Memorandum by the Ambulance Service Association
(FRS 56)
1. ABOUT THE
AMBULANCE SERVICE
ASSOCIATION
1.1 The Ambulance Service Association is
the representative body for the 33 NHS Ambulance Trusts in England,
Wales and Northern Ireland. Its members also include the public
ambulance services in the Channel Islands, the Isle of Man and
Gibraltar which use the same training and clinical guidelines
as, but are not part of, the NHS.
2. THE NHS AMBULANCE
SERVICE IN
CONTEXT
2.1 The ambulance service is the emergency
arm of the NHS. Its partnerships are increasingly with colleagues
from the health service complementing its relationships with the
other blue light emergency services. The traditional role of the
ambulance service is changing to one it which an increasing proportion
of its work is in primary care as set out in the Department of
Health report Taking Healthcare to the Patient published in June
2005.
2.2 The NHS ambulance services in the UK
employ about 38,000 staff, of whom approximately 30,000 are ambulance
clinicians holding posts as paramedics, emergency medical technicians
or ambulance care assistants. Across the UK, the NHS Ambulance
Service receives over six million 999 calls each year, of which
five million result in an emergency response with about four million
patients being transported to hospital. The service also responds
to about one million urgent calls each year made by GPs who making
home visits determine that their patient require urgent admission
to hospital. The third element of the service provides about 16
million non-emergency journeys for patients with transport or
mobility difficulties to attend out-patient departments. Figures
published by the Department of Health show that the service in
England cost about £1.25 billion to run in 2004-05.
2.3 The service has seen a sustained growth
in demand over a period of more than 10 years. The number of 999
calls received has more than doubled over the last decade, though
more effective assessment and increased levels of clinical skill
has meant that the growth in the numbers of emergency responses
and patients transported, while still substantial, has grown at
a slower rate.
Table 1
AMBULANCE SERVICE 999 DEMAND IN ENGLAND 1994-95
to 2004-05
| 1994-95 (million)
| 2004-05 (million) | percentage increase
|
| 999 calls received | 2.61 |
5.62 | 115 |
| 999 responses | 2.61 | 4.53
| 74 |
| Patients transported | 2.27
| 3.47 | 53 |
| | |
|
Source: Ambulance Services, England: 2004-05. DH 2005.
2.4 The NHS Ambulance Service has made, and will continue,
a journey of rapid modernisation in recent years. The traditional
role of the service of transporting patients to treatment has
been replaced by one in which increasingly skilled clinicians
are able to administer treatment at the scene of an incident or
on route, dramatically enhancing patient outcomes and experiences
and increasingly removing the need to take patients with less
serious conditions to hospital. Further changes, announced in
the Department of Health Report Taking Healthcare to the Patient,
are expected to reduce the number of patients transported to hospital
by a further one million per annum. At the time the service will
be making an increasing contribution to primary care assisting
patients with long-term conditions to manage their health at home
or within their local communities.
2.5 To increase the chances of survival from immediately
life-threatening conditions such as cardiac arrest, the ambulance
service prioritises calls aiming to respond to the most urgent
within eight minutes. The Department of Health has set a national
standard for the eight minute response to be achieved in 75% of
cases. Such calls are currently running at about 34,000 each week,
equivalent to about 1.75 million annually. In the year to date
the 75% standard has been met across the country. One of the tools
used to achieve this level of performance has been the recruitment
and training of local first- and co-responders who may be able
to get immediate life support to patients faster than the closest
available ambulance. Individuals participating in responder schemes
include members of the public as well as members of the other
emergency services, particularly retained firefighters, or the
armed services.
3. WORKING WITH
THE FIRE
AND RESCUE
SERVICE
3.1 The level of joint working between the Ambulance
and Fire services varies across the country but is generally very
good. In some locations premises are shared for historic reasons
and the Committee will be aware that Gloucestershire and Wiltshire
recent initiatives have created joint headquarters (also shared
with the police service) and other shared services.
