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Emergency medical services in the United Kingdom

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Emergency medical services in the United Kingdom

A Mercedes Sprinter ambulance of the South Western Ambulance Service responds to an emergency call
The London Air Ambulance in action

Emergency medical services in the United Kingdom provide emergency care to people with acute illness or injury and are predominantly provided free at the point of use by the four National Health Services of England, Scotland, Wales, and Northern Ireland. Emergency care including ambulance and emergency department treatment is free to everyone, regardless of immigraton or visitor status.[1]

The NHS commissions most emergency medical services through the 14 NHS organisations with ambulance responsibility across the UK (11 in England, 1 each in the other three countries), although there is both subcontracting to, and direct commissioning of, private and voluntary ambulance services to respond to some calls.

As with other emergency services, the public normally access emergency medical services through one of the valid emergency telephone numbers (either 999 or 112).[2]

In addition to ambulance services provided by NHS organisations, there are also some private and volunteer emergency medical services arrangements in place in the UK, including all air ambulances (except those operated by the Scottish Ambulance Service), the use of private or volunteer ambulances at public events or large private sites, and as part of community provision of services such as community first responders.

Contents

  • Role of the ambulance services 1
  • History 2
  • Current public provision 3
    • England 3.1
    • Scotland 3.2
    • Northern Ireland 3.3
    • Wales 3.4
  • Usage 4
  • Private and voluntary ambulance services 5
    • Private ambulance services 5.1
    • Voluntary aid services 5.2
    • Air ambulances 5.3
  • Regulation, governance, and monitoring 6
    • Regulation 6.1
    • Measuring performance 6.2
    • Governance 6.3
  • Staffing 7
  • Supporting services 8
    • BASICS 8.1
    • Blood Bikes 8.2
    • Community first responders 8.3
    • Fire Service Responders 8.4
  • See also 9
  • References 10
  • External links 11

Role of the ambulance services

A paramedic's motorcycle in Birmingham

Public ambulance services across the UK are required by law to respond to four types of requests for care,[3] which are:

  • Emergency calls (via the 999 or 112 system)
  • Doctor's urgent admission requests
  • High dependency and urgent inter-hospital transfers
  • Major incidents

Ambulance trusts and services may also undertake non-urgent patient transport services on a commercial arrangement with their local hospital trusts or health boards, or in some cases on directly funded government contracts,[4] although these contracts are increasing fulfilled by private and voluntary providers.

History

The National Health Service Act 1946 gave county and borough councils a statutory responsibility to provide an emergency ambulance service, although they could contract a voluntary ambulance service to provide this, with many contracting the British Red Cross, St John Ambulance or another local provider. The Regional Ambulance Officers’ Committee reported in 1979 that “There was considerable local variation in the quality of the service provided, particularly in relation to vehicles, staff and equipment. Most Services were administered by Local Authorities through their Medical Officer of Health and his Ambulance Officer, a few were under the aegis of the Fire Service, whilst others relied upon agency methods for the provision of part or all of their services.”

The 142 existing ambulance services were transferred by the regional or area health authorities.[5]

This led to the formation of predominantly county based ambulance services, which gradually merged up and changed responsibilities until 2006, when there were 31 NHS ambulance trusts in England.

The June 2005 report "Taking healthcare to the Patient", authored by Peter Bradley,[6] Chief Executive of the London Ambulance Service, for the Department of Health led to the merging of the 31 trusts in to 13 organisations in England,[7] plus one organisation each in Wales, Scotland, and Northern Ireland. Following further changes as part of the NHS foundation trust pathway, this has further reduced to 10 ambulance service trusts in England, plus the Isle of Wight which has its own provision.

Following the passage of the Health and Social Care Act 2012, commissioning of the ambulance services in each area passed from central government control in to the hands of regional clinical commissioning groups.

Current public provision

The commissioners in each region are responsible for contracting with a suitable organisation to provide ambulance services within their geographical territory. The primary contract for each area is currently held by a public NHS body, of which there are 11 in England, and 1 each in the other three countries.

