Consultation outcome

Minimum service levels in event of strike action: ambulance services in England, Scotland and Wales

Updated 6 November 2023

This was published under the 2022 to 2024 Sunak Conservative government

Applies to England, Scotland and Wales

Foreword by the Secretary of State

As Secretary of State for Health and Social Care, the health and wellbeing of the public is my focus and priority. Ambulance services are at the heart of the urgent and emergency care system. The ambulance service epitomises the spirit of the NHS and its constant readiness to support people at their most vulnerable and I am grateful that we have such dedicated and professional staff working in the service.

Keeping people safe

Our top priority is to keep patients safe during any industrial action. It is vital to ensure that people have access to emergency services when they need it, including during any strike action. In recognition of the fact that disruption to blue light services puts lives at immediate risk, we are publicly consulting on proposals to introduce minimum service levels in ambulance services in order to give the public much needed assurance that life-saving and emergency care will continue through strike action.

The right to strike is an important part of industrial relations in the UK, rightly protected by law. However, we need to maintain a reasonable balance between the ability of workers to strike with the protection of the lives and health of the public. Currently during strike action employers are required to negotiate with trade unions to see if they will agree to voluntarily provide a certain level of cover and in which areas, so that certain staff members or groups of staff will be exempted from strike action to provide working cover for essential services. These agreements are known as ‘derogations.’ In addition, employers may be able to introduce short-term mitigating measures such as use of the military, private ambulances and taxi services. Hospitals may also take actions to reduce handover times such as cancelling elective procedures to free up capacity.

Even when these rigorous contingency plans are in place, the risk of industrial action endangering the lives and health of patients and the public remains if we continue to rely on a patchwork of locally agreed voluntary derogations from strike action, that are often not confirmed until very late in the day, or indeed might not materialise on strike days as they are voluntary and staff and unions can withdraw these.

Therefore, we are launching this public consultation on whether to introduce minimum service levels for ambulance services in the event of strike action in England, Wales and Scotland. Your feedback will help to ensure that if minimum service levels are introduced in ambulance services they are proportionate and fair.

We want to create certainty through introducing minimum service levels to better enable NHS providers to protect patients and the public during strike action.

Minimum service levels in other countries

In several western European countries there is legislation permitting minimum service levels to ensure the public continue to receive essential services during strikes. It is appropriate that the right to strike should be balanced with the other rights of service users.

For example in Italy, minimum service levels (MSLs) must be guaranteed for certain essential services throughout strike action, which includes the health services which are necessary to guarantee the protection of health. In Spain, governmental authorities may set MSLs for essential public services, on either a national or local level. In France, the government has the power to impose MSLs, where this would maintain the continuity of public services. Other examples where minimum service levels exist in some form include Germany, Belgium and the Netherlands. In addition, in Canada, Australia and parts of the United States of America there is already the ability to ban blue light services from striking.

Where we go from here

You may be wondering why we are proposing mandatory minimum service levels in the event of strike action. In most recent cases, where strikes have happened, employers and unions have negotiated a level of service to be provided despite the strike action so that life-saving and emergency care is still provided. But these negotiations take time, and their outcome is uncertain, meaning that service providers cannot plan ahead. I remain concerned that in some instances these voluntary agreements have not been agreed until the last minute, or there has been disagreement or uncertainty about what has been agreed.

I do not think that uncertainty is acceptable - for staff, for employers, for the public - especially when it comes to ambulance services. That is why we are considering whether we should bring forward minimum service levels in ambulance services; so that we will all have the much-needed assurance that life-saving and emergency care will always continue through strike action, and employers will be better able to plan for strike action.

Thank you for taking the time to respond to this consultation, to ensure that the NHS remains ready to help all of us in our hour of need.

The Rt Hon Steve Barclay MP

Introduction

The Department of Health and Social Care (DHSC) is seeking views during passage of the Strikes (Minimum Service Levels) Bill (‘the bill’) on, subject to Parliamentary approval, introducing regulations on minimum service levels in England, Scotland and Wales to support minimum service levels in the health service during strike action to protect patient safety.

The UK government has announced its intention to consult on the application of minimum service levels for rail, ambulance and fire services. In health, our intention is that minimum service levels would protect the ability of workers to strike while protecting life and health. This consultation will help to inform a decision as to what health services should be covered in regulations. Our proposal is that ambulance services should be covered in regulations as a priority. This consultation will help to inform a decision as to whether ambulance services should be covered and if so, the detail regarding the minimum service levels required in the ambulance service.

The target audience is:

• the general public
• trade unions
• NHS ambulance service employers
• other NHS and health service employers
• representative organisations and professional bodies
• all workers within ambulance and health services

Current ambulance service

999 calls

Calls to 999 are first answered by a BT operator, who directs the call to the appropriate local ambulance service. An emergency call handler, supported by clinical decision support system (CDSS) software, then asks a series of questions to determine what the issue is. Some calls will also be assessed by a clinician, for example a paramedic or nurse. At the end of this assessment, the call is allocated to a category based on the information given by the caller. The call handler may stay on the line, offering further practical help and advice where necessary.

In England once assessed the call is categorised to one of the following:

• life-threatening
• emergency
• urgent
• non-urgent

In Scotland and Wales there are different equivalent categorisations (see Annex A).

Where a face-to-face response is required, dispatchers in the ambulance control room will allocate an appropriate response for the call. Responses to patients are prioritised by the seriousness of the call, with the sickest patients with life-threatening or emergency conditions, being prioritised over less urgent calls and allocated a ‘blue light’ ambulance response. This may include an emergency ambulance, rapid response vehicle, volunteer first responder or other specialist resources such as a Hazardous Area Response Team response, Specialist Operational Response Team response or clinical first responder.

