By Professor Leo McCann, Professor Ian Kirkpatrick, Dr Tina Kowalski, Dr Shuyi Liu
The NHS emergency and urgent care system in England is currently in a process of transition. Consisting of 11 ambulance trusts and nearly 200 hospitals, the service is under immense operational pressure. Nevertheless, our research focusing on two Ambulance Trusts (funded by The Health Foundation), highlights some emerging, but still fragile, signs of recovery from the post-pandemic crisis.
This recovery is largely attributed to organizational innovations at both national and trust levels that have bolstered capacity. However, a fundamental tension remains: the system is still largely evaluated against an Emergency Medical Services (EMS) model designed in the 1960s for rapid trauma response. This legacy persists, despite the fact that much of current demand has shifted toward unplanned primary care and complex mental health needs.
From our understanding, the term ‘pre-hospital’ no longer accurately describes half of ambulance activity. Data shows that approximately 18% of 999 calls are resolved via telephone (‘Hear & Treat’), and 30% are resolved on-scene (‘See & Treat’), meaning only about 50% of patients are actually conveyed to A&E. Despite this shift, the service remains tethered to somewhat rigid response time targets, specifically the Ambulance Response Programme (ARP) standards. Trusts consistently struggle to meet the 7-minute standard for Category 1 (life-threatening) calls and the 18-minute standard for Category 2 (serious) calls, with current averages for the latter hovering around 30 minutes. Research participants noted that Category 2 is often too broad, leading to dispatch decisions where speed may not be clinically relevant upon arrival. This mismatch between system design and modern patient usage suggests that performance evaluation metrics are increasingly problematic and may not reflect true clinical effectiveness.
Our research revealed that management and leadership capacity are critical to service delivery, yet these functions are often neglected. Encouragingly, the studied ambulance trusts reported reaching full employment for the first time in recent memory, allowing them to proactively address long-standing cultural issues like bullying and harassment. These trusts have also invested in raising professional standards by appointing more managerial staff at Band 7 and 8a. Both have implemented ‘Team-Based Working’ to reduce the span of control for managers from over 30 direct reports to approximately 15. Furthermore, the introduction of the ’Transfer of Care’ policy, which mandates a maximum 45-minute window for handing over patients to hospitals, has significantly reduced the chronic issue of ambulances queuing for hours outside A&E departments, thereby improving both community response availability and staff morale.
The clinical capabilities of Emergency Operations Centres (EOCs), dealing with 999 and 111 services, have also been augmented. By employing senior clinical advisors and navigators to work alongside dispatchers, trusts have improved the accuracy of call prioritization and reduced the proportion of clinically inappropriate callouts. This is complemented by new patient-facing initiatives, most notably in mental health. Following the ‘Right Care Right Person’ policy, which reduced police involvement in mental health calls, ambulance services have innovated with new services. These include Mental Health Response Vehicles staffed by paramedics and mental health nurses and a new training route for specialist mental health paramedics. These specialized units allow for more appropriate treatment pathways and referrals to community teams rather than default transportation to A&E. While successful, these innovations often rely on the individual commitment of managers and clinicians and face an uncertain future because their impact is difficult to measure against traditional Category 2 response targets.
Despite these localized successes, the system faces persistent and overwhelming challenges. Significant variation exists in how different hospitals manage patient handovers, with some units gaining reputations for being notoriously slow or poorly managed. Even with the ‘Transfer of Care’ policy, the lack of clinical capacity in overcrowded A&E departments means ‘medium-risk’ patients still face long waits on trolleys or in corridors after being handed over by crews. These pressures have placed immense physical strain on the system. In one of our cases a specialist emergency unit designed for 140 daily attendees now regularly handles 400. This environment contributes to a crisis in staff wellbeing, with high rates of sickness, depression, and ‘moral injury’ occurring when clinicians feel they cannot provide the standard of care required. Technical integration also remains a hurdle. In particular, the transition to shared platforms for 999 and 111 services—described as a “monster” of a transformation project—is straining managerial capacity and risking staff burnout.
A key recommendation of our research is to stress that investment in managerial capacity must be protected and even augmented. Recent national directives to cut corporate ‘overheads’ across the NHS are likely to be debilitating and could hamper complex system redesign. There is also a clear need for a defined national strategy that moves beyond the ‘obsession’ with Category 2 response times and instead asks what the role of the ambulance service should be within the broader urgent and emergency care ecosystem.
To conclude, despite improvements, weak strategic and financial planning ensures that the current provision of emergency healthcare is uneven and fragile. Without a clear understanding of who sets the standards and how the interests of diverse stakeholders—from the police to Integrated Care Boards—are balanced, the system will remain in a state of organic, contingent evolution. In our opinion a clear national strategy and sustained investment in managerial capacity is urgently required. Otherwise, NHS ambulance service risk being trapped in an outdated emergency model that no longer meets the complex demands of modern patient care.