England

Device of NHS ambulance services in England and Wales

In England there are now ten NHS ambulance trusts, as well as an ambulance service on the Isle of Wight, run directly by Isle of Wight NHS Trust, with boundaries generally following those of the former regional government offices. The ten trusts are:

The English ambulance trusts are represented by the Association of Ambulance Chief Executives (AACE), with the Scottish, Welsh and Northern Irish providers all associate members.

Scotland

The service was operated before reorganisation in 1974 by the St Andrews’ Ambulance Association under contract to the Secretary of State for Scotland.[8] The Scottish Ambulance Service is a Special Health Board that provides ambulance services throughout whole of Scotland, on behalf of the Health and Social Care Directorates of the Scottish Government.[9]

Due to the remote nature of many areas of Scotland compared to the other Home Nations, the Scottish Ambulance Service has Britain's only publicly funded air ambulance service, with two Eurocopter EC 135 Helicopters and two Beechcraft B200C King Air fixed-wing aircraft. There is also a partnership to provide the Emergency Medical Retrieval Service which gives rapid access to the skills of a consultant in emergency or intensive care medicine using Scottish Ambulance Service road and air assets.[10]

Northern Ireland

Device of the Northern Ireland Ambulance Service

The Northern Ireland Ambulance Service (NIAS) was established in 1995 by parliamentary order,[11] and serves the whole of Northern Ireland.

Wales

The Welsh Ambulance Service NHS Trust (also called Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru) was established on 1 April 1998, and has 2,500 staff providing ambulance and related services to the 2.9 million residents of Wales.[12]

Usage

The ambulance services across England have been increasingly busy, with a significant increase in calls in the last two decades,[7] as shown in the table below:

Year Emergency calls Source
1994/5 2.61 million [7]
2004/5 5.62 million [7]
2006/7 6.3 million [13]
2012/3 9.08 million [14]

Calls where a Category A ambulance arrived at the scene rose from 6,856 per day in 2011-12 to 8,564 per day in 2014-15.[15]

Private and voluntary ambulance services

There is a large market for private and voluntary ambulance services, with the sector being worth £800m to the UK economy in 2012.[16] Since April 2011, all ambulance providers operating in England have been required by law to be registered with the Care Quality Commission, under the same inspection regime as NHS services, and there are currently around 250 credentialled providers.[17]

The primary activities of the private and voluntary services include:

  • the provision of ambulances as part of a wider service of first aid at events, construction sites, film sets, or other private provision
  • the provision of additional resource to NHS ambulance trusts
  • urgent patient transport between points of care (such as between two hospitals)
  • non-urgent patient transport

All providers, including NHS, private, and voluntary can bid for many of the available contracts for provision of ambulance services, and private ambulance services now undertake over half of hospital transfers.[18] This places the voluntary providers in direct competition with private services, although the private sector has been growing at the expense of the voluntary services over time.

There is a duty on Category 1 responders (including the NHS) to make appropriate arrangements for major incidents, and as such private and voluntary ambulance services are generally included as part of local planning for the provision of ambulance services during major incidents, such as mass casualty events (including 7 July 2005 London bombings), adverse weather, or severe staff shortage.

Private ambulance services

Private ambulance services are common the UK, with over 200 providers, and their use under contract to the NHS to answer 999 calls has been growing year on year,[19] with every NHS ambulance trust using private providers in each year from 2011−2014, and contracted providers answering three quarters of a million 999 calls in that three-year period.[20] Expenditure on private ambulances in England increased from £37m in 2011−12 to £67.5m in 2013/4, rising in London from £796,000 to more than £8.8m.[21] In 2014−15, these 10 ambulance services spent £57.6 million on 333,329 callouts of private or voluntary services - an increase of 156% since 2010−11.[22] This use of private contractors for frontline services has been politically controversial,[23][24] although 56% of the British public believe that greater private sector involvement will help maintain or improve standards in the NHS.[25]

In 2013, the CQC found 97% of private ambulance services to be providing good care.[17] These private, registered services are represented by the Independent Ambulance Association.

