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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.

The 999 ambulance call handler is critical in responding to emergency patient treatment; however, the call handlers are often a hidden component of the healthcare workforce and an under-researched group. The objective of this study is to understand stress triggers experienced by 999 ambulance call handlers that could lead to burnout and examine personal and organisational mechanisms and strategies which reduced the risk of burnout.

A single interview case study approach applying qualitative methods was undertaken. Participants were identified through a purposive sample of 999 ambulance call handlers with the Yorkshire Ambulance Service National Health Service Trust (UK). Participants were interviewed via telephone between July 2019 and September 2019.

In total, 18 staff participated in this study. Societal factors including public incivility and media representation and organisational factors, such as a demanding environment, lack of appreciation and career progression, training issues and protocols were key stressors. Organisational well-being services were helpful for some, but for others lacked accessibility and appropriateness. Positive public feedback and speaking with peers bolstered well-being. 999 ambulance call handlers suggested that sufficient breaks, co-design or feeding back on training and protocols and creating more informal opportunities to discuss ongoing everyday stressors as methods to reduce stress and burnout.

This paper explores a previously under researched area on stressors and potential burnout in 999 call handlers. This paper highlights the need for improved organisational support services and appropriate public and sector peer recognition of the role of ambulance 999 ambulance call handlers.

The purpose of this paper is to assess the performance measurement in the UK NHS ambulance service documenting various unintended consequences of the current performance framework and to suggest a future research agenda.

The paper reviews the literature on ambulance performance targets and documents several unintended consequences of the current performance system through an in‐depth case study analysis based on interviews with Trust staff and policy experts along with observation of performance review meetings in the chosen Trust. Ethical approval for the study was obtained from a local NHS research ethics committee.

Significant unintended consequences of the ambulance performance targets based on response times have been systematically documented, which are likely to put the target under spotlight, especially that of the eight‐minute response. The current policy focus to reform the eight‐minute target by making it more stringent has the potential of jeopardising the reform agenda based on developing clinical skills of the paramedics and introducing clinical management in the service.

The paper makes an objective assessment of the sustainability of the current policy framework and identifies future lines of enquiry for further research.

This paper makes an original contribution in identifying and documenting the disjuncture between stated and unintended consequences of ambulance performance measurement, which will be of value to academics, practitioners and policy makers.

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).

The purpose of this paper is to establish if organisational factors are leading to a negative effect on ambulance personnel’s health. In recent years, frontline ambulance personnel have displayed a consistent high rate of sickness amongst healthcare workers within the National Health Service in the UK. Post-traumatic stress disorder (PTSD) has previously been cited, but organisational factors may be stressors to health.

A search of electronic databases MEDLINE EBSCO, MEDLINE OVID, MEDLINE PUBMED, AMED, CINAHL, Web of Science, Zetoc within the time period of 2000–2017 resulted in six mixed methods studies. Hand searching elicited one further study. The literature provided data on organisational and occupational stressors (excluding PTSD) relating to the health of 2,840 frontline ambulance workers in the UK, Australia, Norway, the Netherlands and Canada. The robust quantitative data were obtained from validated questionnaires using statistical analysis, whilst the mixed quality qualitative data elicited similar themes. Narrative synthesis was used to draw theories from the data.

Organisational factors such as low job autonomy, a lack of supervisor support and poor leadership are impacting on the health and well-being of frontline ambulance workers. This is intertwined with the occupational factors of daily operational demands, fatigue and enforced overtime, so organisational changes may have a wider impact on daily occupational issues.

The findings have possible implications for re-structuring organisational policies within the ambulance service to reduce staff sickness.

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.

Ambulance response time is an important factor in saving lives and is highly linked with the ambulance location problem. The Maximum Expected Covering Location Problem (MEXCLP), introduced by Daskin (1983), is one of the most used ambulance location models that maximize the probability of stratifying demands for emergency medical service (EMS) centers. Due to huge increase in the operational costs of EMS centers, ambulance location models must consider the cost of coverage and the opportunity to use other companies’ private ambulances to answer emergency calls. The paper aims to discuss these issues.

In this paper, the authors propose to extend the MEXCLP to a bi-objective optimization problem where the cost of satisfying emergency calls is minimized.

The proposed model is tested using data retrieved from the Lebanese Red Cross (LRC) in Beirut capital of Lebanon. The reported findings show significant enhancements in the results where the LRC can fully satisfy the perceived demands from all areas in Beirut within 9 min with an affordable cost.

The model is a first attempt to reduce operational costs of EMS centers while constraining the response time to satisfy emergency calls at an acceptable rate.

Mass casualty incidents are characterised by an immediate, unforeseen and unquantifiable surge in demand for ambulance services which soon becomes apparent and will exceed any “local” resources available. Casualties require the correct treatment, promptly, at an appropriate resource without incurring any further harm. In the absence of firm operational guidelines, this paper provides templates for ambulance commanders both at call centre and on-site to approach the management of mass casualty incidents.

Desk research indicated that there were both guidelines on how various elements of the emergency services should work together plus academic papers on techniques to adopt in mass casualty situations. Standing orders or written protocols for ambulance commanders, however, provide little or no specific guidance or an outline plan upon how they should command in a mass casualty situation. Following analysis of relevant public enquiry reports and discussions with ambulance commanders and using the materials from desk research, a four-stage approach was devised for testing using retrospective analysis from field and desktop exercises.

To have confidence, each commander needs simple digital real-time templates from which they understand their role and how the overall plan defines priorities with the greatest need. A plan should cover call-centre and on-site operations including a basic operational checklist from start to finish; resource structure and inter-relationships; sources and availability of resources plus information and control procedures to impose limited quality control procedures.

The design and implementation of digital templates to provide minute-by-minute visibility to all commanders which have not been recorded before. Such templates give commanders confidence to determine, locate and call forward relevant resources to attend casualties in order of priority of need. Time-lapsed records are useful not just in the minute-by-minute decision processes but also for critical organisational learning and in any post-event review by either a coroner or lawyers at a public enquiry.

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.