NHS

Modernisation Agency

Improvement Partnership for Ambulance Services

Best Practice Guidelines on

Ambulance Operations
Management
www.modern.nhs.uk/ambulance

Improvement Partnership for

Ambulance Services (IPAS)
NHS Modernisation Agency

Third Floor,
Heron House,
322 High Holborn,
London,
WC1V 7PW.
Tel: 0207 061 6820

The NHS Modernisation Agency is

part of the Department of Health

NHS
Modernisation Agency

Best Practice Guidelines on Ambulance Operations Management

READER INFORMATION
Policy
HR/Workforce
Management
Planning
Clinical

Estates
Performance
IM & T
Finance
Partnership Working

Document Purpose

For information

ROCR Ref:

Gateway Ref: 3423

Title

Operations Management for

Ambulance Services

Author

DH/NHS MA/IPAS

Publication date

November 2004

Target Audience

Directors of Operations

Circulation List
Description

Contents
Introduction

Ambulance Trust CEs

Demand Based Cover/Dynamic Cover Plan

A document which covers key tactical

deployment facts, points of learning
and issues which zero starred and CHI
challenged trusts may appreciate.

Utilising Resources:

Cross Ref

N/A

Superseded Docs

N/A

Action Required

N/A

Timing

N/A

Contact Details

Phoebe White
NHS MA/IPAS
3rd Floor, Heron House
High Holborn
WC1V 7PW
020 7061 6820
www.modern.nhs.uk/ambulance
www.modern.nhs.uk/scripts/default.
asp?site_id=60&id=17018

Single Responders

Deployment Regime

Urgent Cases

11

Activation Times

12

Ambulance Turnaround Times

13

Intermediate Tier

14

Helicopter Emergency Medical Service

15

British Association of Immediate Care Schemes (BASICS)

16

Community and Corporate Responders

17

Pre-Determined Response

17

Deployment of Officers/Managers to Serious or Untoward Incidents

18

Performance Updates

18

For Recipients Use

This document is also available on

the Improvement Partnership for
Ambulance Services (IPAS) website
at www.modern.nhs.uk/ambulance

Special Measures

19

Roles

20

Leadership and Communication

20

Managing Rotas

21

Appendix 1: National Standards, Local Action: Health and Social Care

Standards and Planning Framework 2005/06-2007/08.

22

Appendix 2: Definitions for Completion of KA34

23

Appendix 3: Table of Contributors

24

Appendix 4: Definitions and Useful Information

25

Improvement Partnership for Ambulance Services

Best Practice Guidelines on Ambulance Operations Management

Best Practice Guidelines on Ambulance Operations Management

Introduction
The revised National Standards, Local
Action: Health and Social Care
Standards and Planning Framework
2005/06-2007/08 sets out the
framework NHS organisations and
social service authorities are to use in
planning for the next three financial
years and the standards which all
organisations should achieve in
delivering NHS care. Appendix 1of the
National Standards, Local Action
document, lists the existing
commitments to be maintained and
achieved by March 2005 (see
Appendix 1 of this document). These
include the ambulance response time
measures for Category A and B.
Although it is recognised that the first
priority for a Trust is to achieve and
sustain the key target of responding to
75% of all calls categorised as
immediately Life-Threatening within 8
minutes, performance improvement
should be designed to address wider
performance measures as indicated by
the Core and Developmental
Standards in the National Standards,
Local Action document. These include
improving clinical outcomes,
particularly those, which are the
subject of National Service
Frameworks. In addition, there is a
need to comply with Improving
Working Lives, Health and Safety
legislation, Controls Assurance and the
Clinical Governance framework and
other guidance.
This document aims to offer
information and good practice
examples in terms of Ambulance
Operations Management and has been
developed with generous assistance
from Greater Manchester Ambulance
Service, Hereford and Worcester
Ambulance Service and Kent
Ambulance Service. These
organisations experienced a trend of
significant service improvement of up
to 40% by implementing the best

Demand Based Cover/Dynamic Cover Plan

practice cited in this document to
achieve and maintain the Category A
75% of calls within 8 minutes target.

Demand Based Cover relies on

monitoring and analysing historic
activity and extrapolating this data
to predict future demand. It is an
important and useful tool when
drawing up rotas and predicting
when and where to deploy vehicles.
The principle underlying this
approach is to ensure that all
despatch points are situated in areas
where they can reach high priority
Category A scenes within 8 minutes
and that they have the necessary
available resource to meet expected
demand situated within them. They
are often not at the sites of existing
ambulance stations which were
located for different reasons.

In writing this document we recognise

that all trusts experience different
challenges and constraints and that
some issues may impact on an
organisations ability to implement the
suggested good practice. However,
evidence, some of which is presented
in this document, has shown that
implementing such good practice ideas
can lead to real and sustainable
improvements.
The contributors to this document
from Greater Manchester, Hereford
and Worcester and Kent, listed in
Appendix 3, are happy to be
contacted for further guidance on
implementing these practices. These
best practice guidelines are also
covered in more depth in the System
Status Management training
programme, which is run by Keele
University.
It is recommended that the
information and good practice offered
within this document be adopted
within a wider whole systems change
and a service improvement approach
that responds to the Department of
Healths Reforming Emergency Care
agenda. 999 calls to ambulance
services have increased over the years,
(7.7% for the Service as a whole last
year, however some individual Trusts,
for example Bedfordshire and
Hertfordshire, saw increases of 20%)
and consequently this has had an
impact on the demand placed on the
service and the ability of trusts to
meet targets. In June 2002, Margaret
Edwards, Director of Access and
Choice at the Department of Health,
wrote a letter to all ambulance trusts
entitled Delivering the NHS Plan
Strengthening Accountability:
Appropriate Use of Ambulance

Improvement Partnership for Ambulance Services

Services which highlighted local

action that should be taken in
response to malicious and hoax callers
and in response to 999 calls where
sending an ambulance would be
appropriate. This led to many services,
for example London Ambulance
Service, developing a no send policy
for such instances.
Through the modernisation of
ambulance services and the
introduction of new roles, ambulance
trusts are in the position to respond to
the increased demand more
innovatively (for example, it may not
be an appropriate response to take all
999 callers to A&E. Some Category C
callers could be more appropriated
treated at Walk in Centres, Minor
Injuries Units or by links to NHS Direct
etc). Improved relationships with
Primary Care Trust commissioners of
emergency ambulance services and
non emergency patient transport
services can also help ensure that
ambulance services are commissioned
and used appropriately. More
information on this subject is available
in an IPAS document around
commissioning entitled Driving
Change (please refer to Appendix 4).

