- England’s ten ambulance trusts occupy a unique position in serving large health populations, each spanning footprints of multiple integrated care systems. In the context of system working and place-based models of care, ambulance trusts are negotiating emerging systems within their geographic remit, adopting new ways of working to meet the needs of diverse systems across the populations they serve.
- With the move away from clinical commissioning groups to the new integrated care system framework, many want to see a rethink in how systems engage with their ambulance trusts to ensure co-design and co-production from their services as part of a holistic strategy for population health.
- To support this, we interviewed a range of NHS leaders from both integrated care boards and ambulance services to explore how they might evolve their relationship, and to examine the principles that underpin effective and practical collaboration.
- Interviewees identified four key priorities for effective collaboration: thinking creatively about the role of the ambulance service; focusing on data sharing; fostering cultures of collaborative planning; and nurturing relationships.
- By focusing on these four areas, system and ambulance service leaders can design arrangements and relationships that deliver vast improvements to their population’s health in the years ahead.
- Interviewees made practical recommendations for national and local partners about how this can be achieved. These include expediting the implementation of Provider Selection Regime; where appropriate, developing multi-ICB governance structures; and considering how ambulance service data can be used at neighbourhood, place, system, regional and national levels to maximise its impact.
The introduction of statutory integrated care systems (ICSs) in July 2022 evolved the landscape of health and social care service planning, replacing the previous model of clinical commissioning groups (CCGs) with 42 new integrated care boards (ICBs) and integrated care partnerships (ICPs). For many services, this shift has seen a change to the geographical boundaries where health and care is planned and commissioned, which has brought both challenges and opportunities.
England’s ten ambulance trusts occupy a unique position in serving large health populations, each spanning footprints of multiple integrated care systems. In the context of system working and place-based models of care, ambulance trusts are negotiating emerging systems within their geographic remit, adopting new ways of working to meet the needs of diverse systems across the populations they serve.
With the move away from clinical commissioning groups (CCG) to the new ICS framework, with ICB-led strategic commissioning of NHS-funded services, many want to see a rethink in how systems engage with their ambulance trusts to ensure co-design and co-production from their services as part of a holistic strategy for population health.
Previous engagement with the ambulance sector in 2021 identified a preference for multi-ICB commissioning and planning arrangements that cover the entire footprint of the respective ambulance service. For some geographies this represents a step change in ownership across systems, as well as between ICBs and ambulance services.
As a result, NHS England in collaboration with the Association for Ambulance Chief Executives (AACE), NHS Confederation and other partners published guidance in August 2022, setting out minimum expectations for ambulance trusts and ICSs in England as they co-design new ICB arrangements for engagement with ambulance services. The guidance recommended that ambulance commissioning is brought together according to ambulance services’ current geographic boundaries, through a multi-ICB governance structure, such as a joint committee, to agree the commissioning of core 999 services, and share best practice for local delivery arrangements in UEC provision.
This report is not intended to be a comprehensive guide to changing commissioning relationships. Rather, it aims to examine the key themes and principles that should underpin effective and practical collaboration between ambulance services and integrated care boards. 1 It sets out the findings of research involving a range of NHS leaders from both ICBs and ambulance services, and makes recommendations to the array of partners, national and local, that can affect change. This paper will be of interest to leaders across ICBs, ambulance services, NHS England and the Department of Health and Social Care.
We undertook interviews with a range of NHS leaders, including ICB and ambulance service chairs, chief executives, directors of strategy and transformation and commissioning managers.
Our questions focused on:
- the relationships and level of engagement between ambulance services and their host ICB and other ICSs with which they work
- the current commissioning arrangements for ambulance services with the system
- collaboration and co-design between ambulance services and respective ICBs
- governance structures for the commissioning of ambulance services
This report outlines some of the key themes and principles that emerged from this research and makes recommendations for ICBs, ambulance services, NHS England and the Department of Health and Social Care.
- 1. ICBs are the statutory NHS organisation which is responsible for developing a plan for meeting the health needs of the population, managing the NHS budget and arranging for the provision of health services in an ICS’s geographical area. ↑
Lessons for effective collaboration
1) Think creatively about the role of the ambulance service
In thriving systems, leaders view the role of the ambulance service about more than responding to emergencies. Indeed, they view the scope of what an ambulance trust can bring to a local health economy as broad and progressive. Ambulance services can play a significant role in helping ICSs to achieve their four statutory aims.
For example, we heard of ambulance services working increasingly closely with the social care sector to provide more joined-up services to patients in care settings. We heard about the roles ambulance crews are playing in their local communities, supporting people ‘where they are’ and creating links with local economic anchors. We heard about the rich data ambulance services have to offer in helping systems to tackle health inequalities.
