London Ambulance Service
The London Ambulance Service (LAS) is an National Health Service trust that is responsible for answering and responding to medical emergencies within London, such as 999 emergency response and getting help to those who need it as quickly as possible.
It is one of the busiest ambulance services in the world, and the busiest in the United Kingdom, providing care to more than 8.6 million people, who live and work in London. The service is currently under the leadership of chief executive Dr Fionna Moore MBE. The service employ around 4,500 staff.
Once a 999 call has been received by the LAS Emergency Operations Centre (EOC), the service will either resolve the call over the telephone or dispatch a front line or A&E support ambulance, fast response car (FRU), motorcycle response unit (MRU), cycle response unit (CRU) or the Helicopter Emergency Medical Service (HEMS - operating a helicopter, trauma response car and physician response unit), all depending on the nature of the emergency. In exceptional cases, or where the service deems in necessary, specialist teams can be deployed from within the service, such as the Hazardous Area Response Team (HART) and Specialist Operations. These teams are specially trained and equipped to deal with incidents such as working at height or in confined spaces.
It is one of 10 ambulance trusts in England providing emergency medical services, and is part of the National Health Service, receiving direct government funding for its role. There is no charge to patients for use of the service, as every person in England has the right to the attendance of an ambulance in an emergency.
The LAS responded to over 1.8 million calls for assistance, and over 1 million incidents in 2015/16. Incidents rose by 20,000 in 2015/16, putting more pressure on the service. All 999 calls from the public are answered at the Emergency Operations Centre (EOC) in Waterloo, which then dispatches and allocates the appropriate resources. To assist, the service's command and control system is linked electronically with the equivalent system for London's Metropolitan Police. This means that police updates regarding specific jobs will be updated directly on the computer-aided dispatch (CAD) log, to be viewed by the EOC, and the resources allocated to the job.
In 1818, a Parliamentary Select Committee had recommended that provision be made for carrying infectious patients in London "which would prevent the use of coaches or sedan chairs" but nothing was done. In 1866, a Hospital Carriage Fund provided six carriages to hospitals in the metropolitan area, for the use of patients suffering from smallpox or other infectious diseases, provided that they pay for the hire of the horses. The first permanent ambulance service in London was established by the Metropolitan Asylums Board (MAB) in 1879, when a new Poor Law Act empowered them "to provide and maintain carriages suitable for the conveyance of persons suffering from any infectious disorder". The first became operational at The South Eastern Fever Hospital, Deptford, in October 1883. In all, six hospitals operated horse-drawn "land ambulances", putting almost the whole of London within three miles (five kilometres) of one of them. Each ambulance station included accommodation for a married superintendent and around 20 drivers, horse keepers and attendants, nurses, laundry staff and domestic cleaners. A fleet of four paddle steamer "river ambulances" transported smallpox patients along the River Thames to Deptford, where they could be quarantined on hospital ships, departing from three special wharves at Rotherhithe, Blackwall and Fulham. At Deptford, in order to transfer patients between the hospitals at Joyce Green and Long Reach near Gravesend, a horse-drawn ambulance tramway was constructed in 1897 and extended in 1904. In 1902, the MAB introduced a steam driven ambulance and in 1904, their first motor ambulance. The last horse-drawn ambulances were used on 14 September 1912.
Although the MAB was legally supposed to be transporting only infectious patients, it increasingly also carried accident victims and emergency medical cases. The Metropolitan Ambulance Act, 1909, empowered the London County Council to establish an emergency ambulance service, but this was not established until February 1915 and was under the control of the chief of the London Fire Brigade. Also in 1915, the MAB Ambulance Section were the first public body to employ women drivers, due to the number of men who had volunteered for military service. By July 1916 the London County Council Ambulance Corps was staffed entirely by women.