The annual demand for call outs must be

identified, taking into account the reason
for the call, the category (ref Healthcare
Commission Performance Rating Targets
2004/5), the area of call out etc.

ANALYSE DEMAND
OVER A PERIOD
OF TIME PAST

BREAK DOWN
INTO DEMAND
PER UNIT HOUR

There are various command and control

or stand alone software solutions on the
market to help with demand analysis.
These can cost as little as 7,000.
Contact a neighbouring service or a 3
star service for advice on those systems
they use. Contacts from the services in
Appendix 3 can also provide guidance.
An excel spread sheet can be used as a
backup.

The demand analysis then needs to be

extrapolated to produce weekly rotas,
detailing the demand per hour (over 168
hours) for each week of the year. This
will form the baseline for the generic
rota. Adjustments for known increases
in demand will need to be imposed on
top for example seasonal demand (the
Christmas period and school holidays
etc) and large scale public events etc.
The demand per unit hour should be
mapped over a geographic area to
enable the most suitable areas for
despatch points to be identified.

DEPLOY AMBULANCES
ACCORDING TO THESE
HOURLY PATTERNS

The despatch points generated by the

unit hour demand should be located
within 1.5km or 6 minutes response time
from the centre of the area of high
demand. (It is recommended not to
work on an 8 minutes response time as
this does not allow for activation time. It
is established practice for trusts to aim
for a 4 minute response time as this
increases the chance of a positive clinical
outcome for the patient suffering from
cardiac arrest).
Note: Demand varies on each day of the
week and by each hour of the day. The
resources deployed at each despatch
point should reflect these fluctuations in
demand.

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Best Practice Guidelines on Ambulance Operations Management

Best Practice Guidelines on Ambulance Operations Management

Good Practice Example:

In 2001, Hereford & Worcester employed a software company to help them work out their
demand analysis and deployment strategy.
The use of the software let to the consistent achievement of life threatening best
practice measures.
Vehicles are no longer solely stationed at ambulance stations.

Involve staff and unions in any

discussions around reviewing the
demand and deployment process
from the beginning. Its best to be
open, honest and transparent
about the process

Maximum priority cover

should be provided at all
times on all points

DISPATCH POINTS

Try not to deploy more

than one available resource
on any of the despatch points
unless the unit hour
demand dictates

Remember to take into account

rest times and staff changeover
times, including briefing and
debriefing on station management
issues and incidents when doing
the hourly plan

USEFUL TIPS
Talk to neighbouring
ambulance services or staff at 3
star Trusts about software to
analyse and predict demand.
Your demand plan will dictate
the priority of your despatch
points. When moving single
crewed staff from one despatch
point to another in order to
establish a crew, move staff to
the higher priority station.
When priority points have been
covered, move additional
resources to support the highest
priority points as they represent
the highest demand. Also to
cover meal breaks, training etc.
Despatch points dont have to
be ambulance service owned
some services use primary
healthcare facilities, hence
integrating with the local health
economy. Others use fast food
outlet premises, other
emergency services or military
bases too. Approach these and
others to see if you can share
their premises for a nominal fee.
This approach is not the best for
all services and it is advisable to
consult staff and unions about
any planned changes.

Remember:
The Control Room can help in managing demand.
An ambulance may not be necessary for all 999
callers some services employ an NHS Direct Nurse
or other suitably trained staff to offer alternative
care suggestions to Category B or C callers.

Remember:
Not all cases responded to will require treatment at
hospital A&E. It may be more appropriate to refer
patients to alternative care centres, (for example
Minor Injury Units, Walk in Centres or to Treat and
Refer) or develop protocals which allow direct
access to Coronary Care Units, Stroke Units etc.

Remember - Least Vehicle

Moves. This is time saving when
moving vehicles between
despatch points, when adopted
to vehicles that have the least
distance to travel.
Do not ask resources to patrol
mid points between despatch
points.

Improvement Partnership for Ambulance Services

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Best Practice Guidelines on Ambulance Operations Management

Best Practice Guidelines on Ambulance Operations Management

Utilising Resources

USEFUL TIPS
Either ambulances or single
responders can cover priority
despatch points however,
there should not be more than
one available resource in each
despatch point at any given
time.

Single Responders
Ambulance single responders (paramedic or technician) in cars, motor bikes,
or bicycles have an obvious advantage over ambulance vehicles. Bikes and
cars can negotiate the traffic faster and easier and can be up to 50% faster
than an ambulance.

AMBULANCE VEHICLE
showing 8 minutes
response time on

Can assume BIKE/CAR

BIKE/CAR
AND

showing 8 minutes
response time on

the CAD

In these circumstances
the responder should
continue to the call.
However, if a subsequent
Red call is received within
their vicinity whilst en
route to an Amber or
Green call, they must be
redeployed as priority.

time should
be 4 MINUTES

the CAD

Depending on the geographical nature of the service, single responders

should be targeted at Category A calls. If the call is confirmed as an Amber
once en route, they can be stood down. However, the responders can be
utilised if attending cases that will maintain their skills or levels of utilisation
and thus benefiting patient care, for example:

ONE

actual response

MEANS

TWO

Once on scene of an
Amber or Green call the
responder must be ready
and prepared to respond
to any subsequent Red
call as soon as possible,
and must keep the
control room updated
regarding the patients
condition, in particular if
the ambulance can be
stood down.