3.2 Operationally contact is far less frequent. The vast
majority of incidents attended by the ambulance services are purely
clinical. Although there is a joint response to serious road traffic
accidents, fires, chemical incidents, entrapments and major emergencies,
these calls, although resource intensive and likely to result
in more casualties, represent only about 2% of the incidents responded
to by ambulance services.
4. SHARED CALL
AND CONTROL
CENTRES
4.1 In recent years there have been proposals for shared
call and control centres to handle all 999 calls received by the
emergency services. The ASA believes there may be circumstances
in which shared buildings bring benefits but it strongly believes
that the volume and specialist nature of emergency medical calls
make them inappropriate for dealing with by multi-service call
takers, once the initial filter has been made by the BT operator,
or dispatchers.
4.2 Ambulance call takers undertake patient assessments
to determine the degree of urgency that should be given to each
call, collect key medical information for passing to the responding
ambulance clinician and often provide life-saving advice on resuscitation
or management of injuries to the caller whilst the responder is
travelling to scene.
4.3 The current proposals to create regional fire control
centres, together with the likely rationalisation of ambulance
controls once ambulance reconfiguration has been completed, make
it less likely that shared controls would be an effective option
in the future.
5. COMMUNICATION SYSTEMS
5.1 The NHS is in the process of implementing a new digital
radio network for use by NHS ambulance services in England, Scotland
and Wales. The system has been procured from O2 Airwave. The first
ambulance services should be using the new network by late 2006
with coverage across the country by 2008. A requirement of the
contract is interoperable communication between the fire, police
and ambulance services. The ambulance service foresees limited
use of this facility under normal working conditions but welcomes
its availability for use at major incidents and special circumstances.
5.2 To ensure capability and resilience in the interim,
the ambulance service is pleased that a satellite system, which
will be managed by the police service, has been made available.
6. FIRE-FIGHTERS
AS CO
-RESPONDERS
6.1 As recorded under paragraph 2, the ambulance service
relies on first- and co-responders for support in areas and at
times when resources are poorly located to get a responder able
to offer resuscitation quickly to a patient with a life-threatening
condition in which seconds may mean the difference between life
and death.
6.2 The ambulance service is keen to work with the fire
service to provide fire-fighters with the skills and equipment
to fulfil these roles. At the time of the Bain Review into the
future of the fire service there were proposals that fire-fighters
should be trained as paramedics. The ASA argued at the time that
this was misguided as it would involve lengthy and costly training
to provide skills that would be rarely used. Furthermore firefighters
qualified as paramedics would find it very difficult to undertake
the volume of clinical activity necessary to retain the skill
levels required by the Health Professions Council, which is a
legal requirement to practice as paramedic in the UK.
6.3 However there is a strong case, that wherever practical
and subject to the wishes of the local fire and ambulance services,
firefighters should be trained to administer CPR, operate a defibrillator
and administer other basic life support skills to sustain life
until ambulance clinicians arrive at the scene. The use of these
skills can either be used in situations where the fire service
is first-on-scene, eg at a road traffic accident, or in a situation
where the firefighter(s) is dispatched to a medical emergency
by the ambulance service because their response time will be less
than the closest available ambulance resource.
6.4 These arrangements are already in place in a number
of areas, particularly using retained fire-fighters. There are
a range of issues that need to be addressed if these arrangements
are to become adopted more widely. These include:
Funding for training, equipment and deployment
Provision of initial, and refresher, training and equipment
can be costly. National protocols need to be agreed on how the
funding is provided. Differing arrangement currently apply to
meeting the costs of deployment. Ideally they should be standardised.
Clinical governance and audit
The NHS operates to strict standards of clinical governance
to ensure that the highest standards of service and safety are
given to all patients at all times. All healthcare professionals
have to abide by these standards and they should also be met by
those who provide the service on a delegated basis.
