Ambulance Insights
In this short series, hosts Lindsay Mackay ASM and Han-Wei Lee ASM explore the disparities between rural and metropolitan emergency medical services. The series aims to unpack the complex issues affecting care delivery across different geographies and share strategies to improve equity and access.
Ambulance Insights
Beyond Borders: Improving Global Patient Outcomes
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How do we bridge the gap in global ambulance care? From differing service models and overlapping jurisdictions to the realities of workforce distribution and remoteness, these challenges create disparities in access - and we’re asking the big question: how do we improve outcomes for patients worldwide?
This episode we’re doing things a little differently, bringing you a global panel of three incredible voices live from the CAA Congress:
- Jason Killens, - CEO London Ambulance Service NHS Trust, AACE Chair
- Jordan Emery - CEO, Ambulance Victoria
- Nick Nudell, Executive Director, Northeast Colorado Emergency Medical and Trauma
Together, they dive into the multifaceted challenges and opportunities shaping ambulance services across diverse geographical landscapes.
Brought to you by Corvanta and the CAA.
We have to change the way we deliver services to meet the needs of consumers, not meet the needs of ambulance services. What's very interesting in the US, paramedic services or EMS, is not considered an essential service like fire service or law enforcement.
SPEAKER_01Where I'm based, the community would never accept that.
SPEAKER_00We recently did a study and analyzed geographically in the US the extent of ambulance, what we call ambulance deserts, where there is no ambulance available within 25 miles of key population areas.
SPEAKER_01What would success look like for you in ambulance in 10 years?
SPEAKER_02A safer, fairer, and more inclusive organization that delivers better health outcomes for all Victorians.
SPEAKER_03That's why you're the CEO of In this episode, we're going to do things a little bit differently. We're here live at the CIA Congress 2025 in Adelaide, bringing you a global panel discussion on the Great Divide. We've got three distinguished guests from the UK, US, and Australia.
SPEAKER_01Welcome to Ambulance Insights. Thank you so much to the three of you. So we have on our panel today we have Jason Killins, who is the Chief Executive of the London Ambulance Service with nearly 30 years experience across the sector. I feel like I'm giving your age away a bit there, Jason. I'm sorry, I'm sorry. You began your career as an emergency medical technician and you've held senior leadership roles across the UK and South Australia. Welcome, Jason.
SPEAKER_03And welcome to Nick Noodle. He's the Executive Director of the Northeast Colorado Regional AMS and Trauma Advisory Council. That's quite a mouthful, Nick. He also chairs the Emergency College of Paramedics in the United States and he remains a practicing wilderness paramedic.
SPEAKER_01Welcome, Nick. And our final panel member is Jordan Emery. Jordan is the Ambulance Victoria CEO, previously of Ambulance Tasmania CEO, with nearly 20 years of ambulance sector experience. Jordan has got leadership experience across multiple states of Australia and worked in global mental health. Welcome, Jordan. Thanks everybody.
SPEAKER_03Now sorry guys, we did have to cut down the bios a bit because it would have taken up the whole episode because you've got such uh illustrious careers. But we are going to dive straight into it now. Jason, with 10 English trusts and three national services, how do differing service models and overlapping jurisdictional boundaries impact care variation and outcomes in the UK?
SPEAKER_04Okay, so as you say, 10 ambulance services, 10 uh NHS ambulance services in England and then many uh the devolved nations, Scotland, Wales and Northern Ireland. Largely service delivery is consistent across all of those services, but I think there probably there's probably two or three things I'd just draw out. So the performance regime of each of the governments is different, so so success is measured in different ways across the four nations of the UK. Uh in Wales, where as you mentioned, I've recently come from and gone back to London. Uh, we've changed this year, earlier this year, uh the target regime with government support uh to focus much more on clinical outcomes and effectiveness rather than time as the top tier and the primary measure. So first phase of that went live uh back in the last year, and second phase of that would go live towards the end of this year. Whilst time still is important, it's the the the regiment area is now much more focused on the effectiveness and outcomes, and similar discussions are going on in the other nations across the UK. How can we adjust uh I guess the performance and target reading, the expectation of our organ of uh the provision of service in the organizations to better meet uh our patients' needs, but also improve the workplace experience for our people because you know what our clinicians know uh is that chasing a time target uh is not necessarily the right thing uh for patients, is certainly not the right thing uh in some circumstances for how we operate our services. So quite a few bits kind of changing in the UK, but but largely consistent in terms of clinical care, but how it's measured and effectiveness is measured is quite differently.