Improvement Partnership for Ambulance Services

Chest Pain
Diabetic
Epileptic
Unconscious patient
Falls over 6 feet
Road Traffic Crash

THREE

A Single Responder is
seen as available
after the arrival of
an ambulance or any
other professional that
they hand the patient
over to.

Motorcycles can provide great

advantages of speed and
versatility in built up areas and
road networks congested by
slow or stationary traffic,
therefore it is essential they
patrol high traffic density areas
during rush hours and any
location where a gridlock
situation has occurred.
Motorcycles are also useful at
large scale public events
where there will be a high
density of people e.g. open-air
events.
Consider fitting child seats to
the rear of responder cars to
enable vehicles to be able to
transport children under the age
of 4 years.
Suitably trained officers and
managers can be utilised as
first responders to respond to
Category A calls if they are in
the vicinity.
Officers and managers should
keep their blue lights
attached to their vehicles when
on duty and when travelling to
duty. This practice can save up
to 45 seconds! (Trusts should
inform the Police of this
practice).

Deployment Regime
Calls should be allocated to the
nearest available resource in the
following priority:

Cat A
Red

Single Responder
Emergency Ambulance,
Intermediate Tier
Community/Corporate
Responder

Cat B
Amber

Single
Responder
Emergency
Ambulance

Local
Category C
Arrange
-ments
Green

Single
Responder
Emergency
Ambulance

Good Practice Example:

Kent Ambulance Service anticipate that utilising their

intermediate tier will increase their response rates
by 2.1%

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Best Practice Guidelines on Ambulance Operations Management

Deployment Regime
continued:

Best Practice Guidelines on Ambulance Operations Management

Urgent Cases
Urgent journeys should be allocated a vehicle(s) as soon as possible after
they are received in the control room, in the following priority order:

PTS / ACVS
Urgent
Admissions/
Transfer/
Discharge

Discharges

Routine
Admissions

Intermediate Support
initially / PTS, then
Emergency Ambulance if
necessary. ACVS can be
used if the GP agrees

PTS/Intermediate
Support/ACVS initially,
then Emergency
Ambulance if necessary

PTS/Intermediate
Support/ACVS initially,
then Emergency
Ambulance if necessary

On occasions, this may mean that a vehicle

from one area is deployed to another area to
deal with the urgent case.
Intermediate tier and PTS vehicles, no matter
what their location, should be deployed in
preference to A&E vehicles

It may also be worth slightly delaying the

deployment of a resource to an urgent case
to allow time for an intermediate crew to
clear and then be allocated again, rather
than commit an A&E resource

West Midlands Ambulance Service are introducing a Response Generator based on a

simple philosophy of treating the sickest patients first. The Trust is currently working towards a
process of managing Emergency and Urgent calls via a single stream, so that patients are
allocated an appropriate response and resource according to their presenting clinical
condition, irrespective of origin or entry into the system. When fully realised, the Response
Generator, seeks to grade calls into priorities such as: Immediate, Urgent, Sequential and Routine,
with the relevant response delivered by differing members of the health care team, such as, NHS
Direct, primary care and the ambulance service, from paramedics to patient carers, and would
serve to progress the Reforming Emergency Care agenda.

Current identified priority areas

requiring emergency cover (it may
be more appropriate to send a
vehicle which will need to travel
through an uncovered area to
reach the urgent patient).
Whether the crew is due a meal
break.

Improvement Partnership for Ambulance Services

Emergency vehicle from

nearest lower priority
despatch point

Good Practice Example:

The selection of an A&E vehicle for

deployment to an urgent call will
take into account the following
points:

10

Intermediate crew
(see page 14)

Whether the crew are

approaching the shift end time.
It is good practice that, as well as
continuing to determine the latest
time by which the patient should be
admitted to hospital, that call takers
check if we have an ambulance
available before that time, is the
patient ready to admit now?

NSF/CHD - Chest Pain

Any Cardiac related chest pain
requested as an urgent, must
immediately be upgraded, by
the control room/
communication centre to an
emergency and responded
to accordingly

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Best Practice Guidelines on Ambulance Operations Management

Best Practice Guidelines on Ambulance Operations Management

Good Practice Example:

Good Practice Example:

Hampshire Ambulance Service introduced a new procedure for GP Urgents in December

2003 with the aim of reducing response times and ensuring the most appropriate
resources are dispatched in relation to the patients clinical profile. Urgent bookings can
only be booked by a doctor or nurse caring for the patient to enable booking staff to take the
necessary information about the patients condition. Urgent transfers are taken with a pick up
time of two hours (120 minutes) or an emergency (999) transfer may be requested. The
Communications Team Leader (CTL) will be informed of any cases where an ambulance will not
arrive to collect the patient within 80 minutes of the initial request. In such case the CTL will
initiate a comfort call to the patient to assess if their condition has changed/worsened. If it
has, an emergency ambulance (999) will be dispatched. If not the patient is informed that an
ambulance will be with them as quickly as possible. If the ambulance has not arrived within 100
minutes, the call is immediately upgraded to an emergency (999). This procedure has since
seen a marked improvement in performance (96.2% average over the 6 months since the
implementation) and a notable reduction in complaints from patients, GPs and acute units.

Bedfordshire and Hertfordshire Ambulance and Paramedic Service has taken advantage of
the fact that BT allocate telephone dialling codes and the first part of telephone numbers
geographically by holding a database in the bespoke Computer Aided Dispatch (CAD)
system identifying the telephone exchange areas to which numbers relate. As a
consequence, when 999 calls come from a BT land line number, the CAD automatically crosschecks the database and, if a match is found, displays the general area in which the telephone
number is located.

Activation Time

Ambulance
Turnaround Times

Reduction in activation time is one of the most effective ways to improve

response times. It is established practice for trusts to aim for an activation
time of 3 minutes, 95% of the time.

3 minutes
Clock start

5 minutes available for the journey if necessary

Activation

On scene

It is recommended that a faster activation time standard is aimed for as this

allows for increased journey time to meet the 8 minute target. The easiest
way to reduce response times is to deploy vehicles as soon as the area of the
incident is identified by the callers telephone number.

