Overview

Yorkshire Ambulance Service (YAS) is a governmental agency providing mobile healthcare services to over 5 million people.   They respond to more than 1,300 requests for service daily utilizing over 1,900 field providers and 400 specialty vehicles.   I use the term "mobile healthcare services" purposefully because not only do they handle traditional emergency ambulance responses using the local "9-9-9" system, but they also provide in-home medical services and non-emergency patient transports.   YAS is one of eleven ambulance service trusts operating in the U.K.   Over the past few years, the number of ambulance trusts has gone from 26 to 11 in an effort to create more efficient, regionalized services - sound familiar??   Check the IOM report on the need for the U.S. to focus on REGIONALIZATION of EMS.  

In a socialized medicine environment such as the U.K., the healthcare providers are government employees and the cost for providing services to the community is almost exclusively funded through taxes.   There is no billing for the emergency services.

The experience started with my arrival at Huddersfield Ambulance Station (one of YAS' 61 stations).   The first thing that caught my attention was a prominent sign on the door leading from the crew's lounge to the ambulance bay which read that a 30 second activation time was the goal.   Upon asking one of the crew members about the sign, he explained that funding is tied to operational and clinical performance.   Reminders such as the prominently displayed goal statement help remind them of the need to continually strive to meet or exceed the performance measures.

Within moments I was greeted by Ian Firth, YAS' Clinical Leader for the day who began my "orientation" to the YAS district.  

Vehicles and Vehicle Operations

We started with a tour of the ambulances, rapid response vehicles and patient transport units.   Suffice to say that in many respects, the U.K. vehicle design is far and away superior to anything here in the States. 

RELATED PHOTOS  

The vehicle exteriors are designed for utmost visibility.   By law, the vehicles are adorned with lime-green reflective decals, overlaid with darker green reflective accents.  You can most likely see these vehicles by day or night from the Space Shuttle.   Even the interior of the doors have reflective tape (see attached photos).  

The next most interesting feature of the ambulances is the integrated steps and ramps from the rear of the vehicle.   Transport capable units are equipped with a winch as well, which makes it virtually unnecessary to lift the patient and stretcher into the ambulance.   The ambulances are relatively small by our standards due to the 'unique' roads in the U.K.   There is not a straight road in the country and the average two-way traffic road width is equivalent to our one-way traffic road width (not including the fact that everyone in the U.K. parks with one side of the car on the sidewalk and one side in the street).   This makes for very challenging vehicle operations.  

I'm convinced that the U.K. medics are some of the best drivers in the world!   During a response to an apartment fire, my friend Ian was traveling 60 - 70 kph on a street built for a single horse and buggy, passing cars and avoiding oncoming traffic while simultaneously checking the navigation/dispatch interface, talking on the cell phone, changing siren modes and shifting gears in his Range Rover (oh yea, did I mention that ALL the vehicles are STANDARD transmission!?).   Ian is my new driving hero - he got us to the scene with the decals still attached to the truck, despite the constant distraction of my right foot slamming on the floor where the brake pedal was supposed to be!

Clinical Services

U.K. medics receive much more training than our U.S. counterparts.   Their EMTs (called Ambulance Technicians) are essentially equivalent to our paramedics in function.   Paramedics in the U.K. provide much more advanced clinical procedures than we in the States (routine pre-hospital thrombolysis and a drug formulary nearly twice as comprehensive as ours for example).   In addition to the traditional EMT/Medic ambulances, NHS employs Emergency Care Practitioners (ECP).   These specialists operate out of rapid response vehicles and respond either alone, or with ambulances depending on system status (yes, they actually do system status management with "street corner posting" during busy times).   This helps assure a closest unit response.

ECPs are paramedics with significantly more training.   They are essentially akin to Physician Assistants here in the U.S.   The ECPs perform advanced diagnostics, can do suturing and prescribe medicines.   They are used to either respond to low priority calls, or come to the scene at the request of ambulance crews as an alternative to patient transport to the "Accident and Emergency Center".