There are also a number of unregistered services operating, who do not provide ambulance transport, but only provide response on an event site. These firms are not regulated, and are not subject to the same checks as the registered providers, although they may operate similar vehicles, and offer near identical services.[18]

Voluntary aid services

Emergency ambulance of the British Red Cross

There are a number of voluntary ambulance providers, sometimes known as Voluntary Aid Services or Voluntary Aid Societies (VAS), with the main ones being the British Red Cross and St John Ambulance. The history of the voluntary ambulance services pre-dates any government organised service, and includes service in both World Wars.

As they are in direct competition for work with the private ambulance providers, the voluntary providers do operate with some paid ambulance staff to fulfil their contracts.

Voluntary organisations have also provided cover for the public when unionised NHS ambulance trust staff have taken industrial action.[26]

There are a number of smaller voluntary ambulance organisations, fulfilling specific purposes, such as Hatzola who provide emergency medical services to the orthodox Jewish community in some cities.[27] [28][29][30][31]

Air ambulances

With the exception of Scotland, where the Scottish Ambulance Service provides air ambulances, all UK air ambulances are funded by charitable organisations, and operated by private contractors, with medical staff usually seconded from the local NHS ambulance trust.

Regulation, governance, and monitoring

All emergency medical services in the UK are subject to a range of legal and regulatory requirements, and in many cases are also monitored for performance. This framework is largely statutory in nature, being mandated by government through a range of primary and secondary legislation.

Regulation

In England all ambulance services, as well as some medical response organisations like BASICS, are regulated by the Care Quality Commission (CQC) under the provisions of the Health and Social Care Act 2008 and subsequent Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

This requires all providers to register, to meet certain standards of quality, and to submit to inspection of those standards.[32] Organisations not meeting the standards can be sanctioned, or have their registration removed, preventing them from offering any medical services.

The CQC replaced the previous regulator of England's NHS ambulance services, the Healthcare Commission, with its remit expanded to include all private and voluntary providers. Independent ambulance services have only been subject to formal regulation since 2011.[32]

In addition to regulation by the Care Quality Commission on matters of service provision, providers of NHS services are also subject to regulation by either Monitor (for NHS foundation trusts or private providers) or the NHS Trust Development Authority (for NHS services who are not yet foundation trusts) for economic and financial matters.

Measuring performance

The performance of every NHS ambulance provider is measured and benchmarked by the government. Commonly called 'ORCON',[33] after the consultancy used to formulate them, the New Ambulance Performance Standards (NAPS) were developed in the 1990s, and merged in to the Clinical Quality Indicators (CQI) used today.

The benchmarked targets include:[2]

  • Service experience - patient satisfaction with the service
  • Outcome from acute STEMI - the number of patients who recover from a heart attack
  • Outcome from cardiac arrest - the number of patients who get a return of spontaneous circulation and those who are discharged from hospital
  • Outcome following stroke
  • Proportion of calls closed with telephone advice - also known as "hear and treat"
  • Proportion of calls managed without transport to A&E - also known as "see and treat"
  • Recontact rate following discharge of care - patients who have had 'hear and treat' or 'see and treat' and who subsequently call 999 again
  • Call abandonment rate - the number of people who don't get through to an ambulance dispatcher
  • Time to answer calls - the time it takes to answer the phone
  • Time until treatment by an ambulance - the wait time between calling and a health care professional being dispatched
  • Category A response time - in cases triaged as Category A (life-threatening) by the triage software (usually AMPDS or the more recent NHS Pathways), services are targeted to reach the patient within eight minutes of the call. In England, ambulance services are targeted on reaching 75% of Category A calls in 8 minutes, compared to 65% in Wales.

Governance

Every ambulance provider is responsible to the CQC for compliance with best practice. Best practice guidance is published by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC), and most providers follow the majority of this issued guidance.

