulance service treatment. Paramedics and emergency care And incentives to encourage changes in practice are in England 4 practitioners trained to treat patients at the scene or weak. ● Structure on the move rather than simply picking up and ● The patient journey dropping off at the nearest accident and emergency The Department of Health remains committed to ● Activity levels department. introducing payment by results across a wider range ● Ambulance service 5 of services and at the beginning of 2008 said that expenditure Cardiac care is a good example with paramedics urgent and emergency care (including ambulances) ● Sources of income and administering clot-busting drugs (pre-hospital was one of five priority areas for development. A contracts thrombolysis) or making early assessments about number of ambulance trusts are now piloting ● Ambulance service costs 6 patients’ suitability for primary angioplasty different options for tariff funding. (mechanical widening of artery), which would mean Why introduce the patient being taken straight to a facility with a payment by results for dedicated catheterisation laboratory. ambulance services? 9 More recently ambulance services have moved into What are the options providing telephone support-based services and for linking payment to even getting involved with activity? 10 GP out-of-hours cover. And a ● Incidents Department of Health report ● Incident sub-categories/ in 2005 – Taking healthcare to reference costs the patient: transforming NHS ● Calls/reports of incidents 11 ambulance services advocated ● Resources sent expanding ambulance ● Hear and treat, see and services’ role even further – treat, see and convey including, for instance, the ● Patient pathways/ provision of diagnostic unbundling 12 services. However, the way ● Normative tariff ambulance trusts are paid has remained rooted firmly in Key issues/challenges 13 the past. ● National tariff vs local tariff The acute sector has seen the ● Rurality/congestion introduction of payment by ● Market forces factor 14 results in England over the ● Who pays? past few years – linking payment for hospital services Pilot case studies 15 to the actual care delivered. In 2008/09 around £25bn of Appendix: HFMA services were covered by survey of ambulance payment by results, trust finance directors 19 accounting for some 35% of PCT spend and more than 60% of a typical acute provider’s income. But ambulance service funding often has no direct link between the activity hfmabriefing • November 2008 • Ambulance PBR Page 3 The ambulance service in England with vehicle capable of transporting patient). Structure Category C. – Not immediately serious or life Ambulance services have been through a significant threatening. (Targets agreed locally). restructuring in the last two years. The 31 ambulance trusts operating at the beginning of April 2006 In addition to emergency/999 calls, ambulance merged in July of that year to form 13 services (12 trusts can also get requests from GPs, midwives or NHS ambulance trusts and one PCT providing other healthcare professionals requiring the urgent ambulance services). Most of the mergers were transfer of a patient or admission into hospital. These straight forward, simply bringing together existing calls have traditionally been recorded separately as organisations. However two of the old trusts were urgent (or category U). However from 2007/08, split. The old Tees East and North Yorkshire trust was ambulance trusts have been required to assign an split between North East (30%) and Yorkshire (70%). ABC category to these urgent calls as well. The former Two Shires was split evenly between East Midlands and South Central. Staffordshire The call taker will then dispatch a response on the Ambulance Service NHS Trust, which was initially basis of this primary diagnosis/call category. In working in partnership with the new West Midlands practice modern systems mean that a response is Ambulance Service NHS Trust, formally merged with often dispatched as soon as the call is transferred to West Midlands in October 2007. This means there the call centre – particularly important as the clock are now 11 ambulance trusts and one PCT providing starts ticking on the response targets as soon as a ambulance services (see side panel) call is put through to the local control room. (This new way of measuring ambulance response times – Patient journey know as Call Connect – was introduced in April When someone calls 999, it triggers a series of 2008.) In ‘automatic’ dispatch cases, the response events that enable ambulance trusts to respond. initiated would be reviewed on the basis of this 999 calls are initially routed to a national emergency primary diagnosis/call category. switchboard, where callers are asked which emergency service they require. Upon asking for an A number of responses could be ‘dispatched’. These ambulance, they are routed to the control room of include: a fully equipped, double staffed ambulance; the local ambulance service (this is based on the a single responder on a bicycle, motorbike or in a caller’s location as identified from the landline car; or transferring the call to a phone advisory number or mobile phone location). service where cases can be sorted on a ‘hear and treat’ basis. These ‘hear and treat’ advice centres may When the local control room answers the phone, the be run in-house by the ambulance trust (manned call taker will take details of where the ambulance with GPs, paramedics and emergency care needs to be sent and ask a series of scripted practitioners) or externally – for instance NHS Direct. questions to enable a primary diagnosis to be made, which dictates the type of response that the trust Activity levels needs to make. The decision tool used by all but one Ambulances have two principal areas of activity – ambulance trust (the North East Ambulance trust emergency services (typically in response to a 999 has piloted a system called NHS Pathways) is called call) and non-urgent patient transport services (for the Advanced Medical Priority Dispatch System instance picking up patients and taking them to (AMPDS) and its output is to assign one of the hospital for a pre-arranged appointment). Ambulance trusts in England following categories to the call: In 2007/08, 7.2 million emergency and urgent calls North East Category A – Life threatening condition. (National were made to English ambulance services. (In North West Yorkshire target: 75% of category A calls to be reached within 2006/07, there were 6.3 million. However the figures East Midlands 8 minutes and an ambulance to be on scene can not be directly compared as, from April 2007, West Midlands capable of transporting the patient within 19 urgent calls are now recorded with emergency calls East of England minutes in 95% of cases) and prioritised in the same way – category A, B or C. London South East Coast The majority of these urgent calls are likely to be South Central Category B – Emergencies which are serious but not classified as category C.) Of these 7.2 million Great Western immediately life threatening.