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Leadership/Management

EMS Around the World: In Wales, Honesty Is the Best Policy

1809 ESMAtW Wales

Wales is one of the four countries that comprise the United Kingdom. A proud Celtic nation with a distinct heritage and cultural identity, Wales is in many parts sparsely populated, with large areas of beautiful but rugged terrain including two mountain ranges and three national parks. Wales even has its own language, which is spoken by 20% of the population and is the first language in parts of northwest and western Wales. 

At 8,000 square miles, Wales is a fraction bigger than Massachusetts. Its population of 3.1 million is served by a single ambulance service: the Welsh Ambulance Service Trust (WAST). This is a huge service by U.S. standards (the U.S. has around 15,000 services providing emergency responses to a population of around 326 million—22,000 people per service) but not unusual in the U.K., which has just 14 ambulance services within a 9-9-9 system that serves a population of 66 million. WAST is a medium-size ambulance service in U.K. terms. 

In Wales like the rest of the U.K., healthcare is provided on a universal-coverage basis by the National Health Service (NHS), funded via taxation and free at the point of use. This includes EMS: 9-9-9 ambulance services are free for all who need them. 

Welsh EMS: A History

The development of EMS in Wales mirrors the rest of the U.K. From ad hoc local arrangements (e.g., 200 years ago, a horse and cart were used to transport injured slate miners in Bangor, although later in the 19th century, hospitals were built right up in the slate quarries) ambulance services became the responsibility of local medical boards or the police. Later in the 20th century, ambulances were built by Daimler on a concrete floor for improved weight and stability, and if the doctor deemed an ambulance essential, the local mechanic would be summoned to drive the patient to the hospital.

With the creation of the welfare state after WWII, provision of ambulance services became the responsibility of local authorities (i.e., town/regional councils) in 1948, then transferred to the auspices of the NHS in 1974. At that point Wales had five separate regional ambulance services. These were amalgamated to a single service 20 years ago. 

The clinical capability of EMS in Wales has steadily increased. From 1948–1974, local authorities provided only transport and basic first-aid capability. Post-1974, once EMS was brought into the NHS, clinical training and competencies were boosted by the so-called “Miller training,” which included more in-depth knowledge of anatomy/physiology, medicine, and even light rescue (every ambulance station of the era had at least two Neil Robertson stretchers). Concurrently, and especially during the 1970s, the Institute of Certified Ambulance Personnel offered voluntary additional training to a higher level, and talking to veteran EMS staff, it’s clear that building professional pride was important in an era when “ambulance drivers” were still classified as manual workers by their own union. 

Paramedics arrived in the U.K. in the mid-1980s. At this point Miller training morphed into a new national technician training program. Paramedic training was also standardized on a U.K. level, but the actual implementation of this training (and drugs that were carried) varied between services and was determined locally. 

Today WAST is a largely paramedic-delivered service, supported by technicians, with clinical capability comparable to other NHS ambulance services and equipment arguably ahead of the pack. The default clinical guidelines are those of the Joint Royal College Ambulance Liaison Committee (JRCALC), and according to WAST’s assistant medical director, Dr. Jon Whelan, “Our crews are expected to adhere to them unless we say otherwise.”

Wales also has a higher tier of EMS capability in the form of its HEMS service, EMRTS Cymru (the Welsh Emergency Medical Retrieval and Transfer Service). EMRTS has full mobile critical care capability, with onboard physicians and critical care practitioners (mostly from a paramedic background or possibly nurses). The clinical staff are NHS personnel, but the aircraft on which they operate are provided by a charity, the Welsh Air Ambulance, and once again the service is free. There are three first-response EMRTS bases, each with an Airbus H145 T2 aircraft, plus a transfer aircraft. 

Call Responses

Call-handling and dispatch for WAST take place in three control rooms. MPDS v13.1 (which will be familiar to many U.S. readers) is the call-handling interface, with a dispatch cross-reference table that converts MPDS codes into call priorities. 

The U.K. has had an eight-minute target for ambulance response time to highest-priority calls for more than 40 years. In Wales 65% of such calls should have an asset on scene within that interval. Historically, chasing this target has skewed how U.K. ambulance services configured their operations, with fast-response cars being used to “stop the clock” and hit the eight-minute target. Unfortunately, cars can’t convey stretcher patients, so an emergency ambulance was required as well, tying up two assets per call. 

