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This chapter identifies the serious issue of the mental health and wellbeing of English paramedics working in the emergency ambulance service. It identifies the case of the extant top-down performance measurement regime and the absence of indicators of wellbeing in ambulance performance reporting. The impact of such measures on frontline staff and the implications for their motivation and commitment are also documented. More decentralised, open and discursive approaches to performance management in the public sector are advocated as key methods for re-imagining ambulance and wider public services in a global context.

Drawing on relevant literature, the chapter provides the context of the English ambulance service and the challenges it faces with reference to the New Public Management (NPM) and New Public Governance (NPG). Key issues concerning performance metrics and staff wellbeing and welfare are then identified and discussed. The notions of communicative rationality, deliberative democracy and agonistic pluralism are introduced as a framework for analysing the state of both wellbeing and resilience and the performance regime within the English ambulance service. The chapter relates these themes to the re-imagining of public services internationally, proposing a more participative and discursive approach.

It is desirable for the evaluation of public services to include the wellbeing of the healthcare provider, as well as the public service recipient. Additionally, there is a case for greater participative and dialogic engagement to address the intertwined relationship of ambulance staff wellbeing and the performance management regime of the service. The process should be revised, therefore, to take into account the wellbeing of ambulance staff as an integral and intrinsic part of the delivery of the service, and it is recommended that deliberative methods of participation are deployed in reimagining ambulance services and public services more generally.

The challenges facing ambulance services and, more generally, health services globally continue to proliferate and intensify. They are exacerbated by foreseeable contextual challenges such as the demographic profile of patients and service users and budgetary cuts. Traditional and more recent NPM approaches are proving inadequate for this challenge and appear unsustainable in practice. The lack of acknowledgement of welfare indicators in the performance metrics make them unfit for purpose. Our suggested discursive approach would help to re-imagine the service by improving its sustainability and resilience in parallel with the improved wellbeing and personal resilience of the people who provide the service.

Review of major policy paper in relation to the ambulance service [in England] efficiency and productivity with reference to observed “unacceptable variation”.

Critical review of ambulance service/EMS policy approach in England.

Lord Carter’s review describes failings in performance of UK ambulance service/EMS. However, the identified failings are essentially a repetition of many almost identical similar findings. There is a tendency of policy in respect of the ambulance service in England, as exemplified by Lord Carter’s report to consider analysis of the problem a more significant task that actually addressing the shortcoming defined.

This viewpoint comment piece is produced as a viewpoint with all the attendant limitations implied in this approach. However, it has been produced from an informed position.

Challenge to current UK ambulance policy. Previous repetitious finding need to be addressed definitively.

The efficiency of UK ambulance services/EMS is seriously impaired, and indeed these findings have been acknowledge previously. However, little by way of active remediation has been attempted. The current approach as exemplified in Lord Carter's recent review appears to ensure that analysis of the long- standing problems that exist is sufficient and possible preferable to active remediation and improvement.

No previous critical review of this type has been attempted (as it would be career-limiting).

There is a growing academic interest in the examination and exploration of work intensification in a wide range of healthcare settings. The purpose of this paper is to explore the differing staff perceptions in emergency ambulance services in the UK. It provides evidence on the challenges for the paramedic professionalisation agenda and managing operational demands and work intensity in emotionally challenging circumstances, with significant implications for patient safety.

Drawing on the evidence from an empirical study in a large National Health Service ambulance trust in England, this paper examines the challenges and differing staff perceptions of the changing scope and practice of ambulance personnel in the UK. Amidst the progress on the professionalisation of the paramedic agenda, individual trusts are facing challenges in form of staff attitudes towards meeting performance targets, coupled with rising demand, fear of loss of contracts and private competition.

Research findings highlight differing perceptions from various sub-cultural groups and lack of clarity over the core values which are reinforced by cultural and management differences. Need for greater management to explore the relationship between high sickness levels and implications for patient safety including the need for policy and research attention follows from this study. The implications of work intensity on gender equality within the ambulance settings are also discussed.

Ambulance services around the world are witnessing a strain on their operational budgets with increasing demand for their services. Study evidence support inconclusive evidence for patent safety despite the growing specialist paramedic roles. Organisational implications of high staff sickness rates have been largely overlooked in the management literature. This study makes an original contribution while building upon the earlier conceptions of work intensification.

The study findings have significant implications for the ambulance services for better understanding of the staff perceptions on work intensity and implications for patient safety, high sickness absence rates amidst increasing ambulance demand. Study findings will help prepare the organisational policies and design appropriate response.

Societal understanding about the organisational implications of the work intensity in an important emergency response service will encourage further debate and discussion.

This study makes an original contribution by providing insights into the intra-organisational dynamics in an unusual organisational setting of the emergency ambulance services. Study findings have implications for further research inquiry into staff illness, patient safety and gender issues in ambulance services. Evidence cited in the paper has further relevance to ambulance services globally.

