Critical Appraisal of the London Ambulance Case

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This paper describes the case of the London Ambulance Services (LAS) Information Management System by using System thinking as the knowledge management tools and appraises its application in the delivery of the services of the organisation. The issue of some of the failures and successes of the LAS especially the issue bordering the failed Computer Aided Despatch (CAD) system was also discussed and suggestions made on how the London Ambulance Services could improve its knowledge management in terms of information sharing in order to achieve great success in its daily operations.
Keywords: Knowledge management systems; information management; systems thinking; London Ambulance Services; Computer Aided Despatch (CAD)

Knowledge management involves the acquisition, storage, retrieval, application, generation, and review of the knowledge assets of an organization in a controlled way (Watson, 2003).The purpose of knowledge management is to enable an organization to control its information resources and knowledge resources by remembering and applying experience as this is considered as the basis of future economic competitiveness (Watson, 2003). Knowledge management spreads throughout an organization from the information management systems to marketing and human resources (Aykin, 2007).
Information could be seen as the principal key substance to knowledge management in an organisation. Information is regarded as the content of what is exchanged with the outer world as we adjust to it, and make our adjustment felt upon it (Stahl, 2008). It encompasses storage of material resources, as well as the action of other people in the group (Aykin, 2007). According to Davenport (1993), making information and communication significant and accessible would likely make it more controllable; and accessible information is also discussable which results to increased reciprocity. In a nut-shell, information management processes should include the entire information “value chain” which involves starting with the definition of the information requirements, then the collection, storage, distribution, receipt, and use of the information (Davenport, 1993).
Information and knowledge management can be considered as existing along a continuum as they exhibit relationship with their context (Watson, 2003). Information management in an organisation can be enhanced by using the enterprise resource planning (ERP), because it is the system that brings together all the company’s major business functions together and could also be used to forecast future demands and also enable every one working for the company to have instant access to critical information (Marcic and Daft, 2008). Knowledge depends on the information received, thus information increases knowledge value as is seen in IT/IS strategy (Wimmer, 2004).
In any well structured organization such as the London Ambulance Services, the effectiveness of knowledge management would to a great extent depend on how vital information are being shared within the staff and the residents whom they serve. This is because information is a vital tool which occupies a central position in managerial decision making and the more and higher-quality information will lead to better performance (Stahl, 2008).
The potential benefit of extensive information sharing and wider cooperation has been seriously impeded by the unavailability of robust communications or transportation systems to support them. Advance information sharing can aid in resource assessment and contribute valuable information to plan the response effort more effectively, especially in the first few hours after the onset of the any emergency (Aykin, 2007). In order to make effective and innovative local decisions in an organization, subordinates must have information and training because information provides awareness of potential problems, opportunities, and available resources, training to use the tools they need to act effectively to meet the needs (Simons, 1995).
Systems thinking and system approach in an organisation was developed and has been in publication over the past 50 years (Macdonald, et al. 2006). It is concerned with the collection, classification, manipulation, storage, retrieval and dissemination of information and forms an important part of effective information and administrative management (Ferreira, et al. 2010). System thinking is essential for the development of the effective organisation – the learning organisation (Beardwell & Ciaydon, 2007). It enables the ability to conceptualise complex dynamic realities within the systems and its external relationships, and then model them in a simple, coherent way that is yet pregnant with meaning and capable of further elaboration when necessary (Beardwell & Ciaydon, 2007).
In the case of the London Ambulance Service, system thinking would inevitably give an important insight into the role of information systems sequentially from data to capta to information to knowledge. Information systems serve people engaged in what they consider as meaningful action, as in actions which support another to yield a meaningful result (Sherwood, 2002). System thinking involves the conceptualization of a system which provides support by first defining the nature of the system (Currie and Galliers, 1999). Another benefit of system thinking is that it helps to reduce the complexity of real-world problems by providing a structured way of balancing a broad, complete view with the selection of the right level of detail, and as such, enhances decision taking within short time (Sherwood, 2002).
