After the Crash: A Case Study of the

London Ambulance Service Computer Aided Dispatch System

Nancy L. Russo, Northern Illinois University
Guy Fitzgerald, Brunel University

The London Ambulance Service (LAS) is one of the largest ambulance

services in the world. Its area of responsibility covers 7 million people,

and an area of 620 square miles. The LAS comprises 70 ambulance stations, 700

vehicles (around 400 ambulances, plus helicopter, motorcycles, and other

patient transfer vehicles) and over 3,000 people (670 paramedics, 300 control

staff). On average, the Service responds to more than 2,000 emergency calls

per day. The demand for emergency services has increased steadily over the

years with a growth rate of over 16% in recent years.

In 1990 a system to automate the dispatching of ambulances provided by IAL (a

subsidiary of British Telecom) was scrapped just before implementation due to problems relating

to ‘load test performance criteria’ (Page et al., 1993) at a cost of £7.5million (approximately 10.8

million dollars).

The next Computer Aided Dispatch system went live on Monday, October 26, 1992.

Beynon-Davies (1995) reports that on that night "a flood of 999 calls apparently swamped

operators’ screens… and that many recorded calls were wiped… causing a mass of automatic

alerts to be generated, indicating that calls to ambulances had not been acknowledged”. The

operators were unable to deal with the messages that the system was producing and unable to

clear the queues that developed. These queues slowed the system and when ambulances

completed a job they were not cleared. Thus the system had fewer and fewer resources to

allocate.
 The result was chaos in the emergency service. Multiple vehicles appear to have been

sent to some incidents and for others the closest vehicle was not dispatched. One ambulance

arrived to find the patient dead and taken away by undertakers, another ambulance answered a

`stroke' call after 11 hours 5 hours after the patient had

made their own way to hospital (Finkelstein and Dowell, 1996). Crews reported ambulances

from far afield passing them on the way to a call for which they were better placed. The crews

became very frustrated by the delays in arriving at the scene and the angry reaction from the

public. Crew frustration also led to an increase in radio traffic with crews querying the

allocations or requesting further information. This caused radio bottlenecks and further delay of

ambulance mobilizations.

The system staggered on over the long hours of October 26 and on into the 27th, but was

clearly not viable. Finally at 2 p.m. on the 27th the LAS reverted to a semi-manual method of

operation. Calls continued to be taken on the system (including use of gazetteer1) but the incident

details were printed out and allocation of ambulances was done manually. The mobilization of

ambulances continued to be done via the system. This, together with an increase in the number

of allocating staff for each shift, proved relatively successful.

Unfortunately, this semi-manual system did not last long. On November 4, 1992 the

system failed to print out calls and shortly after this the LAS reverted to a fully manual, paper

based system, with voice or telephone ambulance mobilization. Luckily no serious ramifications

were reported as this occurred in the early hours of the morning, nevertheless it was a further

blow to the beleaguered LAS. The London Times of November 5,1992, reported a 25 minute

delay in dispatching an ambulance and that senior management were forced to “concede that the

system could not cope with its task”. The Computer Aided Dispatch system was abandoned.
1
A gazetteer pinpoints the location of an emergency call on a map.
AFTER THE CRASH

John Wilby, the CEO of the LAS who had championed the 1992 system, resigned on

October 28, when it became clear that the system was not working. Martin Gorham, deputy

chief executive of South West Thames Regional Health Authority, was appointed in his place on

a temporary basis. Gorham was a career National Heath Services (NHS) manager, and had been

in the NHS for about 25 years, mainly in hospital management and he had been director of

corporate planning for a large health authority. However, he had no direct experience with

ambulance services but was recognized as someone with strong management and change skills.

As Gorham describes it, “I remember somebody saying to me on day two, what do you know

about ambulance services? I said nothing, but I don’t need to, I’ve got 2,500 experts here. You

tell me. I know about management and leadership. And that was my bargain with the Service.

You tell me the whats and I’ll tell you the hows. And if the whats don’t make sense, I’ll ask you

questions until we clarify what the whats really are. I didn’t pretend to have their expertise.

They’d got it and I wanted to value it, not downgrade it”.

One of the things Gorham had to do immediately was to talk to the union representatives

and try and establish some kind of relationship and dialogue. He saw their role as crucial and

needed them to be, if not completely supportive, at least not too antagonistic. He set out his stall

by saying “I’m not really here for a battle with the trade unions. I’m here to ensure the future of

the LAS and I’m sure that’s what you’re here for too and we’ll achieve it a lot quicker, and a lot

better, working together rather than continuing this highly public confrontation”. Although at the

time this seemed a vain hope, given the previous history of conflict. There had been a very

damaging pay dispute before the current CAD problems and the ramifications were still evident.
Although the dispute had eventually been resolved at a national level the London area had voted

against the settlement. Although, according to Gorham, he felt working together was not

impossible because the unions were apparently quite shocked at the turn of events, particularly

the resignation of Wilby. They had seen him as the problem and now found themselves having

‘won’ that battle but not quite knowing where to go next. In a sense they now needed Gorham as

much as some other people needed him, otherwise they had no frame of reference, which

Gorham describes as ‘quite useful’!