Ambulance control room clinicians can review held calls and provide clinical advice. Some calls can be closed with advice given over the phone or through referral to another non-blue light service such as primary care, mental health services, community services, the falls response team and mental health crisis team, among others. All held calls, including urgent calls, are monitored and reassessed and if a patient’s condition deteriorates, they may be ‘upgraded’ to receive an emergency response.

If a face-to-face response is provided, ambulance staff involved in the response may include paramedics, emergency medical technicians, emergency care assistants or others. Some incidents can be closed with treatment given on the scene. Patients may also be transported in ambulances for further treatment to emergency departments or other treatment providers.

Other services

Ambulance services also include the provision of non-emergency NHS patient transfer and transport services (NEPTS) for patients requiring time-critical treatment with conditions such as renal failure, cancer, palliative care and dialysis, and requiring transport and/or transfer. These services provide free transport to and from hospital, including for people whose condition means they need additional medical support during their journey and/or for people with mobility issues.

Ambulance trusts may also provide inter-facility patient transport services, including time-critical transfers for emergency treatment.

They may also provide NHS 111 services.

Summary of our proposal

We propose that a minimum service level means that all 999 emergency calls should be answered, even during a strike, as disruption to blue light services can put lives at risk. Ambulance services cannot know the nature or severity of an incident until the call is answered.

Our proposal is to ensure that the level of resource available on any given day of strike action will be set at a level to ensure all 999 calls are answered and assessed by ambulance control room staff. It is also to ensure that all life-threatening and emergency calls receive an appropriate response by an ambulance, a Hazardous Area Response Team, Specialist Operational Response Team or other responder. The proportion of urgent calls that are upgraded to life-threatening and emergency would need to be included in assessing the level of cover.

Our proposed approach is that the minimum service level would mean that the employer responsible for running an ambulance service would be required to ensure the resources required to respond appropriately to life-threatening and emergency incidents are in place. By the term “life-threatening and emergency incidents” in England and their equivalent in Wales and Scotland we mean calls that could include stroke, chest pain, loss of consciousness, breathing difficulties, major lacerations, compound fractures, sepsis and major burns, among other incidents of similar severity.

This would mean that, on strike action days, some workers would need to continue their work to ensure that these calls can be answered and responded to appropriately to protect life and health. In the context of strike action, we expect that calls classed as non-life-threatening or non-emergency would not be treated as a priority by the ambulance service as responses to more serious incidents would be prioritised. In some cases we would expect other more appropriate services, such as community services that respond to individuals who have fallen, would respond instead.

Our proposal also includes employers planning so that appropriate resourcing is in place to provide non-emergency NHS patient transport services (NEPTS) for patients with conditions such as renal failure, cancer, palliative care and dialysis and requiring transport and or transfer. These services provide free transport to and from hospital or between NHS facilities for people whose condition means they might need additional medical support during their journey and/or for people with mobility issues. Our proposal also includes employers planning so that appropriate resourcing is in place to undertake emergency inter-facility transfers between specialist centres. This may include land and air critical care transfers of adults, paediatric and neonatal transfers, and retrieval. A senior doctor or other senior healthcare professional should deem this necessary to be undertaken as a life-threatening transfer.

Current ambulance service during strike action

The NHS makes every effort through rigorous contingency planning to minimise disruption and its impact on patients and the public during industrial action. NHS England works with providers, professional bodies, trade unions and other bodies to agree cover in advance of strike action. In previous strike action, employers negotiated with trade unions to see if they would agree to voluntarily provide a certain level of cover and in which areas, so that certain staff members or groups of staff would be exempted from strike action to provide working cover for essential services. These agreements are known as ‘derogations.’

While we are pleased those voluntary derogations have been agreed for the strike action to date, this is not guaranteed to be the case for future action, and previous derogations have often only been agreed at the very last minute. In some cases, voluntary derogations have not been agreed until immediately prior to strike action, with these very late agreements leaving employers with hours, not days, to implement full contingency plans and leading to much uncertainty for all involved. In some areas, there was some confusion about what had been agreed, with no guarantee that staff due to attend work during strike action would actually attend work as had been agreed.

In some circumstances, for example during recent strike action in December 2022, call handlers working in the ambulance service have taken part in strike action, meaning their roles were filled by workers who are not fully trained as employers have not had appropriate time to provide the full training that is normally required. Additionally, in some cases ambulance service workers have returned from the picket line during strike action as part of voluntary derogations, which could lead to a slower response to life-threatening and emergency incidents. All of this, including the last-minute nature of some agreements creates a great deal of uncertainty and confusion for everyone concerned including staff, the public, patients and their families.

Minimum service levels would create certainty, better enabling ambulance services to keep patients safe during industrial action. It would also enable decisions to be taken earlier regarding other measures such as postponement of routine appointments, so that patients can be kept informed.

Strikes (Minimum Service Levels) Bill summary

The purpose of minimum service levels

Minimum service levels (MSLs) aim to limit the impacts of strike action on the lives and livelihoods of the public and to ensure balance between the ability of unions and their members to strike with the rights of the wider public to be able to access key services during strikes.

The introduction of multi-sectoral minimum service level (MSL) legislation, subject to Parliamentary approval of the Strikes (Minimum Service Levels) Bill, is designed to enable people to continue to attend their place of work, access education and healthcare, and go about their daily lives during strikes, while balancing this against the ability to strike. Where MSLs are applied, there should be a more consistent level of service for the public from strike to strike, as well as minimising the circumstances in which there are no services at all. This will help protect the public and guard against disproportionate risks to lives and livelihoods.

Overview of the bill

The bill, if approved by Parliament, will amend the Trade Union and Labour Relations (Consolidation) Act 1992 to:

• impose conditions on the protection of trade unions from legal action in respect of strikes relating to services where provision has been made for minimum service levels (MSLs). The services will be prescribed by regulations, following consultation
• impose obligations on trade unions and individuals to comply with minimum service levels and enabling employers within specified services to issue work notices to roster the workforce required to secure the minimum service level on a strike day

Implementation of MSLs

The bill includes powers for the Secretary of State to set MSLs, for services within specified key sectors (categories), through regulations. There is also a power for the Secretaries of State to specify the ‘relevant services’ within the broad categories listed in the legislation, where MSLs could apply.

