NHS ambulance services

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 ambulance services trusts cover the separate regions of England and; individual nationwide services cover Scotland, Wales and Northern Ireland respectively.

As with other emergency services, the public normally access emergency medical services through one of the valid emergency telephone numbers (either 999 or 112). Additionally, some ambulance services are considering trialing a 999 video calling service, in order to be able to visually assess patients whilst crews are en route.[1]

The work of ambulance services included responsibility for patient transport, but in England this is now often covered by separate contractual arrangements, and often delivered by private providers.

History

The National Health Service Act 1946 gave county (and county borough) councils in England and Wales a statutory responsibility to provide an emergency ambulance service, although they could contract a voluntary ambulance service to provide this.

In 1977/78 ambulance services in the UK cost about £138m. At that time about 90% of the work was transporting patients to and from hospitals.

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 in England and Wales 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.[2]

In Northern Ireland the service was the responsibility of the Northern Ireland Hospitals Authority before 1974, and was then transferred to the four health and social services boards.

Under the provisions of the National Health Service and Community Care Act 1990 England was covered by 31 ambulance trusts, which were structured as below. In July 2006 the number of ambulance service trusts was reduced to thirteen.

Ambulance service	Metropolitan and non-metropolitan counties covered
Avon	Bath and North East Somerset, Bristol, North Somerset, South Gloucestershire
Bedfordshire and Hertfordshire	Bedfordshire, Hertfordshire, Luton
Coventry and Warwickshire	Coventry, Warwickshire
Cumbria	Cumbria
Dorset	Bournemouth, Dorset, Poole
East Anglian	Cambridgeshire, Norfolk, Peterborough, Suffolk
East Midlands	Derby, Derbyshire, Leicester, Leicestershire, Nottingham, Nottinghamshire, Rutland
Essex	Essex, Southend-on-Sea, Thurrock
Gloucestershire	Gloucestershire
Greater Manchester	Greater Manchester
Hampshire	Hampshire, Portsmouth, Southampton
Hereford and Worcester	Herefordshire, Worcestershire
Isle of Wight	Isle of Wight
Kent	Kent, Medway
Lancashire	Blackpool, Blackburn with Darwen, Lancashire
Lincolnshire	Lincolnshire, North Lincolnshire, North East Lincolnshire
London	Greater London
Mersey	Merseyside, Cheshire, Halton, Warrington
North East	Darlington, County Durham, Northumberland, Tyne and Wear
Oxfordshire	Oxfordshire
Royal Berkshire	Berkshire
South Yorkshire	South Yorkshire
Staffordshire	Staffordshire, Stoke-on-Trent
Surrey	Surrey
Sussex	Brighton and Hove, East Sussex, West Sussex
Tees, East and North Yorkshire	East Riding of Yorkshire, Kingston upon Hull, Hartlepool, Middlesbrough, Redcar and Cleveland, Stockton-on-Tees, North Yorkshire (excl. Craven), York
Two Shires	Buckinghamshire, Milton Keynes, Northamptonshire
West Midlands	Shropshire, Telford and Wrekin, West Midlands less Coventry
West Yorkshire Metropolitan	West Yorkshire, Craven district of North Yorkshire
Westcountry	Cornwall, Devon, Plymouth, Somerset, Torbay
Wiltshire	Wiltshire, Swindon

Current ambulance services

There are currently 14 NHS organisations (ambulance services trusts in England) which provide ambulance services across the UK, which are listed below:

Ambulance service	Region served	Population served	Established
England
East Midlands	Derbyshire, Leicestershire, Rutland, Lincolnshire (including North and North East Lincolnshire), Northamptonshire and Nottinghamshire	4.8 million	1999
East of England	Norfolk, Bedfordshire, Cambridgeshire, Essex, Hertfordshire and Suffolk	5.8 million	1 July 2006
Isle of Wight	Isle of Wight	139,800	April 2012
London	Greater London and City of London	8.6 million	1965
North East	Northumberland, Tyne and Wear, County Durham and Cleveland	2.6 million	1 July 2006
North West	Greater Manchester, Cheshire, Merseyside, Cumbria and Lancashire	7.1 million
South Central	Berkshire, Buckinghamshire, Hampshire and Oxfordshire	4 million
South East Coast	East Sussex, West Sussex, Kent, Surrey, and North Eastern Hampshire (Rushmoor and eastern parts of Hart)	4.75 million
South Western	Bristol, Bath and North East Somerset, Cornwall, Devon, Dorset, Gloucestershire, North Somerset, the Isles of Scilly, Somerset, South Gloucestershire and Wiltshire	5.47 million
West Midlands	Shropshire, Herefordshire, Worcestershire, Staffordshire, Warwickshire, Coventry, Birmingham and Black Country	5.6 million
Yorkshire	East Riding of Yorkshire, North Yorkshire, South Yorkshire and West Yorkshire	5 million
Northern Ireland
Northern Ireland	Antrim, Armagh, Down, Fermanagh, Londonderry, Tyrone	1.8 million	1 April 1995
Scotland
Scotland	East Ayrshire, North Ayrshire, South Ayrshire, Scottish Borders, Dumfries and Galloway, Fife, Clackmannanshire, Falkirk, Stirling, Aberdeenshire, City of Aberdeen, Moray, City of Glasgow, East Dunbartonshire, East Renfrewshire, Inverclyde, Renfrewshire, West Dunbartonshire, Argyll and Bute, Highland, North Lanarkshire, South Lanarkshire, City of Edinburgh, East Lothian, Midlothian, West Lothian, Orkney Islands, Shetland Islands, Angus, City of Dundee, Perth and Kinross and Outer Hebrides	over 5 million	1 April 1995
Wales
Wales	Blaenau Gwent, Bridgend, Caerphilly, Cardiff, Carmarthenshire, Ceredigion, Conwy, Denbighshire, Flintshire, Gwynedd, Merthyr Tydfil, Monmouthshire, Neath Port Talbot, Newport, Pembrokeshire, Powys, Rhondda Cynon Taf, Swansea, Torfaen, Vale of Glamorgan, Wrexham, Ynys Môn	around 3.1 million	1 April 1998

England

Subcontracting

In 2019 the Care Quality Commission reported that ambulance services were relying on private providers because of lack of capacity. Some firms had failed to obtain references or carry out criminal record checks and a lack of staff training was leading to serious patient harm. More than £92 million was spent in 2018/9 on private ambulances and taxis.[3]

Targets

NHS England sets targets for response times to 999 calls, which were first established in the 1970s. Call handlers were, until 2017, given just 60 seconds to decide on the urgency of the call. The clock stopped once a vehicle reached the patient - even if it was not the appropriate vehicle.

Category A (Red 1 and Red 2) were classed as life-threatening and the national standard sets out that a vehicle should reach the scene within eight minutes for 75% of these calls . Red 1 calls are for patients who have suffered cardiac arrest or stopped breathing and require two vehicles. If onward transport is required a suitable vehicle should arrive on the scene within 19 minutes. The number of these rose from 2.5 million in 2011/12 to just under 3.4 million in 2015/16, but response times fell steadily and the 75% target was not met after 2013.[4] Green 1 required a vehicle within 20 minutes, Green 2 within 30 minutes. Green 3 required telephone assessment within 20 minutes and Green 4 telephone assessment within 60 minutes. These targets are only recommended.[5]