Nevertheless it could have gone either way. Very early on the union representatives came

into Gorham’s office and demanded that the computer system be switched off completely. At the

time the semi-manual system was in operation. Gorham admits he did not really know what to

do. He had the unions on one side saying it must be shut down and what was left of his

management team telling him that to shut down would be the final abdication. He says “there I

was sat in the middle and didn’t actually understand what they were talking about anyway”. In

fact he managed to buy some time by going to the unions London regional officer to get the staff

to back off for a few days which they did.

Gorham set about making sure minimum management arrangements were in place that

would hold things together. He then tried very rapidly to learn the service by getting out and

meeting people and stressing the basic messages. He was keen to establish a period of stability

and retrenchment. He clearly stated that he was not going to be rushed into changing things, that

he recognised that the Service had been through a period of enormous, very uncontrolled change.

He calculated that people needed a break as they were totally shell-shocked, the last thing he

wanted to do was to be rushed into another ill-thought out scheme. He spent quite some time in

the central control room, because that is where it had happened and describes the staff as being
“in an awful state. They’d all worked very, very hard to make the thing work, and it had just sort

of blown up in their hands. It was like after a bomb, really”. He also spent time with the

ambulance crews and went out with them on calls, a learning process for him and quite a shock

for the crews!

On a longer-term basis Gorham decided to restructure the organization. “The simple fact

was that the current structure was a complete obstacle to making progress. We didn’t have the

level of management resources that we needed. I think that’s one of the reasons why my

predecessor wasn’t able to deliver what he set out to deliver. He just never had the number, the

amount of high level management resource you need to turn around a big high-profile complex

organization which had drifted 10-15 years behind the time.” Gorham adopted a four divisional

structure and created a sort of executive board, which consisted of a Chief Executive, Finance

Director, Director of Personnel, an Operating Director, the four divisional directors, and a deputy

who also managed the Control Room. According to Gorham, “My view was that given the state

of development and the need for effective management of the crews – it was a large fleet,

dispersed throughout 70 stations – we just had to have a much, much stronger management lead

at the operational level. That’s why I went with this very heavy divisional structure”. A planning

function was established and an IT Director, Ian Tighe, was appointed from the West Midlands

Police.

The Page Report (Page et al., 1993), which examined the circumstances leading to the

1992 crash,provided Gorham and his team with some insights into problems with the system.

The 1992 CAD system was the primary means by which the LAS planned to meet new

government efficiency improvement guidelines for the National Health Service (Beynon-Davies,

1995). It was introduced into an atmosphere of mistrust by staff, with no real feeling of
ownership by the majority of users. There was little user involvement in the development of the

system. The system, which would completely change the way calls were taken and dispatched,

continued to be modified practically until the day of implementation. There were serious flaws

in the Computer Aided Dispatch system itself. A significant problem identified in the Page report

was that the 1992 CAD system was developed by an inexperienced, unstable consortium of

organizations, with no one willing to take on a leadership role. (No one consulting company

bidding on the project had both the hardware and software experience called for in the Request

for Proposals; therefore smaller consulting firms joined together for this project. None of the

low bidders had experience developing emergency systems.) The hardware/software platform –

essentially a PC architecture – selected for the 1992 system was unfamiliar and untested in this

environment, and proved to be insufficient for the task. Visual Basic was not a suitable

programming language for a system that had to support huge transaction volumes. Although

management had been warned of delays in readying the control staff, control room, and system

itself for implementation, the scheduled implementation date was viewed as a hard deadline that

could not be missed.

In the wider perspective Gorham saw two big themes that needed to be addressed “The

first is cultural change, which is about getting the staff motivated to do the job right. The second

is putting the things in place which allow people to do the job right, some of these are technical

and some are training and recruiting the right people and so on. Essentially, in a nutshell, that’s

what is always required together with the resources to do it”. The Service had been suffering

from under-investment for many years and required substantial investment. “Half the fleet was

off the road at any one time. There were vehicles on the road that were ten years old, they were

falling apart. You just can’t run an Ambulance Service on half a fleet”. In addition the electrical
supply was discovered to be unsafe, the switchboard was dying on its feet, the existing Control

Room was a mess to the extent that it couldn’t simply be refurbished but needed completely

rebuilding.

The morale of the people in the organization was at rock bottom. The situation had been

bad for some time with a lack of confidence in the management, a damaging pay dispute, and

then the 1992 crash. Some of the war stories were frightening; this was nasty stuff, according to

Gorham. “There was a very deep underlying cultural problem that had to be changed. My

assessment was that this was an organization that didn't respect individuals and this was the core

problem”.

In June 1994 the LAS was again “blown off course” by the tragic case of Nasima Begum,

an 11 year old girl, who died after “being denied an ambulance” (Collins, 1997). Nasima Begum

had a liver condition for which she was receiving regular treatment but on this day her condition

required urgent attention. Unfortunately despite four calls she had to wait 53 minutes for the

ambulance only to die of renal failure. The tragedy was compounded by the fact that she lived

only two minutes from a hospital and that the only available ambulance was sent elsewhere, to

someone that did not really require emergency service. Again, and unsurprisingly, very bad

publicity resulted and resulted in another review of the Service, this time by William Wells,

South West Thames RHA Chairman, on behalf of the Secretary of State. The outcome of the

review and the Nasima Begum case helped show people that although some improvements had

been made and working methods changed it was not enough and that the manual approach was

not really a long-term solution. However, the barriers to introducing and gaining acceptance of a

new computer system, seen by many as the villain of the piece, were formidable.