London Ambulance Service
The London Ambulance Service (LAS) is the only NHS trust that covers the whole of London and provides patients with the highest quality of care to ensure that patients who reside within London obtains the best health outcome in the world ( The primary purpose of the LAS is to save lives and responds effectively to medical emergencies ( ). It is managed by South West Thames Regional Health Authority and is the largest ambulant service in the world as it covers geographical area of over 600 square miles, resident population of over 6.8 million people (
The London Ambulance Service (LAS) responds to all ‘999’ emergency calls for medical assistance in the capital and is staffed 24 hours a day in three eight-hour watches. The control room of LAS takes an average of 2000 calls a day and coordinates the despatches of vehicles from its fleets of ambulances, motor cycles and air ambulances (Stegwee and Spil, 2001). This efficiency is achieved by the help of MapInfo technology to help improve call handling and response time as it helps the LAS to plot the location of ambulance stations, hospitals and area of high priority calls, as well as planning of the crew deployment during emergencies (Nag and Sengupta, 2007).The service has received awards for information system management that may not be matched for years (Stegwee and Spil, 2001).
According to Rowland and Macdonald, (2005), in order to maintain a high quality delivery of all its services, the members of staff from the senior management to the ambulance crew of the London Ambulance Service require the possession of qualifications, experience and qualities which include:
theoretical training as would ensure acquisition of the necessary knowledge of the field in which they are required to work.
a thorough knowledge of the hazards and failure of the equipment for which they are responsible.
an understanding and detailed knowledge of the working practices used in the organisation for which they work, as well as a general knowledge of the working practices in other establishments of similar type.
a detailed working knowledge of all statutory provisions, approved codes of practice, other codes of practice, guidance material and their information relevant to their work, and awareness of legislation and practices, other than those which might affect their work.
Ability to advice others.
the calibre of personality to enable them to communicate effectively with their peers, any staff working under their supervision, and their own supervisors.
an awareness of the current developments in the field in which they work.
an appreciation of their own limitations, whether of knowledge, experience, facilities, resources, etc, and a preparedness to declare any such limitation.
Knowledge management in the London Ambulance Service
The London Analysts Support site team (LASS) developed a dataset in consultation with the London Ambulance to ensure that their data is of good quality and suitable for crime analysis purposes. The team work with the London Ambulance Service to extract data suitable for crime analysis professionals there by making the service delivery of the London Ambulance faster and continuous ( The support team identify incidents of assaults injury via a fairly sophisticated search through various codes and descriptions of incidents that occur in the process of responding to a 999 call. Although the information extracted from this group is highly important in identifying and tracking crimes, it is assumed to be secondary compared to the need to record accurate medical information. Hence, this could result to minor variations in the accuracy of the data over time and in different areas in London.
Experts in crime analysis utilize the data collated to scan for issues, patterns and trends in general violent crime in London and carry out comparisons and variations with traditional sources of intelligence such as recorded data from the police (
London Ambulance services together with other government agencies such as the police work together to ensure that information are securely shared to protect vulnerable adults, and to ensure that any signs of abuse are reported and investigated immediately in such a way that there is less risk of signs of abuse being missed. They do this by encouraging people to inform authorities of abuse, sharing information and investigating reports and incidents where necessary ( Through this cooperative effort, necessary information are efficiently managed and shared whenever cases of emergency occurs and helps in the deployment of necessary solutions to different cases.
Information Management Structure within the ambulance complexes
Information sharing is the key instrument that enhances the operation of the London Ambulance Services. The information management of each local ambulance station complex is controlled by the local authority and PCT area. An information sharing network is used to pass information urgently to assist various units’ representatives to access support in all cases as they arise.
Through information sharing, local authority social services, primary care, mental health and acute trusts and other relevant agencies are networked so as to establish a regular forum to enable specific is plans. This forum enables health and social care workers to advice the London Ambulance crew of any patients that may be posing similar problems to the receptive agencies, and hence could enhance the setting up of an appropriate care pathway.
