• Poor sub-contracting leaves patients vulnerable to being transported by unregistered ambulances 
  • CQC vows to tighten assessment of trusts’ sub-contracting arrangements
  • Report raises fresh quality concerns about growing private ambulance sector

Concerns have been raised that NHS patients are being transported by unregistered private ambulance firms because of poorly monitored sub-contracting arrangements.

The Care Quality Commission was unable to set out the scale of the problem faced by NHS patient transport services to HSJ, but said that it had “identified concerns where sub-contracting arrangements have led to the use of unregistered providers”.

The report said the regulator would be strengthening its assessment of trusts’ sub-contracting arrangements and criticised NHS organisations for making “commissioning decisions on financial rather than quality indicators”.

The state of care in independent ambulance services report said the CQC’s “concerns remain about how safely and effectively independent ambulance providers” operate, with quality varying greatly across the burgeoning sector.

Roughly £58m a year is spent on private ambulances services, according to a government commissioned efficiency review last year by Lord Carter. However, unions estimate the cost at several times that at £235m, according to a report in October. The ambulance sector costs around £1.8bn overall.

Problems raised included the lack of training offered by private providers and “extremely variable” standards of medicine management, with some services not in possession of the required Home Office licence for the procurement and storage of controlled drugs.

It stressed the growing reliance of the NHS on the sector, which mainly offers specialist patient transport services but increasingly provides 999 emergency responses to ambulance trusts.

CQC inspectors found private ambulance providers had “sub-contracted to an unregistered provider[s], without understanding or recognising that it is unsafe and it is a risk”.

The report said: “Our inspection teams have found that [private ambulance providers] are not always able to fulfil their contractual obligations and have then sub-contracted to another organisation.”

It cites one example of a “particularly large independent mental health provider who was commissioning an ambulance provider that wasn’t registered”. It did not name the provider.

The CQC said there was a “tendency for commissioning decisions to focus on financial rather than quality indicators, often with poor contract monitoring arrangements in place”.

The report added: “Many services inspected had a poor understanding of governance which often led to weak recruitment processes. Checks to ensure that staff had the appropriate employment references, Disclosure and Barring Service (DBS) certificates, and driving licence categories (eg to operate heavier vehicles) were not being enforced consistently.”

CQC lead for ambulance services Ellen Armistead told HSJ: “We have identified concerns where sub-contracting arrangements have led to the use of unregistered providers and are aware of an example of this in a large independent mental health service.

“This example highlights the need for providers to assure themselves that directly contracted services are with registered providers and any sub-contracting arrangements make clear the expectation around CQC registration. This applies equally in independent and NHS providers.”

The Independent Ambulance Association said: “As association we have always been fully supportive of the CQC and the vital role they have in ensuring standards of care by providers in England; IAA member companies in England are required to hold (and maintain) CQC registration.

“We will continue to work closely with the CQC to further improve standards in the independent ambulance sector.”