1.5 minutes
Clock start

6.5 minutes available for the journey if necessary

Activation

USEFUL TIPS
Audit the activation times at each despatch point and then customise
the standard for each to ensure deployed vehicles reach incidents in the
area within 8 minutes.

12

Improvement Partnership for Ambulance Services

On scene

This has the benefit of allowing the relevant dispatcher to commence the allocation of a
vehicle process while the call taker is ascertaining the exact location, thus shaving
precious time from the Activation process.
Configuration of the database was relatively fast as BT readily provided the information needed
and the bespoke CAD software had the capacity to deal with the database already.

Ambulance turnaround times (ie the

time between an ambulance arriving
at the hospital receiving department
and the time of handing over the
patient to the care of hospital staff)
can impact on an ambulance trusts
ability to free up capacity and
respond to other patients. The
Sitreps Guidance and Definitions
2003/04 state that 15 minutes is
thought to be a reasonable time to
allow completion of handover at
A&E. However, it is recognised that
the turnaround times vary in
different areas and that they are a
problem in some counties.
Some trusts are working with
hospitals to agree solutions to the
problem. Greater Manchester
Ambulance Service have
implemented the following
approach:

Good Practice Example:

GMAS have put in place an Escalation Policy which is

triggered when the combined at hospital time of one or
more ambulances at a receiving unit/hospital is more than two
hours, and the delay is due to the inability of the crew to
transfer the patient into the care of hospital staff. The
Paramedic Emergency Control (PEC) Duty Manager continually
monitors the situation at hospitals and mobilises a Local Officer
to the affected hospital once pressures start building and the
trigger time is reached.
The Local Officer liaises with the hospital department heads and
bed managers to assess the situation and offer any help or
takes the necessary action to ease the situation for example
ensuring all ambulance discharges/transfers from the receiving
unit/hospital are actioned immediately. These actions may
require action to free bed space and create capacity at other
acute trusts.
If it is felt that the problems cannot be resolved within a
reasonable time (for example 15 minutes), the GMAS General
Manager is contacted and plans to divert ambulances will be
implemented.

Improvement Partnership for Ambulance Services 13

Best Practice Guidelines on Ambulance Operations Management

Best Practice Guidelines on Ambulance Operations Management

Intermediate Tier
Many Services operate an intermediate tier service targeted at GP Urgents.
These can be an additional resource when targeting Category A calls,
however the core function of most are:
Routine admissions, transfers and discharges.
Urgent admissions.
Hospice admissions.

Discharges home.
Urgent transfers.

In addition, some services also use the intermediate tier to respond to some
Category C calls, for example to pick up non injury or in-house assistance.
Depending on the training of the staff, the intermediate tier can also be
utilised for:
Post assessment transport.
Emergency transfers.
PTS may also be deployed to render assistance
to an A&E crew requiring assistance with lifting
or handling their patient; (using emergency
procedures if necessary).

After the patient has been assessed and it

is clear that the PTS crew can provide their
individual care requirements, the A&E
attending resource should be stood down. It
is permissible for the PTS crew to transport
the patient to A&E or other appropriate
location in these circumstances

PTS crews may also be deployed to a

confirmed RED call, if they are the closest
resource in order to render aid until an A&E
crew or single responder arrives. Suitably
trained and equipped PTS crews may
also be deployed to Category A calls

Helicopter Emergency
Medical Service (not
applicable to all services)
If an Air Ambulance is available for
deployment it can be targeted at any
suitable calls that have been
categorised as RED (life threatening)
under the prioritisation system. The
following examples indicate other
incidents where the Helicopter
Emergency Medical service could be
deployed:
All Road Traffic Accidents
involving:
Persons reported trapped.
Persons thrown or ejected from
vehicles.
Possibility of fatalities involved.
Any road traffic accident involving
more than 3 vehicles.

Other means of entrapment:

Any suspected burial or cave-in
incidents.
Any other suspected types of
entrapment.
Traumatic amputations.
High velocity blasts,
penetrating injuries, industrial
accidents, etc taking into
account the type of
situation i.e. firearms.
Collapse/cardiac problems/
chest pains (with long scene to
hospital times or long ETA of
ambulance if cardiac related).
Lower priority calls in remote
or difficult to access by road
areas.

In accordance with best practice in

patient care, the transport time of critically ill
patients or those involved in entrapment MUST be
kept to an absolute minimum. For this reason it is
recommended to land the helicopter at all
confirmed entrapments to assess the patients
suitability for air transfer

In addition to the above they can

also be essential in the transfer
of:
Clinical personnel to the scene of
an incident.
Seriously ill patients being
transferred from one hospital to
another for specialist treatment.

If the aircraft is unable to fly (e.g. due to

mechanical or weather conditions), consider
deploying the paramedic staff in a car to
utilise staff on duty

Good Practice Example:

Westcountry Ambulance Service have in place a policy that minimises the risks of lifting for
ambulance crews attending patients at care homes that come under the auspices of the National
Care Standards Commission (NCSC). This policy has the support of the Care Standards Agency
and the Health and Safety Executive and those care homes who call the ambulance service
out unnecessarily or only to lift uninjured patients (because of an absence of lifting equipment
or trained staff) can be reported to the NCSC who will follow the incident up if appropriate.

14

Improvement Partnership for Ambulance Services

Improvement Partnership for Ambulance Services 15

Best Practice Guidelines on Ambulance Operations Management

Best Practice Guidelines on Ambulance Operations Management

BASICS - British
Association of
Immediate Care
Schemes (for those who
operate the BASICS
scheme)
BASICS are a team of doctors who
are trained in pre-hospital care.
They carry life support equipment
and complement the paramedic
response at an incident. Members of
BASICS generally arrange the criteria
for call out locally by the ambulance
communications centre/control
room. Most schemes cover the
following list:
Road Traffic Crash (RTC) with
reported entrapment of any
kind.
RTC with ejection.
RTC with vehicle overturned.
RTC death in vehicle and other
casualties.
Fire with reported persons on
scene.
Paediatric cardiac arrest.
When an ambulance crew requires
immediate BASICS assistance on
the scene of an incident.
When the communications centre
has strong reason to believe that
BASICS assistance may be
beneficial to any casualtys care
prior to the true and full extent of
the incident being known.
When recognition of life extinct
is excluded for staff and a
BASICS member is attending.
When a request is made via the
communications centre from
another emergency service for
the attendance of a scheme
member.
In the event of a Major Incident
or Major Incident Standby
being declared.