By 1930, the MAB was the largest user of civil ambulance services in the world, however the Local Government Act 1929 meant that work of the MAB was taken over by the London County Council, which also took charge of the modern fleet of 107 MAB motor ambulances, together with 46 ambulances which were run by local Poor law unions. Taken with the 21 ambulances already operated by the LCC, this provided a comprehensive service for all kinds of illness and accident, which was under the direction of the Medical Officer of Health for the County of London. The LCC also took control of the River Ambulance Service, but it was disbanded in 1932.
During World War II, the London Auxiliary Ambulance Service was operated by over 10,000 auxiliaries, mainly women, from all walks of life. They ran services from 139 Auxiliary Stations across London. A plaque at one of the last to close, Station 39 in Weymouth Mews, near Portland Place, commemorates their wartime service.
In 1948 the National Health Service Act (1946) made it a requirement for ambulances to be available for anyone who needed them. The present-day London Ambulance Service was formed in 1965 by the amalgamation of nine existing services in the new county of Greater London, and in 1974, after a reorganisation of the NHS, the LAS was transferred from the control of local government to the South West Thames Regional Health Authority. On 1 April 1996, the LAS left the control of the South West Thames Regional Health Authority and became an NHS trust.
As an NHS Trust, the LAS has a Trust Board consisting of 12 members. The board includes; a non-executive chairman, five of the Service’s executive directors (including the chief executive), and six non-executive directors.
The chief executive and Chief Ambulance Officer have responsibility for oversight of seven directorates:
- Accident and emergency (A&E)
- Finance and business
- Human resources
- Patient transport services (PTS)
Operations are directed from service headquarters in Waterloo Road which houses the Emergency Operations Centre (EOC) from a back-up control room in east London should the main control room become compromised. Special events in London are co-ordinated from the Service's event control room, also located in east London, or from the Metropolitan Police control room as appropriate.
During mass casualty incidents, the command structure works on three (or four) levels: gold, silver and bronze.
- Platinum control: government level command (COBR);
- Gold control: strategic command, located in a situation room close to the main Emergency Operations Centre (EOC) and managing not only the incident but ensuring that normal service function continues with reduced resources.
- Silver control: tactical command, from a designated point in the vicinity of the incident(s);
- Bronze control: on-site operational level organising triage for casualties.
- Advance Paramedic Practitioner (APP)
- Apprentice Paramedic (AP)
- Incident Response Officer (IRO)
- Ambulance attendant (PTS)
- Non-Emergency Transport Service (NETS)
- A&E support (No longer within the service.)
- Trainee Emergency Ambulance Crew level 1 (TEAC1) and 2 (TEAC2)
- Emergency Ambulance Crew (EAC)
- Emergency Medical Dispatcher (EMD1, EMD2, EMD3, Allocator)
- Clinical telephone advisor
- Emergency medical technician (EMT1, EMT2, EMT3, EMT4)
- Student Paramedic Year 1, 2 and 3 (SP1, SP2, SP3)
- Apprentice Paramedic Year 1, 2, 3 4 & 5 (AP1, AP2, AP3, AP4)
- Emergency Care Practitioner (ECP) (No longer within the service.)
- HEMS Paramedic
- Hazardous Area Response Team (HART) operative
Volunteers supporting the London Ambulance Service
Volunteers make up a small but significant proportion of front line ambulance staff that respond to emergency calls in London. Voluntary responders vary in skill level, but their principal purpose remains the same. That is to attend medical emergencies as quickly as possible to improve the patient's chance of survival, saving lives which may have been lost without the additional resources being available to the ambulance service. Importantly, the deployment of any voluntary responder will not replace the automatic allocation of a regular front line ambulance.
There are two principal roles for volunteers within the London Ambulance Service. These roles include:
- Emergency Responder - clinically trained volunteers who operate in marked response cars with blue lights and wear full service uniform, typically working double crewed and doing shifts of up to 10 hours day and night.
- Community responder - defibrillator trained St John Ambulance volunteers attending on call from their homes and responding to 999 calls in their own car without blue lights alongside ambulances.