SPEAKER_03So, Jason, really interesting that um, you know, for ever in a day ambulance services are being measured on their response times. How's that conversation gone with with the public that we s that you serve in terms of focusing on changing that focus from times to clinical outcomes?
SPEAKER_04So look, I I think that the starting point has to be that you know the time-based targets for the ambulance sector uh are anchored in the 70s. Uh and in the 70s, you know, we didn't have paramedics, we didn't have defibrillators, we didn't have you know a lot of the uh interventions that are now, hardly any of the interventions which are now available for our clinicians, registered health care professionals in in most jurisdictions, uh you know, they weren't simply weren't available. So the type of care that we could provide was very different. And the conversation with communities and with politicians and other key stakeholders has been very much look, the service has evolved, our clinicians have evolved, the praxis has evolved, the care we can provide and the places in which we can provide that care have evolved. And if you think about the fact that nearly a quarter of all the emergency calls, 909 calls in Wales are dealt with by way of advice over the phone now, that's a very different service offer to the 70s when we went to everyone and took everyone to an emergency department. And so what we've said to the community is we could provide you tailored care, you know, a specific dedicated care plan for you, um, but that might not mean an emergency ambulance and it might not mean a trip to the hospital because we can provide care for you in the community, in your home, local to where your support members are, and avoid taking you to the ED. Most patients don't. I love that, thanks very much, uh, because they get a tailored bespoke service relevant directly to death.
SPEAKER_01I feel like the um the young paramedic in all of us is like really connects with what you're saying, right? Like I definitely know I could see George nodding there thinking that's what we I think in Australia we would love to be looking at, you know. But when I think about the American context with that, so you know, you obviously make come from America where we have, you know, 14,000 EMSM agencies. So how does that complicate efforts when you really want to provide that equitable care and quality of care, especially as well because that urban and rural geography must be complex?
SPEAKER_00Oh, it's incredibly complex with 14,000 ambulance services and more than a dozen different service delivery models. There's a lot of overlaps, but there's also a lot of gaps. We recently did a study and analyzed geographically in the US the extent of ambulance, what we call ambulance deserts, where there is no ambulance available within uh we used a metric of 25 miles, uh, no ambulance available within 25 miles of key population areas. And we have more than four million people that live in ambulance deserts. So they have no assured response uh for an ambulance. We have more than 5,000 counties that those 14,000 ambulance services are caring for, and in some counties there's one ambulance service for an entire county. That uh in in my region, in my area in Colorado, we have some that are entirely volunteer-based, where the service director is a volunteer, the three or four responders are also volunteers, and there are days when they're unable to respond because they're at their day job or taking care of family matters or they're just not in town. So you have uh that that end of the extreme is it we we call it an ALS paradox in the US, where in the cities where uh there are a lot more resources, there are a lot more ALS level paramedics available. And in those rural areas, there are few or no paramedics available, uh ALS level paramedics. So they're they're providing basic, very basic care and just transport to the closest hospital.
SPEAKER_01I don't think my brain can quite wrap it around some of that. That's um yeah, wow. I mean what it I mean, Jason talked about there earlier about the community. Like, how did the community accept that? Like I think about hearing as you know, well we're not here, we're in Adelaide, but in Victoria, where I'm based, like the community would never accept that. Do they accept it or is it just that's just a given?
SPEAKER_00So what's what's very interesting in the US, paramedic services or EMS, whatever terminology you want to use to describe that service, is not considered an essential service uh like fire service or law enforcement. And so in most of the US that's the case. And so there's a there are some initiatives underway now to try to change that narrative and get legislation across the 50 states to say that an ambulance service is essential for a community in a developed country and that it should be provided. But the the next question that comes up is the big concern about who's going to fund it, because our funding model is is very different, as I'm sure you're aware. We do have some uh tax-supported services, but the vast majority of the services provided as a a payment model that's based off of delivering a patient to a hospital. If you don't take the patient to the hospital, you're not going to be paid. So that's a disincentive for innovation. Right.