16

Good Practice Example:

BASICS in Sussex will attend incidents at the instigation of

the Emergency Patient Communications Centre (EPCC) at
Sussex Ambulance Service. It is the responsibility of the
allocator on duty initially but also the Duty Communications
Officer to recognise when BASICS should be alerted to an
incident. BASICS are called out by pager reading EPCC
Respond Red followed by the location, type of incident, where
Sussex Ambulance are responding from and the incident
number. BASICS will be stood down if, once at the scene, the
paramedics determine they are not required.
In Sussex, it has been agreed that BASICS can be called if a crew
request them, if any incident sounds potentially serious or if
EPCC staff feel it appropriate. However, they will always be
called out for RTC with entrapment, RTC with ejection, RTC
where a vehicle has overturned and RTC involving a fatality.
Good Practice Example:

USEFUL TIPS
BASICS should not be used when:
If waiting for the scheme
members attendance, would
delay the transfer of the
casualty by the ambulance
service to hospital and/or cause
further foreseeable harm to the
casualty.
When the attendance of a
police surgeon would be more
appropriate.
When the attendance of the
patients GP or other primary
care provider would be more
appropriate.
When the attendance of a
scheme member is as a
substitute for the attendance of
the ambulance service.

Improvement Partnership for Ambulance Services

Some services, e.g. GMAS,

operate with good success, a
diagnostic of death
procedure which results in
crews leaving from such
incidents faster, thereby
rendering themselves available
for other calls.

Community and
Corporate Responders
Many services operate a community
single/ first responder scheme, these
operate within predefined
boundaries, and are deployed when
Category A calls are received within
this boundary.
Consideration must be given to
providing timely support and, if
necessary, counselling to community
responders following incidents.

Agree Volunteer Contracts with the HR

department to set out the expectations of each
party, and the entitlements of the volunteers are
stated for example access to counselling and
occupational health schemes.

Pre-Determined Response
Some services have developed a predetermined response to improve
patient care and staff welfare.
An initial pre-determined response of
two resources would always be
deployed to the following;
Cardiac arrests.
Maternity cases if a multiple
birth is expected.

Suspected serious or entrapment

RTCs or multiples casualty
incidents.
Major Incidents at international
airports.
The two resources can be either
2 x ambulances or an ambulance
and single responders.

Crews should be informed if any additional

resources are being deployed in association
with them. This will allow for enhanced
communication and the standing down of
additional resources at an early stage
if not required

In addition a resource being deployed to

back up the original response should be
notified that they are the second or more
crew / resource

Good Practice Example:

Surrey Ambulance Service have a Pre-determined Response in place for the expected
home delivery of twins. The Emergency Dispatch Centre (EDC) will immediately dispatch the
nearest two ambulances to such an incident. The EDC will ask the caller for the details of the
hospital that the expectant mother is booked in to and then call the delivery suite to inform them
that paramedics are attending the expected home delivery of twins and that a midwife may be
required. The EDC will consider the possibility of a midwife requiring transport and move
emergency cover appropriately. The cover may be an ambulance, single responder or Trust
Manager. The first arriving ambulance crew will inform the EDC if a midwife is required, enabling
the EDC to either stand down the midwife or arrange transport (if required) to get the midwife to
the scene.
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Best Practice Guidelines on Ambulance Operations Management

Deployment of
Officers/Managers to
Serious or Untoward
Incidents
Officers/Managers must be notified
at all times of the following
incidents:
Crew requests for officer
involvement.
Major Incident, (standby or
declared).
Three or more ambulances
required on scene.
Multiple casualties (over three
patients).
Confirmed entrapments likely to
be more than 20 minutes.
Injury to staff on duty.
Injury to patient whilst in trust
care.
Any incident of a dangerous or
hazardous nature.
Serious malfunction of equipment
that requires completion of
incident reporting procedure.
Any road traffic accident, no
matter how minor, involving trust
vehicles.
Civil disorders, terrorist attacks,
bomb/suspect device.
Fire calls with confirmed persons
reported.
Damage to or from trust property
or vehicles (to include theft of
vehicle).
Confirmed fire at
hospital/nursing/residential
home site.
Confirmed fire at any trust
property.

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Best Practice Guidelines on Ambulance Operations Management

Performance Updates

Good Practice Example:

All managers should be paged

regularly during the day with the
relevant information to ensure
effective performance management
and to be able to reallocate
resources as necessary.

At West Midlands
Ambulance Service,
appropriate managers have
access to the Trust's CAD
system which holds details of
incidents that are either
current or have been managed
by the Trust.

It is recommended that the pager

message has the following
information:
current performance for
Category A;
current activation standard;
field resource total;
number of all 999 calls;
number of red calls;
percentage of red calls.
The pager message should be sent
to all managers at regular intervals
e.g. Monday to Friday at 0900
hours, 1200 hours and 1600 hours.
Managers should utilise this data to
modify resources to improve
performance. Some services operate
a special measures procedure (see
next page).

Improvement Partnership for Ambulance Services

The Trust have introduced

the 'SmarTerm' software
system which allows
password protected access
to real and post time data,
thereby allowing managers
to actively interrogate the
system in a number of ways
to ensure that responses and
clinical care are managed
appropriately. Such
interrogations may include
National Charter Standards
performance on a cumulative
and individual case basis, as
well as mobilisation, call
assignment, hospital turn
around times etc.
The availability of such
information has proved vital
for enabling Trust managers
at all levels to proactively
manage issues and delays
as they arise.

Special Measures
The decision to implement Special
Measures will take into account the
following elements:
Time of day.
Number of Category A calls.
Number of Category A calls
missed.
Staff hours lost/gained.
Number of outstanding urgents.