Staffing

There are a range of staff grades who work in emergency medical services in the UK. The majority of staff fall in to four main categories (in descending skill order):

  • Specialist paramedic - such as a critical care paramedic, or paramedic practitioner, who may have extra skills such as prescribing
  • Paramedic - paramedics are the core medical treatment grade, and the title is protected (meaning only those registered with the Health and Care Professions Council are entitled to use it, paramedics have autonomous practice, and a range of skills including intravenous cannuulation and advanced airway. in 2014 pay starts between £21,500 to £28,000 depending on experience and rises to £34,500 for team leaders and extended skills training. A full-time working week is 37.5 hours including night and weekend shifts as well as public holidays. Annual leave starts at 27 days per year plus public holidays or time in lieu and rising to 33 after 10 years’ service.[34]
  • Technician - technicians either support paramedics, or work autonomously. There is no single definition or qualification which covers all technicians, and they vary by service, especially between NHS and private providers
  • Emergency care assistants - cannot work autonomously, and operate in support of a paramedic or technician, performing duties such as driving, and first aid skills. As with technician, there is significant variation in the training levels between providers.

In 2014/5 Ambulance Trusts were forced to look overseas to fill vacancies for paramedics. Only one was recruited from outside the UK in 2013-4 but 183 had been recruited since April 2014. Of these 175 were recruited by the London Ambulance Service from Australia. Across England, ambulance services reported that 1,382 of 15,887 posts were vacant – a rate of 9%.[35]

Other roles within the NHS Ambulance Services include Ambulance Nurse (presently only employed by South Central Ambulance Service and identical in role to Paramedic, allowing interchangeability), Emergency Care Practitioner and similar Specialist Paramedic/Nurse roles with a focus on admission avoidance, and a broad range of support staff.

Supporting services

BASICS

The British Association for Immediate Care coordinates voluntary schemes, and individual medical and allied health professionals, providing immediate care throughout the UK.[36] BASICS doctors, nurses or paramedics may assist NHS paramedics at the scenes of serious accidents or be on-hand at major sporting events.

Blood Bikes

A blood bike operated by Freewheelers EVS

Across Great Britain, there is a network of volunteer Nationwide Association of Blood Bikes (NABB).[37]

Community first responders

Volunteer community first responders (CFRs) are now common place resources for NHS Ambulance Service. CFRs are members of the public who have received training to answer ambulance 999 calls, and respond immediately within their local area, during their own time. The schemes originated to provide defibrillation in rural and remote areas, where ambulances could not quickly respond, although they are now present in both rural and urban areas.

CFRs are often operated by a local group, in partnership with the regional NHS ambulance trust, and carry a defibrillator and oxygen, along with other equipment as decided by the clinical governance arrangements. Some schemes have their own vehicles and actively fundraise to support their schemes.

Fire Service Responders

In more rural areas where ambulance responses can take longer, fire personnel have been trained in basic first aid and pain management. They are trained in CPR, use of an AED, oxygen and entonox. They normally take a call from the ambulance Emergency Operations Centre and respond in a car fitted with blue lights, sirens and ambulance / fire service livery. This service is normally staffed by retained firefighters.

See also

References


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local p = {}


-- Helper functions


local function getArgs(frame) -- Fetches the arguments from the parent frame. Whitespace is trimmed and -- blanks are removed. mArguments = require('Module:Arguments') return mArguments.getArgs(frame, {parentOnly = true}) end

local function removeInitialColon(s) -- Removes the initial colon from a string, if present. return s:match('^:?(.*)') end

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function p.formatPages(...) -- Formats a list of pages using formatLink and returns it as an array. Nil -- values are not allowed. local pages = {...} local ret = {} for i, page in ipairs(pages) do ret[i] = p._formatLink(page) end return ret end

function p.formatPageTables(...) -- Takes a list of page/display tables and returns it as a list of -- formatted links. Nil values are not allowed. local pages = {...} local links = {} for i, t in ipairs(pages) do checkType('formatPageTables', i, t, 'table') local link = t[1] local display = t[2] links[i] = p._formatLink(link, display) end return links end

function p.makeWikitextError(msg, helpLink, addTrackingCategory) -- Formats an error message to be returned to wikitext. If -- addTrackingCategory is not false after being returned from -- Module:Yesno, and if we are not on a talk page, a tracking category -- is added. checkType('makeWikitextError', 1, msg, 'string') checkType('makeWikitextError', 2, helpLink, 'string', true) yesno = require('Module:Yesno') local title = mw.title.getCurrentTitle() -- Make the help link text. local helpText if helpLink then helpText = ' (help)' else helpText = end -- Make the category text. local category if not title.isTalkPage and yesno(addTrackingCategory) ~= false then category = 'Hatnote templates with errors' category = string.format( '%s:%s', mw.site.namespaces[14].name, category ) else category = end return string.format( '%s', msg, helpText, category ) end