The key sectors (categories), which are specified within the bill, are:

• health services
• fire and rescue services
• education services
• transport services
• decommissioning of nuclear installations and management of radioactive waste and spent fuel
• border security

The Secretary of State must consult such persons as they consider appropriate on the proposed regulations and the regulations must be approved by both houses of Parliament before they are made. The consultation requirements may be fulfilled before and after the bill receives Royal Assent.

The bill, if approved by Parliament, will come into force on Royal Assent but will not take effect until the regulations which specify the services MSLs will apply to and what the minimum services levels will be, come into force. Once implemented, MSLs may be applied in relation to any strike in the specified services which take place after regulations come into force.

Work notices

Once an MSL is implemented via regulations in relation to a service, where a trade union gives notice of strike action to an employer, the employer may decide to issue a notice (known as a work notice) ahead of the strike days to specify the persons required to work and the work they must carry out to secure that the MSL for that strike period is provided. The work notice must be given no later than 7 days before the day of the strike but can be varied up to 4 days before (or later if agreed with the union).

The employer must consult the union about the numbers of persons to be identified and the work to be specified in the work notice and have regard to their views before issuing the work notice. A work notice must not identify more persons than are reasonably necessary for the purpose of providing the MSLs and, in deciding whether to identify a person in the work notice, the employer must not have regard to whether the person is or is not a union member.

Enforcement of work notices

Where a work notice is validly given by the employer to the union, the bill provides that a union loses its protection from damages claims by the employer in relation to the strike if it does not take reasonable steps to ensure that members of the union named on the work notice comply with the work notice.

The dismissal of an employee who takes part in official and protected strike action will normally be automatically unfair if taking part in the strike is the reason for their dismissal. Under the provisions of the bill, if an employee identified in a valid work notice for a strike day takes strike action on that day, the employee would lose this protection and a dismissal would not be automatically unfair, provided their employer has notified them (before the strike day) that they are named in and must comply with a work notice and the work which they need to carry out. The dismissal may still be found to be unfair for other reasons, it will just not automatically be the case.

The legislation equips employers to manage instances where a worker takes strike action, despite being named to work on a strike day, by removing the employee’s automatic protection from unfair dismissal. It is the discretion of the employers as to what, if any, disciplinary action is taken in these circumstances, and we expect that employers are fair, reasonable and only take this sort of action where it is necessary. A dismissal may still be found to be unfair where it is not fair in all the circumstances.

The duties on unions with respect to this legislation are clear and we are sure that they will want to comply with them. If unions do not do this, then employers can pursue the union for damages or seek an injunction from the court to stop the planned strike action. If workers take part in an unprotected strike, it is the discretion of the employers as to what, if any, disciplinary action is taken. However, our view is that this is very unlikely to happen.

Geographical scope

The bill applies to England, Wales and Scotland (that is, Great Britain). The purpose and substance of the bill is to regulate employment rights and duties and industrial relations in specified services. Employment rights and duties and industrial relations is a reserved matter.

This bill enables the UK government to apply MSLs to key sectors across Great Britain. We recognise that in some cases this will affect employers operating services that are devolved. As part of the development of MSLs and the consultations that are legally required to inform these, the UK government is engaging with the Scottish Government and the Welsh Government on the geographical scope of the regulations - recognising that, in some cases, application of MSLs could affect employers operating services that are devolved.

This consultation covers health services in England, Wales and Scotland. The purpose and substance of the bill is to protect the public by ensuring that access to essential and life-preserving services is still available in times of industrial dispute. Employment rights and duties and the law relating to industrial relations are reserved matters as regards to Scotland and Wales, which means that decisions are taken by the UK Parliament at Westminster. As employment law is devolved for Northern Ireland, it is for the Northern Ireland Assembly to assess whether to implement minimum services levels in the event of strikes there.

International comparisons and legal context

Whether or not MSLs are justified in accordance with Article 11 of the European Convention of Human Rights (ECHR) will depend on a number of factors such as aspects of international law, which includes International Labour Organization (ILO) conventions.

The ILO is a specialised agency of the United Nations which promotes social justice and workers’ rights. The ILO has stated that minimum service levels are justifiable in some situations to protect essential services. This includes where there are “services the interruption of which would endanger the life, personal safety or health of the whole or part of the population (essential services in the strict sense of the term)” (Freedom of Association: Compilation of Decisions of the Committee on Freedom of Association, Sixth Edition, page 164).

Our proposal to introduce MSLs in the ambulance service would aim to protect life, safety or health, and our view is that it is a legitimate and proportionate interference with the right to strike, as has been recognised by the ILO, because it is an ‘essential service’ which, if interrupted, would ‘endanger the life, personal safety or health’ of the public. As such, the proposal strikes the right balance between the rights of workers to strike and the protection of others’ freedoms and rights.

In line with ILO guidance and case law of the European Court of Human Rights, which sets out that MSLs can be justified, there are MSLs in place to varying levels of provision across Western Europe.

In Italy, MSLs must be guaranteed for certain essential services related to constitutional rights throughout strike action, under Law 146/90. These rights include life, health, freedom and safety. Therefore, MSLs can be introduced for the health services which are necessary to guarantee the protection of health.

Employers and unions must negotiate agreements for MSLs during strike action, with these agreements being subject to approval by the Commission of Guarantee, an independent expert body which determines whether proposals correctly strike the balance between the right to strike and the wider constitutional rights of the population. Employees, trade unions and others who do not comply with MSLs may be subject to financial and administrative penalties, such as fines of up to €50,000 for unions, which can be doubled in certain circumstances.