In July 2017 a new set of performance targets for the ambulance service were announced after a trial across four different ambulance trusts, looking at more than 1 million patients overseen by Sheffield University.[6] These are to apply to all 999 calls for the first time. Call handlers will be given four minutes to assess the urgency of the call before the clock starts. The target for the most seriously ill patients is now seven minutes. The ‘clock’ stops when the most appropriate response, not necessarily the first, arrives. There are condition-specific measures which will track time from 999 call to hospital treatment for heart attacks and strokes. 90% of eligible heart attack patients should receive definitive treatment (balloon inflation during angioplasty at a specialist heart attack centre) within 150 minutes by 2022. 90% of stroke patients should also receive appropriate management (thrombolysis for those who require it, and first CT scan for all other stroke patients) within 180 minutes of making a 999 call.[7] For other emergencies the target is for 90% to be seen in 40 minutes. Urgent or non-urgent calls should expect an average response time of 120 and 180 minutes respectively. Extensive trials have shown that fewer patients are classed as life-threatening and fewer vehicles are dispatched, but responses for the most urgent calls improved.[8]

Trusts asked for more resources to meet these targets, in particular the standards for the top 90% of responses. Taking patients to the “right” hospital rather than the nearest, leads to longer journeys. They were supported by a benchmarking exercise undertaken by the National Audit Office.[9]

In July 2018 eight of the ten services in England missed the seven-minute target. A review conducted by Lord Carter of Coles found that the rate of sickness of ambulance staff was the highest in the NHS - 20 days per person. Use of information technology was advancing very slowly. 25% of ambulances, of which there were 32 different types, were more than seven years old. There were large differences in costs and performance between the different trusts, some of which were attributable to local geography and the performance of other parts of the NHS.[10] Responses to the most urgent calls averaged 11 minutes in rural areas in 2018 but 7 minutes in urban areas. The worst waits were around Wells-next-the-Sea.[11]

Funding and activity

Between 2011-12 and 2015-16 ambulance activity in England rose by 30%. Funding only increased by 16%.[12] In May 2018 several trusts told commissioners that they needed to spend many millions on extra staff and ambulances if they were to meet the response time targets.[13]

Information technology

In November 2018 NHS Digital launched the National Record Locator Service which gives ambulance staff access to patient records of mental health trusts, initially for the North West, North East, Yorkshire and London Ambulance Services. It is planned to roll it out across England and to include other records.[14]

See also

• Category:NHS ambulance services trusts

References

1. Whitehead, Dan (10 May 2018). "Medics to assess 999 callers by video before ambulance sent". Sky News.
2. "Royal Commission on the National Health Service". Socialist Health Association. HMSO. Retrieved 12 June 2015.
3. "Patients 'at risk' as NHS spends £92m on private ambulances and taxis". Independent. 27 August 2019. Retrieved 2 October 2019.
4. "Ambulance response times". Quality Watch. November 2016. Retrieved 15 July 2017.
5. "Ambulance response categories explained". North East Ambulance Service. Retrieved 15 July 2017.
6. "Jeremy Hunt signs off changes to 'dysfunctional' ambulance targets". Health Service Journal. 13 July 2017. Retrieved 23 August 2017.
7. "New ambulance service standards announced". NHS England. 13 July 2017. Retrieved 15 July 2017.
8. "Fewer ambulance 999 calls to be classed as 'life-threatening'". BBC News. 13 July 2017. Retrieved 15 July 2017.
9. "Ambulance trusts demand millions to meet new targets". Health Service Journal. 4 May 2018. Retrieved 13 August 2018.
10. "Ambulances not an A&E taxi service, NHS warned". BBC. 27 September 2018. Retrieved 27 September 2018.
11. "Critically injured? The longest waits for 999 help". BBC. 6 March 2019. Retrieved 15 April 2019.
12. "'Model ambulance' to be created to achieve Carter savings". Health Service Journal. 20 June 2017. Retrieved 15 July 2017.
13. "Ambulance trusts demand millions to meet new targets". Health Service Journal. 4 May 2018. Retrieved 26 June 2018.
14. "New National Locator Service links paramedics to shared care record". Digital Health. 28 November 2018. Retrieved 29 November 2018.