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.
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).
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.
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, with the exception of Great North Air Ambulance Service who employ their own paramedics. Doctors are provided by their home hospital and spend no more than 40% of their time with an air ambulance service.
Public ambulance services across the UK are required by law to respond to four types of requests for care, 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, although these contracts are increasingly fulfilled by private and voluntary providers.
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.
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, 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, 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.
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.
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.
The service was operated before reorganisation in 1974 by the St Andrews’ Ambulance Association under contract to the Secretary of State for Scotland. 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.
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.
The Northern Ireland Ambulance Service (NIAS) was established in 1995 by order in council, 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.
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.
The ambulance services across England have been increasingly busy, with a significant increase in calls in the last two decades, as shown in the table below:
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.
There is a large market for private and voluntary ambulance services, with the sector being worth £800m to the UK economy in 2012. 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.
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. 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 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, 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. 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. 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. This use of private contractors for frontline services has been politically controversial, although 56% of the British public believe that greater private sector involvement will help maintain or improve standards in the NHS.
In 2013, the Care Quality Commission found 97% of private ambulance services to be providing good care. 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.
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.
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.
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.  These have however run into difficulties due to use of vehicles not legally recognised as ambulances.
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)
All 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 2 helicopters and 2 fixed wing aircraft and 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.
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.
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. 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.
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.
The performance of every NHS ambulance provider is measured and benchmarked by the government. Commonly called 'ORCON', 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:
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.
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%.
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.
The British Association for Immediate Care coordinates voluntary schemes, and individual medical and allied health professionals, providing immediate care throughout the UK. 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.
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).
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.
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.
ASHICE is one of several mnemonic acronyms used by emergency medical services in the United Kingdom and the Republic of Ireland to pass summarised advance details of a patient to the next group of persons or organisation dealing with them (others include ATMIST and CASMEET). In the English and Welsh NHSs the procedure is not used for non-critical patients on their eventual journey to hospital but is used as standard procedure for handovers of patients before transport to hospital where a site or event is staffed by trained personnel of both paid or voluntary ambulance services. This procedure is in addition to written records of the patient's personal and medical details and any treatment or medication applied prior to transport to hospital.
The word is treated as a noun by personnel (whether first aiders, community first responders or paramedics) who might refer to e.g. 'passing an ASHICE'. The purpose of an ASHICE message is to enable persons involved in the next stage of treatment to make an advance determination of the appropriate personnel and facilities to deal with a patient and the degree of urgency to be applied.Air ambulances in the United Kingdom
Air ambulance services in the United Kingdom are provided by a mixture of organisations, operating either helicopters or fixed-wing aircraft to respond to medical emergencies, and transport patients to, from, or between points of definitive care. These air ambulances fulfil both emergency medical services functions, as well as patient transport between specialist centres, or as part of a repatriation operation.Children's Air Ambulance
The Children's Air Ambulance is an air ambulance charity that transfers critically ill children from local hospitals to specialist paediatric centres throughout Great Britain. It also moves specialist teams and equipment to local hospitals when a child is too sick to travel. The service also sometimes acts as a patient transport service, returning children and families home after treatment. It was founded in 2005 and has been run by The Air Ambulance Service charity since 2011. More than 400 missions have been performed since the service began. The number of missions is anticipated to rise to more than 600 per year with the launch of the new helicopters.College of Paramedics
The College of Paramedics is the recognised professional body for paramedics in the United Kingdom. The role of the College is to promote and develop the paramedic profession across England, Scotland, Wales and Northern Ireland.
The College represents the paramedic profession across key organisations such as the UK regulator - Health and Care Professions Council (HCPC), the Department of Health and the Joint Royal Colleges Ambulance Liaison Committee (JRCALC).Community first responder
A Community First Responder (CFR), is a person available to be dispatched by an ambulance control centre to attend medical emergencies in their local area. They can be members of the public, who have received basic training in life-saving interventions such as defibrillation, off duty ambulance staff, or professionals from a non-medical discipline who may be nearby or attending emergencies, such as firefighters or security officers. Community first responders are found in the emergency healthcare systems of the United Kingdom, the United States, Ireland, Israel, Italy (soccorritori), Australia, Singapore and Romania.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 (except Glossop, Hadfield and Tintwistle), Leicestershire, Rutland, Lincolnshire (including North and North East Lincolnshire) and Northamptonshire.Emergency Care Practitioner
An Emergency Care Practitioner (ECP) generally come from a background in paramedicine and most have additional academic qualifications, usually at university, with enhanced skills in medical assessment and extra clinical skills over and above those of a standard paramedic, qualified nurse or other ambulance crew such as EMT's and Ambulance Technicians. It has been recommended by the College of Paramedics that ECPs be trained to PgDip or MSc level, although not all are. Evidence of the best way to target Emergency Care Practitioners is limited with utilisation of traditional Ambulance dispatch codes not always being shown to be most effective and referrals from GPs also potentially failing to deliver management of demand that would be appropriate for this different level of practitioner. Evidence however clearly demonstrates that in discreet groups of patients the use of these extended role staff responding to emergency calls can reduce admissions and thus improve patient outcomes as well as delivering a clear cost saving to the NHS.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.