In Spain, governmental authorities may set MSLs for essential public services, on either a national or local level. The Spanish Constitution of 1978 recognises that the right to strike can be regulated, by establishing the guarantees necessary to ensure the maintenance of essential services, which is set out in Royal Decree 17/1977.

MSLs can be justified in Spain where they strike a proportionate balance between the right to strike and the constitutionally protected rights of members of the public. Unlike in Italy, there is no legal requirement to consult trade unions on MSLs. Employers may take disciplinary action against employees who do not comply with an MSL.

In France, the central government has the regulatory power to impose MSLs and restrict the right to strike, where this would protect the security of people or premises, maintain public order, or maintain the continuity of public services.

Other examples where minimum service levels exist in some form include Germany, Belgium and the Netherlands.

In addition, in Canada, Australia and parts of America there is already the ability to ban blue light services from striking. In Canada, MSLs are in place at a federal level, to provide for circumstances where a failure to meet the MSL would a cause immediate and serious danger to the health and safety of the public.

Policy objective

The priority is to keep patients safe during any strike action. While we recognise the importance of the ability to strike, we need to balance this against the need to protect the health and lives of the public during strike action. It is vital to ensure that people have access to emergency services during any strike action.

In recognition that disruption to blue light services could put lives at immediate risk, we are publicly consulting on introducing minimum service levels in ambulance services to give the public much needed assurance that life-threatening and emergency care will continue through strike action. Life-threatening and emergency incidents could include strokes, chest pain, loss of consciousness, breathing difficulties, major lacerations, compound fractures, sepsis or major burns, among other incidents.

Even when rigorous contingency plans are in place, the risk of industrial action endangering the lives and health of patients and the public remains. Currently during strike action employers are required to negotiate with trade unions to see if they will agree to voluntarily provide a certain level of cover and in which areas. This is so that certain staff members or groups of staff will be exempted from strike action to provide working cover for essential services. These are known as voluntary derogations.

In some cases, voluntary derogations have not been agreed until immediately prior to strike action, leaving employers with hours not days to implement full contingency plans. This creates a great deal of uncertainty for everyone concerned including staff, the public, patients and their families. In some circumstances, during recent strike action in December 2022, call handlers working in the ambulance service have taken part in strike action, meaning their roles were filled by workers who are not fully trained as employers have not had appropriate time to provide the full training that is normally required. Additionally, in some cases ambulance service workers have returned from the picket line during strike action as part of voluntary derogations, which could lead to a slower response to life-threatening and emergency incidents.

There is currently no obligation for ambulance services to continue in times of strike action and currently it is based on goodwill and cooperation of multiple trade unions, subject only to a criminal offence if a person maliciously breaches their contract knowing it will endanger life or cause serious bodily injury. This means that there is no certainty that there will be an adequate number of staff working during strike action to protect patient safety, and there could be variation in access to life-threatening and emergency care for patients. Regulations setting a minimum service level for ambulance services would provide greater assurance that patients will be kept safe and allow employers to better plan their services on strike action days.

The government is clear that in setting minimum service levels it is not suggesting that these levels should be seen as an acceptable service on non-strike days. Rather, these are the absolute minimum service level it is reasonable and necessary to expect in order to protect the public on a strike day balanced against respecting the right of workers to take strike action. It does not and should not replace the normal approach that ambulance services would take to ensure that sufficient resourcing and capacity is in place on days where no strikes are taking place.

NHS ambulance services

NHS ambulance services in England, Wales and Scotland respond to emergency 999 calls in accordance with patient need. This could involve:

• dispatching an ambulance or other vehicle with appropriate clinical staff such as a paramedic, Hazardous Area Response Team, Specialist Operational Response Team, community first responder or other appropriate staff
• providing advice over the telephone, often referred to as ‘hear and treat’
• referring people to appropriate services which can be referred to as either ‘hear and treat’ or ‘see and treat’

Ambulance services may also provide other services, such as transporting patients to and from or between hospitals, NHS 111, non-emergency patient transport and, in addition, Scotland provides specialist air and land transport retrieval services. The exact range of services provided can vary.

Ambulance services in England work to the Ambulance Response Programme, a set of national standards implemented in the 2017 to ensure that the sickest patients get the fastest response, and that patients receive the right response first time. Scotland and Wales have slightly different national standards.

Ambulance vehicles can carry a wide range of equipment including intravenous drips, drugs, oxygen and heart defibrillators. The types of worker that may be involved in ambulance response could include:

• call handlers
• dispatchers
• paramedics
• nurses
• ambulance care assistants
• emergency care assistants
• emergency medical technicians
• volunteer first responders
• doctors, other clinicians, managers acting as commanders or in a leadership role and other support staff

In England, ambulance services are provided by 10 NHS ambulance trusts, plus the Isle of Wight NHS Trust which also provides ambulance services on the island. 999 emergency ambulance services are only provided by NHS ambulance trusts. They may also provide other NHS services such as NHS 111, non-emergency patient transport services and inter-facility transfer services.

In Wales, ambulance services are provided by the Welsh Ambulance Services NHS Trust.

In Scotland, ambulance services are provided by the Scottish Ambulance Service.

Proposed approach

Our proposal is to ensure that the level of resource available on any given day of strike action will be set at a level to ensure all 999 calls are answered and assessed by ambulance control room staff and that all life-threatening and emergency calls receive an appropriate response by an ambulance, a Hazardous Area Response Team, Specialist Operational Response Team or other clinical first responder. The proportion of urgent calls that are upgraded to life-threatening and emergency would need to be included in assessing the level of cover. By the term “life-threatening and emergency incidents” in England and their equivalent in Wales and Scotland we mean calls that could include stroke, chest pain, loss of consciousness, breathing difficulties, major lacerations, compound fractures, sepsis and major burns, among other incidents of similar severity.

