Emergency medical services in the United Kingdom

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One of London Ambulance Service's frontline vehicles LJ58OJX LONDON AMBULANCE QUEEN VICTORIA STREET CITY OF LONDON (26124592264).jpg
One of London Ambulance Service's frontline vehicles

The London Air Ambulance in action London's Air Ambulance Helicopter at Tower Bridge.jpg
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 immigration or visitor status. [1]

Contents

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).

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, 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.

Most air ambulance services in the UK are not part of the NHS and are funded through charitable donations. Paramedics are usually seconded from a local NHS ambulance service.

Role of the ambulance services

A paramedic's motorcycle in Birmingham Motorcycle paramedic London Ambulance Service.jpg
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:

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 increasingly 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 last St John Division, (the original designation of a local unit, now called 'branches'), to be so contracted is reputed to have been at Whittlesey in Cambridgeshire, where the two-bay ambulance garage can still be seen at the branch headquarters. 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 National Health Service Reorganisation Act 1973 from local authority to central government control in 1974, and consolidated into 53 services under 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 into 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 into 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 provider 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

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. On the 14 November 2018 West Midlands Ambulance Service became the UK's first university-ambulance trust. [8]

Scotland

The service was operated before reorganisation in 1974 by the St Andrews’ Ambulance Association under contract to the Secretary of State for Scotland. [5] 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 Airbus Helicopters H145 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

The Northern Ireland Ambulance Service (NIAS) was established in 1995 by order in council, [11] and serves the whole of Northern Ireland. To date universities in Northern Ireland do not facilitate Paramedic Science (BSc) degree meaning members must complete their degree either in England, Wales or Scotland.

Wales

The Welsh Ambulance Service NHS Trust (Welsh: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:

YearEmergency callsSource
1994/52.61 million [7]
2004/55.62 million [7]
2006/76.3 million [13]
2012/39.08 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, voluntary and charity 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:

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 in 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. [15] This use of private contractors for frontline services has been politically controversial, [22] [23] although 56% of the British public believe that greater private sector involvement will help maintain or improve standards in the NHS. [24]

In 2013, the Care Quality Commission found 97% of private ambulance services to be providing good care. [17] These private, registered services are represented by the Independent Ambulance Association. In 2017 the Commission warned all independent ambulance providers that during its inspections it had found “problems with the safety” of the care offered. 70 independent ambulance providers had been inspected and improvement notices had been issued to 25 out of 39 whose reports had been published. Plymouth Central Ambulance Service and Intrim Medical and Rescue Services were closed down after very poor practice was found. [25]

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

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] These have however run into difficulties due to use of vehicles not legally recognised as ambulances. [32]

The British Association for Immediate Care (BASICS) has numerous medical staff (including doctors, nurses and paramedics) who volunteer their time to respond to serious medical emergencies. (see below: Supporting services)

A brand new charity air ambulance, touching down at its launch event for Essex & Herts Air Ambulance EHAAT AW169.jpg
A brand new charity air ambulance, touching down at its launch event for Essex & Herts Air Ambulance

Charity air ambulances

Most UK emergency air ambulances are funded by charitable organisations, with medical staff usually seconded from the local NHS trust. The only exceptions are in Scotland & Wales. The Scottish Ambulance Service provides funding for two helicopters and two fixed wing aircraft. The Welsh Assembly Government fully funds the clinical and road components of the Emergency Medical Retrieval and Transfer (EMRTS) Cymru service, with aviation (HEMS capability) provided in partnership with the Wales Air Ambulance Charity. There is an additional helicopter, Scotland's Charity Air Ambulance, which is funded by charitable donations only.

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. [33] 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. [33]

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', [34] after the consultancy used to formulate them, the New Ambulance Performance Standards (NAPS) were developed in the 1990s, and merged into the Clinical Quality Indicators used subsequently. New targets were established in July 2017. See NHS ambulance services.