Skill proficiencies are closely monitored, but quite honestly, the annual patient:paramedic ratio in the YAS is about 250:1, so these folks are HIGHLY utilized and subsequently have great proficiency rates.

Accident and Emergency Centers

By U.S. standards, you might call the U.K. emergency departments "austere", however, I would call them "efficient".   The patient rooms consist of basically a stretcher and a sink.   Specialty equipment necessary to manage cardiac, neurologic, orthopedic or other categories of emergency conditions are brought TO the patient in carts.   This prevents the need to have every room equipped for major types of emergencies.   They do have code/trauma rooms, casting rooms and specialty eye treatment rooms.   There are specialty hospital centers for trauma, cardiac and obstetrics.   Patients are taken to hospitals and specialty centers based on their clinical need, not necessarily based on their choice.

Communications Centers

YAS operates three communications centers in their district.  The center I visited was a combined "9-9-9" and NHS Direct center.   NHS Direct is the non-emergency information and referral department of NHS.   At NHS direct, callers can seek medical advice, ask for a referral to a practitioner, or request a home visit by a nurse or emergency care practitioner.  

 The three communications centers handle about 500 emergency medical calls and 5,000 Patient Transport Service (ambulatory/wheelchair/stretcher) requests per day.   They do full emergency medical dispatch with pre-arrival instructions using the Priority Dispatch, Advanced Medical Priority Dispatch System.   When I visited the Wakefield Center, there were 7 dispatchers and 6 call takers on-duty, fairly typical staffing according to the center manager.   

Doing the math that means call-takers average 13 calls handled per hour and the dispatchers average 10 calls handled per hour!   Awesome work!

Field Supervision

During my ride time, there were 2 field supervisors on duty (of course, one went home at about noon, leaving poor Ian to manage the whole district on his own for the second half of his shift).   Ian fielded calls about every 5 - 10 minutes on his ever present cell phone.   You can imagine the types of calls - vehicle and equipment malfunctions, personnel issues, staffing for the next day, dispatch concerns and vehicle placement for SSM, with a sprinkle of emergency responses thrown in (and some dang Yankee riding along who kept trying to get into the DRIVER's side of the Range Rover - the steering wheel is on the wrong side!).   He handled it all with the grace and understanding of a well skilled mentor!

Economics of NHS

Much has been discussed here in the U.S. about the state of our healthcare system, especially in the current political contest.   Some are also critical of the NHS system, but you cannot deny the outcome performance of the main indicators.

Yes, in the U.K. it might take you 6 months to get the elective knee surgery you can get in the U.S. tomorrow, but does that really matter in the overall scheme of things.  

Yes, some will argue that smaller ambulances with standard transmissions (yes, you can get car sick REAL fast in that scenario) are not as cool as F450 Type I's, but in the overall scheme of things, does that really matter?

Granted, NHS is government run, but that in itself eliminates two main disconnects with our U.S. EMS systems.   First, in the U.S. many medical directors fear malpractice concerns, thus preventing true innovation in EMS delivery.   Second, there is no incentive to bring the right services to the right patient at the right time and in the right setting.   Conversely, we are incentivized to use the most expensive mode of transportation to bring the patient to the most expensive place to receive what is in many cases, simply primary healthcare.   Just makes you scratch your head and say "Huh?"   And we wonder why the Medicare system is failing?  

Yorkshire Ambulance Service is a perfect example of a highly effective, efficient and integrated mobile healthcare delivery system.   We Yanks would do well to try and mimic many of the outstanding systems they have put in place.

Now, if they can just do something about the weather - six hours of blue sky during a six day visit - YUK!

  Author's Note:   My personal thanks to Shirley Plummer and Robert Eastwood of NHS for arranging the visit and to Ian Firth for his hospitality and insight!