Emergency medical personnel most often work in an ambulance alongside another member of staff. Typically, an ambulance will be crewed by either a paramedic with another crew member (technician or emergency care assistant), two technicians or a technician with an emergency support worker. No NHS ambulance trust in the country currently offers a paramedic on every ambulance.
The majority of emergency medical personnel are employed by the public ambulance services of the National Health Service, although many are also employed by private ambulance companies and the two voluntary aid societies (British Red Cross and St. John Ambulance), either providing private services such as event medical cover, or providing support to the NHS ambulance services under contract.As part of a cost-saving exercise NHS is in the process of phasing out the ambulance technician/emergency medical technician (Band 4 on the Agenda for Change) role from the services and replacing it with the Emergency Care Support Worker or Emergency Care Assistant roles (Band 3 on the A4C), and most services are no longer training staff at technician level.HICESC
Hertfordshire Intensive Care & Emergency Simulation Centre (HICESC) is an advanced teaching facility based at the University of Hertfordshire. At its creation in 1998, it was an inter-Faculty practical laboratory hosted by the Department of Electronic, Communication and Electrical Engineering (ECEE) for access by medical engineering students and jointly established by the Department of Nursing and Paramedic Sciences, Faculty of Health and Human Sciences for use by their students.
The development of this centre has heavily been influenced by a project grant received from the British Heart Foundation, which effectively started in 2000 with the appointment of a "BHF project co-ordinator" and finished in 2003. The project conducted was to investigate the effectiveness of scenario-based simulation training with undergraduate nursing students using Objective Structured Clinical Examinations (OSCE).Hazardous Area Response Team
The hazardous area response team (HART) is an NHS ambulance service initiative devoted to providing medical care to patients in the "hot zone" of hazardous environments.
Teams are activated and sent to various incidents, such as CBRNe, hazmat, collapsed buildings, patients at height or in confined space, water rescue, and flooding, firearms incidents and explosions.
HART teams are made up of emergency medical personnel, such as paramedics who have undergone specialised training in the use of special procedures, skills and vehicles & equipment.
Their specialised equipment includes personal protective equipment (such as breathing apparatus, hazmat suits, and climbing tethers for working at height), cutting equipment for extrication, and flotation devices and rafts for working on water.Independent Ambulance Association
The Independent Ambulance Association or IAA is the non-profit body representing ambulance services regulated by the Care Quality Commission in England, but not part of the statutory National Health Service provision, who are represented by the Ambulance Service Network.Joint Royal Colleges Ambulance Liaison Committee
JRCALC is the Joint Royal Colleges Ambulance Liaison Committee. Their role is to provide robust clinical speciality advice to ambulance services within the UK and it publishes regularly updated clinical guidelines. The first meeting of JRCALC was in 1989 and was hosted by the Royal College of Physicians, London.The guidelines are supposed to be produced from evidence-based medicine. However, organisations such as the College of Paramedics have criticised the committee for poor reference to available evidence in the past.JRCALC have produced a number of systematic reviews on various topics. Available evidence is researched and discussed by a team of academics and clinicians including representatives from all UK ambulance services, and a number of medical disciplines. The Guidelines are produced by the JRCALC Guideline Development Group (JRCALC-GDG) hosted by the University of Warwick.Lincolnshire Integrated Voluntary Emergency Service
Lincolnshire Integrated Voluntary Emergency Service, known commonly as LIVES, is a registered charity staffed by volunteers providing pre-hospital care services across Lincolnshire. LIVES operates alongside the East Midlands Ambulance Service to provide clinical and critical care skills as well as immediate medical responses in the form of community first responders. LIVES operates under the national pre-hospital care co-ordinating body, the British Association for Immediate Care.