London Ambulance Service volunteers are supported by a charity called London Ambulance Service Voluntary Responder Group (registered charity no.1061191), providing logistical and financial assistance to keep volunteers operational. The London Ambulance Service can also call upon auxiliary aid from external voluntary organisations such as St John Ambulance and the British Red Cross, as demonstrated on 7/7.
The LAS operates around 450 emergency ambulances. In addition it can deploy around 100 rapid-response units in various cars, motorcycles, or bicycles. Although not a part of the LAS, London's Air Ambulance can also be deployed by, and for, the LAS from its base at the Royal London Hospital in Whitechapel using either its ground RRVs or its helicopter.
As well as accidents and emergencies, the LAS operates a 195-vehicle patient transport service (PTS). Previously a centrally funded service, this element of the LAS is now subject to an open market and is required to tender for work from primary care trusts (PCTs) and other NHS bodies. As well as being contracted by a number of London hospitals and PCTs to take patients to and from their pre-arranged hospital or clinic appointments, the PTS responds to ad-hoc journey requests and provides specialist transfer facilities.
Mercedes Sprinter ambulances are used as the primary ambulance, while Skoda Octavia and Vauxhall Zafira cars are used as Rapid Response Vehicles (RRV). Motorcycle responders are equipped with the Honda ST1300. Cycle responders, who operate in areas such as the City of London, the West End and Heathrow Airport, use custom built Rockhopper mountain bikes manufactured by Specialized Bicycle Components.
The LAS plays a significant role whenever an incident causes mass casualties in London. Examples include:
- 7 July 2005 suicide attacks: Four suicide bombings across London. Voluntary aid services needed to assist the LAS due to scale of the attacks.
- Paddington train crash: Two trains collided a short distance outside of Paddington station, killing 31 people
- Cannon Street rail crash: Two people were killed and over 500 injured
- Marchioness disaster: A pleasure boat, Marchioness, was in collision with a dredger; 51 people died
- Clapham Junction train crash: 35 people were killed and 69 seriously injured
- King's Cross fire: 31 people died in a major fire in the Underground station
- Moorgate tube crash: the train driver and 42 passengers were killed
- Provisional IRA bombing campaign: a list of these and other bombings in London to which the LAS responded can be found here.
Due to an increase in demand, the LAS has used private ambulance companies, including some charities, to provide additional everyday operational cover. This is largely to ensure set response targets are met and so that the level of resources available to the service stays at a safe level. The future of private ambulances within the LAS is unclear. IN March 2014 operational difficulties were reported at Hillingdon Hospital because the private ambulances did not appear on the A&E hospital alert system.
Difficulties and criticisms
In 2000, the LAS faced funding difficulties and an increase in the volume of 999 calls, and it was criticised for poor performance in its response times. The service was sued for negligence in the case of Kent v Griffiths. The chief executive at the time, Michael Honey, left his post after talks with other members of LAS management.
In 2010 the service lost its funding for the emergency care practitioner (ECP) role and existing ECPs were told they must change to a different role within the service, or leave.
A fire in the basement of its Waterloo base in October 2010 caused the LAS to relocate the EOC to the back-up control room in east London due to an interruption to the building's power supply. The service took the step of urging the public to find other means of transport to hospital for anyone suffering non-life-threatening injuries.
In September 2014 the trust announced that it would reduce the number of category C calls (the least serious) which receive an ambulance response by 15%. These calls will be triaged by a call handler and either referred to NHS 111 or given telephone advice by a paramedic. In 2014 only 64 per cent of category A patients were reached within eight minutes and it is hoped that by this measure there will be an improved response to the most urgent calls. It has also implemented a system of “Intelligent conveyancing” where ambulances avoiding hospitals that are known to be under pressure. This has reduced the average waiting time for handover from ambulance to hospital staff by 180 seconds, though the average journey time has increased by 27 seconds.