SPEAKER_04That's that's one of the key issues, one of the key challenges in getting incentives in the right place to provide care, the right care that we now can for patients.
SPEAKER_03And particularly with the focus, well, I mean we've just had two days of uh IRCP, it seems quite disongruous, doesn't it, that you've got this disincentive um not to put load on the system. Nick, I I'd be really interested, what's what's the reality? What's the reality for those people who, if a volunteer is not available to respond in those ambulance deserts, what's the reality for those people? Are they driving themselves to hospital? How does that work?
SPEAKER_00That's that's a very good question. Even in uh the jurisdiction where I live, we can have a two or three hour response just to get to a patient. And in in those kind of scenarios where they're very uh far away, you you'll have multiple different agencies responding. You may have a helicopter that is being dispatched there because maybe they'll get there first and be able to provide the initial care and transport that an ambulance from somewhere will be dispatched. And oftentimes the fire department, uh in those cases it's usually a volunteer fire department, so even their response is not assured, and they they will be there probably closer than the ambulance, so maybe they'll get there first and provide some stabilizing care while waiting for the the mode of transport to arrive. Wow.
SPEAKER_03That's um it uh it certainly puts things into perspective when we look look at look at things around Australia. Most definitely. Um Jordan, we've we've just heard about a quite, I guess, disparate workforce and distribution model in the US. How how does workforce distribution service models and remoteness shape disparities in ambulance across and disparities in ambulance access and outcomes in Australia?
SPEAKER_02You know, it is sort of natural to hear some of what Nick shared with us then and be shocked by that, but I don't think we should be blind to disadvantage in access to healthcare in Australian context as well. And there is a ton of literature that demonstrates that rural and remote Australians experience poorer health outcomes and that uh inequity is further magnified when you're talking about First Nations Australians. And so whilst there is a significant investment and resourcing into public sector ambulance services across most Australian jurisdictions, and then public-private partnerships with St John Ambulance in WA and the Northern Territory, even within government ambulance services, there is still disadvantage and there is still an important obligation on all of us as ambulance sector leaders to do whatever we can to address that inequity. And and Victoria is embarking on some of those important improvements in terms of the paramedic practitioner model and ways we can better support access to healthcare in rural areas, and that's a really exciting step forward for us, taking learnings from other jurisdictions like the United Kingdom. But I still think we have a way to go, and I think rural uh Victorians would tell us we have a way to go.
SPEAKER_01I think most definitely, and I think that's the key thing here. Every every jurisdiction has got in country, has got their own challenges, and I don't think we're immune to it. I don't think anyone I've seen around the world has this right. Imagine if we had a global approach. I feel like that's for another podcast, so we'll hold on that one.
SPEAKER_04It is more than half an hour to talk that one's over here.
SPEAKER_02The other thing too is that I don't think, in the spirit of true community collaboration, and in the Victorian context, the public sector ambulance service meeting the needs of community as the driver, um, and and not dissimilar to your discussion about clinical outcomes, Jason. Um, I do think, you know, I do think it's really important that we recognize that a level of localization is really important. How we meet individual needs without trying to retrofit a whole of state or whole of country approach to very unique challenges. And the story of First Nations Australia is a perfect example of that, of where it's clear that the way we deliver services, if we're serious about addressing health inequity, then we have to change the way we deliver services to meet the needs of consumers, not meet the needs of ambulances.
SPEAKER_04And I think just to develop that a bit further, if I think about my experience when I was here in SA, you know, seven, eight years ago, we shouldn't be afraid of designing and creating local service delivery models with communities in particularly rural and remote communities, because the one size fits all approach is just not going to work for you. And so we I think we as you know ambulance providers, and this is true in the UK too, need to be more flexible and open to alternative ways of delivering care in communities rather than saying you know this is a one-size-fits-all emergency ambulance approach for the whole of the jurisdiction.
SPEAKER_02Yeah, yeah. And I think I think it'll probably always be the case that there'll be boundaries around that at a system level. Yeah, yeah. And that will be important for maintaining you know um the high levels of clinical governance, safety, and quality that we will we require. But yeah, we're just different. Yeah, and we should be alive to that and we should meet the needs of the community because, in my mind, that's the sort of sacred calling of public service to serve the needs of the community.