Based on data held by ambulance services in England on calls received in the past, ambulance services know relatively accurately the level of resource needed to respond to calls on any given day. Data published by NHS England shows that, while varying monthly, incidents categorised as immediately life-threatening currently account for up to around 15% of all calls. Incidents categorised as emergencies account for around 65% of calls. Urgent calls account for around 20% of calls and non-urgent calls typically account for less than 1% of all calls. See NHSE data on ambulance quality indicators.

Our proposal would involve ensuring that, on strike days, all 999 emergency calls to the ambulance service would be answered. This is because ambulance services cannot know the nature or severity of an incident until the call is answered.

The call handler would use a clinically-led process to decide the appropriate level of response for the call (as would normally happen on a non-strike day). Ambulance service clinicians contribute to this process using their clinical experience.

Our proposal is that calls classed as life-threatening and emergency incidents would always receive an appropriate clinical response when there is strike action. In England, currently, these calls are classified as Category 1 (immediately life-threatening) and Category 2 (emergency) calls and there are equivalent categories in Wales and Scotland (see Annex A for more detail). Decisions on which calls are assigned to which categories are made by a clinically led process.

On strike action days, some workers would continue their work to ensure that these calls can be answered and responded to appropriately to protect the life and health of patients. This approach means we would expect NHS services to have in place on strike days adequate capacity and resourcing in the call control room to ensure that 100% of emergency 999 calls to the ambulance service are answered.

We would expect ambulance service employers to be able to identify what proportion of their staffing resource would be required on a strike action day to ensure that sufficient resourcing and capacity is in place for an appropriate response by ambulance clinicians, a Hazardous Area Response Team, Specialist Operational Response Team or other responders for life-threatening and emergency incidents as necessary.

Where this approach would differ from normal practice in ambulance services on days where this is no strike action, is that in this context we expect that calls not classed as a life-threatening and emergency incidents (currently classed as Category 3 and 4 in England and equivalents in Wales and Scotland) would not necessarily be responded to by the ambulance service. However, they may be responded to if they had capacity on a strike day to answer those calls. Examples of these types of incidents could include late stages of labour, non-severe burns, diabetes, diarrhoea, vomiting and urine infections, among other incidents.

This approach would also mean that calls which are not classed as life-threatening and emergency incidents may be held much longer than usual until a resource becomes available to respond or a different response could be suggested, for example taking an alternative mode of transport to hospital, such as a taxi, referral to a GP or support provided by a community health service.

The condition of a patient may deteriorate over time while awaiting medical response - a call initially not assessed as a life-threatening or emergency incident may evolve over time to become a life-threatening or emergency incident. For a small number of patients who are initially assessed by ambulance services as a non-life-threatening or non-emergency incident their condition may change to be deemed by a senior clinician as a life-threatening or emergency incident. We would expect employers to ensure any assessment of adequate resourcing and capacity on strike days included such incidents.

Our proposal also includes employers planning so that appropriate resourcing is in place to provide non-emergency NHS patient transport services (NEPTS) for patients with conditions such as renal failure, cancer, palliative care and dialysis and requiring transport and or transfer. These services provide free transport to and from hospital or between NHS facilities for people whose condition means they might need additional medical support during their journey and/or for people with mobility issues. Our proposal also includes employers planning so that appropriate resourcing is in place to undertake emergency inter-facility transfers between specialist centres. This may include land and air critical care transfers of adults, paediatric and neonatal transfers, and retrieval. A senior doctor or other senior healthcare professional should deem this necessary to be undertaken as a life-threatening transfer.

We would also expect employers to plan to ensure that adequate resources are in place for other critical infrastructure and resources including IT support for the control room as well as recovery and fleet maintenance mechanical support in the event of breakdown of ambulance vehicles.

It would be for the employer responsible for running an ambulance service to name the appropriate number and names of a range of workers in a work notice to ensure that the required minimum level of service can be maintained on a strike day. We expect this could include:

• call handlers
• call dispatchers and supervisors
• clinicians in control rooms
• ambulance crews
• paramedics
• nurses
• ambulance care assistants
• emergency care assistants
• emergency medical technicians
• doctors, clinicians, managers acting as commanders or in a leadership role and other support staff
• Hazardous Area Response Teams - comprised of specially recruited staff who are trained and equipped to provide the ambulance response to high-risk and complex emergency situations such as specific, large scale or high-profile incidents, either accidental or deliberately caused
• Special Operations Response Teams - comprised of staff who respond to major incidents that could include nuclear, chemical and radiological ones. These teams have specially equipped vehicles with decontamination equipment on board
• other staff - however, it will be for employers to determine the appropriate mix of staff required to maintain the minimum service level as set out in the regulations

Devolved governments

Ambulance services are run differently in England, Scotland and Wales and are the responsibility of the Scottish and Welsh Governments respectively. We are keen to understand, including through the responses to this consultation and engagement with devolved governments, the differences between ambulance services in England, Scotland and Wales and the implications of those differences for setting minimum service levels. This will help to inform a decision on whether minimum service level regulations are needed across Great Britain and, if so, whether different regulations for England, Scotland and Wales are needed to take account of operational differences.

How to respond

The easiest way to respond is via the online survey.

If you require any clarification on the consultation document, email [email protected]. Do not send any personal information to this email address.

The consultation is open for 12 weeks. The deadline for responding is 11:45pm on 9 May 2023.

Consultation questions

Question

Roughly how far away do you live from the nearest hospital? If you’re unsure, see the NHS service Find a hospital, or select ‘Don’t know’.

• Less than 1 mile
• 1 to 2 miles
• 2 to 5 miles
• 5 to 10 miles
• 10 to 15 miles
• 15 or more miles
• Don’t know or prefer not to say

Question

Do you have any physical or mental health conditions or illnesses lasting or expected to last 12 months or more?