LIVES is a registered provider of healthcare with the Care Quality CommissionNHS 111
111 is a free-to-call single non-emergency number medical helpline operating in England, Scotland and parts of Wales. The 111 phone service has replaced the various non-geographic 0845 rate numbers and is part of each country's National Health Service: in England the service is known as NHS 111; in Scotland, NHS 24; and in Wales, either NHS Direct Wales or 111 depending on area.
The transition from NHS Direct (0845 4647) to NHS 111 in England was completed during February 2014 with NHS 24 Scotland (08454 24 24 24) following during April 2014. NHS Direct Wales started a phased roll-out of a similar 111 service in late 2016. As of June 2018, the 111 number is not currently in use across Northern Ireland .
The service is available 24 hours a day, every day of the year and is intended for 'urgent but not life-threatening' health issues and complements the long-established 999 emergency telephone number for more serious matters, although 111 operators in England are able to dispatch ambulances when appropriate using the NHS Pathways triage system.NHS Direct Wales continues to operate via 0845 4647, but began a transition to 111 during late 2016. Initially available in Swansea, Bridgend and Carmarthenshire, the service is due for a country-wide roll-out by 2021. The health service of Northern Ireland will be able to introduce its own similar service using the 111 number if it chooses to do so.NHS targets
Conservative governments set targets for the NHS in the 1990s – for example, guaranteeing a maximum two-year wait for non-emergency surgery and reducing rates of death from specific diseases. The Blair government introduced far more targets and managed performance far more aggressively - a management regime sometimes referred to as 'targets and terror'. Targets have been blamed for distorting clinical priorities, and in particular for one organisation achieving a target at the expense of another. For example, ambulances have been forced to queue up outside a busy emergency departments so that the ambulances might not be able to meet their target in responding to emergency calls, but the hospital can meet its A&E target. Excess emphasis on the targets can mean that other important aspects of care, especially those not easily measured, may be neglected. NHS England under the Conservative governments reduced the number of targets, in particular removing most of those relating to health inequality, and encouraged a system wide approach. However shortage of staff and funding meant that performance against targets declined. Guidance published in February 2018 conceded that most of the targets would not be met before April 2019.Royal National Lifeboat Institution
The Royal National Lifeboat Institution (RNLI) is the largest charity that saves lives at sea around the coasts of the United Kingdom, the Republic of Ireland, the Channel Islands and the Isle of Man, as well as on some inland waterways. There are numerous other lifeboat services operating in the same area.
Founded in 1824 as the National Institution for the Preservation of Life from Shipwreck, the RNLI was granted a Royal Charter in 1860. It is a charity in the UK and in the Republic of Ireland. Queen Elizabeth II is Patron. The RNLI is principally funded by legacies and donations, and most of the members of its lifeboat crews are unpaid volunteers.
The RNLI, whose main base is in Poole, Dorset, has 238 lifeboat stations and operates 444 lifeboats. Crews rescued on average 22 people a day in 2015. RNLI Lifeguards operate on more than 200 beaches. They are paid by local authorities, while the RNLI provides equipment and training. The Institution also operates Flood Rescue Teams (FRT) nationally and internationally (iFRT), the latter prepared to travel to emergencies overseas at short notice.
Considerable effort is put into training and education by the Institution, particularly for young people; more than 6,000 children a week are spoken to by education volunteers about sea and beach safety, and over 800 children a week receive training. The Institution has saved some 140,000 lives since its foundation, at a cost of more than 600 lives lost in service.Surrey Ambulance Service
Surrey Ambulance Service was the ambulance service for the County of Surrey in England until 1 July 2006, when it was succeeded by a South East Coast Ambulance Service also covering Sussex and Kent.The Air Ambulance Service
The Air Ambulance Service (TAAS) is a registered charity in the UK that runs two emergency air ambulances, the Warwickshire & Northamptonshire Air Ambulance (WNAA) and the Derbyshire, Leicestershire & Rutland Air Ambulance (DLRAA), and also operates the national Children's Air Ambulance, an emergency transfer service for seriously ill babies and children.
The Charity's membership of the Association of Air Ambulances is currently suspended due to an investigation by the Charity Commission.West Midlands CARE Team
The West Midlands Central Accident, Resuscitation & Emergency (CARE) team is a charitable organisation who respond to serious medical incidents within the West Midlands, UK. Working in teams alongside West Midlands Ambulance Service, volunteer doctors, nurses and other healthcare professionals deliver enhanced critical care to seriously injured and unwell patients.
The charitable aims of the organisation are the relief of persons suffering injury or illness by the provision of immediate medical care and advancing the study of immediate medical care by the provision of training and research.
Emergency medical services around the world
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