The London Ambulance Service is ranked as the highly organized and the largest free ambulance service in the world. This service provides care to more than one and a half million patients every year. Its foundation stone was laid in 1930. It was administered previously by the Metropolitan Asylums Board. NHS took over the charge of this service in 1974. Presently, this service is being managed by South West Thames Regional Health Authority. It spans over the area of over 600 square miles accommodating the resident population of 6.8 million people (greater during daytime, especially in central London). Its headquarters are based at Waterloo, which are recognized as the largest emergency operations centre in Europe. Its services are broadly categorized into following units:
The daily received calls amounts to about 3000 out of which approximately 1300-1600 fall into category of emergency calls. LAS have employed over 500 people which work on shift basis. It shuttles across over 5000 patients every day.
A computer aided despatch (CAD) system is regarded as one of the latest developments aimed to increase the ambulance despatch operations. The primary command and control functions which are provided by LAS are listed below:
Call taking, accepting and verifying incident details including location.
Resource mobilisation and communication of the details of the incident to a suitable ambulance to be dispatched.
Resource identification, determining which ambulance to send.
Ambulance resource management, primarily the positioning of suitably equipped and staffed vehicles to minimise response times.
Furthermore, a CAD system will provide management information to assess performance and help in medium and long term resource management and planning.
In order to perform a variety of functions a CAD system comprises of a set of following:
CAD software.
Communication interface (RIFS).
Radio system.
CAD hardware.
Gazetteer and mapping software.
Mobile data terminals (MDTs).
Automatic vehicle location system (AVLS).
Rationale behind Development of CAD
Computer aided despatch system possesses the following features which enable it to overcome most of the discrepancies or deficiencies of a manual system:
A computer based gazetteer with public telephone box identification.
Computer based intelligence to help identify duplicates and major incidents.
Direct mobilisation to the ambulance on the completion of an emergency call thus potentially, in simple cases, achieving mobilisation within one minute.
Removal of the necessities to move paper around the control room.
Timely and (in the case of location information) automated update of resource availability information.
These advantages make a convincing case for automation.
LAS and CAD
LAS has made an endeavor to launch the computer aided dispatch system for the first time in 1980 and then with more conversions in 1991. But the operations of the CAD system stopped the proper working on the 26th and 27th of October and then later on 4th of November 1992.
There were a lot of drawbacks found in the CAD system and its ancillary infrastructure. The main problems encountered by CAD system were recorded as:
Poor interface between crews, MDTs and the system;
Need for a near perfect input information in an imperfect world;
Unreliability, slowness and operator interface.
Failure of CAD Led to Following Results
Build up of exception messages and awaiting attention list;
Slow down of the system as the lists and messages built up;
Duplicated, poor and delayed allocations;
A high number of call backs and delays in telephone answering
The
Useful Lessons
The fiasco of operations of CAD in London Ambulance Services cemented the fact that the Computer Aided Despatch (CAD) system and its users were at the risk of disruption of services on the key stipulated dates. So, it is paramount that all the major stakeholders e.g. management, trade union representatives, staff and the service's information technology advisers should be involved in consultation for the development of a strategy for the future of computer aided despatch within the London Ambulance Service.
The following pitfalls can be considered as the main causes behind the malfunctioning of the CAD:
The CAD software was not perfect, neither was it properly polished nor fully tested. The pliability of the hardware under a full load had not been verified.
There were outstanding issues concerning with the transmission process of data from to and fro the mobile data terminals.
The precision and accuracy record of the 'Automatic Vehicle Location System (AVLS)' wasn't groovy.
The fall back option to the second file was not verified properly.
The sheer dependence on the only use of computer generated resources on that day was highly risky.
The management of LAS sunk into oblivion of taking care of adaptation or modernization of services as demanded by challenging situations.
Employees, both within Central Ambulance Control (CAC) and ambulance crews, were not provided the full training which resulted in the loss of confidence in the system.
The strained and strenuous relations between the management and five recognised trade unions.
