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Ambulance service puts too much emphasis on response time to detriment of overall care, says National Audit Office

BMJ 2011; 342 doi: (Published 10 June 2011) Cite this as: BMJ 2011;342:d3672
  1. Jo Carlowe
  1. 1London

A new report into England’s ambulance service has shown inefficiencies and wasteful practice.

The report, by the National Audit Office, says that the ambulance service could save the NHS £165m (€190m; $270m) a year if all 11 ambulance trusts adopted the best practices. Moreover it says that the Department of Health has placed too much emphasis on speed of response as a measure of performance rather than on clinical outcomes.

“Over the last 10 years, until the beginning of April 2011, the Department has focused on response time targets, rather than taking a more rounded view of whether cost-effective clinical outcomes have been achieved,” states the report.

“The 8-minute response target, intended for the most seriously ill patients, is one of the most demanding in the world. However, without more direct measures of patient outcomes, its application has skewed ambulance trusts’ approach to performance measurement and management.”

The report explains that this has led to such practices as sending more vehicles than needed, to ensure that the target is met. In addition, the report identifies inefficiencies, noting that the cost per incident varies between trusts from £176 to £251 and that a lack of an integrated system has led to delays in turnaround times at hospital accident and emergency departments.

Over a fifth of patient handovers took longer than the recommended 15 minutes, leaving ambulances queuing outside hospitals, making them less available to respond to other calls.

Amyas Morse, head of the National Audit Office, said, “The time taken to respond to calls has until recently been the ‘be all and end all’ of measuring the performance of ambulance services. Illustrating the principle that what gets measured gets done, the result has been a rapid response to urgent and emergency calls. However, this led to an increase in the number of multiple responses to incidents, equating to millions of unnecessary ambulance journeys.

“It is welcome that the [health] department has now introduced new measures [launched in April] and a new broader performance regime, but improvements to the whole urgent and emergency care system will depend on its working more coherently.”

The health minister Simon Burns said that he was pleased that the audit office had endorsed the government’s approach of “focusing on a wider range of patient outcomes, not just arbitrary targets.”

He added, “This is only one element of our drive to modernise ambulance services by delivering better results for patients while ensuring greater efficiency.”

As part of the promised £20bn efficiency savings in the NHS the ambulance service will be expected to identify 4% of savings in its budget (around £75m a year).

Responding to the report, Jo Webber, director of the Ambulance Service Network, said, “The ambulance service has a pivotal role to play in the performance of the entire urgent and emergency care system. It is currently offering better care, more quickly, to more people than ever before. The ambulance service is keen to build on this progress by moving towards performance measures based on outcomes for patients rather than just speed of response.”

She added that the service recognised the need to reduce variation and to share information across the urgent and emergency system.

Commenting on the findings, the public sector trade union Unison said that the report highlighted the need for more clinically qualified staff.

“The most cost effective response to 999 calls is to get the right people with the right skills to patients first. Time driven targets have led to the ratio of clinical to non-clinical staff going down, and trusts need to reverse this trend,” said Christina McAnea, Unison’s head of health.


Cite this as: BMJ 2011;342:d3672


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