SPEAKER_03Jordan, um, you talked about you know the disparities in Indigenous health. Is there anything in particular Ambulance Victoria is doing in terms of programs or initiatives to sort of bridge that gap?
SPEAKER_02Yeah, look, I think the sort of journey to reconciliation is a really important one in the Victorian context. We had our first uh Reflect Reconciliation Action Plan last year. We're about to embark on our second reconciliation action plan. Um, but importantly, um, we've also just had the findings handed down from the Europe Justice Commission, which is the first truth-telling process in Australia, and it's an incredibly powerful read. It is uh five volumes in total, but the fourth volume really focuses on health, and there are many stories, um tragic stories, of First Nations people uh not all that long ago being told they can't be born in the hospital uh wards, so they're born on the balconies or the doorsteps of hospitals because First Nations people weren't permitted to be within the hospital itself. And whilst some of those stories are 70, 80, 90 years old, those Australians, those First Nations Australians still carry the incredible harm from that uh racism, that rejection. And there's a lot of work to do for us as public health systems to repair that because that is that is our story, and and it's a story that is not all that far from the present day.
SPEAKER_01I think it's something we all have to be aware of when it comes to that generational trauma that people experience as well, and how we respond to that in different and new ways for sure. I feel like again, that's another topic we could go on, and I definitely know we've got to we can't do that, we can't extend the episode by a couple of hours, they'd be chasing us at the Congress. But um, if I just think back, if we just go kind of look into the future, so kind of Jason, if you were to look at how technology and collaboration work together, so if we bring them together, how do you think technology will bring, you know, bridge that gap when it comes to the services?
SPEAKER_04Well, so I mean there's clearly a role for for technology in in how we provide services now. If you think about what we're doing, you know, most ambulance services have got some kind of electronic placecard now. Most ambulance services have issued some kind of device or devices to their clinicians. You know, over the last five or ten years that's been happening. We are increasingly digitising a lot of our processes and have been very heavily relying on technology and controls, particularly contact sensors, for years to manage increasing activity and do give it in the most efficient and effective way. But you look ahead, you think, oh, so so whilst Nick's for key, AI has got been, you know, we've got a trial underway in London at the moment with uh And we've listening in and KDP uh where AI is transcribing in essentially recording. Um now, early days on the pilot, but but that's looking very positive in terms of productivity benefits and and essentially accuracy of clinically record. We've got uh a small number of uh pilots underway again in with ambient listening uh in the field, uh so so out uh uh in the back of the evenings in the patient's home, again transcribing the penalization, the creation utility record. There's conversations running about well, how can we use AI in call handling? You know, either in emergency call handling, so 90900 kind of context or potentially in the urgent care space. So I think that there are there's a number of cases, clear technologies in today's modern people say this, we're just really starting to pick at the edges if that's possible. I don't think we know yet what's possible. Um we're starting to see with some limited kind of pilots that are underway is is a lot of potential. That's just in the kind of operational management space. Uh and we've got all over users are thinking in culprits or back office roles that enable chemicians to get in and do what do you using used technology?
SPEAKER_03Yeah, I think I think Jason, you're like we're only just starting to see what things like AI, um what technology can bring to make our jobs more efficient, make us enable us to deliver better care to patients. So it's going to be exciting to see, I think, what's around the corner. Nick, what what does an equitable ambulance system look like to you over in the US?
SPEAKER_00That's a million-dollar question. I think in the American context, each community needs to decide for itself what is what they are willing to accept or what they're willing to pay for because we are gonna have to transition to a subsidized, uh, tax-supported ambulance service across the U.S. And many states are working towards that through requiring ambulance services to be an essential service. So that's going to allow us to have conversations at the local level, much to your your point about having locally driven solutions, to decide as a community, are we comfortable with relying on volunteers for this essential service? Or are we willing to put a little money in and have a professional, I don't mean professional in a negative sense, in a comparison sense, but a paid service versus volunteer. Or are we willing to regionalize and bring together a larger group of communities to work together so that not every town has to have its own service, which is more expensive and complicating and just continues the fragmentation that we've suffered from for uh 50 plus years.
