Since 2012 Clinical Commissioning Groups (CCGs) and Trusts have sought to outsource non-emergency transport for the NHS. Emergency work has largely remained the remit of the ambulance trusts across the country.
This began with groups of CCGs and Trusts across England signing framework contracts for non-emergency ambulance services and have continued with Integrated Care Boards and Trusts. These framework contracts list large numbers of private ambulance companies, not-for-profit organisations, such as The Red Cross, large transport companies, such as Arriva, and taxi companies. All organisations listed on a framework contract can be used to undertake non-emergency transport of patients.
Another phenomenon has been the appearance of intermediary companies: these companies are listed on the framework agreement, but do not themselves have ambulances, they sub-contract the work to other companies who do have ambulances. An example of such a company was Coperforma, which was awarded a contract in Sussex for patient transport.
Below are a few examples of how contracts have gone wrong in this sector.
Safety and quality concerns for EMED patient transport services
The private ambulance/patient transport company EMED has contracts worth over £500 m with several Integrated Care Boards (ICBs) in England, including in Kent and Surrey, despite concerns about service performance and risk to patients.
The concerns highlighted by several trusts include missed and late appointments, including those for renal patients attending for dialysis. On trust, Ashford and St Peter’s in Kent, has had to directly commissioned two ambulances for 10 hours a day to mitigate some of the problems. A report to its ICB board said patient complaints were very high, staff sometimes had to stay on site to look after patients waiting for transport after units had closed, and it was increasingly relying on contracted third-party transport which came at a cost.
Surrey Heartlands Integrated Care Board’s board papers show concern over a high volume of complaints, safe transfer of patients and “poor quality of care for renal and end of life” patients. EMED is under “enhanced oversight”, according to its board papers.
EMED has been delivering the non-emergency patient transport service in the Surrey Heartlands area since April 2024. The Surrey Heartlands contract is worth around £43m before VAT and is for five years.
EMED has also recently won a 10-year contract worth around £223m covering Buckinghamshire, Oxfordshire and Berkshire West and Frimley integrated care systems, and a contract covering Sussex which is worth around £230m over 10 years. It has also won a contract in Derbyshire worth up to £59m excluding VAT over five years. These all start in April 2025.
All of the contracts in the South East were previously run by South Central Ambulance Service Foundation Trust which expects 330 staff in the Thames Valley and 140 in Sussex to transfer to EMED in April.
Cairngorm Capital, a private equity company, began investing in E-zec, a patient transport company in 2021. EMED was formed by the merger of E-zec with ERS Medical on 1 February 2023 to form a company with revenue of over £110m.
Coperforma and the Sussex non-emergency transport contract
One of the most controversial contract failures in recent times has been the Coperforma contract in Sussex for non-emergency patient transport. This four year contract worth £63.5 million was awarded in 2015 by seven CCGs, led by the High Weald Lewes Havens CCG. Coperforma replaced the NHS’s South East Coast ambulance service (SECamb) on 1 April 2016; it was then just a matter of days, before problems with the contract hit the headlines. By mid-April local and national press were reporting on a service in chaos, with crews not turning up to pick up patients leading to missed appointments and patients languishing for hours in hospitals awaiting transport home. Patients included those with kidney failure with appointments for dialysis and cancer patients attending chemotherapy sessions. The GMB union representing the ambulance crews said it was an “absolute shambles”. There then began calls to strip Coperforma of its contract.
In mid-April 2016 the CCGs that awarded the contract launched an investigation. In June, these Sussex CCGs produced a report criticising Coperforma for “unacceptable levels of performance”, noting patients having problems contacting the service and being collected late or not at all.
Despite this report and continued complaints, Coperforma’s service failed to improve and cracks started to show in the way the contract work was organised through sub-contractors.
Under the contract, Coperforma acted as an intermediary sub-contracting out the ambulance work to private ambulance companies. Many of the staff working for the sub-contractors had transferred from SECamb after this organisation lost the contract. However, by August it was evident that there were issues of payment to sub-contractors. VM Langfords was the first sub-contractor to go bust in June 2016, followed in September 2016 by Docklands Medical Services.
