The NHS is suddenly showing a lot of interest in buying into air ambulances. So are these charity services ready to do business? Alison Moore reports

Air ambulances are the glamorous side of healthcare: life-saving, media-friendly services that scrape Top Gear presenters off the tarmac supported with heart-warming sponsored events by grateful former patients.

But that picture could be about to subtly change. Air ambulances have always had an edgy relationship with the NHS but now there are new pressures and incentives for the two to work together.

"We have been absolutely gobsmacked at the appetite from the NHS side," says David Philpott, chair of the Association of Air Ambulance Charities. "There has been a turn in the tide, 18 months ago I was seen as a pain in the derriere up and down the country."

He is now getting calls from commissioners who want to get services from him; from the Department of Health, which wants to talk to him; and from hospital consultants, who see a role for air ambulances in improving care.

Part of this is due to a shift by the air ambulance charities themselves, which are now working more closely. Some - such as the services Mr Philpott heads across Kent, Surrey and Sussex - are keen to move towards providing something akin to a trauma centre in the air. Their helicopters now fly with specialist emergency care doctors on board, with the aim of providing emergency care on the roadside or in the air rather than simply transferring the patient speedily.

But some of this change is coming from the NHS. National emergency access director Sir George Alberti flagged up the role air ambulances could play in Emergency Access: clinical case for change. He has set up a working party on air ambulances, expected to report this summer.

The move towards regional trauma centres and the acceptance that district general hospital accident and emergency may not offer the best quality care to a badly injured patient are also important.

Mr Philpott says some of this interest can be traced to the Trauma: who cares? report released before Christmas. "It is a whole different environment we are working in now. There is an acceptance that we need to move away from being an ambulance that flies," he says.

But what are the barriers to a greater role for air ambulances? The first is funding - and linked with that, independence. Currently air ambulances in England and Wales are run by charities. NHS support is usually limited to paying for the costs of paramedics who fly with them - something the DH agreed to in 2002. The London Air Ambulance - which has always flown with trauma doctors and can carry out invasive surgery on the spot - gets some funding from London primary care trusts. But air ambulances are mainly kept flying by public and company donations.

Flying with doctors is much more expensive and some air ambulance services would welcome NHS support to meet this. The DH says this is a matter for local NHS bodies to consider - but warns that including a doctor on every air ambulance could risk diverting staff away from A&E departments.

Anthony Marsh, who is leading one of the workstreams within the air ambulance working party as well as being chief executive of West Midlands Ambulance Service trust, says that evaluating how different skill-mixes on air ambulances contribute to outcomes will be important. His workstream wants to define excellence in air ambulance, covering aspects such as clinical governance as well as staffing.

Valued independence

Air ambulances have traditionally flown with paramedics, whose skills have increased dramatically in the past few years, but emergency care doctors and critical care practitioners - paramedics trained to carry out a wider range of procedures - are increasingly options.

But air ambulances value their independence and some fear closer relationships with the NHS could endanger this.

"Total government control might not result in the service being used for its original purpose," says London Air Ambulance chief executive Andrew Cameron. "More money is welcome but we would not want that to come with interference."

Mr Philpott insists air ambulances want to remain charities and none would want to go down the Scottish route of a fully funded and managed service. There are also freedoms that air ambulances hold dear such as taking a patient to what they judge the most appropriate hospital - which might be a specialist hospital further away than a local one. In Kent, for example, a significant proportion of trauma patients are flown into London hospitals.

But there are costs which Mr Philpott would like to see the NHS meet, such as employing emergency doctors, clinical governance, and drugs and dressings. These cost the Kent, Surrey and Sussex charities - which operate two helicopters between them - around£650,000 a year.

Even centralising trauma into fewer units is a challenging issue for air ambulances, as it could add to their costs with longer flights.

But to use air ambulances in this way would offer a solution to the problem of distance from trauma units and potentially calm public fears over access times. Mr Marsh argues that the public perceptions of the "dangers" of longer transfers to hospital need to change - but does think there will be a bigger role for air ambulances.

