Winter pressures and the NHS Ambulance Services: ‘Doing more with less’ is not an option

ambulances queuing outside A&E at a North West hospital

Paresh Wankhade, Professor of Leadership and Management and Emergency Services Management Expert discusses the issues the Ambulance Service faces as winter approaches in his latest Comment blog:

With each passing year, the winter crisis puts a massive strain on the NHS ambulance resources with huge bottlenecks in the transfer of patients into the hospital Accident and Emergency (A&E) wards. In 2017, media carried several reports which highlighted delays on the part of ambulance crews arriving at the scene, including deaths of the patient waiting for an ambulance. Some of these arguments have been well rehearsed and have also prompted emotional debates and the cries of “52 weeks of the year crisis” in the Parliament.  I have highlighted four issues which in my view are the key flash points for ambulance services to deal with such recurrent crisis.

Address the funding-demand gap

The sustainability of an underfunded and overstretched ambulance services is though well recognised, but remains unresolved. The National Audit Office reported that between 2009-10 and 2015-16, the number of ambulance calls and NHS 111 transfers increased from 7.9 million to 10.7 million (average year-on-year increase of 5.2 per cent), and income for NHS ambulance trusts’ urgent and emergency care activity increased by 16 per cent from £1.53bn to £1.78bn between 2011-12 and 2015-16, but ambulance activity over this period (NHS ambulance calls and NHS 111 transfers) rose by a massive 30 per cent. This is accompanied by significant shifts in the demand with only 10 per cent of 999 callers having a life threatening emergency despite the average annual increase of five to six per cent in ambulance demand.  Doing even ‘same with less’ is proving difficult for ambulance trusts, something I have argued in my recent piece.


Move away from response time targets

Response time targets have been historically used to measure ambulance performance. Since July 2017, performance of NHS ambulance trusts is being benchmarked against four new national standards, based upon patient’s condition, now enshrined in the NHS Constitution.  However, during May-September 2018, ambulance services in England failed to meet  all the standards. A recent Parliamentary Report concluded that ‘ambulance trusts have organised themselves to meet response-time targets, at the expense of providing the most appropriate response for patients’ (p.5).  Another view that ‘commissioners, regulators and providers still place too much focus on meeting response times” reported in the National Audit Report (p.8) is deeply worrying.

Our research points to similar conclusions. We have systematically documented a range of unintended consequences  of response time targets used by the ambulance services.  We have also explored the relationship between cultures, performance measures, and organisational change to understand how organisational culture is perpetuated and found the targets to be a significant factor impeding the process of change. Ambulance services have embarked on the drive for ‘professionalisation’ but our latest research suggests that as ambulance work continues to intensify, ‘issues around dignity, staff retention and the meaning of work are becoming ever more challenging’.


Introduce fines/penalty for hospital delays

Ambulance handover delays to hospital A&E departments can have serious implications for patient safety and reduce available ambulance resources. The 30 minute cycle (handover and readiness for next call) is proving difficult to resolve. NAO  figures suggest that in 2015-16, only 58 per cent of hospital transfers met the 15-minute expectation in 58 per cent of cases as against 80 per cent in 2010-11, and only 65 per cent of ambulance crews were then ready for another call within 15 minutes. There are inconsistencies on the part of commissioners to penalise hospitals that do not adhere to the guidance of 15-minute transfers in absence of a fining regime. A quality indicator for measuring hospital performance in meeting the transfer-time target has not yet materialised, notwithstanding the recommendations of the Committee of Public Accounts.

Improve efficiency and productivity

The Carter Efficiency Review, published last month, highlighted concerns about huge variations in the delivery of ambulance services. It suggested potential savings of £300m a year by cutting unnecessary ambulance transfers, along with further £200m through use of more efficient models of operations and procurement.  But the review also raised fundamental questions over the need for significant investment in the ambulance sector. The shortage and retention  of paramedic staff coupled with high sickness absence rates continue to be a problem, an issue highlighted in the draft NHS Workforce Strategy. However, the review raises the clear need for investment since one of the recommendations to reduce high conveyance rates is likely to have cost implications. This will also require high quality staff engagement.



