Han-Wei Lee [00:01:01]  
In this episode we’re going to do things a little bit differently. We’re here live at the CAA 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. Welcome to  

Lindsay Mackay [00:01:22] 
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 year’s 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. 

Han-Wei Lee [00:01:49] 
And Welcome to Nick Nudell. He’s the Executive Director of the Northeast Colorado Regional EMS 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.  

Lindsay Mackay [00:02:07] 
Welcome Nick. And our final panel member is Jordan Emery. Jordan is the Ambulance Victoria CEO, previously 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. 

Han-Wei Lee [00:02:29} 
Now sorry guys we did have to cut down the bios a bit because it would’ve taken up the whole episode, because you’ve got such illustrious careers But we are going to dive straight into it now. 

Jason, with 10 English trusts and three national services, how did differing service models and overlapping jurisdictional boundaries impact care variation and outcomes in the UK. 

Jason Killens [00:02:50] 
Okay, so as you say, 10 ambulance services, 10 NHS services in England. And then the, the Devolved Nations, Scotland, Wales, and Northern Ireland. Largely, service delivery is consistent, across all of those services. But I think 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 success is measured in different ways across the four Nation of the UK. 

In Wales, where as you mentioned, I’ve recently come from and gone back to London. We’ve changed this year, earlier this year, the target regime, with government support, to focus much more on clinical outcomes and effectiveness rather than time as the top tier of primary measure. So, the first phase of that went live back in the last year, and the second phase of that will go live towards the end of this year. Whilst time still is important, the regime is now much more focused on clinical effectiveness and outcomes and similar discussions are going on in the other nations across the UK. How can we adjust, I guess the performance and target rating to the expectation of the provision of service in organistions to better meet our patients needs, but also improve the workplace experience for our people. Because our clinicians know that chasing a time target is not necessarily the right thing, for patients and certainly not the right thing, in some circumstances for how we operate our services. So, quite a few bits kind of changing in the UK, but largely consistent in terms of clinical care, but how it’s measured and effectiveness is measured quite differently.  

Han-Wei Lee [00:04:36] 
So Jason really interesting that you know, for ever and a day, ambulance services have been measured on their response times How’s that conversation gone with the public that you serve in terms of focusing on changing that focus from times to clinical outcomes? 
 

Jason Killens [00:04:55] 
So look, I think that the, starting point has to be that, you know, time-based targets for the ambulance sector are anchored in the seventies and in the seventies you know, we didn’t have paramedics, we didn’t have defibrillators, we didn’t have you know, a lot of the interventions that we have now, hardly any of the interventions which are now available for our clinicians, registered healthcare professionals in most jurisdictions, they  simply weren’t available. So the type of care that we could provide was very different.

And the conversation with politicians and other key stakeholders, it’s been very much, look, the service has evolved, our clinicians have evolved, the practice 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 emergency calls, 919 calls in Wales are dealt with by way of advice over the phone now, that’s a very different service offered to the seventies when we went to everyone and we took everyone to an emergency department. And so what we’ve said to the community is, we can 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 networks are and avoid taking you to the ED and most patients are going “I’ll have that. Thanks very much”. Because they get a tailored, bespoke service relevant directly to them.  

Linday Mackay [00:06:27] 
I feel like the young paramedic in all of us really connects with what you’re saying right, I definitely do, I could see Jordan nodding there, thinking that’s probably I think what an Australia would love to be looking you know. But when I think about the American context with that, so obviously Nick coming from America where we have you know 14,000 EMSM agencies, how does that complicate efforts when you really want to provide that equitable care and quality of care especially as well across that urban and rural geography? It must be complex? 

Nick Nudell [00:06:58] 
Oh, 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 analysed geographically in the U.S, the extent of ambulance, what we call ambulance deserts, where there is no ambulance available within, we used a metric of 25 miles, no ambulance available within 25 miles of key population areas. 

And we have more than 4 million people that live in ambulance deserts, so they have no assured response 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 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 that end of the extreme, is we, we call it a ALS paradox in the US where in the cities where, 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, ALS level paramedics. So they’re providing basic, very basic care and just transport to the closest hospital. 

Lindsay Mackay [00:08:53] 
I don’t think my brain can quite wrap my head around some of that wow. I mean Jason talked about there earlier about the community, how did the community accept that. Like I think about in Victoria where I’m based, community would never accept that. Do they accept it or it just that’s just a given? 

Nick Nudell [00:09:13] 
So what’s very interesting in the US paramedic services or EMS, whatever terminology you want to use to describe that service, it’s not considered an essential service, like fire service or law enforcement. And so in most of the US that’s the case. And so there’s 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 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 tax supported services, but the vast majority of the services provided as 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. 

Jason Killens [00:10:16] 
But 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.  

Han-Wei Lee [00:10:23] 
And particularly with the focus, well I mean we’ve just had two days of the IRCP, it seems quite incongruous doesn’t it that you’ve got this disincentive not to put load on the system. Nick I’d be really interested – what’s the reality for those people 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?  

Nick Nudell [00:10:59] 
That’s a very good question. Even in the jurisdiction where I live, we can have a two or three hour response just to get to a patient and in those kinds of scenarios where they’re very far away, 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, then an ambulance from somewhere will be dispatched. And oftentimes the fire department, in those cases, it’s usually a volunteer fire department. So even their response is not assured, and they will be there probably closer than the ambulance. So maybe they’ll get there first and provide some stabilising care while waiting for the mode of transport to arrive.  

Han-Wei Lee [00:11:47] 
Wow, that certainly puts things into perspective when we look at things around Australia. Jordan, we’ve just heard about a quite I guess disparate workforce and distribution model in the US, how does workforce distribution service models and remoteness shape disparities in ambulance across and disparities in ambulance access and outcomes in Australia? 