-- Format link -- -- Makes a wikilink from the given link and display values. Links are escaped -- with colons if necessary, and links to sections are detected and displayed -- with " § " as a separator rather than the standard MediaWiki "#". Used in -- the template.


function p.formatLink(frame) local args = getArgs(frame) local link = args[1] local display = args[2] if not link then return p.makeWikitextError( 'no link specified', 'Template:Format hatnote link#Errors', args.category ) end return p._formatLink(link, display) end

function p._formatLink(link, display) -- Find whether we need to use the colon trick or not. We need to use the -- colon trick for categories and files, as otherwise category links -- categorise the page and file links display the file. checkType('_formatLink', 1, link, 'string') checkType('_formatLink', 2, display, 'string', true) link = removeInitialColon(link) local namespace = p.findNamespaceId(link, false) local colon if namespace == 6 or namespace == 14 then colon = ':' else colon = end -- Find whether a faux display value has been added with the | magic -- word. if not display then local prePipe, postPipe = link:match('^(.-)|(.*)$') link = prePipe or link display = postPipe end -- Find the display value. if not display then local page, section = link:match('^(.-)#(.*)$') if page then display = page .. ' § ' .. section end end -- Assemble the link. if display then return string.format('%s', colon, link, display) else return string.format('%s%s', colon, link) end end


-- Hatnote -- -- Produces standard hatnote text. Implements the template.


function p.hatnote(frame) local args = getArgs(frame) local s = args[1] local options = {} if not s then return p.makeWikitextError( 'no text specified', 'Template:Hatnote#Errors', args.category ) end options.extraclasses = args.extraclasses options.selfref = args.selfref return p._hatnote(s, options) end

function p._hatnote(s, options) checkType('_hatnote', 1, s, 'string') checkType('_hatnote', 2, options, 'table', true) local classes = {'hatnote'} local extraclasses = options.extraclasses local selfref = options.selfref if type(extraclasses) == 'string' then classes[#classes + 1] = extraclasses end if selfref then classes[#classes + 1] = 'selfref' end return string.format( '
%s
', table.concat(classes, ' '), s )

end

return p-------------------------------------------------------------------------------- -- Module:Hatnote -- -- -- -- This module produces hatnote links and links to related articles. It -- -- implements the and meta-templates and includes -- -- helper functions for other Lua hatnote modules. --


local libraryUtil = require('libraryUtil') local checkType = libraryUtil.checkType local mArguments -- lazily initialise Module:Arguments local yesno -- lazily initialise Module:Yesno

local p = {}


-- Helper functions


local function getArgs(frame) -- Fetches the arguments from the parent frame. Whitespace is trimmed and -- blanks are removed. mArguments = require('Module:Arguments') return mArguments.getArgs(frame, {parentOnly = true}) end

local function removeInitialColon(s) -- Removes the initial colon from a string, if present. return s:match('^:?(.*)') end

function p.findNamespaceId(link, removeColon) -- Finds the namespace id (namespace number) of a link or a pagename. This -- function will not work if the link is enclosed in double brackets. Colons -- are trimmed from the start of the link by default. To skip colon -- trimming, set the removeColon parameter to true. checkType('findNamespaceId', 1, link, 'string') checkType('findNamespaceId', 2, removeColon, 'boolean', true) if removeColon ~= false then link = removeInitialColon(link) end local namespace = link:match('^(.-):') if namespace then local nsTable = mw.site.namespaces[namespace] if nsTable then return nsTable.id end end return 0 end

function p.formatPages(...) -- Formats a list of pages using formatLink and returns it as an array. Nil -- values are not allowed. local pages = {...} local ret = {} for i, page in ipairs(pages) do ret[i] = p._formatLink(page) end return ret end