The Occupational Stress Indicator (OSI) was used to investigate job stress in an ambulance service in the north‐west of England. Seven different aspects of the stress‐strain relationship were assessed and the findings compared with those from the fire service. Ambulance service employees were found to be experiencing major stress outcomes of low job satisfaction and poor mental and physical health. Fire service employees revealed significantly poorer physical health. Assesses the sources of job stress, type A behaviour, locus of control and coping styles and discusses them in the light of change in the public services.

The purpose of this paper is to apply agent-based modeling and simulation concepts in evaluating different approaches to solve ambulance-dispatching decision problems under bounded rationality. The paper investigates the effect of over-responding, i.e. dispatching ambulances even for doubtful high-risk patients, on the performance of equity constrained emergency medical services.

Agent-based modeling and simulation was used to evaluate two different dispatching policies: first, a policy based on maximum reward, and second, a policy based on the Markov decision process formulation. Four equity constraints were used: two from the patients’ side and two from the providers’ side.

The Markov decision process formulation, solved using value iteration method, performed better than the maximum reward method in terms of number of patients served. As the equity constraints conflict with each other, at most three equity constraints could be enforced at a time. The study revealed that it is safe to over-respond if there is uncertainty in the risk level of the patients.

Further research is required to understand the implications of under-responding, where doubtful high-risk patients are denied an ambulance service.

The need for good triage system is apparent as over-responding badly affects the operational budget. The model can be used for evaluating various dispatching policy decisions.

Emergency medical services have to ensure efficient and equitable provision of services, from the perception of both patients and service providers.

The paper applies agent-based modeling to equity constrained emergency medical services and highlights findings that are not reported in the existing literature.

Telephone triage or hear and treat (H&T) describes the process of UK ambulance services nurses and paramedics undertaking enhanced telephone assessments of patients to determine the most appropriate response, which can sometimes result in no ambulance being sent. Given, however, that 999 is not considered an advice service, it may be reasonable to assert that the expectation of those calling 999 is always an immediate ambulance response. This may not always be realised and may affect patient experience. The purpose of this paper is to ascertain the following: to what extent are the views of UK ambulance telephone triage service users being gathered? In answering this research question, this review also aims to explore the findings to determine service users’ expectations of ambulance telephone triage and the possibility that these expectations are influenced by the UK media. The findings of which could be used to inform the need and nature of future research.

Phase one consisted of a computerised literature search of online databases CINAHL, Pubmed, Science Direct, Cochrane library, Web of Science and UK government-funded databases. Phase two consisted of searches of all UK ambulance services websites and the submission of freedom of information requests. Phase three consisted of a computerised literature search of the ProQuest international news-stream database.

A total of 78 results were identified and after further screening 34 results were excluded, leaving 44 for final review. The extent to which users experience of ambulance service telephone triage are being gathered is low; and often limited to one off pieces of non-peer reviewed work. Patients felt overall that they were treated with respect, dignity and care. However, being listened to, reducing anxiety and a need for prompt assurances remain important to those whose overriding expectation is that an ambulance should attend every time a 999 call is made. There appears to be a balanced media portrayal of H&T with the UK media. However, unrealistic public expectations represent a significant barrier to providing sustainable care that users consider to be of high quality.

Some user experiences may have been gathered in more broad research exercises which explored various aspects of 999 ambulance service experience. This was not included if it could not be clearly differentiated as being related to H&T and thus may have resulted in data being omitted. It was not possible to systematically search social media platforms (such as facebook or twitter) for any media results related to this search strategy; only traditional print and online media platforms. This also may have resulted in data being omitted. The inclusion of non-peer reviewed research results and grey literature represents a possible limitation to the conclusions drawn within this review. The concept of Insider Research Bias cannot be ignored within this review. The author himself practices in telephone triage within a UK ambulance service; however, this insider bias is mitigated by the clearly articulated systematic methodology and use of the Critical Appraisal Skills framework. In a similar vein, reviews of this nature are also often conducted as part of a team, to reduce bias, increase objectivity and ensure the validity of findings. This review was a sole effort, and while this is not uncommon, there were no cross checks by peers of the search terms, strategy, paper selection, exclusion criteria or data extraction. This lack of peer critique is considered a possible limitation in mitigating selection and reviewer bias.

The results of this review would suggest a need to increase the amount of research and patient feedback gathered from those being assessed and managed by ambulance service telephone triage within the UK. Ambulance services could hold regular monthly small-scale qualitative interviews with patients and families to ascertain their views, perceptions and anxieties which can then provide an up-to-date understanding of user expectations and the health educational needs of local communities. Patient feedback received directly to ambulance services or via the Patient Advice and Liaison Service could be retrospectively analysed by researchers to determine key themes of positive practice or negative patient experience. Such feedback can be tracked through time and be used as a pre and post community intervention measure, to determine any changes. Moving forward, nationally standardised research frameworks should be adopted to provide more easily collated local and national data, which can monitor improvement strategies and provide a comparison between services to aid the sharing of best practice principles.