Achieving the ‘upstream shift’
Ambulance services can be crucial partners for achieving the ‘upstream shift’ fundamental to the four purposes of ICSs
One system, while noting the wider role of the ambulance service in delivering for local communities, cautioned that in the current national context, its focus has been on performance recovery and engaging ambulance colleagues as key partners in developing and driving service re-design to improve and stabilise performance. However, if leaders can create the headspace to look beyond day-to-day pressures, many agreed that ambulance services can be crucial partners for achieving the ‘upstream shift’ that is fundamental to the four purposes of ICSs – centred around communities, prevention, out-of-hospital care and providing services ‘where people are’, such as in homes, supermarkets, high streets and places of worship.
Additional headspace may provide the capacity needed to focus on transformation and the ‘art of the possible’, moving away from simply managing day-to-day performance. One system noted that this could be achieved by entering longer-term contracts with ambulance services, removing the pressure of annual renegotiations and enabling greater focus on transformation.
Learning from the fire service
Regarding the prevention agenda, one ICS leader said: “It can’t just be about responding when someone wants an ambulance, but about playing an active role in supporting local communities to help prevent illness and keeping people out of hospitals.” They pointed to non-health services as a demonstration of what is possible: “I think there are lessons in what the fire service did, getting into people’s homes, fitting smoke alarms and taking other preventative measures to stop fires happening. The data suggests this has been very successful and this is where they now spend most of their time – not putting out fires.”
Reducing health inequalities
One system leader highlighted the need to strengthen the role of ambulance trusts in reducing health inequalities. As a result, their system has included a statement of intent within its contract with the ambulance service. Indeed, the ambulance service’s strategy recognised the geographical variations and significant seasonal changes across the region and has committed to work collaboratively with partner organisations to deliver several key objectives during the contract to improve population health and health inequalities.
Barriers to transformation
While positive about the role the ambulance services can play, interviewees cited the delayed implementation of the NHS Provider Selection Regime (PSR) as a potential barrier to this transformation. One ambulance service leader outlined, for example, a desire to examine ways to increase productivity and efficiency in places including 111 services and patient transport but that, with contracts coming to an end, this is increasingly complicated where PSR would simplify it.
Delays to the introduction of PSR mean that ambulance providers could end up competing for lots of individual contracts (under the current rules) rather than taking a coordinated approach (under PSR) which could boost productivity. Ambulance trust and ICB leaders requested the implementation of PSR as soon as possible to enable increased collaboration and integration for the benefit of the public.
What is the NHS Provider Selection Regime?
The NHS Provider Selection Regime (PSR) will be a new set of rules for arranging healthcare services in England. The aim of the PSR is to give decision makers a more flexible process for deciding who should provide healthcare services, to make it easier to integrate services and enhance collaboration and to remove the bureaucracy and cost associated with the current rules.
Subject to parliamentary process, the Department of Health and Social Care aims to introduce the PSR by the end of 2023.
Both ICB and ambulance service leaders were ambitious about the role that the ambulance service can play within systems – with an emphasis on their ability to do more than responding to emergencies, helping to prevent ill health, keeping people out of hospital, and actively engaging in local health economies.
To achieve this, it was recognised that thinking creatively to tackle patient flow challenges in urgent and emergency care (UEC) will help to relieve the pressures on the ambulance sector, enabling it to recover performance in emergency response and play a more strategic role in the system.
To accelerate this, the following recommendations are made:
- ICBs should actively consider how their ambulance service(s) can help achieve their four core purposes, 2 and what role they can play in communities beyond responding to emergencies.
- Ambulance service leaders should be proactive in engaging with systems in their widest sense, and actively seek roles that go beyond UEC.
The UK Government should expedite the implementation of the Provider Selection Regime (PSR).
2) Focus on data sharing
A common theme highlighted by interviewees was that data sharing is crucial to good collaboration between ICBs and ambulance services. The ability for ICBs to coordinate data so that members of the public only have to give their basic information once and then for this to be used consistently across the system was seen as important.
Supporting population health management
Ambulance services hold crucial data on patients and could support systems in tackling population health issues and inequalities
One leader cited the abundance of data held within ambulance services, noting the ability to examine gaps across pathways, highlighting the influence of, for example, deprivation and local demographics, and identifying areas with performance issues. Participants agreed that ambulance services have an important view of what is happening on the ground in systems, spanning NHS, social care and community environments. This can be invaluable in helping to inform system decision-making. One system leader highlighted that ambulance trusts have the ability to use their data to accurately predict urgent and emergency care demand within the system, and such intelligence continues to be vital to the system.