SPEAKER_03Yeah, that that duplication of you know 14,000 services, you you just think of all the layers of clinical governance, management, training, different uniforms, CAD systems, mobile data systems, different types of ambulance configurations, and you just sort of go, wow, there's so much duplication and expense there that could be put to those servicing those ambulance deserts.
SPEAKER_00Yeah. And in the US each community it really likes its identity and to where they like to see the name of their town on the side of the ambulance or something along those lines. And so if you're trying to regionalize, that becomes complicating because the kids in school play sports against the kids in at the neighboring town school. And then they become adults, and so then they have history of competition with each other or things like that that make it hard for them to come together. There are many, many stories I could tell you about that sort of thing. It just community dynamics are very interesting. So we we try to scrape off that layer and get down to what are the important factors, what kind of service does that community want? What what do they need? And that depends on the demographics of the community and who's there and what kind of industry or traffic patterns or tourism. Many areas that suffer from this are tourist heavy areas. So people don't live there, but they come to visit there because it's beautiful and it's remote, and so they need to be able to provide services for the community as well as the visitors. So it's very complic complicated to reach a level of we we can't look at it at a high level and say this is equitable or not equitable. The community is who decides.
SPEAKER_01So many questions. As you're talking, I'm like, I could keep going and going, but I know we're gonna get wraps up soon. Yeah, thanks, Nick. That's um some great ideas there sharing. And um, just really quickly, Jordan, do you want to share anything around technology and how you think it can help bridge the gap?
SPEAKER_02Yeah, look, I I think you know, um Jason made some really, really important points about technology and the untapped potential and and the critical enabling function of technology to improve or increase health equity. I just think we should also be alive to the very real evidence that women are underrepresented in STEM fields, and there's very compelling research that has come out of the University of Tasmania and other institutions that show how generative AI and other newer technologies can continue to perpetuate entrenched views, particularly around women and the role of women, and so of course we should move quickly towards technological innovations that improve health equity, but we should always be alive to the reality that technology has the potential to further perpetuate health inequity, and we really need to do everything we can to disrupt that in partnership with industry.
SPEAKER_01And I think it's conversations like this that bring it to the forefront, right? Because people might think about all the exciting things around technology and not realise that there is consequences as well to you know each part of the chessboard we play with, really. This has been great. I know that we're coming to the end of our conversation, so I just wanted to ask to end with a big question. You only need to give a sentence or two, but what would success look like for you in ambulance in 10 years? Maybe we'll start with yourself, Jordan, while you've got the mic there.
SPEAKER_02One sentence.
SPEAKER_01Um or two, I'm generous.
SPEAKER_02A safer, fairer, and more inclusive organization that delivers better health outcomes for all Victorians.
SPEAKER_01All right, across to our next CEO, come on, Jason same.
SPEAKER_04So, success for me looks like a great workplace experience for our people, fantastic care for our patients, care that's increasingly delivered by our clinicians in communities, in people's homes, and only taking patients that really, really, really need to go to the emergency department. Uh and we are, I think the final thread for me is that we're organizations embedded in our health systems. And we are coordinators, needies, providers of care uh across our organizations, across our health systems, not looking in as we historically have as ambulance services, but looking out across uh the rest of the end of change, the end. Yeah. Such a great point.
SPEAKER_01And what about you, South Nick? What does 10 years in America, what does it look like for you?
SPEAKER_00Actually, it's very similar to their comments. I think we will see a wholesale revolution in how we provide our services and providing non-transporting services more frequently and transporting less frequently. So we're bringing the the equitable care to people's homes, their workplace, wherever they may be, not requiring them to leave their communities to go to a hospital in a distant city. I think we're going to make a lot of progress in ten years in the States. We won't be done, but we'll we'll have a good step forward.
SPEAKER_03Sounds great. Thanks so much, Nick and um Jason and Jordan. Um look, unfortunately, that's all we've got time for today. It's been absolutely fascinating to hear about the different global perspectives on the Great Divide. CAA provides a fantastic opportunity to bring the ambulance health sector together to exchange ideas and strategies to innovate, elevate, and inspire the sector. Thank you to our esteemed guests. Tune in for the rest of the series as we continue to explore the Great Divide. Thanks, Al. Thanks, everyone.