(Photo credit: Magnus D)

Our three-part blog series explores the greater role transport data can play in supporting ambulance dispatch, in the context of health devolution in London.

THIS TIME (PART 3): A STEP IN THE RIGHT DIRECTION? WHAT THE MAYOR CAN DO

The Mayor of London has a chance to empower the ambulance service with the data it needs to save lives. By taking big data seriously as a potential lifesaver, the Mayor can be a pioneer in harnessing the power of new technology.

Archie Drake


Health devolution in the smart city context represents an opportunity for the Mayor. Our suggestion is that the Mayor should direct TfL to prioritise working with LAS on traffic data as an operational goal. Within a relatively short timeframe of perhaps a year (or six months, with the right level of priority), it should be possible for a joint venture project between LAS and TfL to clarify and take up the opportunity for better integration of transport data into LAS decision processes.

Evidently budgets are under severe pressure, and it’s not obvious that there is significant justification to allocate either organisation’s resources to this activity. Also it may be that the right skills are not immediately available amongst existing personnel to staff the project effectively. But with the right planning and funding, neither of these problems would be insuperable. This is about improving the public service infrastructure which exploits the ‘data revolution’ for healthcare purposes; the government has just unveiled its Industrial Strategy which promises to scale up investment around these ‘grand challenges’. There are a range of ways to access research and innovation systems’ capacity for a project like this. There are also a range of potential academic and industry partners suitable for involvement in this effort depending on needs, including actors drawn from the wider public and private sector landscapes.

There is no need for the Mayor to wait for London’s health devolution journey to progress further before taking this initiative, because it is based not on developing Mayoral health powers but on established powers to instruct TfL initiatives. The GLA Act in fact requires the Mayor ‘to develop and apply policies to promote and encourage safe, integrated, efficient and economic transport facilities and services to, from and within London’.

There is a tendency to recognise that London’s emergency services have a reasonable claim to priority as users of London’s transport system, for example in the Centre for London’s recent ‘Street Smarts’ report. The figure from that report below is a small example, showing ‘emergency services’ in a prominent location at the top of the tree. But then the emergency services do not feature in the text of the remainder of the report (apart from brief mentions as priority users of street kerb spaces).

In practice, local leadership on how transport policy can support health has tended to suffer from a mismatch in responsibilities: the nationally administered health system and London’s locally managed transport system simply don’t talk to one another in ways that you might expect. This initiative over transport data for London’s ambulances would address that through an example of the Mayor applying the ‘health in all policies’ aspiration.

Centre for London (pdf)

Ambulance data initiative as a contribution to wider health devolution and smart city policy

Although perhaps not the highest priority issue, compared to Brexit staffing risks for example or in the context of overall NHS winter pressures, we think a project to support a TfL-LAS partnership would be worthwhile now, on its own merits, because of the potential to support LAS efficiency in its work. It would also be a useful first step towards wider smart city and health devolution goals for London.

The benefit of a ‘smart city’ is relatively easy to understand, based for example on the potential for cities like London to make city-level connections between technical domains rather than letting them operate in silos. The Centre for Cities has pointed out that several barriers constrain progress with smart city initiatives, including problems which have been relevant here like difficulties in cross-sector working and limited city influence over basic services. Putting transport data more firmly at the disposal of ambulances is one way to overcome these barriers.

The wider benefit to health devolution is sensitive and less easily appreciated. On one level, it’s about finding ways to overcome the current difficulties with health devolution, which were outlined in Part 1 of this series. We observed that:

  • The Mayor lacks London-level organisations through which to act. LAS is under-appreciated as the only health delivery organisation currently operating at the London level – not least because structurally it sits at the lowest level within the NHS (below CCGs). It is not necessary to make any change to that situation for the Mayor to be able to take initiatives involving LAS that are readily understood as useful London-oriented measures.
  • The current state of the NHS is making it difficult to foster public engagement. LAS is uniquely visible in the city, as a supportive (as opposed to coercive) public function. Londoners see branded ambulances and uniformed paramedics working in the streets every day, calling the NHS to mind regardless of whether they are accessing health services or not. It has developed an effective public engagement function which draws peoples’ attention and is currently London’s most effective health communications channel, with campaigns around alcohol abuse, for example, and a recent BBC documentary series having a material impact on perceptions and service use behaviour.
  • The Mayor is being forced to adopt defensive, reactive system-oriented governance reform measures, as opposed to more progressive, proactive initiatives with demonstrable direct patient benefit. Addressing LAS needs offers the potential to add a much more progressive approach because it is a service fundamentally enabled by digital technology (in that it depends on a computer assisted dispatch (CAD) system and its day-to-day operations require modern communications technology). It also serves people out in the city, around the clock. People call 999 for an ambulance when they feel they need care in an emergency, or urgently, out in the community, in homes or on the street, and often out of working hours for other health and care services.