Health minister Ben Bradshaw said in a recent radio interview: "I think there may well be implications for air ambulances in the way we treat trauma and other conditions which may make it more cost effective to increase the funding for air ambulances. But we are not there yet." He pointed to a 2003 study suggesting air ambulances needed to save four lives a year to make it worth the government meeting all their costs.

However, it would need helipads at all trauma centres and potentially helipads at other A&E departments to allow transfer when patients start off in the "wrong" unit. Mr Marsh supports helipads being included in all new builds but some hospitals likely to be designated trauma centres don't have them and it may be very expensive to provide them. Air ambulances can use other landing sites but that means adding a journey by land ambulance.

Another issue exacerbated by having doctors on board is the need to make the most appropriate use of the air ambulance. A lot depends on relationships locally with ambulance control rooms. In London, for example, there are clear protocols governing which incidents the air ambulance must be called out for. In other serious cases, it may be deployed but normal 999 evaluation procedures will be followed.

Other areas have worked hard to avoid air ambulances being called out for minor incidents, a historical problem which can cost them a lot of money and cost NHS staff's time.

Wider uses

However, Mr Marsh points out that often the need to use an air ambulance is determined by the terrain and remoteness of where an incident happens as well as the nature of the incident. Even if injuries are relatively minor, it may be better to airlift a patient rather than transport them a long distance by stretcher, with risks both to patient and rescuers.

One solution being tried in Kent, Surrey and Sussex is to have air ambulance staff working alongside ambulance service dispatchers. Incidents attended have dropped but seriousness of incidents attended has increased. Each of its two helicopters now attends around three incidents a day. Half those attended are life-threatening.

But is there also scope to use air ambulances for other tasks - such as urgent patient transfer to intensive care units, or even transplant organ delivery, where time can be vital?

Here opinions differ: Mr Philpott thinks it could be possible, although such services may have to be commissioned and paid for by acute trusts or PCTs.

Mr Marsh also supports use for patient transfer, pointing to the benefits of hospital medical teams needed to accompany seriously ill patients being away for a shorter time. Patients could be flown to a trauma centre or a specialist hospital from an A&E department once the extent of their injuries or illness becomes clear.

Andrew Cameron is reluctant to see air ambulances' main purpose diluted, arguing that there are other providers to do these jobs. "I would be so upset if we had been instructed to transfer someone to Coventry after an operation and a child went under a train in Croydon," he says. "The government must not forget these are charities. The way it could work would be for us to purchase another helicopter that is dedicated to that sort of work. But there needs to be funding. To put up a second helicopter you would be looking for an investment of anything up to£1.5m." But he thinks the public would still support urgent patient transfers - and more public contact may strengthen support.

Extending hours of operation is another key issue; many helicopters are not equipped for night flying and there are severe restrictions on night flights and landing. Transfers at night would be possible but only between lit helipads, says Mr Marsh. There would also be ramifications for hospitals at either end - such as the provision of staff to meet safety standards around risks such as fire.

In London, the air ambulance crews run rapid response cars from dusk to 1am with increased hours at the weekend. Ultimately, the charity would like to offer a 24/7 response using either cars or helicopter.

A vehicle substitute will only work in a dense urban area. Mr Philpott says equipping a helicopter with the level of equipment the Civil Aviation Authority would like to see for night flying would cost£1m - beyond the reach of many charities.

But the Kent, Surrey and Sussex air ambulance charities are now working with Sussex police, who have their own helicopter suitable for night flying. From 1 April, paramedics will fly in this helicopter from dusk until 1.30am and, as well as police work, it will attend medical emergencies across much of the South East, flying patients into London hospitals.

It costs the charity around£250,000 a year but extends its "on duty" hours considerably, especially in winter. Such joint working may well become more common as both the charities and the NHS see benefits from working together.

"We are on the same journey as the hospices were 20 years ago," says Mr Philpott. "Now hospices get 34 per cent of their operating costs from PCTs and I suspect a few years down the line that's where we will end up."