There are no easy fixes and addressing the winter pressures will necessitate strong and visionary leadership by ambulance chiefs and cooperation from other health care partners, in a political climate dominated by Brexit. A ‘whole systems’ approach is crucial to deal with this crisis. The Dalton Review called for successful leaders to act as a ‘systems architect’ to use their entrepreneur skills to explore innovative organisational models, as set out under the NHS Five Year Forward View. The Carter Review necessitates ambulance leaders to make right business and spending decisions which will impact the NHS. Devising an effective public education campaign to minimise misuse of ambulance resources and managing public expectation, will be a good starting point.

Sore throats and false nails – the ambulance call-outs that cost millions

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Brian A Jackson/Shutterstock

Keegan Clay Shepard, Edge Hill University

Ambulance call-outs are increasing, resulting in services operating under enormous, and probably unsustainable, pressure. While most calls do need an emergency response, far too many don’t. A study of 300 consecutive emergency ambulance arrivals to an accident and emergency (A&E) department in London, England, found that only 54% of the patients legitimately needed an ambulance.

The tabloid press are fond of reporting daft ambulance call-outs, like one to revive a dead pigeon, and another to see if McDonald’s had run out of chicken nuggets. Funny though they are, these kinds of calls put a strain on services and take paramedics away from emergencies that are genuinely life threatening.

These calls can also be truly disheartening for paramedics who see themselves as health professionals who are there to treat people and save lives. Research has found this to be a common concern among paramedics who are obliged to respond to patients no matter how silly they perceive the call to be. In my ongoing study of the perceptions of patient safety in three English ambulance service NHS trusts, an emergency operations centre supervisor told me of her frustration:

I have questioned one drunken man’s request for an ambulance because he had a sore throat, and this is when there were 23 calls waiting to get through, and I was angry about that.

Her anger at situations like these is both understandable and common, with one paramedic involved in my study discussing his concern for other patients with legitimate emergencies, when having to respond to calls they find to be ridiculous:

You laugh, but when I started I got a call-out to a girl because of false nails. She’d been playing with her boyfriend, bent her nail, bent back and the nail come off … And while I’m dealing with that, there could be a cardiac arrest somewhere, someone could be stuck under a lorry.

Not an emergency. CRM/

As well as tying up resources that could be used to treat genuine medical emergencies and increasing the waiting times at A&E departments, these calls can be expensive for the ambulance services. In the UK, each call costs about £7, £180 if an ambulance is sent to treat a patient and £233 if the patient is brought to the emergency department. Given that a significant portion of calls are seen as not requiring an emergency response, this can add up to millions of pounds every year.

24/7 culture

Although the rise in the rate of demand for ambulance services, at 6.5% each year, is relatively recent in the UK, inappropriate call-outs have been documented in research going back at least two decades. One study proposed a couple of reasons why patients phone the emergency services for conditions that could be treated in primary care, including difficulty getting a GP appointment and a perception that they will be treated more quickly.

The high number of inappropriate calls could also be attributed to a 24/7 culture, where people expect immediate treatment for any condition, no matter the severity. A paramedic in my study considered it to be a generational problem, with millennials making the most of these calls:

It’s a great generation, but young people today don’t understand what the services are for, and we didn’t have this problem as bad some decades ago. They will call us for just about anything.

Public awareness

With demand projected to increase in coming years, it is clear that the ambulance services need to address the issue of inappropriate call-outs soon. Many things can be done to lessen the pressures of demand and to allocate the resources of the ambulance services more efficiently. However, to reduce the number of silly call-outs, it’s clear that public perception of what the ambulance service is for, needs to change.