In some cases, a conference may be held in order to get the patients to understand property their health situations. This is often done by the London Ambulance Services via writing notification to patient, carer and advocate inviting them to participate in the conference, and during the process, all the clinical issues will be resolved.
A case with the London Ambulance Services
In bid to increase the efficiency in the delivery of her duties to the large population in London, the London Ambulance Service introduced the Computer Aided Dispatch system to deliver that goal. This dispatch systems was hoped to stand out as it was highly innovative system that fully command and control functions of the LAS starting from the receipt of emergency call at the control centre, through decisions on which ambulance to allocate to the call, and to mobilize appropriate resources (Howcroft and Trauth, 2005). In this design, the call details would be captured online and tracking devices would be fitted to ambulances so that their locations could be monitored continually to enhance information flow via electronic link room to the control centre, and then to either mobile data terminal or printers on ambulance stations (Hall, 2007).
This computerized despatch system was designed by System Options to increase the service delivery of the London Ambulance Service and was launched into operation on October 26th, 1992. This despatch system lasted just for few hours and then crashed because it was not capable of handling the information loads being placed on it, a problem being blamed on inadequate knowledge management parameter such as system thinking, as the staff and management were in continual conflict over information hoarding (Howcroft and Trauth, 2005; Dutton and Peltu 1996).
Some of the problems the despatch system encountered included: lack of confidence in the system being able to automatically locate vehicle locations by staff both within Central Ambulance Control and ambulance crews due to lack of adequate training. Other problems identified were failure of calls to reach ambulances, failure to identify duplicate calls, poor prioritization of error messages, and loss of calls in the system (Day, 2002;
All these problems made the system to close down the next day leading the London Ambulance Services to revert to semi-manual operation (Day, 2002). An inquiry which was ordered to determine the cause of the crash revealed that the system was very complex, making it difficult for any software house to develop a suitable solution (Day, 2002). Besides, System Options had good reputation but lacked sufficient experience for designing or developing packages for safety-critical command-and-control system, otherwise they would have identified the risk and plan measures to avoid it, or to ensure an effective action (Day, 2002; Duquenoy, et. al. 2007; and Clarke, 2001). The finding of the inquiry team also revealed that the CAD software was incomplete, not properly tuned and not fully tested (
The failure of the dispatch system was also blamed on the inadequate training given to the operators and inadequate testing of the system according to a press release in 1993. During the training of the staff that was carried out in line with the operation of the despatch system, the ambulance crew and the central control crew staff were trained separately in different rooms which did not lead to proper working relationship between the pair (Mantas, 2004). The report of the press release about the staff training reads: “Much of the training was carried out well in advance of the originally planned implementation date and hence there was a significant “skills decay” between then and when staff were eventually required to use the system. There were also doubts over the quality of the training provided, whether by the Systems Options or the LAS’s own Work Based Trainers (WBTs) (Mantas, 2004).
This training was not always comprehensive and was often inconsistent. The problem was exacerbated by the constant changes being made to the system (Mantas, 2004). It was also reported that one of the reason for the failure of the London Ambulance Computer Aided Dispatch attributed to the complexity inherent in the system design which was intentional as those in charge of the system development activities had wanted to be in control of all possible outcome (Khosrowpour, 2003). Besides, top management hoped to bypass the union, and also replace the controllers so as to reduce cost. For this reason, the staff of the union were not involved in the development of the system which resulted to the leaving behind the input of people who were most experienced with the way the ambulance service worked (Macauley, 1996; Rowbotham, et al. 2007).
Strategies to prevent future Crises in the London Ambulance Services
According to the document submitted by the London Ambulance Service NHS Trust (Wp85) published by the Department of Health in June 2005, outlined a vision of where NHS ambulance services should be within the next five years:
Providing significantly more clinical advice to callers and work in a more integrated way with partner organisations;
Providing and coordinating an increasing range of mobile healthcare services for patients who need urgent care;
Continuing to improve the quality of services to patients with emergency care needs;
Providing an increasing range of other services in primary care, diagnostic and healthcare promotion.