This is about health conditions, illnesses or impairments you may have. Consider conditions that always affect you and those that flare up from time to time. These may include, for example, sensory conditions, developmental conditions or learning impairments.

• Yes
• No
• Prefer not to say

Question

Do any of your conditions or illnesses reduce your ability to carry out day-to-day activities?

This is about whether your health condition or illness currently affects your ability to carry out day-to-day activities.

• Yes, a lot
• Yes, a little
• Not at all
• Prefer not to say

Question

The proposal to introduce minimum service levels for ambulance services relates to England, Scotland and Wales (Great Britain).

To which part of the UK does your response relate? Select all that apply.

• England
• Scotland
• Wales
• Northern Ireland
• Prefer not to say

NHS ambulance services

Currently during strike action employers are required to negotiate with trade unions to see if they will agree to voluntarily provide a certain level of cover and in which areas, so that certain staff members or groups of staff will be exempted from strike action to provide working cover for essential services. These agreements are known as ‘derogations.’ In addition, employers may be able to introduce short-term mitigating measures such as use of the military, private ambulances and taxi services. Hospitals may also take actions to reduce handover times such as cancelling elective procedures to free up capacity. These negotiations do not take place until very close to the strike action, and their content may not be agreed. This can lead to uncertainty for people planning services.

Our preliminary view is that MSLs for ambulance services will enable a more consistent level of service for the public from strike to strike, as well as minimising the circumstances in which there are no services at all. They will also help to provide some certainty for employers so that they are better able to plan for strike action to ensure minimum service levels are in place. This will help protect the public and guard against risk to life.

Question

To what extent do you agree or disagree with the proposed introduction of minimum service levels for ambulance services in the NHS?

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

If you wish, please explain your position and provide any supporting evidence. (Maximum 500 words)

Question

Currently on strike days, employers seek voluntary agreement from trade unions so that certain staff members refrain from taking strike action, in order to provide cover for essential services. To what extent to you agree or disagree that current arrangements are sufficient?

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

If you wish, please explain your position and provide any supporting evidence. (Maximum 500 words)

Scope of health services

Question

To what extent do you agree or disagree that it is important to have consistent standards for minimum service levels in the event of strike action in the ambulance services across England, Wales and Scotland?

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

If you wish, please explain your position and provide any supporting evidence. (Maximum 500 words)

Subject to the outcome of this consultation, our intention is that minimum service level regulations would be introduced to ensure that the ambulance service can respond to life-threatening and emergency incidents in England, Wales and Scotland during strike action. Therefore, we are considering designating ambulance services as relevant services where MSLs could be set.

Question

To what extent do you agree or disagree that the ambulance service should be specified as a relevant service where MSLs could be required on strike days?

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

If you wish, please explain your position and provide any supporting evidence. (Maximum 500 words)

Our proposal is that life-threatening and emergency incidents would be responded to in times of strike action. These incidents could include stroke, chest pain, loss of consciousness, breathing difficulties, major lacerations, compound fractures, sepsis or major burns, among other incidents of similar severity. This could mean that less serious calls may be held until a resource becomes available to respond or a different response could be suggested, for example taking an alternative mode of transport to hospital, such as a taxi, referral to a GP or support provided by a community health service. By less serious calls we mean incidents such as late stages of labour, non-severe burns, diabetes, diarrhoea, vomiting and urine infections, among other incidents. Less serious calls could be reassessed as needing a prioritised response if a person’s condition changed and became a life-threatening and emergency incident.

Question

Which of the following types of medical incidents should be responded to, even in times of strike action, if any? Select all that apply.

• Life-threatening cases or those needing immediate intervention and/or resuscitation (for example major trauma and cardiac and respiratory arrest, among other incidents)
• Emergency cases including serious time-sensitive incidents (for example strokes and heart attacks, among other incidents)
• Urgent issues that are not immediately life-threatening but need treatment to relieve suffering (for example pain control), and transport or management at the scene such as falls, among other incidents
• Non-urgent cases that need assessment and possibly transport within a clinically appropriate timeframe
• None of the above
• Don’t know or prefer not to say

If you wish, please explain your position and provide any supporting evidence. (Maximum 500 words)

Our preliminary proposal is for MSLs to cover the following services provided by NHS ambulance services:

• 999 emergency ambulance services
• Non-emergency patient transport services
• Inter-facility transfer services
• NHS 111
• Hazardous Area Response Teams
• Special Operations Response Teams
• Unexpected births in the community
• Healthcare practitioner call response

Question

Which of these ambulance services, if any, should be covered by MSLs in ambulance services? Select all that apply.

• 999 emergency ambulance services
• Non-emergency patient transport services
• Inter-facility transfer services
• NHS 111
• Hazardous Area Response Teams
• Special Operations Response Teams
• Unexpected births in the community
• Healthcare practitioner call response
• Other
• Don’t know or prefer not to say
• None of the above

If you answered other, please explain your answer. (Maximum 500 words)

See tables in Annex A for definitions of the category of calls in England, Wales and Scotland.

Question

We have outlined some options below on how MSL regulations could operate. Which options, if any, do you agree with? Select all that apply.

• Requiring ambulance trusts to respond to all life-threatening and emergency incidents, provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure, for example IT support
• Requiring ambulance trusts to respond to a specified list of medical issues, provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure, for example IT support
• Requiring ambulance trusts to respond to calls under the national ambulance response time categories, (for example in England all or a subset of Category 1, Category 2, Category 3 or Category 4 calls and equivalents in Scotland and Wales - see Annex A for category definitions), provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure, for example IT support
• Requiring a percentage of service capacity to respond to 999 calls, provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure, for example IT support
• Requiring a percentage of staffing to respond to 999 calls, provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure, for example IT support
• None of the above
• Other
• Don’t know or prefer not to say

If you wish, please explain your position and provide any supporting evidence. (Maximum 500 words)

In practice, where an MSL is set in regulations, employers will be able to issue a work notice, which must specify who will be required to work on strike days and what work will be undertaken. The work notice is therefore a mechanism by which the employer can plan a minimum level of service on strike action days. This will help to ensure the minimum level of service set in regulations, such as ambulances being able to respond to life-threatening and emergency calls, is in place during any strike action.