Awareness could be spread through educational campaigns, using social media to reach the patients online, such as South Central Ambulance Service’s 999 Misuse Costs Lives campaign, which informed patients of when it’s appropriate to dial 999 and when it’s appropriate to use a different service, such as a GP clinic.

The ConversationAlthough changing people’s expectations is essential, a more holistic approach will also be necessary – one that gives patients appropriate access to alternative care settings, such as their GP or walk-in centres. Until this is done, some people will continue to rely on the ambulance service to treat minor ailments.

Keegan Clay Shepard, PhD Student and Graduate Teaching Assistant, Edge Hill University

This article was originally published on The Conversation. Read the original article.

How to reboot Britain’s fractured emergency services

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Professor Paresh Wankhade, Edge Hill University

The Grenfell Tower fire and recent terrorist attacks in Manchester and London have put the spotlight on spending cuts for emergency services.

In Manchester, an independent review into the emergency response was ordered in the aftermath of the bombing to look into the “the strain of spending cuts” on police. The city mayor is also investigating the fire service after crews were apparentley “held back” from helping the victims.

Whatever the outcome of these investigations – and others like them – I believe the problems go far beyond staff numbers and resources. The only way forward is to engage in a full system “reboot” to get better results.

The problems are legion. For starters, the emergency services are far too fragmented. There are huge differences across the emergency services when it comes to size, funding and organisational structures with no overarching body for coordination.

Disconnected ministerial oversight also creates uneven and localised outcomes in performance. And the government’s approach to the problem is vague and unclear. The Policing and Crime Act 2017 has brought important changes to the governance of the police and fire and rescue services – but ambulance services remain independent of these provisions. It places a duty on police, fire and ambulance services to work together which currently remains undefined.

Ambulance demand is growing at an annual rate of about 5.2%. Managing such levels of demand and maintaining the quality of patient care is unsustainable and it is no secret that ambulance services across the country are struggling to meet their performance targets. The police are witnessing a reduction in recorded crime but are increasingly dealing with cases relating to cybercrime, child and sexual exploitation and mental illness. Meanwhile fire services have seen a massive reduction in fire call-outs. But these organisations continue to be performance-managed and target-driven – and current models of service delivery do not reflect these changes.

The focus for the emergency services remains on performance metrics and stringent target regimes. Alongside this is the influence that staff associations and unions have on determining the scale and pace of reforms. Workforce issues such as stress remain largely neglected and recruitment and retention of black, Muslim and ethnic minorities (BME) continues to be a challenge.

Issues around Post-Traumatic Stress Disorder (PTSD) and other illness – which are common among emergency workers – are not being fully addressed and ambulance staff sickness is highest within the NHS. Media reports also increasingly highlight cases of harassment and bullying within the emergency services.

There are no easy fixes for all these problems but emergency services do need a “road map” to help them navigate the shifting political landscape and the changes to training and performance regimes. Here are five ways to improve the emergency services and better equip them for the future.

Leadership reform

There needs to be a move from isolated chiefs calling all the shots to a more collaborative culture. This is because front-line staff and managers should have confidence in their own leadership and decision-making skills while dealing with other 999 services during major incidents and during interactions with the public.

Promote collaboration

A top-down bureaucratic approach to force the merger of police and fire services is unlikely to work and should be abandoned if it proves costly and does not bring results. Proposals for merger and reorganisation of the fire services need to be reconsidered, along with the feasibility of a national or regionally organised police force like in Scotland.
Further reforms should allow pooling organisational and management oversight.

Similarly, the role of the ambulance services within the emergency architecture should be spelt out more clearly, since they derive their funding from the National Health Service budget. They work more as the emergency arm of the health services rather than the health arm of the emergency services.

Adapt to changing demands

There is a clear need to understand how usage is changing – and to support staff to respond to new challenges. This will help to improve workforce motivation and reduce the cost of ill health by building a “resilient” organisational culture.

Academic partnerships

Developing partnerships with academia will be useful in building modern and professional organisations and to further improve the research base in the “Blue Light” services.

