What is the Ambulance Service?
The ambulance service is the emergency response wing of the National Health Service (NHS).
The ambulance service has two main functions: an accident and emergency paramedical function, and the Patient Transport Service function which transfers immobile patients to and from their hospital appointments.
There are currently 10 NHS ambulance trusts in England, some of which are now foundation trusts. Scotland, Wales and Northern Ireland have their own separate ambulance services.
Ambulance Trusts receive funding through annual NHS Service Level Agreements made with primary care trusts and clinical commissioning groups in a particular geographic area.
The Department of Health provides a capital allocation each year, together, with additional funding for CBRN (chemical, biological radiological, nuclear) response training.
Ambulance trusts also generate income from their attendance at public events like music festivals, and from the provision of commercial training. Many have charitable funds that also receive donations.
Each Ambulance Trust has a Board which allocates it annual expenditure.
The ambulance service in the UK dates back to the late 19th century, with locally-funded services such as the Metropolitan Asylums Board operating in the London area in 1897. The earliest British Ambulance Flight was recorded in war torn Turkey in 1917. It was not until the formation of the National Health Service (NHS) in 1948 that it became a public duty to provide ambulances for all those who needed them.
Between then and today, ambulance services have undergone numerous reorganisations and redefinitions.
In 2001, the Government set out a programme for reforming emergency care services over the following four years. ‘Reforming Emergency Care’ saw improvements in emergency response times, the deployment of new technology (including satellite navigation systems and better equipment to deal with heart patients) and funded increases in frontline ambulance staff and vehicles.
The NHS Modernisation Agency also formed an Ambulance Group, ‘The Improvement Partnership for Ambulance Services’, to support ambulance staff to modernise their own services, help individual ambulance trusts improve performance and spread good practice.
On 1 July 2006, significant changes were made to the organisation of the ambulance service. The number of ambulance trusts covering England was reduced from 31 to 13.
Today there are 10 ambulance services in England providing emergency access to healthcare. Emergency 999 calls for an ambulance are prioritised into two categories: emergencies which are immediately life-threatening and emergencies which are not life-threatening.
Emergency ambulance crews now typically comprise an emergency care assistant and a paramedic. All crews are required to train to a very high level, which enables them to deal with any aspect of emergency care, from minor injuries to cardiac arrest, or multiple casualties sustained in serious road accidents. Emergency ambulances carry a wide range of equipment including intravenous drips, drugs, oxygen and heart defibrillators.
The patient transport service (PTS) branch of the ambulance service provides transport for a wide range of patients including: out patients; disablement service centre patients; routine discharges and admissions; geriatric and psycho geriatric day care; non-urgent inter-hospital transfers; those unable to attend hospital by any other means.
PTS ambulances are manned by ambulance care assistants – or PTS drivers – whose training includes comprehensive first aid, specialist driving skills, patient moving and handling techniques, basic life support and patient care skills.
A recent innovation has been the bicycle ambulance – officially the Cycle Response Unit – which operates in London. Initiated by Tom Lynch, a former competitive cyclist who joined the ambulance service at the age of 22, a formal trial of the service took place in 2000 and today the unit has a team of 60 staff.
The Cycle Response Unit uses custom-built Rockhopper mountain bikes with London Ambulance Service livery, blue lights and a siren. The rider wears London Ambulance Service livery and protective equipment and carries a comprehensive medical kit. A bicycle paramedic is said to cycle approximately 140 miles a week.
Like all NHS bodies, the ambulance service has to meet national performance targets – and it has not been immune to accusations of distorting priorities as a result. A report in Health Which? magazine in 2002 claimed that ambulance service paramedics had admitted to manipulating response times to meet ambitious new government targets.
The article quoted from one paramedic who stated that if the crews were in danger of missing the targets: “That’s where the magic pen comes in. Crews do a rough calculation. If it is not within eight minutes, they change it.” The magazine even alleged that some ambulance Trusts had begun a practice of re-classifying certain conditions as non-life threatening so that they could avoid the eight-minute target.
Suspicions were raised of potential malpractice when figures published by the ambulance service showed a dramatic improvement in performance, with 28 out of 32 ambulance trusts in England meeting the target, compared to just three the previous year.
However, many changes have been made to the ambulance service in recent years and a significant investment in the training and development of ambulance crews has, according to the Department of Health, resulted in “more effective patient care than ever before.”
In addition, ‘clinical quality indicators’ were introduced in April 2011 to allow patients and the public to see the quality of care provided by ambulance services. They are also intended to encourage discussion and debate amongst ambulance staff, NHS managers, commissioners and the public about how the quality of the care can be improved.
The indicators cover: Service Experience of patients; Outcome of patients from acute STEMI (ST segment elevation myocardial infarction – a type of heart attack; Outcome from cardiac arrest: return of spontaneous circulation; Outcome from cardiac arrest to discharge; Outcome following stroke for ambulance patients.
They also cover: Proportion of calls closed with telephone advice or managed without transport to A&E; Re-contact rate following discharge of care – to ensure that ambulance trusts provide safe and effective care the first time; Call abandonment rate – to ensure ambulance trusts can take 999 calls and that people don’t abandon their 999 call before a control room operator has answered; Time to answer calls – measuring how quickly all 999 calls are answered; Time until treatment by an ambulance-dispatched health professional; Category A: eight minutes response time – measuring whether those patients most in need of an emergency ambulance get one quickly.
Outsourcing of non emergency transport
Since 2012 Clinical Commissioning Groups 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 practice has involved so called ‘framework contracts’ which procure the services of external organisations to provide non-emergency ambulance services. These framework contracts involve transport companies (like Arriva and taxi firms), charities such as The Red Cross, and private ambulance companies.
Not all of these ‘framework contracts’ have gone well. In particular attention has focused on the Coperforma contract in Sussex for non-emergency patient transport. Awarded jointly by seven Commissioning Care Groups, the contract was said to be worth £63 million over four years. However after a number of media reports about crews not turning up to pick up patients and around delays for patients in hospitals awaiting transport home, an investigation was launched. A subsequent report criticised ‘unacceptable levels’ of performance.
Each year about one in twenty people in the United Kingdom will use the accident and emergency ambulance service. However, responding to 999 calls makes up only 10% of the total number of ambulance service journeys, they are also involved in non emergency work through the patient transport service. [Source: NHS]
Emergency 999 calls to the ambulance service are prioritised into two categories to ensure life-threatening cases receive the quickest response: Immediately life threatening – An emergency response will reach 75% of these calls within eight minutes. Where onward transport is required, 95% of life-threatening calls will receive an ambulance vehicle capable of transporting the patient safely within 19 minutes of the request for transport being made. All other calls – For conditions that are not life threatening, response targets are set locally. [Source: NHS Choices – 2012]