Ambulance services also hold crucial data on patients and could support systems in tackling population health issues and inequalities. One leader outlined that they were currently examining data that will enable systems to understand how best to optimise and integrate ambulance services with the wider UEC care pathways and referral route, to improve patient experience and outcomes. The leader stressed that there was a need to understand what data is available, where the current gaps are and what hinders ambulance crews to use these pathways.
Barriers to transformation
However, it was noted that due to variation in the digital maturity of systems, data was not currently being shared widely enough to realise its potential, hampering system transformation. This is a broader challenge for ICSs as data sharing can be a mixed picture across services and systems. Not only can good data sharing allow for more joined-up planning at system level, it can actively improve patient safety – allowing for better responses to peoples’ needs and earlier intervention.
Ambulance services hold a wealth of data that not only spans single systems, but regions, which can help to improve system level decision-making. ICBs need to make sure the right infrastructure is in place to do this successfully.
To achieve this, the following recommendations are made:
- ICBs should focus on improving their data sharing infrastructure to help make the most of the data held by ambulance services.
- Ambulance services should look for opportunities to share the wealth of data they hold across the systems in which they operate.
- Consideration should be given to how ambulance service data can be used at neighbourhood, place, system, regional and national levels to maximise its impact.
3) Foster a culture of collaborative planning, not transactional commissioning
Among our interviewees, there was strong support for increased collaboration and joined-up commissioning for ambulance services. Ambulance services have traditionally been commissioned on a lead or ‘coordinating commissioner’ model. While these models worked well for some, feedback from stakeholders indicated that this approach could lead to a lack of engagement from those across a region that do not lead on commissioning.
In one region, we heard that “around 80 per cent of conversations regarding hospital handovers were with the trust’s host ICS and 20 per cent with the other ICSs within the region.” It was agreed by interviewees that a greater degree of collaboration across the whole region, where this applies, would help improve outcomes for all.
Some colleagues from both ICBs and ambulance services highlighted that the word ‘commissioning’ itself has transactional connotations that reduce the relationship to a mere trade of services. All interviewees want to see a transition to greater co-design and collaboration in planning service delivery.
Changing the culture
While language does not directly change outcomes for the public, it signals the intentions of those involved and helps to change the culture of working between parties. One system leader stressed the need for flexibility from both ICBs and ambulance trusts, particularly to help drive local solutions and innovations. One ambulance service leader described the historical commissioning relationship with CCGs within the trust’s operating region which has continued through the transition to ICBs. The previous model saw each CCG engage with a central oversight board which would take discussions forward for agreement on a case-by-case basis. In the previous model, this was highly focused on operational issues. However, it has since been reviewed and there has been a shift towards a more strategic focus, with operational issues being handled by a separate committee. The leader reflected that this latter model works “pretty well”, and they hope the strategic shift will help accelerate progress.
Governance and ownership need to be shared with increased delegated authority
One system leader outlined an ambition to develop the lead commissioner approach further, allowing for certain triggers, for example related to spending or performance, which would allow the partnering ICBs to intervene. Participants from the system noted that the current model resulted in lengthy decision-making processes that became increasingly complex and difficult in dealing with urgent issues. Interviewees were quick to note that it is often a time-consuming process to bring all partners together to work through each issue, challenge or opportunity.
While there was support for the move toward a lead commissioning model, it was noted that there was reluctance from some to see the host ICB make decisions on the behalf of other systems. Interviewees stressed that to do this right, governance and ownership needed to be shared with increased delegated authority.
The model outlined above, whereby a lead commissioner provides the day-to-day support for the ambulance service, but mechanisms are built into the model to allow for other ICBs to trigger taking decisions into their own hands – for example, if their budget is significantly under or overspent, or if performance has declined – is one way forward. Moreover, we heard from interviewees that governance processes that allow for ICBs across a region to work more closely with the ambulance service on strategic issues related to their four purposes, while the lead commissioner focuses on the day-to-day, should be pursued.
It was also stressed by one leader that it is important to recognise that each system will have a unique set of challenges, illustrated by the need to agree local plans for the deployment of additional national investment within ambulance services. In addition, the leader noted that while planning across the region is necessary and crucial, individual systems must have their own plans and accountability mechanisms with ambulance trusts, reflecting the differing needs of each system.
All interviewees recognise the shift in emphasis that is needed: away from traditional, transactional relationships between commissioners and ambulance services, and towards co-design and collaboration. While this may seem straightforward to some, it is a cultural change that requires embedding into governance and decision-making structures across systems and regions.
To accelerate this transition, the following recommendations are made:
- Where appropriate, as per the national guidance, ICBs and ambulance services should consider developing multi-ICB governance structures that work for all parties and ensure these are designed to encourage ambulance services to play significant roles across all the systems they work with.
ICBs that are not lead commissioners should continue to proactively engage with ambulance services and co-design a role for the service’s input into their individual system decision-making.