New management skills

Addressing staff morale and retention and setting performance criteria that make sense will be central to improving the services. The obsession with a target-chasing culture should give way to broader sets of measures to reflect the new challenges and changing organisational realities. We need a new set of collaborative leadership and management skills to inspire a shared purpose across a network of organisations to respond quickly to current and future problems.

The ConversationThis is an important moment for the emergency services. The steady rise in the 999 demand along with shrinking budgets are seen by many as two of the key challenges which are unlikely to go away in the near future. There is an urgent need to restart Britain’s limping emergency services and bring about real “transformational” change. But it requires determination, imagination and leadership – or the 999 services will be facing their own emergency situation.

Professor Paresh Wankhade, Professor of Leadership and Management with expertise in emergency service management, Edge Hill University

This article was originally published on The Conversation. Read the original article.

In the future your ambulance could be driverless

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Driver not required. Gervasio S. _ Eureka_89/Shutterstock

Keegan Shepard, Edge Hill University

The revolution in driverless vehicles will make many jobs obsolete. In the US alone, it is estimated that driverless vehicles will wipe out 4.1m jobs. Truck drivers, delivery drivers, taxi drivers and Uber drivers will be out of work, and sooner than you might think. But automation can be a force for good, doing jobs more cheaply, safely and efficiently. In fact, there’s one service that’s crying out for more automation: the ambulance service.

Demand for ambulance services is growing rapidly in developed countries due to a combination of a growing and ageing population, an increase of chronic diseases, and a scarcity of primary care clinics and providers. This leaves the emergency services overburdened, with a dismal outlook for the future.

With driverless vehicles already on the road, some governments are looking into the possibility of driverless ambulances. Driverless ambulances and other technology could take some of the strain off the emergency services, freeing paramedics to deal with high-risk patients where each minute waiting for treatment significantly reduces a patient’s chance of surviving. This would include cardiac arrest patients, where brain damage typically starts within four to six minutes.

Initially, health services could introduce a fleet of driverless ambulances alongside their current manned models to deal with low-risk patients – essentially starting out as “medical taxis”. Low-risk patients would be picked up by a driverless ambulance and transported to the nearest hospital or clinic for treatment. With the introduction of these ambulances, the need for paramedics to respond to every call – regardless of severity – would be greatly reduced.

However, not everyone is in favour of automated ambulances. One survey of just over 1,000 people in the US found that around half said they would be comfortable riding in one.

Supported by drones

As well as delivering Amazon packages, spying on neighbours and conducting military strikes, drones could also be used by health services to take the pressure off the ambulance service. They would be especially useful for delivering medical equipment to remote locations. In fact, a start-up called Zipline is already successfully delivering blood and medicine across Rwanda. But these services could also be used in developed countries. For example, if a doctor in a remote rural location has to treat a patient with a rare condition, but she lacks the necessary medical supplies at her GP clinic or local hospital, a drone could deliver the supplies. Alternatively, drones could be used to deliver vital medical equipment to a drop point prior to the manned ambulance’s arrival. This would allow the patient to be treated as soon as the paramedics arrive.

Drones could also be used to transport specialised equipment, medication or even blood products between hospitals. This would reduce the need for ambulances to drive further distances to find somewhere that can treat their patient.

Drones could be used to drop essential medical supplies in remote or hard to reach areas. gualtiero boffi/Shutterstock

Predicting emergencies

For several years, police forces around the world have been using sophisticated algorithms to predict areas where crime is most likely to occur. This allows police departments to deploy officers to areas of “high demand”. While these Minority Report-style systems have proven to be controversial, a similar system that predicts illness hotspots is less likely to raise eyebrows.

A similar system could be used by ambulance services. It would collect previous trip data from the ambulances (both manned and unmanned). The software would take into consideration the time of year, weather, public events (such as concerts and protests), populations (such as elderly or deprived) and past emergencies that ambulances have responded to. This would enable the driverless ambulances to locate themselves within high-risk areas when they are not in use, allowing them to respond much faster to calls.

