Ambulances and management

BMJ 1995; 310 doi: (Published 21 January 1995) Cite this as: BMJ 1995;310:150

Any general practitioner who does night calls will sympathise with the ambulance staff quoted in last week's report on the London Ambulance Service (see p 147). Among the “inappropriate” emergency calls ambulance crews responded to were someone with an eyelash in his eye, a woman (described as a model) with a broken fingernail, and a man with a stubbed toe.

The inappropriate calls—and, probably more importantly, the lack of a means of assessing requests for emergency ambulances—are just one of the factors that emerged in the report as a cause of the poor service that the London Ambulance Service currently offers the capital's citizens. This is not the first report on failures in London's ambulance service.

Last year another report documented the collapse of a new computer aided dispatch system, and, despite measures to restructure the management and respecify the computers set in train after that report, it is clear that all is still not well in London's ambulance service.

The specific incident that led to the setting up of this review was the death of a young girl in east London following the failure of an ambulance to attend for 53 minutes despite several calls from the girl's distraught family. The report, written by a team of three who spent seven weeks visiting ambulance stations in London and elsewhere in Britain, riding with crews, sitting in the ambulance control centre, and talking to staff, lists chronologically what happened on the evening of this event. The picture that emerges is of a much bigger demand than usual. This demand simply broke the back of a system that was ramshackle and undermined by absenteeism, cumbersome processes, lack of technology, and a lack of trust between management and staff. Indeed, the report itself draws the conclusion that “very few people… got a good service from the London Ambulance Service that evening.”

Sadly, reports of inquiries into things that have gone wrong usually make fascinating reading. Apart from a few cases where blame can unequivocally be attributed to individuals, the pattern that often emerges is of a whole system that fails—both its staff and its “customers.”

Failure of a system sounds like trying not to blame anyone, but it takes pretty exceptional individuals to influence events in rotten systems. The review of the London Ambulance Service pays tribute to the vast majority of staff who take a professional pride in their work, but it is clear that they have not been well served by a management structure that has hampered decision making, including investment, and a management style that has not allowed clarity of purpose or encouraged teamwork between controllers and ambulance crews. Indeed, the report criticises the “blame culture” that has been allowed to grow within the service. For this reason many of the report's recommendations concern the way the service should be managed, though the review team gives credit to many of the changes set in train following the previous review.

Doctors are often sceptical of management, and often rightly so when it is clumsy, but reports such as this on systems that go wrong highlight above all a lack of management. George Orwell said that good prose was like a window pane: not only shouldn't it block the view, people shouldn't really notice it was there. Good management should share the same characteristics. When it doesn't things can lurch from bad to worse—despite the best efforts of individuals.—JANE SMITH, BMJ

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