Comment / Decision time

Ambulance trust finance directors seem firmly behind the introduction of payment by results in their sector; on that they all agree (see page 8). Given the lack of consensus on how and what to implement, though, it’s not surprising that the Department of Health implementation team has cold feet on what to do next.

The HFMA’s survey of ambulance finance directors provides a fair assessment of a collective view. With 11 English ambulance trusts left after last year’s mergers, eight responses represents reasonable coverage. Each respondent supports the implementation of payment by results, but the variations in preferred approach are remarkable.

Implementation of payment by results in ambulance-land has its challenges. In an environment driven by response targets, resource needs are materially affected by rurality. Frankly, however, that’s no more complex than adjusting for market forces.

The biggest block to implementation is that there is no consensus on whether payment should be linked to a national tariff. To me, this feels quite bizarre. How could the ambulance sector justify such a divergence from national policy? What makes it different from acute hospitals, which also perform essentially similar tasks in different ways, for different populations, with different cost structures?

From the survey it seems that payment by results is taken as a means of delivering better commissioning. It is a sad indictment of the poor standard of commissioning (on both sides) that payment by results is needed to establish a link between payment and activity.

When you delve into the detail, the position looks murkier. Pilot projects are being set up using different currencies. I advocate a simple currency: the incident – the ambulance equivalent of the ‘spell’. Other colleagues are committed to developing payment mechanisms based on how to perform duties (see and treat, hear and treat, see and convey), which is unlike payment by results in the rest of the NHS.

When payment by results was first introduced, the aim was to expand the regime to ambulance trusts in 2008. There was a question over whether this meant 2007/08 or 2008/09. Well, the former is almost over and the latter is almost upon us and we seem little closer.

The Department recently identified ‘urgent and emergency care’ as a priority for payment by results. Last year’s consultation suggested we are looking at beyond 2010/11 although a national currency could be introduced earlier. The mood at a recent pilot projects meeting, however, suggested it could be as long as decade.

Implementation of payment by results wasn’t easy for anyone. It has been done with much of the learning on the job. Ambulance trusts and the Department must work on how this can be achieved for emergency services, not why it can’t. Whatever form payment by results takes, I want in. It’s time to incentivise efficiency, and to curb excess. To me, April 2009 sounds like a good date.

Keith Wood is director of finance at West Midlands Ambulance Service NHS Trust and chair of the HFMA’s Financial Management and Research Committee


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