As these systems log more and more information, they will become increasingly more accurate at predicting medical emergencies, in the same way that data mining tools, used by social media and advertising companies, get better at figuring out what food, clothes, movies and so on you like best, and what you might like in the future.

The ConversationThese new methods may seem far off, but depending on how fast healthcare systems invest and adopt these technologies, they could be changing the way we receive medical treatment within decades. In the face of ever rising demand, technology is likely to be the saviour of ambulance services, making it faster, more effective and safer. However, it may take a while before the public are comfortable with the idea.

Keegan Shepard, PhD Candidate, Edge Hill University

This article was originally published on The Conversation. Read the original article.

Increasing Ambulance Demand: Need for a Strong Leadership and Positive Culture

The growing pressure on the NHS ambulance services as a result of increased ambulance demand has been a subject of media attention in the recent weeks. This is also accompanied by a growing academic interest in the examination and exploration of work intensification in prehospital care settings. Staff retention and staff recruitment is proving to be difficult and the shortage of paramedic staff is becoming a national problem.

Ambulance services are witnessing a period of turbulence. Amidst the progress on the professionalisation of the paramedic agenda, individual trusts are facing challenges in form of staff attitudes towards meeting performance targets, coupled with rising demand, fear of loss of contracts and private competition. Historically and in the new commissioning framework, performance (and payment) of individual ambulance trusts is still guided by the achievement of the eight-minute response time target. This has implications for patient safety, high sickness absence rates amidst increasing ambulance demand.

It doesn’t come with much surprise that the recent inspections reports from the Care Quality Commission (CQC) have highlighted some of the issues discussed above. The latest report for the North West Ambulance Services NHS Trust published last week reported regional variation in the culture across the trust:

“Staff in some areas felt very positive about the culture, but in other areas, they felt that there was a high degree of pressure and the focus was on performance targets rather than care for patients (p. 39).”

The report also highlighted staff vacancies across all areas of urgent and emergency care services and the overall vacancy rare was 5.7%. (p.3)

The increasing pressure to meet performance targets was also picked up in the CQC inspection report for the South East Coast Ambulance Service NHS Trust in September 2016:

“However, many staff reported a culture of bullying and harassment. Much of these reports stemmed from style of contact and lack of support during sickness…Staff also attributed the bullying and harassment culture to the organisation drive towards attaining performance targets. In particular the pressure placed on middle and junior managers, many of whom have not had developmental support to deliver their role”(p.31).

The CQC report highlighted a culture of operating in a crisis by ‘ fire-fighting’ and a lack of step down process and medium and long term planning led to a lack of sustainable change.

The CQC inspection report for the London Ambulance Service NHS Trust in November 2015 while giving the Service a ‘good’ rating for its care of patients, highlighted a number of areas of concern and judges the Service to be ‘inadequate’ overall and recommended to place the Service into special measures. It reported (p.2) that the trust was operating with a shortage of trained paramedics in the light of a national shortage and due to paramedics leaving its service for a number of reasons including better pay elsewhere.  Paramedics from Australia and New Zealand were recruited to address the shortage. The report expressed significant concerns about a reported culture of bullying and harassment in parts of the trust:

“Bullying and harassment was a major concern for the organisation. Several frontline ambulance staff perceived that they were bullied by managers; and an independent, external review into bullying and harassment in the organisation found that the problem was widespread.” (p.5).

It’s worth mentioning here that in the latest inspection by CQC, it has been reported4 that the trust has focused on bullying and harassment with workshops, and holding conversations instead of resorting to formal processes (p.3). Issues of bullying and harassment could be reported via ‘pulse’, an internal website staff could access, and there was a telephone line to report any incidents of this nature (p.20).  The bullying and harassment policy had been revised, relaunched and is now called ‘dignity at work’.