Question

If minimum service level regulations are made, based on the requirement to name staff in work notices, which staff groups should be included within a minimum service level for the ambulance service? Select all that apply.

• Emergency operations centre staff including call handling, clinicians, supervisors, ambulance dispatch staff and navigators
• Paramedics (also including specialist paramedics, advanced paramedics, consultant paramedics)
• Ambulance crews
• Emergency care assistants
• Ambulance care assistants
• Emergency medical technicians
• Doctors, other clinicians, managers acting as commanders or in a leadership role and other support staff
• Hazardous Area Response Teams
• Special Operations Response Teams
• Don’t know or prefer not to say
• None of the above
• Other

If you wish, please explain your position and provide any supporting evidence. (Maximum 500 words)

This consultation is focused on ambulance services. Other health services are not included in this consultation. The government may consult in the future regarding minimum service levels in the event of strikes for other health services.

Question

To what extent do you agree or disagree that other health services should be included in MSL regulations?

• Strongly agree
• Agree
• Neither agree nor disagree
• Disagree
• Strongly disagree

If you think other health services should be included, which health services should these be? Please explain your position and provide any supporting evidence. (Maximum 500 words)

Impact and implications of the policy

Question

Are there particular groups of people, such as (but not limited to) those with protected characteristics, who would particularly benefit from the proposed minimum service levels for ambulance services?

See the Equality and Human Rights Commission definition of protected characteristics.

• Yes
• No
• Don’t know

If you answered yes, which particular groups might be positively impacted and why? (Maximum 500 words)

Question

Are there particular groups of people, such as those with protected characteristics, who would be particularly negatively affected by the proposed minimum service levels for ambulance services?

See the Equality and Human Rights Commission definition of protected characteristics.

• Yes
• No
• Don’t know

If you answered yes, which particular groups might be negatively impacted and why? (Maximum 500 words)

Equality impact assessment

Intended outcomes

We are consulting on the scope and implementation of minimum service levels in the health service, during strike action. Subject to Parliamentary approval, the power to set these at a national level will be conferred by the Strikes (Minimum Service Levels) Bill, which was laid before Parliament in January 2023.

This legislation will amend the legal framework around industrial action by giving the government the power to introduce minimum service levels in the health service during strike action to ensure that patient safety is protected. These minimum service levels will balance the right of workers to strike while ensuring the public are also protected from a disproportionate level of disruption.

The government’s strong preference is for voluntary agreements, such as those that were agreed for recent NHS strike action, however, this is not always guaranteed to be the case for future action. This legislation would provide greater assurance that essential services will continue to operate even during strike action.

Public sector equality duty

In introducing strike minimum service level regulations for ambulance or other health services, the Secretary of State for Health and Social Care must have due regard to the duties under the Equality Act 2010 to:

• eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under the Equality Act 2010
• advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it
• foster good relations between persons who share a relevant protected characteristic and persons who do not share it

Initial consideration has been set out below. Further consideration will be needed in light of evidence gathered as part of this consultation.

Data

Data for this initial consideration has been drawn from the September 2022 NHS Digital publication on staff working in NHS trusts and core organisations in England, see NHS workforce statistics - September 2022 (including selected provisional statistics for October 2022).

Consideration of other demographic data on affected groups is planned to inform an updated assessment which will be undertaken once the consultation has concluded.

We have identified that the following groups of people are most likely to be affected:

• those working for ambulance services
• members of the public who may require ambulance services

Impact on ambulance staff

Professionally qualified ambulance staff are more likely to be male (54%) than non-medical staff in other health services (20%). The introduction of MSLs on ambulance staff may, therefore, impact these groups disproportionately, in that they are more likely to be working in a role where they may be subject to a work notice, and therefore have their ability to take strike action on a particular day restricted.

Impact on the public

Our assumption is that the elderly and those with disabilities or long-term health conditions are more likely to require care from ambulance services. As MSL regulations are intended to help ensure a minimum level of service can be maintain in the event of strike action, this policy could therefore have a positive impact on these groups.

Discussion

Our initial assessment indicates that the impact of MSL regulations for ambulance services would be mixed and that there would need to be a balance between the potential detriment of MSLs for certain groups and the potential advantages of MSLs for others.

We need to maintain a reasonable balance between the ability of workers to strike with the rights of the public, who work hard and expect essential services they pay for to be there when they need them. The public and workers themselves reasonably expect government to intervene to protect people’s lives and livelihoods, and that is what we are doing by ensuring essential services continue even while workers are exercising their right to strike.

The government’s strong preference is for voluntary agreements, such as those that were agreed for recent NHS strike action, however, this is not always guaranteed to be the case for future action. This legislation would provide greater assurance that essential services will continue to operate even during strike action.

This is an initial view that we will refine as the consultation proceeds.