On another level, engaging with LAS in this way might help mark a paradigm shift for digital health policy in London by striking a very different tone from the usual:

  • In, not out. Instead of an exclusive focus on protecting data within the health system and stopping it getting out into the wrong hands (which tends to add to the pressure of expectation on an already stressed system), we can consider more what non-health data can usefully be passed in as a supportive resource for health system actors to use.
  • Environment, not individual. In keeping with the state-of-the-art in public health, reflected in the Mayor’s inequalities strategy, we can put more emphasis on scientific observation of data on the environment through time and space rather than individual-level data (which provokes far greater concerns over privacy and security, for example). The image below is taken from the Mayor’s own draft health inequalities strategy and shows exactly this kind of approach to health by showing ‘social, economic and environmental influences on health and wellbeing’.

Better Health for all Londoners report (pdf)

  • Specific, not general. Rather than expecting digital health initiatives to arise from the health sector generally, we can recognise that specific institutional circumstances give the best head start. Engaging with health system actors like LAS to understand the barriers preventing them from taking up digital opportunities and then provide support in overcoming them is likely to produce better and quicker digital progress than a general sector approach.

To be clear, we’re not suggesting a major structural or strategic adjustment to LAS. Ambulance services are playing a crucial role as part of the post-2013 Keogh Urgent and Emergency Care Review efforts to rationalise how people access care, including direct participation in delivering London’s 111 urgent telecare system. It is particularly important not to raise expectations unduly or promote non-emergency use of 999 emergency facilities, since this is likely to exacerbate existing problems of excessive demand. This initiative on transport data should be designed as a relatively small contribution aimed at supporting the existing work of LAS and encouraging its performance.

It would be wrong to object to this idea on the basis that ambulances are anyway a fundamentally reactive service which are inconsistent with the Mayor’s emphasis on strengthening prevention. This misunderstands LAS as it works today. Although we are finding that people are often surprised at how little information is made available to ambulances about where patients come from or go to, LAS is not just a reactive organisation based on responding to needs as and when people call it. Its work increasingly anticipates demand, for example with communications aimed at guiding people through heatwaves and winters. It has paid careful attention to engage proactively with NHS pressures in London across the full range of needs, despite the recent challenges of organisational fragmentation in the NHS. Its Pre-Hospital Emergency Department Data Sharing Project, for example, is linking LAS data to that of emergency departments to gain a better understanding of what happens to patients once they are transferred out of LAS’ care.

LAS demand already contains strong elements apparently driven by factors which should in theory fall within the purview of mental health, social service or primary care provision. Studies have shown that supposedly ‘inappropriate’ ambulance demand reflects complex social factors involved in access of ambulance services by apparent ‘primary care sensitive’ health problems. And LAS is already innovating to improve the way services are provided to specific demand elements such as elderly fallers (through initiatives like the ‘Supporting You At Home’ pilot with the Royal Voluntary Service) and patients with chronic breathing difficulties.

Vitally, technology offers the Mayor a chance to get into health issues in ways that might not otherwise be possible. Two provocations in closing. First, part of the power of data is its capacity to offer insights into systems that would otherwise be hard to imagine. This is why the Mayor’s draft Health Inequalities Strategy was accompanied by a map, for example. Initiatives of the kind suggested here have good potential to be communicated in a visually impactful way. Why not move to capture peoples’ imaginations through visual impact?

Policy Institute research

Second, if we do nothing then we risk being left behind by events and potentially losing some of the value of our ambulance services altogether. Technology is already disrupting ‘traditional’ distinctions between health needs and services of different types, and work is underway to work out how GPs, 111 and ambulances relate to each other in the future. Location-based general practice is being disrupted by video link models, including Babylon’s striking ‘GP at Hand’ service, which can link patients to clinicians with astonishing rapidity and whose adverts are now all over the Tube. Where will that leave 111 and emergency ambulance services, which still rely overwhelmingly on voice-only connections?

Take a first step: the Mayor and TfL

We think this all adds up to a persuasive case that the Mayor and the GLA should take up a focus on supporting LAS through the health devolution process. This can help extend the impact of health devolution in a manner which addresses health inequalities in the city, realising the ‘health in all policies’ integration of health issues directly with the Mayor’s other key policy priorities, including transport and the ‘Smart City’ agenda. It can help London’s ambulances operate “smartly”, responding faster and more effectively informed by real-time data sources, resulting in more lives saved.

There are serious reasons why it’s difficult to put more emphasis on digital policy in health devolution to London. But more could be done. A good first step: direct TfL to support LAS on transport data.