1. Once a decision has been

made to implement special
measures, the control room
must be informed immediately
and all staff and managers
paged accordingly.

2. Ensure that all managers are

paged with the message
Special Measures
Implemented giving details of
current performance status.

3. On receipt of a Special Meas

ures Implemented pager message,
all officers and managers are to
clear their diaries and report their
availability for operational duties
to the control room.

4. The Fleet Department is to

immediately establish which
vehicles can be released from
workshops for operational use
and inform communications
centre and general managers.

5. The Training Department is to

establish if any personnel can be
made available for operational
duty and inform the control
room accordingly.

6. Senior Managers should ensure

that all resource information is
recorded adequately and that all
managers take appropriate action
upon receipt of Special Measures
Implemented notification.

7. The decision to stand down

from Special Measures will be
made by the Senior Managers /
Directors.

8. Once the decision has been

made to stand down, the duty
control room officer will ensure
that all managers are paged and
that relevant personnel are
informed.

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Best Practice Guidelines on Ambulance Operations Management

Roles
There is some good practice
guidance on roles and
responsibilities in control rooms in
various trusts and it is advisable that
those wishing to review their own
practices make contact with other
services.

Managing Rotas
The contacts from GMAS and Kent
listed in Appendix 3 of this
document, would be happy to
discuss their arrangements with you.

Leadership and Communication

There has been much research and
evidence to indicate that effective
leadership and communication are
crucial tools that are necessary to
bring about and manage change
and sustain improvements. This is
also true within the ambulance
service, as the example below
suggests. However, IPAS would not
prescribe a particular leadership style
or communications approach but
leave it to individuals and
organisations to determine a style
and approach that is appropriate to
their circumstances. IPAS can be
contacted for reference points or
training and development advice by
those wishing to explore this area
further.

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Best Practice Guidelines on Ambulance Operations Management

Good Practice Example:

To engender accountability, responsibility and a sense of

belonging for individuals, GMAS introduced a team structure
for Control and Operations staff. Each of the 4 teams
consists of a Control Manager, Resource Manager, Supervisor
and 6 Emergency Medical Dispatcher (EMD) Call Takers and 10
EMD Dispatchers. These 24-hour teams work the same shift
patterns and there are also alternating teams and additional
shift staff to help cover Thursday, Friday and Saturday night
peak demand times.
Each team is given key performance indicators (that include the
Category A, B, C and GP Urgent targets) and the Control
Manager for each team is accountable for the performance of
the team and the individual team members.

Improvement Partnership for Ambulance Services

Advantages, for example, better

leave management and effective
matching of resource to demand,
can be gained through central
management of rotas. It is
recommended that local self
rostering between crews be applied
to allow adjustments after the
central rota is set. Overlap for shift
starts and ends should be factored in
to allow of cleaning and restocking
of vehicles unless you are following
the model of skill mixing on these
tasks.

Planned Leave
For example annual leave, study
leave etc.

There are various factors that can

adversely affect unit hour resource
availability and need to be
considered when planning and
managing rotas:

In conjunction with the Human

Resources Department, unplanned
leave should be analysed and
planned into the demand analysis.
The average relief rate is 33% of the
whole time equivalent in order to
provide an effective service for
annual, sick and study leave.

Seasonal Demand
Demand analysis will highlight
seasonal demand which will affect
all services, for example increases
during December and January.
However, depending on geography,
demand can significantly alter during
summer months due to:
The weather (the Met Office can
predict future demand in
healthcare based on their weather
forecasts).
Epidemic illnesses.
Large scale public events.
School or public holidays
(impending changes to educational
holidays will influence demand).

It is advisable to calculate the

maximum hours allocated to
planned leave per location, per
week, and not to allow actual leave
to exceed this calculation. Advance
plans should be made for the
appropriate number of staff to be
off per week during the year.
Unplanned Leave
For example sickness.

Staff sickness levels need to be

monitored and proactively managed
and reported through performance
reports, especially if levels are above
4%. Systems, such as the Bradford
Index or other suitable system,
should be used for monitoring and
analysis. Further guidance can be
found in Section 5 of the IPAS
document Human Resources
Information for Ambulance Services
To assist in the delivery and
measurement of your HR Services
from IWL to CNST published in
October 2004 (see Appendix 4 of
this document for further
information).

Part-time Staff, Bank Staff,

Annualised Hours
Huge advantages can be gained
from the lateral use of part time and
bank staff and annualised hours
during peak demand hours and to
cover planned and unplanned leave.
Job share practices also allow for
flexibility. These staff groups should
be recruited and trained on the basis
that they will be used e.g.
recruitment adverts should state that
they will be used during periods of
high demand only.
Appraisals and Training
Uninterrupted time should be
secured to enable regular appraisals
to be conducted and appropriate
training to be provided. Appraisal
should be used to discuss an
individuals performance and analysis
on their response rates etc should be
fed back.
Vehicle Maintenance
This should be planned during times
when demand is low, for example
weekday evenings after 11pm, and
should be co-ordinated and agreed
with the Fleet Department.

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Best Practice Guidelines on Ambulance Operations Management

Best Practice Guidelines on Ambulance Operations Management

Appendix 1 - National Standards, Local Action:

Health and Social Care Standards and Planning
Framework 2005/06-2007/08
Existing commitments
to be maintained
Commitments due to be achieved
before March 2005
Reduce to four hours the
maximum wait in A&E from arrival
to admission, transfer or
discharge.
Guaranteed access to a primary
care professional within 24 hours
and to a primary care doctor
within 48 hours.
All ambulance trusts to respond to
75% of Category A calls within 8
minutes.*
All ambulance trusts to respond to
95% of Category A calls within 14
(urban)/19(rural) minutes.*
All ambulance trusts to respond to
95% of Category B calls within 14
(urban)/19(rural) minutes.*
Maintain a two-week maximum
wait from urgent GP referral to
first outpatient appointment for all
urgent suspected cancer referrals.
Maintain a maximum two-week
wait standard for Rapid Access
Chest Pain Clinics.
3 month maximum wait for
revascularisation by March 2005.
From April 2002 all patients who
have operations cancelled for nonclinical reasons to be offered
another binding date within 28
days or fund the patients
treatment at the time and hospital
of the patients choice.

