GPs Withhold Ambulance Service Funding Due to Lack of Plan to Improve Response Times

Monday, January 6th, 2014. 11:28pm

Ambulance Service Staff Appearing In Front of Councillors at a Cambridgeshire County Council Scrutiny Committee

Cambridgeshire and Peterborough Clinical Commissioning Group is currently withholding 2% of the money it usually pays each month to the East of England Ambulance Service.

The Clinical Commissioning Group (CCG) is a group of local GPs and others which is responsible for buying the region’s ambulance service from the ambulance service. Withholding 2% of the service’s funding is the way the group have decided to respond to the service’s failure to come up with a plan to sort out problems with ambulance response times.

My View

My view is that this shows up the crazy things which happen when we ask civil servants to pretend they’re commercial entities operating in a market place.

Reducing the amount of taxpayer’s money being shifted from one public body to another isn’t going to achieve anything; this isn’t real money to any of the civil servants involved, it isn’t going to affect their incomes or the viability of their organisations. Elements of the public sector are not businesses and don’t respond in the same way as a business would.

There are no local elected representatives responsible for either the CCG or the Ambulance Service; this is an area where we lack local democracy. We have Ministers who are responsible for distributing taxpayers money to the GPs via NHS England but no local accountability.

Rather than a bizzare financial penalty; which won’t really impact anyone I would rather see local councillors taking a lead, being clear about what the public want (an ambulance quickly if one is needed), finding out what the problems are and giving clear directions to the civil servants involved so they can address them.

While our local councillors don’t hold the purse strings in this case; they do have influence.

In 2012 I asked Cambridgeshire County Council’s relevant scrutiny committee to take an interest in the performance of our ambulance service, which it did (minutes)

That meeting wasn’t particularly productive as the councillors all appeared to think they already knew what the problem the ambulance service has been having is – waiting to handover patients at hospitals. Councillors didn’t appear interested in extracting more information from the service or holding those responsible for running it to account.

A major omission from the data published by the CCG and Ambulance service is information on how badly the targets are being missed in those 25-30% of immediately life threatening cases where ambulances are not arriving within the target 8 minutes.

I would like to see a graph showing how badly this target is being missed; and perhaps a table showing in how many cases the wait is over say 10, 15, 30, 45 minutes .. or whatever categories make sense to monitor given the data.

It may well be that what we need locally is not primarily better performance against the national target; but a reduction in the frequency of times it is wildly missed.

I suspect, but don’t know, that the CCG’s action against the ambulance service is not really due to what is shown in the report; the missing of the target, but frequent reported cases of very long waits for ambulances which come to light via the press.

I think elected representatives should represent the views and interests of their constituents to whoever they need to, if they have specific power and responsibility in the area or not. As elected representatives councillors can be influential within all parts of the public sector and even when lobbying commercial behemoths like Tesco (who my local councillors have invited into one of North Cambridge’s Area Committees).

January 7 2014 CCG Meeting in Cambridge

A meeting of the CCG is to be held in public in Cambridge on the 7th of January (meeting papers). p69 of the Integrated delivery report (PDF) to be presented to that meeting explains:

EEAST – Urgent and Emergency Ambulance contract

A contract query was issued by the consortium on 14.08.13 on the failure of EEAST to deliver against the Red 1, Red 2, and Cat A19 targets in the contract year to date.

There has been no improvement in performance and EEAST have failed to produce a RAP which clearly demonstrates their ability to rectify this under performance

Therefore, with effect from December 2013, 2% of the monthly contract sum is to be withheld until such time as EEAST provide satisfactory RAP

The actual and potential implications of this under perform ance on clinical quality and safety, is currently being reviewed by the Consortiums Clinical Quality and Governance group. The Clinical Quality Commission commenced a follow up inspection w/c 09.12.13

The performance statistics referred to are reaching the “Red 1″ “Red 2″ priority calls within 8 minutes. The “A19″ target is an ambulance arriving to transport a patient within 19 minutes.

The latest figures published by the Ambulance Service are for November 2013 and show that in Cambridgeshire and Peterborough 8 minute target is being met in 76.8% of “Red 1″ cases and 69.09% of cases categorised “Red 2″.

Notably the figures for the same month reported to the CCG (p12 of the “delivery report) are slightly different; with 74.52% for “Red 1″ and 68.47% for “Red 2″. This inconsistency doesn’t give me confidence in the figures reported.

The performance threshold / target used by the Clinical Commissioning Group for both categories is 75%.

Presumably an update on the position will be provided at the meeting.

The report to the Clinical Commissioning Group also shows the Ambulance Service is not working with hospitals on the issue of handover delays, it states:

A meeting with HHCT and EEAST was arranged for 22.11.13. but EEAST did not turn up so meeting cancelled. This has been escalated within the CCG and needs to be resolved by EEAST in the next 2 weeks.