BBC South East from four of the sub-contractors claimed the problems had reached “critical levels”. The email was highly critical of Coperforma’s management, its staff, its operating system, and warned that the company was struggling financially. The email said Coperforma was withholding and refusing to pay invoices, with the three main providers owed more than £1.2 million. The email warned NHS managers “to act now before the service collapses.”
In October a third sub-contractor, Thames Ambulance, reported financial difficulties. The sub-contractors all blamed Coperforma, saying they are owed millions in unpaid invoices by the company. The lack of payment to sub-contractors meant that many of the ambulance crew members had not been paid and were owed thousands in back pay.
Finally in October 2016, Coperforma were forced to give up the contract. Despite promising to transfer money to pay the ambulance crews, High Weald Lewes Havens CCG had to step in and provide the money for the back pay. In November 2016 the CCGs announced a managed transition to the NHS’s South Central Ambulance Foundation Trust beginning immediately and with a final takeover in April 2017.
In December 2016, a report by Brighton & Hove’s Healthwatch based on the experience of dialysis patients listed a litany of failures by Coperforma, including anxiety and stress due to failures of the service, transport failing to turn up and drivers who did not know the area and were inappropriately trained and equipped. In early November it was revealed that the Care Quality Commission had served six improvement notices on the company.
The CQC report showed significant concerns about Coperforma’s oversight of its subcontractors. Areas needing improvement included the timeliness of services, registering a manager with the CQC, and vehicles and equipment being appropriate for safe transport of patients, including those in wheelchairs.
In 2018, Coperforma went into voluntary liquidation and in 2019 HSJ reported that the company had just a few thousand pounds in its bank accounts and owed £11.3m to unsecured creditors, including NHS organisations and suppliers of ambulances and staff. CCGs had launched legal proceedings to try and get back the millions owed. In March 2022, the CCGs finally got back a “significant” amount of money from a company called Sinocare Group Ltd, based in Hong Kong; this was one of the parent companies of Coperfoma.
Thames Ambulance to be stripped of its North Lincolnshire contract.
Thames Ambulance Service Ltd (TASL) started its contract with North Lincolnshire in 2016 for non-urgent patient transport. Problems in the service soon surfaced, but despite working with the CCG and recommendations from the Care Quality Commision (CQC), the company failed to improve. As a result, in March 2018 the CCG served notice on the company.
An inspection by the CQC in October 2017, led to a damning report in February 2018, which can be found on the CQC website. The CQC uncovered a range of failings including one day when 13 patients were left waiting at hospital for transport. Patients were also left waiting in the cold for transport and missing appointments because the service couldn’t be provided adequately enough to get patients there on time.
One of TASL staff members described their employer as “inept” and “disorganised”. The state of the service’s vehicles was also highlighted by the CQC inspectors, with one vehicle 5,000 miles past its service due date and no hot water being available to clean them properly, inspectors found.
Private Ambulance Service – Bedfordshire and Hertfordshire
In late September 2017, the private ambulance company, Private Ambulance Service contracted to run non-emergency patient transport from hospitals in Bedfordshire and Hertfordshire went into administration, with trading ceasing 9 October 2017. The business, which 126 vehicles and employed 300 people, took over the contract in April 2017. Problems had been reported with the service, including a report in the Herts Advertiser in July 2017 about Herts Valleys CCG issuing an apology after ongoing problems with the performance of the company, including leaving vulnerable patients stuck in their homes or in hospital for hours waiting for transport.
Arriva and North West Ambulances
In September 2015 the transport company Arriva was found to have wrongly claimed £1.5 million in bonuses on the contract to run non-emergency transport for NHS patients in Manchester. Arriva wrongly reported its performance in order to gain the bonus payments. Arriva was awarded the contract in 2013 after saying it could run the contract cheaper than the North West Ambulance service. In 2014 Arriva received 600 complaints about the service with 80% partially or wholly upheld. Arriva has paid back the bonuses and apologised.
See further reading below for more on contract failures.
