The NHS: Where does all the money go?
The NHS: Where does all the money go?
Ambulance Trusts - What does £4 billion get you?
There are ten individual NHS Ambulance Trusts (some of which are now Foundation Trusts) in England. We assessed their total income by looking at their annual accounts for 2023/24, which comes to just over 4 billion pounds (£4,035 million). See the end of this post for the account links and each trust's income.
We also looked at the NHS Workforce statistics to see what the money pays for.
In total, Ambulance Trusts employ 58,503 (as of July 2024). Of these, 20,608 (35%) are ambulance staff, and 28.624 (49%) are classified as support staff. There are 1,165 managers, 539 senior managers, and a host of other people - such as central functions - we don’t quite understand what they do.
Substantial variation exists in the proportions employed across the trusts. The East of England Ambulance Service NHS Trust employs 89 senior managers, 1.38* of the total workforce, compared to 24 (0.35%) in the West Midlands Ambulance Trust.
Further variation exists in the number of ambulance staff employed, varying from 27.3% in the North East Trust and 27.7% in the South Central to 40.5% in the West Midlands Ambulance Trust and 42.5% in the South West.
So what do you get for £4 billion?
The figures show a threefold variation in ambulance response for serious, urgent conditions. The causes are complex.
A 2022 review of why ambulance waiting times have worsened showed that paramedics have increased by 13% since March 2018. However, sickness absence, commonly attributed to poor mental health, has increased from 5% in March 2019 to 9% in March 2022 – the highest of any NHS organisation type.
The NHS Long Term Workforce Plan (now shelved) recognised the need to increase the paramedic workforce. However, a recent culture review proved that ambulance trusts must balance operational performance with people's performance at all levels. Despite all the managers, one of the main recommendations was to improve the leadership and management culture.
While the workforce has increased, capacity has been reduced as ambulances wait longer with patients outside hospitals. For example, hospital delays caused the East Midlands Ambulance Service to lose 25,000 hours in two months. Handover delays are a significant contributor to the decline in performance.
We looked at the latest data for September 2024 from NHS England
Category 1 (C2): Life-threatening injuries and illnesses, such as cardiac arrest
The current mean response time for a C1T ambulance call is 10.08 minutes, with the 90th centile being 18.27 minutes. C1T is the time it takes for the transporting vehicle to arrive for a C1 patient. The national standard for C1 calls is to respond in an average of 7 minutes and to respond to 90% of C1 calls within 15 minutes.
Category 2 (C2): Serious but non-life-threatening emergency calls, such as stroke patients
The average response time for a C2 ambulance call is 18 minutes, and 90% of C2 calls should be responded to within 40 minutes. However, response times haven’t come anywhere near this. The current mean response time is 32.27 minutes, with 90% of patients being seen within one hour of 8.29 minutes.
What no one has picked up - and the media missed - is the NHS has moved the goalposts for a deteriorating service. The NHS set a new target for 2023/24 to respond to C2 calls in 30 minutes on average. A target will also be included in the 2024/25 NHS objectives.
So, if we have this right, if you're not hitting your targets, then make the target easier to hit—perhaps that is part of the new NHS strategy.
Recommendations
Review the variation staff ratio, ensuring that, as a proportion, at least half of the workforce are patient-facing ambulance staff.
Ensure these additional front-line staff have the equipment to do their job efficiently.
Ask the National Institute for Health and Care Research (NIHR) to develop an evidence base for strategies that eradicate ambulance handover times.
Publish an atlas of variation on NHS ambulance performance.
Oh, and look after your staff who often do a difficult, complex and stressful job.
This post was written by two old geezers who don’t move their goalposts. The first old geezer did the heavy lifting, and the second had a few questions.
What is going on?
How can an emergency service be burdened by such a high number of non-front-line staff?
Why are the government, Parliament, the National Audit Office, Uncle Tom Cobbley and all the others not investigating what is happening instead of fleecing taxpayers at least twice over?
Wait for it - they’ll be throwing more billions at a service they have described as “broken”.*] What is going on?
Tom is not, by nature, suspicious, but the evidence from this series points to one answer that Tom does not like at all. Not to ruin your day, Tom will keep it for himself—for now.
*this post was written before HM Chancellor’s budget, however we are not modellers who can see the future. This prophesy was easy.
Ambulance Trust Income and Accounts for 2023-2024 with Links.
North East Ambulance - Accounts: Income of £220 million; operating expenditure of £223 million
Yorkshire Ambulance - Accounts: Income of £405.5m; operating expenditure £406m.
North West Ambulance - Accounts: Income of £498.4m; operating expenditure £498.4m
West Midlands Ambulance - Accounts: Income £401.2m; operating expenditure £401m
East Midlands Ambulance - Accounts: Income £294.7m; operating expenditure £302.7m
South Western Ambulance - Accounts: Income £398.3m; operating expenditure £399.4m
South Central Ambulance - Accounts: Income of £353.2m; operating expenditure £354.8 million
South East Coast Ambulance - Accounts: Income of 332.9m; operating expenditure £334.0m,
London Ambulance - Accounts: Income of £688.6m; operating expenditure 684.7M
East of England Ambulance - Accounts: Income £442.9m; operating expenditure £442m
It's pretty obvious that delays in handover result in longer wait times for people, plus further deterioration of patients waiting on a trolley. My mother died alone waiting for an ambulance in 2015. They did not keep her on the phone, I heard she'd phoned twice. I wrote asking to listen to the call(s) but they denied me. A first responder was first on the scene but my mum was either dead or unconcious and he could not gain entry so police then called to break down the door. She was pronounced dead in hospital. Although coming up to 9 years next month, her dying alone still haunts me today.
Not living in England, I can only offer personal and therefore anecdotal 'evidence' of deteriorating ambulance services. Living close to two main routes to the huge University Hospitals, before lockdowns I could hear ambulance sirens rushing to and fro. Now: not a peep. No, the streets haven't vanished. If what happened to me is what is going on across the Welsh Capital, then the answer is: people are told by the nice triage nurses answering 111 calls that they should go by private car or taxi unless they are prepared to wait for three, four hours for an ambulance.
Meanwhile - and I suspect this is happening across England as well - the local MSM are no longer publishing stories about people having to wait for ambulances, therefore, that problem clearly can't exist any longer.
See how easy it all is?