“We have to straddle the health service and the emergency services camp—we have a foot in both,” says London Ambulance Service Trust (LAS) chief executive Jason Killens.

It’s not a new dilemma—and is far from a binary choice—but ambulance services increasingly see themselves as part of the NHS. That means casting off the mantle of being a ‘scoop and run’ service, concerned mainly with how quickly it can reach patients, load them into an ambulance and deliver them to hospital.

Now the job is also about providing advice over the phone, accessing alternative services better placed to help and giving care at the scene—using the skills of paramedics and others to keep people out of A&E.

Killens has run LAS since the middle of last year and is also chair of the Association of Ambulance Chief Executives (AACE). He and his team spend a lot of time speaking to trusts and ICBs, and will do so even more as neighbourhood health evolves. He works closely with London mayor Sadiq Khan, and the leaders of the capital’s three police forces, fire brigade and the RNLI are also likely to feature in his phone contacts. “Twenty per cent of our time is working with emergency service partners, 80% of it is with the NHS,” he says.

The job is challenging and complex, Killens says, but ten years as an ambulance chief executive means he has experience to bring to it—just as well, as the indications are that the job won’t get any easier.

Demand for ambulance services is growing by around 3-3.5% a year but that doesn’t fully capture the particular pressures in some areas: LAS has seen the number of 999 calls involving mental health rise by 90% in two years; it’s now exploring with mental health providers what’s driving this increase and how these patients can be best managed.

The Right Care, Right Person policy—where police will not attend someone in mental health crisis where there is no immediate risk of serious harm or death—has changed the way LAS reacts to some cases. “We’ve had to deploy different kinds of response to deal with it… we’re putting a couple of paramedics through a specialist course for mental health,” he says. In practice, the policy is “largely okay”, he adds, although “sometimes there are some operational tensions around who will take primary responsibility for a particular patient.” Ambulance crews need access to alternative services in the community for these patients to avoid more trips to A&E, he stresses.

All ambulance trusts are already under pressure to improve response times. LAS narrowly missed the 30-minute target for category 2 responses in 2025-26 and will be aiming for 25 minutes this year. That reduces to 21 next year, with a final target of 18 minutes by 2028-29.

Killens insists the money is there to achieve 25 minutes. Although the trust needs to find more than £20 million in “cost improvements”, all but a tiny fraction of that has been identified, he says.

But getting to 18 minutes will be tough. “I hate this phrase but it’s going to be about working smarter, not harder,” he says. This could involve working with partners to change the response model within the existing rules while lobbying for more fundamental changes, as well as “modernising” some workforce practices.

Hospital handovers have improved to an average 17 minutes—better than the national picture and just shy of the 15-minute target—and LAS has not experienced the persistent issues which have left ambulances queuing outside A&E in other parts of the country. “It’s about leadership and it’s about process,” Killens says. “It’s the flow through the whole hospital, it’s not just [about] the handover at A&E.

“One of the key things is getting colleagues [in other NHS organisations] to see the risks… that we have 200 people stacking up waiting for an ambulance,” he adds. “It’s about sharing the risk and everyone being aware of where the risk sits.”

The ambulance service has been plagued by sexual safety issues—including harassment and inappropriate behaviour by staff, and verbal and physical abuse by patients and the public.

While ambulance crews are vulnerable—working in twos, without the back up available in other emotionally fraught environments like A&E—verbal abuse is often aimed at control room staff. Half of LAS staff said they had experienced physical or verbal abuse in the last staff survey, Killens explains.

De-escalation training is among “the interventions we can deploy”, he says, but the trust is also encouraging the use of body-worn cameras to record incidents and is engaging with the London mayor, the courts and the CPS about using the full extent of sentencing powers. Staff who have been abused or assaulted need to feel justice has been done, Killens adds, but he wants to get ahead and prevent abuse happening in the first place. Initiatives in London have included the recent “all we want for Christmas is respect” campaign. More broadly, AACE has written to all four health ministers in the United Kingdom to ask for more action in policy terms.

Asked if the ambulance sector has the managerial capacity to cope with such unprecedented change, Killens stresses that capability is just as important as capacity. “I think we’ve got enough people but I think we have a job of work to do to ready those people…[so they have] the right experience and skills for what we need,” he says.