(HHCT = Hinchingbrooke Health Care Trust ; EEAST = East of England Ambulance Service Trust)

GP Led?

General practitioner led commissioning is the policy behind giving much of the cash for NHS services in Cambridgeshire to the Clinical Commissioning Group who then buy things like hospital services, accident and emergency, out of hours care, and ambulance services from hospitals and others who provide it.

Cambridgeshire and Peterborough’s CCG Governing Body is made up of 4 lay members, 4 Executive Directors of the Clinical Commissioning Group, 8 GPs and one hospital doctor. The GPs are not even in a majority locally.

The Clinical Commissioning Group is an Expensive Decision Making Committee / Organisation to Run

Position Pay
Chief Clinical Officer £85,000 (3 days per week) Plus annual compensation payment to practice of £40k paid monthly
Chief Operating Officer £130,000 (pro-rata fro 1.1.2014)
Chief Finance Officer £121,000
Director of Corporate Affairs £90,000
Director of Quality, Safety & Experience £97,277
Interim Director of Performance & Delivery £93,000
Director of Commissioning & Contracting £106,000
Lay Chair £41,411 per annum (3 days per week)
Lay Member, Governance £13,136 per annum (3.5 days per month)
Lay Member, Finance £7,882 per annum (3.5 days per month)
Lay Member, Patient Engagement £7,882 per annum (3.5 days per month)

Pay rate sources: Director’s Pay – September 2013report from May 2013 containing pay of Lay members

15 comments/updates on “GPs Withhold Ambulance Service Funding Due to Lack of Plan to Improve Response Times

  1. Richard Taylor Article author

    When I suggested to councillors they scrutinise the ambulance service locally I mentioned a Panorama documentary.

    The documentary must have been mentioned when the scrutiny chairman wrote to the ambulance service in advance of the meeting as a letter from the service to the chairman has now been published. It says:

    We were approached by Panorama just over a week before the programme was aired on television and it became apparent very quickly that they did not understand how ambulance services operate, the triage systems in place and that they had only carried out very limited research into this sector

    At the time of the meeting I called for this letter to be made public; a councillor assured me it didn’t contain anything interesting:

  2. Richard Taylor Article author

    I used the opportunity for members of the public to speak at the end of the Cambridgeshire and Peterborough Clinical Commissioning Group on Tuesday 7 January 2014 to make my suggestion that the CCG consider how badly the ambulance response time targets are being missed, when they are missed, and to look at the distribution of response times beyond the 8 minute target.

    Harper Brown, the CCG’s Director of Commissioning & Contracting (who is not listed as a member of the Governing Body on the Clinical Commissioning Group’s list of members) responded. The response made during the meeting didn’t really relate to the suggestion which I made, however I spoke to him after the meeting and I was able to explain what I was suggesting again and I think he understood. He told me he, and the Clinical Commissioning Group, didn’t know how badly the response targets were being missed and agreed it would be a good thing to know.

    I suggested the statistics may provide a reassurance if they show that the 8 minute target is generally only being missed by a minute or two; rather than tens of minutes or hours.

    I asked Harper Brown what had prompted the CCG to sanction the ambulance service; asking if it was the technical breach of the target, or reports of long waits for ambulances; his response was that there never had really been a decision to take, he was simply following the contract. The contract provides for the sanction in these circumstances so it was applied he told me.

    We talked about the state of statistics from the ambulance service; Mr Brown pointed out there were lots of important metrics; including the overall outcome of a call for an ambulance. Mr Brown told me what he’d like to see is the CCG being given the NHS numbers of patients, and postcodes, so they can better assess performance; however at the moment he told me the ambulance service didn’t collect information about the identity of their patients so they don’t hold it to pass on.

    I noted the fact different numbers for the same statistics were given on the CCG and Ambulance Service websites; Mr Brown said he was surprised by this and stated that they should be the same. He showed me the weekly reports he gets from the ambulance service which are yet another different presentation of the information.

    My own view is we still need the information to identify if there really is still a problem and to characterise it (How much of a problem is there? Where and when is it occurring). Just missing a central government set target isn’t a problem in itself; inappropriately long waits for ambulances are though, especially if there are consequences for people’s health.

  3. Richard Taylor Article author

    The Clinical Commissioning Group meeting on 6 May 2014 received the response to the question I raised on Ambulance response times on the 6th of January.

    The response states:

    Governing Body received an update from Harper Brown. The Ambulance Trust reached 72% of the 8 minute target in January. 4 waited (Red 1) over 30 minutes. 174 waited (Red 2) over 30 mins and 4 waited over 60 mins. The Ambulance Trust has developed a Complete Recover Plan covering 19 CCGs.

