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A major review of the ambulance service published today paints a grim picture of the sector, finding that it has the highest sickness rates and complaints about bullying and harassment across the whole NHS.

Lord Carter’s review was tasked with highlighting the efficiency opportunities, setting out the case for an ambitious £500m of productivity gains within the sector. While agreeing with much of the review, providers did contest the scale of the potential savings it said were on offer (see our story here).

But the review arguably does more to highlight the sector’s need for investment rather than the ease at which costs could be squeezed out.

It should act as a timely reminder to system leaders as they approach the business end of the discussions around the long term plan that they must come up with credible plans for the business end of the NHS.

The workforce scenario makes for especially alarming reading. Sickness absence among ambulance trusts was the highest of all NHS sectors at an average of 20 days per person a year, the report said.

The review said 48 per cent of ambulance service staff reported bullying and harassment from patients, relatives or the public, while 28 per cent report it from other staff. This has translated to high vacancy rates, which means existing staff are under even more pressure to meet rising patient demand.

As with many problems in the NHS, it would be unfair to suggest ministers and system leaders are standing idly by.

The government, for example, announced in 2016 that paramedics would be moved up the NHS Agenda for Change pay scale from band 5 to band 6, in recognition of the recruitment and retention problems. (band five staff are paid between £23k and £29k, band sixes between £28k and £36k)

Health Education England, meanwhile, increased the number of paramedics entering training from 750 in 2013 to 1,850 in 2018 as part of its workforce strategy. But even HEE’s own workforce modelling has identified that more are needed to meet increasing demand, which is rising at six per cent a year, according to the review.

And this is without taking into account the cost implications of the kind of measures Lord Carter is advocating around improving conveyance rates by, among other measures, ensuring paramedics treat more patients at the scene.

An increase in patients avoiding a hospital visit would be welcome news for the NHS and patients alike. But it requires investment in higher skilled paramedics.

London Ambulance Service Trust’s laudable plans to cut its conveyance rates illustrate some of the costs involved.

LAS has pledged to reduce conveyance rates from 63 per cent to around 50 per cent by 2022-23 as part of an ambitious five year plan, as we reported in June.

But to achieve this the trust estimated it will need to quintuple the number of advanced paramedic practitioners from the 15 it currently has to as many as 75.

The APP role is a band 7 job, so such a programme has significant costs attached, with the extra cost for London alone conservatively estimated at around £2m a year.

In terms of fleet, the Carter review said the NHS “may need to invest in up to 3,300 new ambulances within the next five years to replace and expand the existing fleet”, at a cost of £280m.

Ambulance trusts have already planned to purchase or lease 2,600 vehicles over the next five years but this still leaves a significant shortfall.

Overall, the ambulance sector accounts for a modest £2.3bn of the NHS’s circa total £125bn expenditure. But spending decisions made for ambulances could be felt right across the service if system leaders get them wrong,