While these initiatives need to be welcomed, issue raised above have significant management and leadership implications for devising appropriate employment practices across the ambulance trusts. It raises questions about whether it is possible and sustainable to motivate staff and/or retain and recruit new ambulance staff while moderating these negative influences. Development of strategies to prevent significant levels of sickness and occupational health issues, to combat prevalence of general and specific ambulance specific stress factors needs immediate policy and management attention.

Concerns over patient safety in NHS ambulance services are growing

Keegan Shepard, Edge Hill University

Even with all the wonders that modern medicine has to offer, it is clear that patients remain at significant risk while receiving care. And no more so than when in the care of the ambulance service.

Patient safety has been a principle in healthcare ever since the 1950s but has been of worldwide attention after the Institute of Medicine released the report “To err is human: building a safer health system” in 1999. This report prompted a great deal of concern after it highlighted that 44,000 to 98,000 patients died each year due to medical error in the US. These threats to patient safety are present in Britain’s NHS as well. In 2013, the Francis Report concluded that an estimated 400 to 1,200 patients of the Stafford Hospital died due to poor quality of care.

While most research on patient safety has been done on hospitals, major concerns exist in the NHS ambulance services, where quick responses to emergency situations are key.

The NHS ambulance services have seen a rapid growth in the number of 999 calls in England over recent years. From 2014 to 2015, they recorded a 6.1% increase from 8.49m to 9m calls, averaging 24,661 calls received every day. The Department of Health released a report detailing how the 999 demand for ambulance services is increasing at a higher rate than the growth in demand for other emergency and urgent-care settings, as well as faster than the growth in population.

An increase in demand has also led to an increase in waiting times. In November, a total of 2,955 patients had to wait over 12 hours to be either admitted, transferred or discharged following their arrival at A&E, a 22% increase from a year ago. The steep rise in demand against a backdrop of budgetary cuts and paramedic shortages presents serious concerns to the safety of patients using these services.

An increase in demand has led to an increase in waiting times. Robert Kneschke/

Staggering rise in patient safety incidents

The National Reporting and Learning System (NRLS) has been collecting data on patient safety incidents in the NHS since 2003. A patient safety incident is defined as “any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS care”. In the ambulance services, the number of reported patient safety incidents in England rose by 4,132 between July 2009 and June 2010, and by 10,375 between July 2014 and June 2015.

In only five years, the annual rate of patient safety incidents has more than doubled. Over the same period, all care settings in the NHS in England also saw a rise of patient safety incidents from 1.1m to 1.7m. To put this into perspective, the rate of reported patient safety incidents rose by 151% in the ambulance services, while the NHS as a whole experienced a more modest growth of 51%. The sheer level of the recent growth of incidents reported by ambulance services compared with other care settings or the NHS as a whole is very troubling.

Some research indicates that the ambulance services are less prone to reporting incidents than other care settings in the NHS. This suggests that more patient safety incidents are occurring in the ambulance services than are being reported. Even if the data from the NRLS is under-reporting the scale of the problem, it’s clear that this staggering rise in incidents does not appear to be slowing down. In all likelihood, patient safety incidents may continue to grow at a faster rate due to the increased demand and other pressures.

In addition to the number of incidents, the NRLS also details the level of severity of reported patient safety incidents, ranging from no harm to death. About 30% of the incidents in the ambulance services from October 2014 to September 2015 caused harm to a patient while receiving NHS care. If the demand continues to rise, an increase in the risks for patient safety incidents is also likely.

It has been almost 18 years since the release of the Institute of Medicine’s To err is human, and four years since the Francis Inquiry. Reports like these act as reminders of the grave consequences of low quality of care, and they put pressure on the services to improve. It is hoped that future research can identify the causes of incidents as well as develop strategies to make care safer for the patients. It is clear that NHS ambulance services have a long way to go.The Conversation

Keegan Shepard, PhD Student and Graduate Teaching Assistant, Edge Hill University

This article was originally published on The Conversation. Read the original article.