Commitments due to be achieved

after March 2005
Improve life outcomes of adults
and children with mental health
problems by ensuring that all
patients who need them have
access to crisis services by 2005,
and a comprehensive Child and
Adolescent Mental Health service
by 2006.
Ensure that by the end of 2005
every hospital appointment will be
booked for the convenience of the
patient, making it easier for
patients and their GPs to choose
the hospital and consultant that
best meets their needs. By
December 2005, patients will be
able to choose from at least four
to five different health care
providers for planned hospital
care, paid for by the NHS.
Ensure a maximum waiting time of
one month from diagnosis to
treatment for all cancers by
December 2005.
Achieve a maximum waiting time
of two months from urgent
referral to treatment for all cancers
by December 2005.
800,000 smokers from all groups
successfully quitting at the 4-week
stage by 2006.

*Note: The underlying definitions for

these standards and the split between
rural and urban services will be
clarified later in 2004, as part of the
current ambulance review.

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In primary care, update practicebased registers so that patients

with CHD and diabetes continue
to receive appropriate advice and
treatment in line with NSF
standards and, by March 2006,
ensure practice-based registers and
systematic treatment regimes,
including appropriate advice on
diet, physical activity and smoking,
also cover the majority of patients
at high risk of CHD, particularly
those with hypertension, diabetes
and a BMI greater than 30.
A minimum of 80% of people
with diabetes to be offered
screening for the early detection
(and treatment if needed) of
diabetic retinopathy by 2006, and
100% by 2007.
Achieve a maximum wait of 3
months for an outpatient
appointment by December 2005.
Achieve a maximum wait of 6
months for inpatients by
December 2005.
Deliver a ten percentage point
increase per year in the proportion
of people suffering from a heart
attack who receive thrombolysis
within 60 minutes of calling for
professional help.
Delayed transfers of care to reduce
to a minimal level by 2006.

Appendix 2 - Definitions for Completion of KA34

Emergency calls and patient
journeys:
Category A emergency calls are
those classified as immediately lifethreatening. Urgent and nonurgent transport requests may be
classified as Category A calls after
interrogation and the agreement of
the caller. Where there have been
multiple calls to a single incident,
only one call should be recorded
(except in line 01 where all
emergency calls are to be counted).
Category B &C emergency calls are
those classified as being other than
immediately life-threatening. Urgent
and non-urgent transport requests
may be classified as Category B or C
calls after interrogation and the
agreement of the caller. Where there
have been multiple calls to a single
incident, only one call should be
recorded (except in line 01 where all
calls are to be counted).
Patient journeys: each patient
conveyed is counted as an individual
patient journey.
Urgent patient journeys are those
resulting from an urgent transport
request. An urgent transport request
is defined as a request when a
definite time limit is imposed such
that the vehicle and crew must be
despatched quickly, although not
necessarily immediately, to collect a
patient, perhaps seriously ill, on the
advice of a doctor for admission to
hospital.
Exclude urgent transfer requests
which, after interrogation and the
agreement of the caller, are treated
as Category A, B or C emergency
calls. "High dependency" calls
should be included only if they
satisfy the definition of an "Urgent"
Patient Journey.

Non -urgent patient journeys exclude non-urgent transfer

requests, which after interrogation
and the agreement of the caller are
treated as Category A, B or C
emergency calls or Urgent Patient
Journeys
Timing of response times
An Association of Ambulance
Services (ASA) publication defines
"clock starts" as the time
according to the current Department
of Health guidelines ie after
confirmation of the location and
chief complaint. For AMPDS users
this will be when the response to
Question 13 is entered or when
ProQA protocol is commenced. For
CBD users this will be when the
chief complaint is entered.
For all users there will be automatic
clock start 60 seconds after the first
key stroke if the points defined
above have not yet been reached.
(Reference: ASA A report into the
measurement of emergency
response times and 999 call
categorisation, August 2002)
The "clock stops" when the
emergency response vehicle arrives
at the scene of the incident.

Urban/rural services
Urban services are those where the
population density of the area
covered was greater than 2.5
persons per acre in 1991.Rural
services are those where the
population density of the area
covered was less than 2.5 persons
an acre in 1991.The following areas
are classified as urban:
London, Avon, Merseyside, South
Yorkshire, West Midlands, West
Yorkshire, Greater Manchester,
Surrey.
Source of info:
AMBULANCE SERVICES: GUIDANCE
NOTES FOR COMPLETION OF KA34,
2002-03
Pg17 of Ambulance Services,
England: 2002-03 (National Statistics
prepared by Government Statistical
Service)
NB: The underlying definitions for
the above targets and the split
between rural and urban services
will be clarified as part of the current
ambulance review.

A response within eight minutes

means eight minutes zero
seconds or less. Similarly, 14
minutes means 14 minutes 0
seconds and 19 minutes mean 19
minutes 0 seconds or less.
Emergency response
An emergency response may be by:
an emergency ambulance: or a rapid
response vehicle equipped with a
defibrillator to provide treatment at
the scene; or an approved first
responder equipped with a
defibrillator, despatched by and
accountable to the ambulance
service.