In December 2014 it asked other ambulance services for help after its busiest ever week with 11,008 call outs for the most seriously ill and injured. Demand is up 15% on the same time last year. Help has only been requested previously in respect of events like the Olympics or the 2005 bombings. The service has more than 400 vacancies and has had problems recruiting people. It is failing to reach its response targets. In 2014/5 the Trust recruited 175 paramedics from Australia.
The trust was placed into special measures following a report by the Care Quality Commission in November 2015 which rated it "inadequate" overall and raised "significant concerns" about its performance. 54 inspectors visited 16 ambulance stations and emergency operation centres in June. Criticisms focussed on:
- a "culture of harassment and bullying" and a perception that "discrimination" was not dealt with. Verbal and physical abuse, ostracisation, sexual harassment, misuse of power and cyber-bullying had been featured in an earlier independent report
- long working hours, with high levels of stress and fatigue reported by a large number of "demoralised" frontline staff
- response times which had deteriorated since March 2014 with a consistent failure to meet the national benchmark of 75% of patients with life-threatening conditions receiving treatment within eight minutes
- many frontline vacancies, and insufficient appropriately trained paramedics to ensure patients were consistently safe and received good care
- lack of necessary equipment
- insufficient understanding of the challenges staff experienced by senior managers and board members
- insufficient supervision for newly qualified paramedics from senior colleagues
- Failure to review major incident procedures, which are supposed to be reviewed annually,or to ensure all staff were aware of them
Concerns were raised in internal LAS documents over the performance of radios and communication equipment used in the emergency operations after the 7/7 attacks. Again, the sheer volume of emergency calls received made radio communications difficult and put pressure on staff in the ambulance control room. Staff were also hampered in their use of mobile phones as the mobile phone networks were temporarily brought down during the day. In July 2009 the new radio system recommended after the bombings was rolled out.
Despite the changes after 7/7, the LAS was criticised in 2010 for failures to provide fully working radios to its frontline staff. Health and safety inspections found that some radios failed during heavy rain and staff sometimes had to do without. Crews also raised concerns that the panic buttons on their radios did not work properly.
In 1974, the LAS commissioned a computer-aided despatch system that remained unused for 13 years because union members refused to operate it. A replacement system failed acceptance tests in 1990 and a further replacement system was designed and ordered. On 26 October 1992 the LAS started to use the new computer-assisted dispatch (CAD) system, known as LASCAD. Poorly designed and implemented, its introduction led to significant delays in the assigning of ambulances, with anecdotal reports of 11-hour waits. A subsequent enquiry found no evidence to support union claims that up to 30 people may have died as a result of the crash. The crash coincided with hundreds of control room exceptions messages related to alerts that crews responding to emergencies had not reported mobile, and the ambulance had not moved 50 metres within 3 minutes of despatch. The then-chief executive, John Wilby, resigned shortly afterwards. This failure is often cited in case studies of poor engineering management.
During its implementation it developed technical problems and was replaced by a pen-and-paper method for several hours until a decision was taken to revert to the previous system, CTAK, in the early hours of 9 June. It was later announced that a review of the difficulties experienced would be undertaken.
A second attempt at implementing CommandPoint took place on 28 March 2012. The trust was considering terminating its contract with Northrop Grumman if the re-attempt to go live with the new system failed. Despite a drop in response times to "Category A" (life-threatening) emergency calls in the period immediately after implementation, which coincided with above average demand, the LAS stated that “The new system is now familiar to all control room staff and demand has returned to more or less predicted levels, with a corresponding increase in performance”.
On the morning of 1 January 2017, one of the busiest nights of the year due to new year celebrations, a system failure impacted the system for several hours. Between 00:30 and 05:15 control room staff had to fall back on pen and paper methods. Response times were further impacted by the concurrent failure of the web based tracking system and of automated satellite navigation systems for ambulance crews. This required location details to be passed by radio and then manually entered into satellite navigation systems in vehicles. The ambulance service stated that an investigation would be launched to establish the reasons for the system failure.
In April 2015 the Trust asked its commissioners for £27m extra funding to help it recruit more staff and buy new vehicles.
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