Annex A: description of call category services in England, Wales and Scotland

England

Category	Description
Category 1	Ambulance calls are the most serious calls classified as ‘life-threatening’, including major trauma, cardiac and respiratory arrest
Category 2	Calls are ‘emergency’ calls, including serious time-sensitive incidents such as strokes and heart attacks
Category 3	Ambulance calls are ‘urgent’, issues that are not immediately life-threatening but need treatment to relieve suffering (for example pain control) and transport or management at scene, such as falls
Category 4	Calls are ‘non-urgent’

Scotland

Triage term	Description
Immediately life-threatening	Patients whose condition is potentially life-threatening and a fast response is vital. This accounts for less than 10% of 999 calls received. These patients will be responded to by skilled paramedics and will normally be taken to A&E or specialist care. An example would be a patient in cardiac arrest
Urgent and emergency	Some emergency and urgent calls will also require a quick response and conveyance to hospital, that is, GP calls and non-life-threatening emergencies
Hear, treat and refer	Patients whose condition is not serious enough to require an ambulance to attend or likely to result in any need to go to hospital. These patients can safely be given telephone advice by a paramedic, referred onto NHS 24 for further advice or referred onto another service, such as a GP. An example would be a person with flu like symptoms
See, treat and refer	Patients whose condition requires face-to-face assessment by a skilled paramedic but, in many cases, may be safely and effectively treated by that paramedic at scene without any need to go to hospital. Alternatively, these patients may be referred directly to more appropriate services. An example would be an elderly patient who has fallen but is uninjured who could be referred onto a specialist community team and their care could be managed at home
Anticipatory care	Patients living with one or more long-term conditions whose care can be managed proactively at home, where a package of care has been put in place to support patients to stay at home. Specialist Paramedics can help deliver this care package working alongside colleagues in health and social care. An example would be a patient living with chronic obstructive pulmonary disease whose acute exacerbation requires urgent care
Non-emergency (scheduled care)	Patients who require to be admitted or discharged from hospital, or transferred between hospitals for further treatment and patients attending hospital for a scheduled outpatient appointment. These patients require a degree of clinical or mobility support but are in a stable condition. An example would be a patient admitted for elective surgery or attending an outpatient appointment where ambulance transport was required

Wales

Category	Description
Red	Immediately life-threatening (someone is in imminent danger of death, such as a cardiac arrest)
Amber	Serious but not immediately life-threatening (patients who will often need treatment to be delivered on the scene, and may then need to be taken to hospital)
Green	Non-urgent (can often be managed by other health services) and clinical telephone assessment

Privacy notice

Summary of initiative

The Department of Health and Social Care (DHSC) is seeking views during passage of the Strikes (Minimum Service Levels) Bill, subject to Parliamentary approval, on introducing regulations on minimum service levels in England, Scotland and Wales to support minimum service levels in the health service during strike action to protect patient safety.

The UK government has announced its intention to consult on the application of minimum service levels for rail, ambulance and fire services. In health, our intention is that minimum service levels would protect the ability of workers to strike while protecting patient safety. This consultation will help to inform a decision as to what health services should be covered in regulations. Our proposal is that ambulance services should be covered in regulations as a priority. This consultation will help to inform a decision as to whether ambulance services should be covered and if so, the detail regarding the minimum service levels required in the ambulance service.

The target audience is:

• the general public
• trade unions
• NHS ambulance service employers
• other NHS and health service employers
• representative organisations and professional bodies
• all workers within ambulance and health services

The bill, if approved by Parliament, will amend the Trade Union and Labour Relations (Consolidation) Act 1992 to:

• impose conditions on the protection of trade unions from legal action in respect of strikes relating to services where provision has been made for minimum service levels (MSLs). The services will be prescribed by regulations, following consultation

• impose obligations on trade unions and individuals to comply with minimum service levels and enabling employers within specified services to issue work notices to roster the workforce required to secure the minimum service level on a strike day

Data controller

Department of Health and Social Care is the data controller.

What personal data we collect

Data to be collected includes age (as a category), sex, gender, IP address and geographical location.

How we use your data (purposes)

The consultation confirms in what instances you may be contacted via your email address.

The processing of personal data (namely, demographic information about respondents) is necessary to ensure that the government complies with the public sector equality duty (PSED) and captures if and how certain groups, such as those with protected characteristics, may be positive or negatively impacted by the policy.

It will be used to, for instance, compare how support or opposition to the policy, or views on its scope, may differ by characteristics which in some cases (such as age) are likely to be impacted by the policy.

Legal basis for processing personal data

Under the General Data Protection Regulation (GDPR), the lawful bases we rely on for processing this information are:

• Article 9(i) conditions for processing special category data (public health)
• Article 6(e) we need it to perform a public task

Data processors and other recipients of personal data

We do not anticipate data being shared with any third parties.

International data transfers and storage locations

The information will be stored in DHSC secure systems in the UK.

Retention and disposal policy

We anticipate retention of data for 12 months to enable time for analysis of responses. The data will then be destroyed or securely disposed of.

How we keep your data secure

The information will be stored in DHSC secure servers.

Your rights as a data subject

By law, data subjects have a number of rights and this processing does not take away or reduce these rights under the EU General Data Protection Regulation (2016/679) and the UK Data Protection Act 2018 applies.

These rights are:

• the right to get copies of information - individuals have the right to ask for a copy of any information about them that is used
• the right to get information corrected - individuals have the right to ask for any information held about them that they think is inaccurate, to be corrected
• the right to limit how the information is used - individuals have the right to ask for any of the information held about them to be restricted, for example, if they think inaccurate information is being used
• the right to object to the information being used - individuals can ask for any information held about them to not be used. However, this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case
• the right to get information deleted - this is not an absolute right, and continued use of the information may be necessary, with individuals being advised if this is the case

Comments or complaints

Anyone unhappy or wishing to complain about how personal data is used as part of this programme, should contact [email protected] in the first instance or write to:

Data Protection Officer
1st Floor North
39 Victoria Street
London
SW1H 0EU

Anyone who is still not satisfied can complain to the Information Commissioners Office. Their website address is www.ico.org.uk and their postal address is:

Information Commissioner’s Office
Wycliffe House
Water Lane
Wilmslow
Cheshire
SK9 5AF

Automated decision making or profiling

No decision will be made about individuals solely based on automated decision making (where a decision is taken about them using an electronic system without human involvement) which has a significant impact on them.

Changes to this policy

This privacy notice is kept under regular review, and new versions will be available on our privacy notice page on our website. This privacy notice was last updated on 9 February 2023.