There is no other piece of work published which has reviewed the data in this area of clinical practice within the UK.

A study of perceived sources of stress in the Devon Ambulance Service was carried out using interview and questionnaire surveys. Semi‐structured and non‐directive interview surveys were used to identify broad areas which were regarded as being stressful, while the questionnaire survey attempted to establish more precisely the levels of stress associated with different situations faced by Ambulance Service personnel. Factor analysis of the questionnaire results yielded four main elements: organisational and managerial aspects; new, unfamiliar and difficult duties/uncertainty; work overload; and interpersonal relations. The questionnaire results indicated that the most significant sources of stress were extrinsic, mainly involving the way Ambulance Service personnel were treated by other people. Based on the interview survey results, however, it is argued that the format of the questionnaire survey may have led to an underestimation of the role of intrinsic factors as a source of stress, particularly those involved with dealing with patients.

Complaints are an integral element of the quality control and clinical governance process of UK ambulance services, and form a valid and reliable way of identifying areas of practice that require improvement. The purpose of this paper is to assess to what extent such complaints and their possible causes are researched; to identify any possible areas of practice requiring further investigation.

A computerised literature search was conducted using the online databases Science Direct, Cochrane library, and Web of Science, as well as specific searches of the Journal of Paramedic Practice and the International Journal of Paramedic Practice database. Online databases were searched for peer-reviewed full research articles between January 2012 and May 2016.

A total of 125 papers were identified and after further screening 90 articles were excluded. Additional screening using the critical appraisal skills programme (2014) criterions excluded a further 21 papers, leaving 14 studies for inclusion within the review.

This review found no specific research focussing on any causes of complaints made to UK ambulance services. Moreover, no research was identified specifically investigating the top three cited themes of complaints made in the last three years. More research is required both in researching those themes of complaints already known but also determining any other possible causes of complaints made. This review has evidenced that studies investigating response times improvement strategies, ambulance staff attitudes, and educational assessments of errors, all have findings which are meaningful and valid to determining the possible causes of complaints and possible improvement strategies. Ambulance services, commissioners, practitioners, and clinical academics should endeavour to research and share causes of complaints made to improve the quality of patient care.

Untimely responses to emergency situations in urban areas contribute to a rising mortality rate and impact society's primary capital. The efficient dispatch and relocation of ambulances pose operational and momentary challenges, necessitating an optimal policy based on the system's real-time status. While previous studies have addressed these concerns, limited attention has been given to the optimal allocation of technicians to respond to emergency situation and minimize overall system costs.

In this paper, a bi-objective mathematical model is proposed to maximize system coverage and enable flexible movement across bases for location, dispatch and relocation of ambulances. Ambulances relocation involves two key decisions: (1) allocating ambulances to bases after completing services and (2) deciding to change the current ambulance location among existing bases to potentially improve response times to future emergencies. The model also considers the varying capabilities of technicians for proper allocation in emergency situations.

The Augmented Epsilon-Constrained (AEC) method is employed to solve the proposed model for small-sized problem. Due to the NP-Hardness of the model, the NSGA-II and MOPSO metaheuristic algorithms are utilized to obtain efficient solutions for large-sized problems. The findings demonstrate the superiority of the MOPSO algorithm.

This study can be useful for emergency medical centers and healthcare companies in providing more effective responses to emergency situations by sending technicians and ambulances.

In this study, a two-objective mathematical model is developed for ambulance location and dispatch and solved by using the AEC method as well as the NSGA-II and MOPSO metaheuristic algorithms. The mathematical model encompasses three primary types of decision-making: (1) Allocating ambulances to bases after completing their service, (2) deciding to relocate the current ambulance among existing bases to potentially enhance response times to future emergencies and (3) considering the diverse abilities of technicians for accurate allocation to emergency situations.

The purpose of this paper is to explore the issues around the considerable increase in emergency calls experienced by a large county ambulance trust and implications for the implementation of government policy in relation to the English National Health Service Ambulance Service.

The paper involves a literature review and the analysis of the ambulance service data based on emergency call outs, and discussions with senior ambulance and health authority personnel.

Increased calls were mainly explained by a large increase in cancellations, especially after the vehicle had arrived at the scene. The term “cancellation” is potentially misleading and may carry connotations of wasted resources. There was little evidence of inappropriate calls and no single cause of cancellations or any simple solution. Instead, a wide range of actions were included, many of which seem potentially worthwhile. However, the way the data are presented disguises their diversity and potential value. This reflects the tension between policy and practice, and organisational culture and performance measurement regime.

This is a single case study and is limited by the parameters of the data base gathered by the ambulance service as part of their normal operational procedures.

This paper gives support to the enhanced role of the ambulance paramedic and the need to recognise this changing role through a more appropriate approach to performance measurement. The present emphasis on response times and transportations to hospital may result in undervaluing activities at the scene.

The paper identifies a key area where research into policy and governance issues has been limited and presents recommendations for future analysis.