To that end, the AACE has been working with Hult Ashridge business school to offer courses to staff aiming for a chief paramedic or chief operating officer job in an ambulance trust. CPOs are relatively new roles and can only really be filled by someone already working in the sector, although COOs could come from outside.

Keeping the troops on board is a key part of any CEO’s job: like community and many mental health trusts, ambulance trusts have a dispersed workforce operating from different sites and working variable hours.

Killens devotes some of his time to a twice-yearly series of ’roadshows’, which see him travel to different ambulance stations over a period of three to four weeks to hear from staff. “The fact that I’ve done the job, I can talk the language they talk in… you could run a conversation with a group of staff about what’s irritating and frustrating for them in a way which resonates with them. A colleague who hasn’t got that background – it’s not impossible for them to do but it will be harder,” he says.

There’s always been a delicate balance between internal promotions and external appointments in the ambulance service. Currently, five out of nine ambulance chief executives in England have worked on the frontline, higher than in the past. As a former chief paramedic in London, John Martin, chief executive of the South Western Ambulance Service, has shown that being a CPO can be the route to the top job.

Killens’s own path included working as an emergency medical technician in London before moving into operational management, ending up as executive director of operations. Along the way he was strategic commander for the 2012 Olympic and Paralympic Games and was involved in the response to the London bombings in July 2005. Having gone into the NHS to help people, he thought he could do more in a management role, he explains.

Killens then led the ambulance service in South Australia for three years, an experience he describes as “formative”. Half the workforce–generally in rural areas—were volunteers and the service made extensive use of aircraft to reach patients over a vast geographical area. “You don’t have that in London—a fixed wing aircraft landing in Oxford Street to pick someone up,” he jokes.

“The issues were the same for staff and obviously patients are the same, but the context in which you are operating is just very different,” he says. “I learnt a lot about me—my leadership, what was good and what was not so good.”

He always intended to come back. Returning to the UK in 2018, he ran the Welsh Ambulance Service for seven years. “It was a blend of what I’d had before in London and what I had had in Australia,” he says. “It’s a national service but the context is different. The politics are closer, a direct line of communication and accountability to government, no NHS England in the middle. There was much more autonomy in how you configure the service and what you can do, and ultimately that is what led to changing the service delivery model and targets in Wales.”

Killens initiated a different way of measuring ‘success’ for the Welsh ambulance service. In England, the focus has been almost entirely on response times—especially the category 2 response (including suspected strokes, seizures and burns), which has dominated the narrative for several years. Wales, in contrast, now has a more nuanced system which looks at clinical outcomes as well as response times.

The new system was introduced just as Killens left, and he sees some clear advantages over the English system, which can inhibit ambulance crews from doing the best for some patients, he says. Convincing the government of this may be an uphill battle but he feels progress is being made.

AACE represents ambulance services across all four UK nations. They are “all in different places but the challenges are basically the same,” he says. All four are dealing with increased activity and can see bigger increases coming down the track. “We know that an elderly population uses the ambulance sector more. What that says is that the activity is going to continue to rise.

“We either carry on with the existing model we’ve got and put in a lot of very expensive double [crewed] staff to take ever increasing numbers of patients to emergency departments, [or] the sector starts to shift and pivot and invest heavily in advanced practice, in specialist paramedics in multidisciplinary teams, connecting better with local alternatives that already exist in the NHS,” he explains.

“We have to diversify the workforce, invest in different people in our organisation with different skills and get smarter by managing the vast majority of the 999 activity we see—where we can safely do it—in communities.”

A community-based approach to urgent care will give patients a better experience and ambulance clinicians greater job satisfaction, he adds, but a fast response and transfer to A&E will always be needed for emergency cases and the trust needs to do that consistently well.

Ideally, commissioning for ambulance services would evolve too, he says. He would like to see regional commissioning for the 999 service with NHS 111 services being run by ambulance trusts on a regional basis too. Better co-ordination between the two services would allow patients to reach the right service regardless of how they enter the urgent and emergency care system. “We think we are best placed to do that… because we’ll be able to offer at scale,” he says.

LAS engages with around five million people a year—both through 999 and 111—where it provides services in every part of the capital. The CEO job in London may have come up earlier than he expected, Killens admits, but it was not something he could refuse. “Why would I say no to… being in the privileged position of working with such great people and leading an organisation which is pivotal to London’s success?” he says. “It’s a great leadership role in a great organisation of 11,000 people. And I’m having fun!” //