    The target for attendance at both the “Red 1″ “Red 2″ priority calls is within 8 minutes; the Red 2 are those categorised as less time sensitive though.

    That we have 4 callers in a month waiting over 30 minutes for an ambulance in the most urgent of situations is awful. This should never be allowed to happen.

    That there are 174 people, deemed to have a requirement for an urgent ambulance, waiting over 30 minutes in a month, and some waiting over an hour shows our elected representatives need to start taking more of an interest in this and getting it resolved.

    The Clinical Commissioning Group papers show it is torn between wanting to withhold money to “punish” the trust for failing; and responding to calls to spend more on the service to help it “transform”.

    The latest report to the CCG describes the Ambulance Service as still failing

    The performance continues to be below National Targets and is a risk to patient safety and integrated care across our CCG area. Our CCG Performance for 2013/14 was : Red 1 : 64.34%, Red 2 : 72.13%, A19 : 93.36%

    Over 35% of the most urgent calls are not being responded to within the 8 minute target.

    As noted above the performance statistics referred to are reaching the “Red 1″ “Red 2″ priority calls within 8 minutes. The “A19″ target is an ambulance arriving to transport a patient within 19 minutes.

    1. Richard Taylor Article author

      That’s still many tens of people a month assessed to need an ambulance as urgently as possible waiting over 25 minutes for an ambulance; and thousands of those whose needs are classified as being less urgent.

  4. Richard Taylor Article author

    Some further statistics on how badly the targets are being missed is being made available via NHS England. The time within which 99% of Category A (Red 1 & Red 2) calls are responded to is published. I have made a chart showing these 99% response times for the East of England Ambulance Service available at:

    There is a wild swing in performance from January 2015 to March 2016.

    I think this data which shows how long, in some of the worst cases, ambulance staff take to arrive is a key thing our elected reps should be monitoring; how our ambulance service performance at its worst is important – you, or someone you care about personally might be one of those waiting for an ambulance when the system is not performing as we would like it to. As well as the “99%” figure I’d also like to see the absolute worst waiting times published too, as a matter of routine. I appreciate one does not want to make strategic decisions based on rare events so looking at the 99% and 75% percentiles can be useful to exclude outliers, but I want an ambulance service which is resilient enough such that the worst cases are not too bad.

    View spreadsheet, source.

    This is an alternative presentation of the data to that shown in previous comment; for a full understanding what we really need is the full frequency distribution graph – showing the number of calls responded to between 1-2mins,2-3mins, …. right up to however long the longest response took. All the data is clearly being collected it’s just a matter of making it available.

    These times shown here are for the most urgent calls; the response time also matters in calls which are less urgent but still mean people left lying on the ground in pain for far too long.

  5. Richard Taylor Article author

    In April 2017 the cardiac arrest survival rate in the East of England Ambulance area was 32.0% compared to 25% in January 2012. source.

    Clinical outcomes appear to be improving despite longer waiting times for an ambulance response. There may be lots of explanations – community first responders, better protocols for care when ambulance staff do arrive, and at hospital for example.

    One thing not yet captured in the statistics is the pain and distress for the patient and those around them when an ambulance takes far too long in cases where the situation isn’t categorised as most urgent.

  6. Richard Taylor Article author

    The crazy practice of withholding money from the ambulance service when it fails to meet targets appears to have been stopped.

    A paper on ambulance handovers presented to a meeting of Cambridgeshire and Peterborough Clinical Commissioning Group in January 2018 states:

    Cambridgeshire and Peterborough CCG has … suspended the use of punitive fines and penalties for non-delivery of standards … no money will be withheld upon failure to deliver agreed milestones.

  7. Richard Taylor Article author

    My latest tweets, and twitter exchanges, mentioning “ambulance”:

  8. Richard Taylor Article author

    While the local Clinical Commissioning Group has stopped penalising the ambulance service for poor performance, central Government are still doing so:

  9. Richard Taylor Article author

    The East of England Ambulance Service board has moved online, making it easier to ask public questions.

    I asked:

    What were the slowest response times for i/ category 1 and ii/ category 2 responses in the period for which performance is being reported today? Why does the board not require information on the slowest responses to be routinely included in performance reports and made available to them, the public and commissioners?

    The response stated that longest waits and “tail-breaches” are monitored. The existence of an “accountability committee” was mentioned, and it was stated that the breaches / longest waits are also reviewed on a daily basis.

    The board were told that the response time to seven category one calls in July [2020] was over 30 minutes.

    There appeared to be a commitment to consider making better data available to the public.

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