Emergency services collaboration: role and future of the ambulance services?


Collaboration between emergency services is neither novel nor new. Many emergency services are already working with each other and other public bodies to provide better services while improving efficiencies. It was however argued that the present levels of coordination and collaboration are uneven and not as well developed as they might be. In September 2015, the UK Government published the consultation document ‘Enabling closer working between the Emergency Services’ aimed at promoting better coordination of emergency services in England. Early this year, the responsibility for fire and rescue policy was transferred to the Home Office from the Department of Communities and Local Government (DCLG). The Government also published its response to the consultation in January 2016. The Summary of consultation responses and next steps sets out legislative proposals to:

  • introduce a high level duty to collaborate on all three emergency services, to improve efficiency or effectiveness;
  • enable Police and Crime Commissioners (PCCs) to take on the functions of fire and rescue authorities (FRAs), where a local case is made;
  • where a PCC takes on the responsibilities of their local FRA, further enabling him or her to create a single employer for police and fire personnel;
  • in areas where a PCC has not become responsible for fire and rescue services, enabling them to have representation on their local FRA with voting rights, where the local FRA agrees; and
  • abolish the London Fire and Emergency Planning Authority and give the Mayor of London direct responsibility for the fire and rescue service in London.

The latest consultation response assumes both the desirability of PCCs taking over the leadership of fire services and the ‘single employer’ form of merger to promote greater efficiencies. Arguments for and against the proposals to bring together the fire and police services under the remit of PCCs have been well rehearsed in the media. The consultation response does not specify the exact nature of collaboration between the ambulance services and the police and fire services. Other than suggesting a legal duty to collaborate, the role and responsibility of the NHS ambulance trusts in determining their legal duty remains unclear and has not attracted much attention and scrutiny.

The Association of Ambulance Chief Executives (AACE) has welcomed the intention of the Government backing to keep ambulance services as part of the NHS, while reaffirming its support for closer collaboration and more innovative blue light working between the three emergency services. The Keogh Review and the NHS Five Year Forward View also acknowledge the role and contribution of the ambulance services to the Government’s urgent and emergency care strategy. This view was also echoed by several speakers at the recent Ambulance Leadership Forum 2016.

Whether ambulance services see their future as part of NHS or whether there is a drive to integrate-fully or partially with other emergency services, there will always be the need for two functions currently provided by the ambulance services namely, (i) a means of supported transport of patients in the community to services provided in health care facilities and (ii) responsive, professional, timely outreaching emergency diagnosis and management service. These are the core of current ambulance services and will be the core of any future service(s). What is likely to change is the means of delivery and the professionals that delivers the service. Technology will enable better remote triage; increasingly skilled practitioners will use better decision support mechanisms to deliver more sophisticated heath care.

There is however a significant change in the profile for demand for the ambulance services as compared to the police and fire services. The overall attendance of fire services incidents has shown a decline of more than 40% over the last decade. Recorded crimes (other than fraud) are showing a downward trajectory since its peak in 2003-04. But ambulance demand has shown a steady increase of almost 10% over the last five years. Ambulance services are also no more the sole employer(s) of the paramedics, many of whom now work outside the NHS ambulance settings such as the GP surgeries, out-of-care facilities and with private ambulance providers. With a shortage of paramedic staff, managing such levels of demand and quality of patient care is clearly unstainable and it is no secret that ambulance services across the country are struggling to cope up with increased activity and meet their performance targets.

This is a changeable moment for the ambulance services. Steady rise in 999 demand and shrinking budgets are seen by many as two of the key challenges which are unlikely to go away in the near future. While their position within the blue-light architecture is still being decided, it presents opportunities for exploring new innovative organisational forms and management structures to bring about real reforms and transformational change. There has never been a greater need for an open and honest conversation between the ambulance leaders, policy makers and other stakeholders to debate the role and future of the ambulance services we all love and care about.