function p.formatPageTables(...) -- Takes a list of page/display tables and returns it as a list of -- formatted links. Nil values are not allowed. local pages = {...} local links = {} for i, t in ipairs(pages) do checkType('formatPageTables', i, t, 'table') local link = t[1] local display = t[2] links[i] = p._formatLink(link, display) end return links end

function p.makeWikitextError(msg, helpLink, addTrackingCategory) -- Formats an error message to be returned to wikitext. If -- addTrackingCategory is not false after being returned from -- Module:Yesno, and if we are not on a talk page, a tracking category -- is added. checkType('makeWikitextError', 1, msg, 'string') checkType('makeWikitextError', 2, helpLink, 'string', true) yesno = require('Module:Yesno') local title = mw.title.getCurrentTitle() -- Make the help link text. local helpText if helpLink then helpText = ' (help)' else helpText = end -- Make the category text. local category if not title.isTalkPage and yesno(addTrackingCategory) ~= false then category = 'Hatnote templates with errors' category = string.format( '%s:%s', mw.site.namespaces[14].name, category ) else category = end return string.format( '%s', msg, helpText, category ) end


-- Format link -- -- Makes a wikilink from the given link and display values. Links are escaped -- with colons if necessary, and links to sections are detected and displayed -- with " § " as a separator rather than the standard MediaWiki "#". Used in -- the template.


function p.formatLink(frame) local args = getArgs(frame) local link = args[1] local display = args[2] if not link then return p.makeWikitextError( 'no link specified', 'Template:Format hatnote link#Errors', args.category ) end return p._formatLink(link, display) end

function p._formatLink(link, display) -- Find whether we need to use the colon trick or not. We need to use the -- colon trick for categories and files, as otherwise category links -- categorise the page and file links display the file. checkType('_formatLink', 1, link, 'string') checkType('_formatLink', 2, display, 'string', true) link = removeInitialColon(link) local namespace = p.findNamespaceId(link, false) local colon if namespace == 6 or namespace == 14 then colon = ':' else colon = end -- Find whether a faux display value has been added with the | magic -- word. if not display then local prePipe, postPipe = link:match('^(.-)|(.*)$') link = prePipe or link display = postPipe end -- Find the display value. if not display then local page, section = link:match('^(.-)#(.*)$') if page then display = page .. ' § ' .. section end end -- Assemble the link. if display then return string.format('%s', colon, link, display) else return string.format('%s%s', colon, link) end end


-- Hatnote -- -- Produces standard hatnote text. Implements the template.


function p.hatnote(frame) local args = getArgs(frame) local s = args[1] local options = {} if not s then return p.makeWikitextError( 'no text specified', 'Template:Hatnote#Errors', args.category ) end options.extraclasses = args.extraclasses options.selfref = args.selfref return p._hatnote(s, options) end

function p._hatnote(s, options) checkType('_hatnote', 1, s, 'string') checkType('_hatnote', 2, options, 'table', true) local classes = {'hatnote'} local extraclasses = options.extraclasses local selfref = options.selfref if type(extraclasses) == 'string' then classes[#classes + 1] = extraclasses end if selfref then classes[#classes + 1] = 'selfref' end return string.format( '
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end

return p
  1. ^
  2. ^ a b
  3. ^
  4. ^
  5. ^
  6. ^
  7. ^ a b c d
  8. ^
  9. ^
  10. ^
  11. ^
  12. ^
  13. ^
  14. ^
  15. ^
  16. ^ Plimsoll, 2013, Ambulance Services Market Report
  17. ^ a b
  18. ^
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  20. ^
  21. ^
  22. ^
  23. ^
  24. ^ Ipsos MORI/DH Perceptions of the NHS Tracket June 2013
  25. ^
  26. ^
  27. ^
  28. ^
  29. ^
  30. ^
  31. ^ a b
  32. ^
  33. ^
  34. ^
  35. ^ BASICS website
  36. ^ Blood Bikes UK

External links

  • NHS Confederation Ambulance Service Network
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