Criminal Records Bureau checks
Concerns about the dangers to vulnerable patients have led
to the requirement for all ambulance clinicians to have up-to-date
CRB checks. These are required by individuals from the community
acting as lay first-responders and should also be made on fire-fighters
acting as co-responders. ASA understands that most firefighters
are not CRB-checked by their employers as matter of course.
7. EMERGENCY PREPAREDNESS
7.1 The ambulance service has an emerging role in providing
leadership and co-ordination for the NHS in health emergency situations.
7.2 The NHS ambulance service and fire and rescue services
have worked together over many years to ensure an effective response
to civil emergencies. Under the Civil Contingencies Act 2004 they
are both category one responders and are required to work together,
and with other designated responders, to ensure that they are
fully prepared to deal with incidents such as major accidents,
natural disasters and terrorist attacks.
7.3 At senior level the services meet through the auspices
of the Cabinet Office Civil Contingency Secretariat which holds
regular meetings for the ASA, CFOA and ACPO. The three associations
also hold bi- and tri-lateral meetings as the need arises.
7.4 Joint training at all levels of command is now undertaken
regularly, for example Gold/Silver Command courses run by the
Police National CBRN Centre at Winterbourne Gunner, to which both
ambulance and fire service staff are seconded as specialist advisers
and trainers.
7.5 At the local and regional level, joint training is
organised in both table-top and mock incident exercises. The services
also meet regularly through the local and regional resilience
forums set up by the Government Offices for the Regions. Bi-lateral
meeting are also held to discuss issues of mutual concern.
8. DECONTAMINATION
8.1 The NHS, through the ambulance service, has operational
lead for the decontamination of people as a result of CBRN or
hazmat incidents. NHS ambulance services each have the equipment
and staff trained, to manage this process for a reasonable number
of people. The maximum that can be dealt with by ambulance services
will depend on the circumstances of each incident. Where the requirement
for decontamination is beyond the capacity of the ambulance service,
the mass decontamination units provided to the fire service under
the New Dimensions Programme will be used under the direction
of the ambulance service. Non-ambulant casualties would continue
to be decontaminated by the ambulance service.
8.2 The ambulance service does not have responsibility
for routine decontamination of other emergency workers, unless
those workers are injured or fall sick, during the either the
response or recovery phase of an incident. Generally the ambulance
service would withdraw from the scene of an incident once all
casualties have been attended to, but limited facilities would
remain available in case of incidents to those involved in recovery.
8.3 The Department of Health and the ODPM are currently
updating the Memorandum of Understanding which governs the arrangements
for decontamination of casualties.
9. WORKING IN
THE "HOT
ZONE" AT
CBRN INCIDENTS
9.1 Until now NHS policy has been that clinical staff,
including ambulance personnel, do not enter the hot zone to assist
with either treatment or recovery of casualties. The fire and
rescue service has had responsibility for recovery of casualties
to a place of relative safety at which staff can offer medical
aid. Experience from exercises and evidence from overseas has
suggested that more casualties would survive at major incidents
if ambulance staff are available within the hot zone to help identify
those whose rescue is of the greatest clinical urgency, and where
appropriate administer treatment to casualties. Procedures to
enable this to policy to be introduced are being developed jointly
by the Department of Health, the ASA and other stakeholders with
a view to trialling the procedure in London later this year.
10. RECONFIGURATION OF
AMBULANCE TRUSTS
10.1 The Committee will be aware that there are currently
more fire services than ambulance services, with co-terminosity
in only a minority of services. The NHS ambulance service in England
is currently being re-configured with the Government's preferred
option of 11 services, one in each of the Government Office Regions
except for south-east and south-west each of which has two, out
to consultation at present. The new ambulance services are likely
to become operational from mid-2006. If the proposals are implemented
only the fire services in London and Northern Ireland will be
co-terminus with ambulance trusts.
10.2 There will, therefore, be issues later this year
involving the development of new relationships between the services
at senior management level, though it is hoped that at the county
and sub-regional level most of the staff from the ambulance service
with whom fire service staff work would remain unchanged.
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