Like the rest of the public sector, the UK Ambulance Service faces financial constraints that are unlikely to be eased in the near future. The Ambulance Services have therefore got to work smarter to consistently deliver high-quality, cost-effective services against an ever-changing demand.
A paper written in September 2014 by Hayden Newton of H. Newton Associates Ltd, entitled Mission Critical Communications in the Ambulance Service, argues that new communication technology will assist the ambulance services to do this.
Newton summarises the key issues facing the Ambulance Services and the Emergency & Urgent Care sector as:
• Improving clinical quality while improving efficiencies
• Improving patient safety
• Achieving performance against key standards for the 999 service
• Implementing cost-improvement programmes within a flat-cash budget.
He notes that all these issues are inter-related and if one starts to fall below the agreed standard it will have a domino effect on the others. Before trying to assess how new technology might help the service meet its goals, Newton argues that it is necessary to try to predict what the sector might look like in the next three to five years. He suggests:
• All Patient Transport Service contracts will be provided by the private and/or voluntary sector to reduce cost
• There will be a greater emphasis on ‘hear and treat’ rather than ‘see and treat’
• The private or voluntary sector through formal contract arrangements will respond to a greater share of emergency calls
• Clinical Commissioning Groups (CCGs) will explore the possibility of using alternative providers for the 999 Ambulance Service
• There will be a greater reliance on family carers, volunteers, neighbours and others to support older people in their homes
• HART teams will be pressured to demonstrate best value; differing views as to how they should be used may reduce the effectiveness of their response and challenge interoperability, resilience and mutual aid
• Back-office functions in Ambulance Trusts will be reviewed and reduced even further to strengthen frontline staffing budgets
• Ambulance Services are likely to reduce their reliance on the front-loaded response model, as hear and treat calls and alternate care pathways increase.
Currently, the ambulance services rely on the Airwave TETRA two-way radio network for voice communications and some data. The service allows interoperable communications with the police and fire and rescue services, which also use the Airwave service.
It should therefore be noted that an increased reliance on the private and voluntary sector, which does not have access to the Airwave network, will reduce interoperability and effective communications with the ambulance services.
Newton argues that new technology has a major part to play in enabling the modern ambulance service of the future. Requirements fall into four broad categories:
Mission critical voice and mobile data communications
The delivery of exacting and very demanding performance standards for Ambulance Services depends on the rapid transfer of live computer-aided despatch (CAD) data to 999 vehicles while they are on the move.
Therefore, the speed of data transfer and coverage is critical between the emergency operation centres (EOC) and frontline clinical resources. Air-to-ground and sub-terrain coverage are also essential requirements.
A useful future development would be for clinicians to know where other vehicles are in a sector and for what calls they have been deployed. This would enable a more effective deployment of resources. Newton acknowledges that this facility is available on the TETRA system, but it is used reluctantly because of cost.
Vehicle and body-worn video technology
There is currently no live streaming of data to an EOC in place for ambulance services. The introduction of live video treaming from the field would provide useful information for service managers and commanders.
In addition, a significant amount of 999 calls are responded to by a single response vehicle, which will assess the patient and decide on the best care pathway to use. Body-worn video cameras will help the clinician link the patient to a more senior or specialised practitioner, so that telemedicine can be undertaken. Cameras will also aid staff safety.
Telemedicine/video technology: clinician to clinician communications
A challenge to health and social care providers serving large and remote rural areas with a dispersed population is in getting the right care in the right place at the right time.
The development of remote-working telemedicine/video links between clinicians and also social care service providers will improve the service to patients and reduce the number of admissions to hospital. Links could also be established between frontline paramedics and major trauma centres.
Taking back-office functions to the frontline
Ambulance paramedics rarely return to their base stations these days, but paper records still dominate the sector and these are audited, reviewed, filed and retained in a number of back-office functions at either base stations or head offices.
Services could be streamlined and admin costs reduced by using electronic forms on handheld mobile devices. A device could contain clinical guidelines, patient assessment and referral forms, non-conveyance form, list of alternative care pathways, business emails, ongoing update training and access to all current policies and procedures.
It should also be able to access all hospital, health and social care and GP services.
Interoperability between ambulance services using TETRA and private and third-sector ambulance providers (who tend to use mobile phones) would be greatly improved if the latter could access Ambulance Service communication systems and be visible on the CAD and EOC.
LTE enabling technology
The most obvious enabling technology for all the above is the 4G LTE radio standard, which can handle far more data, far more quickly than TETRA – including live streaming of video.
Newton rightly points out that LTE has not been developed to meet mission-critical requirements – this is being worked on by the standards bodies such as 3GPP, but is not expected to be fully incorporated into the LTE standard until 2018 at the earliest, quite possibly not until 2020 or later.
Newton also notes that the ‘industry is lobbying for dedicated spectrum to ensure that blue light users do not have to fight for bandwidth at times of critical operational or safety need’.
Newton does not allude to the government’s current Emergency Services Network (ESN) tender procedure to replace the emergency services TETRA network with a 4G-based service from 2017. It should, however, be noted that the government’s plan is to move the service onto a commercial mobile phone operator’s network, forcing the emergency services to share bandwidth with millions of UK subscribers.
Nonetheless, Newton observes that once LTE is developed as a mission-critical application it will provide considerable opportunity for ambulance services to transfer even more data quicker to and from other providers and across the other blue light services improving interoperability and crew safety at large or major incidents.
He adds that data transfer and enhanced voice quality will assist lone workers in health and social care to access the right services in the right place at the right time, improving the clinical outcomes for patients.
He believes one of the biggest beneficiaries will be patients and staff in rural and remote areas of the UK, where travelling distances to hospitals are greater and transport may not be available or appropriate.
However, he does point out that these are the very areas where mobile network coverage is poor or even non-existent – hence the need for dedicated spectrum. The government has insisted that ESN’s 4G coverage will match Airwave’s geographic coverage.
Newton concludes his paper by saying: ‘Often ambulance leaders have little time to reflect on what has been achieved as they manage a multitude of issues on a day-to-day basis. But we should not lose sight of the tremendous progress made around clinical training and education, vehicle design, mutual aid, resilience and emergency preparedness.
‘An underlying thread to all of these and many more is the development and implementation of mission-critical communications through TETRA, in terms of any future change we must not allow coverage, resilience, interoperability and patient and staff safety to be compromised.
It is a duty of care.’
Hayden Newton is an independent consultant working at times for Airwave Solutions as a strategic advisor. He was CEO of the East of England Ambulance Service for six years until early 2013.
Prior to his appointment he was the National Implementation Lead at the Department of Health on the development and implementation of ambulance performance standards.
He is also a former chief executive of Kent Ambulance Service and an ambulance paramedic on frontline duties.