In order to achieve the above vision, education and development needs for the ambulance service workforce has been redesigned including all the training courses to enable the service to cater for the need of the 800,000 patients it attends to each year (House of Commons Health Committee Report, 2006-7).
This is why a school of thought has argued that systems thinking such as soft systems thinking could be a way of conceptualising the social processes in which a particular group of people in an organization can conceptualize their plans and actions they intend to undertake (Wickramasinghe, et al. 2009). This kind of basic thinking relevant to the provision of information systems may not have been properly applied in the provision of the London Ambulance Service Computer Aided Despatch system that failed.
According to Currie and Galliers (1999), in order to ensure proper knowledge management and information sharing, any development of a strategy for the future computer aided dispatch within the London Ambulance Service (LAS) must involve a full process of consultation between management, staff, trade union representatives and the Service’s information technology advisers. It may be appropriate to establish a wider consultative panel involving experts in CAD from other ambulance services, the police and fire brigade.
It is necessary that the geographical, social and political environment in which the London Ambulance Service operates in the delivery of her valued services be adequately carried along in the information sharing and information management of both the LAS management and staff via organizing of regular and open consultation with staff representatives (
Furthermore, regular training for the staff of the London ambulance Services on the use of modern IT infrastructure that relates to their service delivery could be done regularly to enable the members of staff to keep abreast of all the updated information regarding the efficient delivery of their duties. This is because; an organisation that encourages learning among its staff promotes exchange of information between employees thus creating a more knowledgeable workforce. In addition, IT contributes to knowledge capture, information distribution, and information interpretation.

Information is power, and as such, few people in an organization would like to monopolize it instead of sharing it to facilitate the diffusion of knowledge. Information flows are up, down, and across the organization as information is collected, shared, communicated, and debated (Rescher, 2003). Therefore, information sharing should be encouraged in the operations of the London Ambulance service as this will empower all the staff to be more productive in delivering their duties, and will avert any disaster in future when the organisation considers the design of another despatch system.
It is a clear fact that computer-based information systems are essential to the operation of modern businesses especially in all transaction that entails the production of large information in an organization like the London Ambulance Service. Information diffusion means the degree of information sharing within an organization (Simons, 1995). Hence, in the case of the London Ambulance Services, information diffusion should be high so as to maintain free flow of information to everyone in the organization and not hoarding it or making it only available to selected few individuals.

Information sharing can be viewed as a firm’s willingness to share key information that is timely, accurate, responsive and useful with its staff, associated partners and final consumers of her services. Some of these ingredients of professional knowledge management were not adequately utilized in the circumstances that led to the failure of the London Ambulance dispatch systems. In subsequent future design of a CAD despatch system that will work, the LAS management or any other company that will be used, and the London Ambulance should consider conducting adequate training of all their staff as part of the product development and implementation cycle.

System Options was reported to have had no previous knowledge of building despatch systems for ambulance services (Beynon-Davies, 1995), and as such should have not accepted the offer as it falls outside their professional competence especially as there was strict deadline to deliver the contract.
Again, the Inquiry report findings reveal that System Options did not used PRINCE project management method which is the acceptable method for managing public sector projects, and the team had no previous project management experience (Duquenoy, 2007). This means that there was no proper knowledge management on the side of the London Ambulance Service as LAS should have ensured adequate project management experience of its contractor.
System Options failed to properly apply proper system thinking techniques as it relates to realizing the CAD project within the proposed deadline. They entered the agreement and could not opt out as that would have been unprofessional (Beynon-Davies, 1995). It is recommended that for a successful professional service delivery, CAD or IT/IS providing firms should maintain a cordial information and time management relationship with its clients. In the case of System Options and LAS, System option should have informed the client of their concerns over the short time frame.
Beynon-Davies (1995) identified the issues of poor testing and quality assurance of the despatch system. System Options should have followed the rule of professional system development and implementation ethics which comprises of testing, quality assurance and proper training of all staff involved in the design and final use of the product.
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