A few years ago WAST was one of the first U.K. ambulance services to reconfigure its model to one more suited to a modern urgent-care service, recognizing that a very small proportion (around 5%) of 9-9-9 calls represent immediately life-threatening complaints. “We wanted a clinically honest model,” says Whelan, “that stopped focusing on clock-stopping and instead aimed to get a 9-9-9 patient the right asset the first time, in a clinically appropriate time.”

Hence, since 2015 WAST’s call prioritization system has differed from the rest of the U.K.'s. There are still five priority levels, but by reducing the number of jobs requiring two assets, asset availability has improved, and crews are reaching the highest-priority calls more quickly. “Prior to 2015, an average of 1.4 assets were tasked to each 9-9-9 call,” Whelan says. “This has now fallen to 1.2, which makes a big difference when we are answering around 450,000 emergency or urgent calls each year.” 

Like all ambulance services in the developed world, WAST is wrestling with increased demand in terms of call volumes, the effects of demographic change, and ever-rising patient expectations. The same factors are affecting hospitals: ED crowding results in delayed handovers as ambulances queue at the front door (familiar to those in the U.S. as “ramping”) waiting to offload. WAST loses many thousands of ambulance hours from the road in this way. 

There are political influences too. Healthcare in Wales is the responsibility of the devolved Welsh government, not the (U.K.’s) Westminster government. However, the Welsh government currently has no tax-raising powers and relies on a block grant from Westminster. Hence, austerity policies of the Westminster Tory government have resulted in large cuts in both NHS and social care budgets in Wales as well as England, exacerbating service challenges. 

On the other hand, when it comes to actually spending money on the NHS, the close and direct links between the health minister and senior NHS clinicians in Wales (including within WAST) facilitate service development enormously. The wholesale change in WAST’s call prioritization categories in 2015 was introduced in only four months “based on a group of experts applying common sense,” whereas England is now trialing something that looks remarkably similar but had to wait two years for full scientific appraisal of available evidence. Commissioning of EMS is done collaboratively between WAST and the Welsh government and is much simpler than the multiple commissioning partners with which most English ambulance trusts contend. 

Other Challenges

The geography of Wales brings with it logistical challenges that have remained unchanged since Welsh EMS began and will be familiar to anyone running EMS in sparsely populated areas: the effects of rurality, distances involved, and prolonged job cycles. In addition, Whelan identifies rising demand and rising public expectations as his biggest challenges. WAST’s director of operations, Richard Lee, mentions demand increases and frailty too, but also “the lack of 24/7 alternatives to conveyance in primary and community care, dispersed families, fuel prices, and lack of in-vehicle technology.” With a fleet of more than 700 vehicles, diesel and upgrading equipment doesn’t come cheap!

WAST has embraced being an integral part of the Welsh NHS’s urgent care service, not just a clinical transport system. Its nonconveyance rates—historically among the highest in the U.K.—are currently around 60%, with 7.5% of calls closed at the “hear and treat” stage and the remainder assessed face to face. But with hospitals bursting at the seams and increasing recognition of the harms of hospitalization in elderly patients, WAST is upgrading a proportion of its paramedic workforce to advanced paramedic practitioners. APPs have an MSc in advanced practice and are trained to assess and diagnose in the medical model, as well as carrying a wider range of drugs (including antibiotics)—for U.S. readers they’d be akin to some community paramedics. 

The Next Chapter

It is clear that WAST is committed to shaping its service into what is really needed by the population. Linkage between WAST patient clinical record data and hospital data, undertaken retrospectively, is available for about 85% of calls. This recently available feedback loop offers tantalizing possibilities to further refine prioritization of calls but is only just starting to be explored. 

The author would like to thank Alan Murray (WAST CEO, 2006–2010), Dafydd Jones-Morris (retired as WAST director of operations in 2012 after 40 years in the service), Dr. Jonathan Whelan (WAST assistant medical director), and Richard Lee (WAST director of operations) for their assistance preparing this article.   

Linda Dykes, MBBS (Hons.), is a consultant in emergency medicine at Ysbyty Gwynedd (Gwynedd Hospital), Bangor, Wales, and a member of the EMS World editorial advisory board. 

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