Jordan Emery [00:12:09] 
You 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 an Australian context as well. And there is a tonne of literature that demonstrates that rural and remote Australians experience poorer health outcomes. And that 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.  

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 Victorians would tell us we have a way to go. 

Lindsay Mackay [00:13:26] 
I think most definitely and I think that’s the key thing here is that every jurisdiction, country has got their own challenges and I don’t think we’re immune to that, I don’t think anyone I’ve seen around the world has this right. imagine if we had a global approach, but I feel like that’s for another podcast so we’ll hold on that. 

Jordan Emery [00:13:46] 
The 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,  and not dissimilar to your discussion about clinical outcomes, Jason. 

I do think, you know, I do think it’s really important that we recognize that a level of localization is really important. Yeah. 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 Australians is a perfect example of that, of where it’s clear that the way we deliver services, if we are serious about addressing addressing health inequity. Then we have to change the way we deliver services to meet the needs of consumers, not meet the needs of ambulance services.  

Jason Killens [00:14:36] 
And, 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 in rural and remote communities because the one size fits all approach is just not going to work for you. And so we as 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.  

Jordan Emery [00:15:22] 
I think it’ll probably always be the case that there’ll be boundaries around that at a system level. And that will be important for maintaining the high levels of clinical governance, safety and quality that we require. 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.  

Han-Wei Lee [00:15:50] 
Jordan, you talked about the disparities in indigenous health. Is there anything in particular Ambulance Victoria is doing in terms of programs or initiatives to sort bridge that gap? 

Jordon Emery [00:15:55] 
Yeah, look, I think, the journey to reconciliation is a really important one in the Victorian context. We had our first reflect reconciliation action plan last year. We’re about to embark on our second reconciliation action plan. But importantly, 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 five volumes in total. But the fourth volume really focuses on health. 

And there are many stories, tragic stories, of First Nations people,  not all that long ago being told they can’t be born in the hospital ward 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 while some of those stories are 70, 80, 90 years old, those Australians, those First Nations Australians still carry the incredible harm from that 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 it’s a story that is not, all that far from the present day. 

I 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. 

Lindsay Mackay [00:17:31] 
For sure I feel again there’s another topic we could go on about and we  can’t extend the episode by a couple of hours, they’d be chasing us at the Congress, but if I just think back if I look into the future so, 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? 

Jason Kills [00:17:51] 
Well, there’s clearly a role for technology 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 case card. Most ambulance services, have issued some kind of device or devices to their clinicians. Over the last five or 10 years that’s been happening. We are increasingly digitising a lot of our processes. and have been very heavily reliant on technology and control rooms, particularly contactcentres for years to manage increasing activity and do it in the most efficiently effective way. But you look ahead, you think so,what’s next? Clearly, AI has got to be the next thing. We’ve got a trial underway in London at the moment with ambient listening in our clinical hub, where AI is transcribing, essentially a clinical record  

Now early days on the pilot, but that’s looking very positive in terms of productivity benefits and, and certainly accuracy of the clinical record. We’ve got a small number of pilots underway, again with ambient listening in the field. So in the back of the ambulance, in the patient’s home again, transcribing the conversation, creating a clinical record. There’s conversations running about, well, how can we use AI in call handling? Either in emergency call handling, so nine oh nine triple zero kind of context or potentially in the urgent care space. So I think that there are a number of use cases. Technology in today’s modern service, we’re just really starting to pick at the edges of what’s possible. 

I don’t think we know yet what’s possible. But what we’re starting to see with some pilots that are underway, is a lot of potential. And that’s just in the operational management space. And we’ve got a whole load of other opportunities, in the corporate support / back office roles that enable clinicians to get out there and do use technology. 

Han-Wei Lee [00:19:58] 
I think we’re only just starting to see what things like AI, what technology can bring to make our jobs more efficient, enable us to deliver better care to patients. So it’s going be exciting to see what’s around the corner. 

Nick what does an equitable ambulance system look like to you over in the US? 

Nick Nudell [00:20:16] 
That’s the 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 going to have to transition to a subsidized attack supported ambulance service, a across the US 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 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 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, 50 plus years.  

Han-Wei Lee [00:21:36] 
Yeah that duplication of you know 14,000 services; 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 this So much duplication and expense there that could be put to those servicing those ambulance deserts  

Nick Nudell [00:22:00] 
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 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. Community dynamics are very interesting. So 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 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 complicated to reach a level of, we can’t look at it at a high level and say; this is equitable or not equitable. The community is who decides. 

Lindsay Mackay [00:23:22] 
So many questions. As you’re talking I’m like I could keep going and going but I know we’re going to get wrapped up. Thanks Nick. That’s some great ideas there sharing, and Jordan, do you want to share anything around technology and how you think it helped bridge the gap? 

Jordon Emery [00:23:34] 
Yeah, I think Jason made some really important points about technology and the untapped potential. 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.  

Lindsay Mackay [00:24:38] 
And 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 realize that there are consequences as well to, each part of the chess board we play with. 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.  

Jordon Emery [00:25:03] 
A safer, fairer, and more inclusive organisation that delivers better health outcomes for all Victorians.  

Jason Killens [00:25:16] 
So 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 need to go to the emergency department. And I think the final thread for me is that we are organisations that are embedded in our health systems. And we are coordinators, leaders, providers of care across our organistions, across our health systems, not looking in as we historically have as services. Looking out across the rest of the health service.  

Nick Nudell [00:26:00]  
Actually, 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 that we are bringing 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 10 years in the States. We won’t be done, but we’ll take a good step forward. 

Han-Wei Lee [00:26:40] 
Thanks so much Nick, Jason and Jordan. 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.