Measuring patients' views: the optimum outcome measure.

quarter of ambulance crews in London are paramedics, but analysis of workload suggests that less than one tenth of calls require paramedical skills. The London Ambulance Service already trains more paramedics than any other service in Britain and loses some of them to provincial services after training. Only one third of hospitals served by the London Ambulance Service provide clinical training placements for paramedics, and even to meet current needs this will require a substantial increase. To achieve the Department of Health's target will require a substantial increase in training at considerable cost. Is this likely to be economic? How will most paramedics maintain their skills when only a small proportion of calls require them?'0 Will the damage to the morale of staff who are not paramedics, seen in other services with the development of an elite, occur in London? The London Ambulance Service has avoided many of these problems by ensuring that some extended skills, such as provision of defibrillation and nebuliser treatment, are taught to every qualified ambulance person. Evidence also exists that ambulance staff who are not paramedics can safely identify and treat hypoglycaemia with glucagon." If implementing a dispatch system responsive to medical priority shows that resources are being effectively targeted according to clinical need the aim of having a paramedic in every front line vehicle would need to be reconsidered. Historically, informal links with individual clinicians and specialty groups have facilitated many changes in ambulance training, operations, and equipment. As the range and complexity of prehospital care increases, however, the mechanisms for medical input to the London Ambulance Service and the audit ofoutcomes will need review. Currently, there is official medical input to extended training in the form of the paramedic steering committee as required by the NHS Training Directorate, but in other matters of policy the only other medical forum, the medical advisory group, has no operational responsibilities. Recent initiatives that have required close liaison are the development of joint training for ambulance and medical incident officers in the management of major incidents,'2 proposals for increasing direct communication between ambulances and accident and emergency departments, and the development of alternatives to obstetric flying squads.'3 The input of the medical advisory group to long term planning and development would be valuable. Unified medical input and systematic audit'4 are particularly necessary in view of the differing medical opinions and prejudices regarding the philosophies of "scoop and run" versus "treat in the street." How best to coordinate medical advice for the London Ambulance Service should be a matter for debate. In particular, the potential benefit to London of the consultant medical director model-popular in the United States and currently being pioneered in the Scottish Ambulance Service-will need careful assessment. Public interest in the London Ambulance Service is obvious, but public confidence, shaken by the 1989 ambulance strike and by the problems of last year, needs to be restored. Although response times have the highest profile-being easily measured-the quality of clinical care delivered is also crucially important, and its absence from the topics included in the service's annual corporate review is regrettable.15 The London Ambulance Service's new management must make an unequivocal commitment to both basic and extended training and the establishment of systematic clinical audit to build on the progress made to date. As a consumer, the public has a part to play in making the service more efficient, and a health education campaign supported by the government is long overdue. Management commitment is likely to produce better response times over the next three years, but this will be a hollow achievement without advances in clinical care.