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Best Practice Guidelines on Ambulance Operations Management

Appendix 3 - Table of Contributors

Appendix 4 - Definitions and Useful Information

This document has been written with the kind contributions of:

Control Room - this is terminology used

in this document to mean communication
centre also

Ray Creen
Director of Patient Services, Kent Ambulance Service NHS Trust
Anna Garrett
Ambulance Policy, Department of Health
Keith Prior
General Manager, Paramedic Emergency Control,
Greater Manchester Ambulance Service NHS Trust keith.prior@gmas.nhs.uk
Dom Robertson
Deputy Director of Operations, Hereford and Worcester Ambulance Service NHS Trust
dominic.robertson@hwas-tr.wmids.nhs.uk
Manjit Smith
Business Manager, IPAS
Julia R A Taylor
National Programme Director, IPAS
Phoebe White
Support Worker / PA, IPAS
IPAS would also like to thank the following for their contributions:
Anthony Marsh
Chief Executive, Essex Ambulance Service NHS Trust
Barry Johns
Chief Executive, West Midlands Ambulance Service NHS Trust
Anne Walker
Chief Executive, Bedfordshire and Hertfordshire Ambulance Service NHS Trust
Simon Featherstone
Chief Executive, North East Ambulance Service NHS Trust
Gary Butson
Director of Operations, Surrey Ambulance Service NHS Trust
Andy Cashman
Director of Operations, Sussex Ambulance Service NHS Trust
Mike Cassidy
Director of Operations, Hampshire Ambulance Service NHS Trust
Steve Pryor
Director of Operations, WestCountry Ambulance Service NHS Trust

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Best Practice Guidelines on Ambulance Operations Management

Improvement Partnership for Ambulance Services

Dynamic Cover Plan - Where despatch

points are allocated
Despatch Point - A point (which is worked
out by data analysis) from which an
ambulance can be deployed to an incident
within the target time. This point is not
only the ambulance station, but can be the
side of a road, GP surgery/healthcare
centre, other emergency service partners (ie
Police or Fire station). Some fast food
outlets may let ambulances park on their
premises free of charge and may even
provide refreshments. The added benefit is
that most of these premises are in high
priority areas.
High Priority Area - An area, which
through demand analysis, has indicated a
high density of Category A incidents at
specific periods of time.
AMPDS - Advanced Medical Priority
Despatch System
CBD - Criteria Based Despatch
PTS - Patient Transport Service
ACA - Ambulance Care Assistant
Intermediate Tier This has different
definitions at different Trusts i.e. at Kent
this called Special Transport Service
resourced by a Technician and ACA, and at
Hereford and Worcester this is called High
Dependency Service resourced by an ACA
with additional skills.
National Standards, Local Action:
Health and Social Care Standards and
Planning Framework 2005/06-2007/08 sets out the framework NHS organisations
and social service authorities are to use in
planning for the next three financial years
and the standards which all organisations
should achieve in delivering NHS care. The
document can be found of the Department
of Health website at:
www.dh.gov.uk/PublicationsAnd
Statistics/Publications/Publications
PolicyAndGuidance/fs/en

Delivering the NHS Plan Strengthening

Accountability: Appropriate Use of
Ambulance Services (28th June 2002)
Can be found at the Department of Health
website at
www.dh.gov.uk/assetRoot/04/01/37/27/040
13727.pdf
Good Practice Guide on Human
Resource for Ambulance Services
To assist in the delivery and
measurement of your HR Services from
IWL to CNST (2004) - A best practice
document developed by IPAS which
summarises the key requirements of HR
standards and provides a checklist for all
actions required. Available on the IPAS
website at www.modern.nhs.uk/ambulance
Improving Working Lives -The Improving
Working Lives Standard (IWL) sets out a
model of human resources practice. NHS
employers will be kite-marked against their
ability to show that they are providing a
better deal for NHS staff in their working
lives. For guidance on how to apply the
practice, refer to the Human Resources
Guidelines for Ambulance Services.
The following documents/toolkits are also
available:
NHS Childcare Toolkit III: The new
dimension Published by the
Department of Health & Daycare Trust,
July 2004.
Available at the Department of Health
website
www.dh.gsi.gov.uk/PolicyAndGuidance/
HumanResourcesAndTraining/Model
Employer/ImprovingWorkingLives/fs/en
Or: www.dh.gov.uk/assetRoot/04
/08/42/65/04084265.pdf
Improving Working Lives for
Ambulance Staff For a copy of the
document email doh@prolog.uk.com
quoting reference 40206 or at the
Department of Health website at
www.dh.gov.uk/PublicationsAnd
Statistics/Publications/PubliationsPolicy
AndGuidance/fs/en
Or view at
www.doh.gov.uk/assetRoot/04/08/
46/16/04084616.pdf

Improving Working Lives: Practice

Plus National Audit Instrument
Hard copies available from the NHS
Response Line on 08701 555 455 or
via the Department of Health
website at
www.dh.gov.uk/PublicationsAnd
Statistics/Publications/PubliationsPolicy
AndGuidance/fs/en
Or view at
www.dh.gov.uk/assetRoot/04/08/44/
63/04084463.pdf
Health and Safety Legislation Guidance around ensuring the health and
safety legislation is implemented can be
found in the Human Resources Guidelines
for Ambulance Services, or visit the
Department of Health website
www.dh.gov.uk/PolicyAndGuidance/
OrganisationPolicy/HealthAndSafety/fs/en
Controls Assurance - The NHS Controls
Assurance project requires NHS boards to
give assurances that their organisations are
doing their reasonable best to protect
patients, staff, visitors and other
stakeholders against risks of all kinds.
Consult the Human Resources Guidelines
for Ambulance Services for guidance on
implementing the assurances or visit the
Department of Health website
www.dh.gov.uk/PolicyAndGuidance/HealthAn
dSocialCareTopics/ControlsAssurance/fs/en
Clinical Governance - Clinical governance
is the system through which NHS
organisations are accountable for
continuously improving the quality of their
services and safeguarding high standards of
care, by creating an environment in which
clinical excellence will flourish. The Human
Resources Guidelines for Ambulance
Services are useful in ensuring a suitable
system is in place. The Department of
Health website also provides useful
information
www.dh.gov.uk/PolicyAndGuidance/Health
AndSocialCareTopics/ClinicalGovernance/fs/
en
Driving Change Good Practice
Guidelines for PCTs on Commissioning
Arrangements for Emergency
Ambulance and Non Emergency Patient
Transport Services - Available on the IPAS
website at www.modern.nhs.uk/ambulance

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Best Practice Guidelines on Ambulance Operations Management

This document is also available on

the Improvement Partnership for
Ambulance Services (IPAS) website
at www.modern.nhs.uk/ambulance
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