The benchmarked targets include: [2]

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 into four main categories (in ascending skill order):

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%. [37]

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. [38] BASICS doctors, nurses or paramedics may assist NHS paramedics at the scenes of serious accidents or be on-hand at major sporting events. All professionals volunteer their time, but doctors must have undergone additional training to support their working-environment.

Blood Bikes

A blood bike operated by Freewheelers EVS FJR1300 emergency blood.jpg
A blood bike operated by Freewheelers EVS

Across the British Isles, a network of volunteer Blood Bikes charity groups provide motorcycle courier services for blood, tissue and organs which require transport to, or between, hospitals. Some are equipped with blue lights and sirens which can be used when transporting urgent blood or human tissue for transplant. Groups are largely independent, and operate in collaboration with their local healthcare providers. Many are represented through the Nationwide Association of Blood Bikes (NABB). [39]

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

General:

Related Research Articles

London Ambulance Service

The London Ambulance Service is an NHS trust responsible for operating ambulances and answering and responding to urgent and emergency medical situations within the London region of England. The service responds to 999 and 111 phone calls, providing triage and advice to enable an appropriate level of response.

Scottish Ambulance Service Special health board providing Scotlands public ambulance services

The Scottish Ambulance Service is part of NHS Scotland, which serves all of Scotland's population., The Scottish Ambulance Service is governed by a special health board and is funded directly by the Health and Social Care Directorates of the Scottish Government.

Welsh Ambulance Service

The Welsh Ambulance Service, formally the Welsh Ambulance Services NHS Trust, is the national ambulance service for Wales and one of the three NHS trusts in the country. It was established on 1 April 1998 and has 2,576 staff providing ambulance and related services to the 3.1 million residents of Wales.

NHS ambulance services trusts are organisations which provide ambulance services within the English National Health Service.

NHS Scotland government agency in City of Edinburgh, Scotland, UK

NHS Scotland, sometimes styled NHSScotland, is the publicly funded healthcare system in Scotland. It operates 14 territorial NHS Boards across Scotland, seven special non-geographic health boards and NHS Health Scotland.

South East Coast Ambulance Service

The South East Coast Ambulance Service NHS Foundation Trust is the NHS Ambulance Services Trust for south-eastern England, covering Kent, Surrey, West Sussex and East Sussex. It also covers a part of north-eastern Hampshire around Aldershot, Farnborough, Fleet and Yateley. The service was made an NHS foundation trust on 1 March 2011.

North West Ambulance Service

The North West Ambulance Service NHS Trust (NWAS) is the ambulance service for North West England. It is one of 10 Ambulance Trusts providing England with Emergency medical services, and is part of the National Health Service, receiving direct government funding for its role.

South Western Ambulance Service

The South Western Ambulance Service NHS Foundation Trust (SWASFT) is the organisation responsible for providing ambulance services for the National Health Service (NHS) across South West England. On 1 March 2011, SWASFT was the first ambulance service in the country to become a foundation trust. The trust acquired neighbouring Great Western Ambulance Service on 1 February 2013.

Yorkshire Ambulance Service

Yorkshire Ambulance Service (YAS) is the NHS ambulance service covering most of Yorkshire in England. It was formed on 1 July 2006 following the mergers of the former West Yorkshire Metropolitan Ambulance Service (WYMAS), South Yorkshire Ambulance Service (SYAS) and Tees, East and North Yorkshire Ambulance Service (TENYAS). It is one of ten NHS Ambulance Trusts providing England with emergency medical services, free at the point of care and as part of the National Health Service it receives direct government funding for its role.

South Central Ambulance Service

South Central Ambulance Service NHS Foundation Trust (SCAS) is the ambulance service for the counties of Buckinghamshire, Oxfordshire, Berkshire and Hampshire. It is a foundation trust of the National Health Service, and one of 10 NHS ambulance trusts in England.

East of England Ambulance Service

The East of England Ambulance Service is an NHS trust responsible for providing National Health Service (NHS) ambulance services in the counties of Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk, in the East of England region. These consist of 5.8 million people and 7,500 square miles.