4) Actively nurture relationships
The introduction of ICSs aimed to bring about a change in relationship between service providers across a sector and across a system. Breaking down the culture of competition and building one of collaboration allows for more joined-up planning, more holistic services for the public and a more cohesive journey for people entering the health system. These principles, we heard, apply as much to the ambulance service sector as to anywhere else in health and care.
Interviewees said that the relationships between ICBs and ambulance services need to be proactively nurtured – with time taken out of all leaders’ busy schedules to actively invest in their interactions with one another. Moreover, where relationships are strong between ambulance services and their system counterparts, we saw that this extended beyond just the chief executive and chair of the ICB, but also to wider partners that sit on the ICB or the wider system – including local authorities, the acute, mental health and primary care providers and VCFSEs (voluntary, community, faith and social enterprises) and community interest companies (CICs).
While ambulance service leaders noted that the process of engagement with ICBs created challenges on senior leadership time and other resources (after all, one ambulance service chief executive engaging with more than a handful of ICSs is a significant time investment, and often ICS board meetings take place at the same day and time each month), many ambulance services have developed ways of managing this internally. One ambulance service, for example, has allocated responsibility for nurturing relationships with each ICS to different members of the executive team to enable bespoke engagement, building deeper relationships between system partners.
Signalling the right intentions
Making the reasons for this clear to partners – i.e. that it is a result of the practical challenge of engagement for one chief executive, not a sign of the importance (or lack thereof) attributed to specific relationships – is important to signal the right intentions between partners. It is a similar challenge to that faced by other partners, such as local authorities whose footprints can span more than one ICS. The issue of time commitment and allocation at executive level could be reduced by implementing the multi-ICB committee approach, providing all accountable officers were included in this.
Seeking long-term arrangements
Those we spoke to outlined that the degree and nature of engagement can depend on the maturity of the ICS. In some places, we saw ‘buddying systems’ between the ambulance trust’s and each ICB’s executive teams, to build relationships and work closely to ensure approaches to commissioning are consistent with respective ICB annual and multiyear plans. Some also noted that before the emergence of ICSs and ICBs, a CCG within the region would often host commissioning on a two-year basis.
System leaders reflected on this, saying that in this model, they often spent a year getting to know the ambulance service better, building relationships across the region, developing the best arrangements, and grasping all the tools at their disposal, before preparing to handover the commissioning to the next CCG. It was suggested that this meant the relationships were in an almost constant state of transition, building everything from the ground up only to restart again. Seeking more long-term arrangements, in whatever model, would help to plan better, learn from experience, and embed relationships over several years.
Actively building deeper, longer-term relationships will help drive outcomes-focused improvement
Both ambulance and system leaders in one region noted that they had developed very strong relationships, with a service leader noting that there were high levels of trust and engagement, with the ambulance service feeling that “we are being listened to”. However, it was also felt that “we often don’t see this transfer beyond senior relationships”, citing particularly strong chief executive and chair engagement. Building relationships across their respective commissioning and operational teams, beyond the senior level, was seen as one way in which collaboration can be improved.
One ambulance service and system we spoke to highlighted that they now have a memorandum of understanding (MOU) in place which sets out principles around partnership working values and behaviours. Leaders noted that they had held face-to-face workshops with further sessions anticipated to identify key priority areas and agree how these will be collectively taken forward.
Actively building deeper, longer-term relationships will help drive outcomes-focused improvement and maintaining a focus on the four purposes of ICSs.
Time and again we hear that good relationships are crucial to improving outcomes. Relationships built on trust, mutual respect and candour can help tackle the root causes of issues. Both system and ambulance service leaders recognised the need to put relationships first.
To achieve this, the following recommendations are made:
- ICBs and ambulance services should have an open, collective discussion about how to best nurture their relationships, considering the strains that working with many ICBs puts on ambulance service leadership, as well as the challenges that ICB leaders face.
- 2. ICSs have four statutory aims set out in the Health and Care Act 2022 and NHS England’s ICS Design Framework. These are: 1) to improve outcomes in population health and health care; 2) to tackle inequalities in outcomes, experience and access; 3) to enhance productivity and value for money; 4) to help the NHS to support broader social and economic development. ↑
This report is not intended to be a comprehensive guide to changing commissioning relationships between ICBs and ambulance services. Instead, it highlights the common themes and principles that underpin good practice and reflections from system and ambulance service leaders about how this relationship can evolve and flourish in the new architecture for health and care.
By focusing on these four areas (thinking creatively about the role of the ambulance service; focusing on data sharing; fostering cultures of collaborative planning; and nurturing relationships), system and ambulance service leaders can design arrangements and relationships that deliver vast improvements to their population’s health in the years ahead.