Inadequacy of resources to provide the services as demanded by purchasers.
Lack of proper forecast system to estimate the implications of inaccurate or incomplete data available to the system (late status reporting/vehicle locations etc.).
Poor communications between staff and staff associations and senior LAS managers led to the development of atmosphere of mistrust.
LAS Board was not aware of the right information about the exercising of responsibilities devolved on it by South West Thames RHA for the routine-wise management of the LAS.
Several managers and staff commented on the deadlines set by the top management as rigid and inflexible.
The Rapid Response Units (RRUs) were not appropriately enforced owing to unavailability of required funding.
SOLUTIONS || Computer Aided Despatch Recommendations
CAD system must be consistent with the following imperatives:
It must be launched and developed in a timescale while having a complete understanding of the requirements for earliest introduction, should also accommodate the opportunities for testing, consultation, assurance of quality along with suitable training.
Management and staff should demonstrate the reasonable level of confidence in the consistency of operations of the system.
The reliability and flexibility of the system must be assured with full verification and testing protocols along with fully tested levels of back-up.
Full ownership should be delegated to management and staff, both within CAC and the ambulance crews.
No stone should be left unturned in order to improve the quality and level of the provision of ambulance services.
The launching of new systems should be made stepwise and the advantageous steps should be introduced first.
Project Subcommittee of the LAS Board should be established.
LAS must employ an IT Director should be appointed by LAS, who will supervise the system; and should be provided direct access to the LAS Board.
A protection should be guaranteed to current or potential investors in the system
CAC staff must be provided proper training relating to operations of system to make sure that they are well-acquainted with its characteristics and can run the system in a wholly consistent and well-trained way.
The services of highly qualified and experienced project manager should be hired immediately to oversee the implementation plan of the proposed stage of CAD.
Management and Operations Recommendations
The following main recommendations for the management and operation of the LAS are presented below:
LAS management should given the due consideration to its most valuable asset such as its staff and credibility among the investors.
Further restructuring of management should be taken into account by reducing the span of control of some Executive Directors and by enforcing an effective level of management, with devolved responsibility for decision-making.
The introduction of recognized uniforms to all levels of operational and control management.
The nomination of the trade union membership would be made by trade union; and members should be accountable to trade unions.
A "planned vehicle replacement program" must be carried out properly.
The basic needs of manpower of LAS should be fulfilled to achieve the real motivational level in them towards the goals of LAS.
A second tier of divisional joint committees can sort out issues of divisional commitments at the lowest possible level.
LAS should develop the necessary management information on urgent basis which will work in the absence of early information arising from the CAD system.
LAS must strengthen its HR department which should develop resourced training strategy for crews, CAC staff and management.
Accountability of Executive Directors before the Board Chief Executive must be assured.
All the assigned functions, roles and commitments of the Chair and non Executive Directors on the LAS Board must be consistent with the members of the Board and the South West Thames RHA.
The Chief Executive should be responsible before LAS Board for their actions.
The corporate objects should govern the development of personal aims and objectives of the Chief Executive, Executive Directors and senior managers; this consensus exists between the LAS Board and South West Thames RHA.
LAS must provide basic knowledge and information to the main stakeholders about the performance levels in respect of 999 telephone answering times, activation percentage within three minutes, response percentage within 8 minutes and response percentage within 14 minutes.
LAS management must follow an open approach towards regular meetings with the media and other outside bodies and should accept the positive criticism with the aim to resolve the issues raised by them.
LAS should take a considerable effort in answering complaints pertaining to permanent staff coached in the complaints procedures, backed by the essential administrative support.
False reports in media pertaining to alleged patient deaths due to serious CAD breakdowns must be discouraged.
Conclusion
In sum, personal and contextual, it appears that by following the above mentioned recommendations LAS can successfully implement CAD without any fear of future breakdowns. However, it is shown in the Inquiry report that they still believe that a technological solution is required. High-reliability organisations focus on developing a culture of avoiding failure. Also they should learn from failures rather than keep trying to diverting blames to each other.