Great Western Ambulance Service Former NHS emergency services trust.

The Great Western Ambulance Service NHS Trust (GWAS) was a National Health Service (NHS) trust which provided emergency and non-emergency patient transport services to Bath and North East Somerset, Bristol, Gloucestershire, North Somerset, Swindon and Wiltshire, in the south west of England. It was formed on 1 April 2006 by the merger of the Avon, Gloucestershire and Wiltshire ambulance services. The ambulance service was acquired by neighbouring Foundation Trust South Western Ambulance Service (SWASFT) on 1 February 2013.

North East Ambulance Service

North East Ambulance Service NHS Foundation Trust (NEAS) is the authority responsible for providing NHS ambulance services in North East England, covering the counties of County Durham, Northumberland and Tyne and Wear and the area of the former county of Cleveland in North Yorkshire. The trust was formed on 1 July 2006, following the merger of the existing North East Ambulance Service and the Tees division of the Tees, East and North Yorkshire Ambulance Service (TENYAS). Northumbria Ambulance Service and County Durham Ambulance Service had previously merged on 1 April 1999.

West Midlands Ambulance Service

The West Midlands Ambulance Service University NHS Foundation Trust (WMAS) is the second-largest ambulance service, and the first university ambulance trust in the UK. It is the authority responsible for providing NHS ambulance services within the West Midlands region of England. The trust won the contract for non-emergency patient transport services in Cheshire, Warrington and Wirral previously provided by the North West Ambulance Service in 2015. It transferred in July 2016. The trust is currently under the leadership of chief executive Dr Anthony Marsh and chair Sir Graham Medlum . It is one of 10 Ambulance Trusts providing England with Emergency medical services, and is part of the National Health Service. There is no charge to patients for use of the service.

Emergency medical personnel in the United Kingdom

Emergency medical personnel in the United Kingdom are people engaged in the provision of emergency medical services and this includes paramedics, emergency medical technicians and emergency care assistants. 'Paramedic' is a protected title, strictly regulated by the Health and Care Professions Council, although there is tendency for the public to use this term when referring to any member of ambulance staff.

National Health Service Ambulance Services provide free at the point of use emergency medical care to any person requiring treatment, regardless of immigration or visitor status, within the United Kingdom. These services are provided by National Health Services of England, Scotland, Wales and Northern Ireland. The current system comprises 14 NHS organisations: 11 NHS Trusts cover the separate regions of England and; individual nationwide services cover Scotland, Wales and Northern Ireland respectively.

Health care in the United Kingdom

Health care in the United Kingdom is a devolved matter, with England, Northern Ireland, Scotland and Wales each having their own systems of publicly funded healthcare, funded by and accountable to separate governments and parliaments, together with smaller private sector and voluntary provision. As a result of each country having different policies and priorities, a variety of differences now exist between these systems.

Healthcare in Britain is mainly provided by England's public health service, the National Health Service, that provides healthcare to all permanent residents of the United Kingdom that is free at the point of use and paid for from general taxation. Since health is a devolved matter, there are differences with the provisions for healthcare elsewhere in the United Kingdom. Though the public system dominates healthcare provision in Britain, private health care and a wide variety of alternative and complementary treatments are available for those willing to pay.

East Midlands Ambulance Service

East Midlands Ambulance Service National Health Service (NHS) Trust (EMAS) provides emergency 999, urgent care and patient transport services for the 4.8 million people within the East Midlands region of the UK - covering Nottinghamshire, Derbyshire, Leicestershire, Rutland, Lincolnshire and Northamptonshire.

NHS Pathways

NHS Pathways is a triage software utilised by the National Health Service of the United Kingdom to triage public telephone calls for medical care and emergency medical services - such as 999 or 111 calls - in some NHS trusts and five of the ambulance services in the country. In its emergency capacity, it has replaced the Advanced Medical Priority Dispatch System for some trusts, and in non-emergency telephone triage it is found in many medical care triage systems, such as NHS 111.

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