The British Ambulance Services Panel a DTI / NAPAS Associated Foresight Program has considered the above document is some detail. The Chairman has checked the whole document on behalf of the panel, and extracted the relevant sections that would be applicable to the Panels Ambulance Expertise. We have outlined in hopefully an understandable format the changes that need to be made; below we list the items that have been considered. Notes following the text denotes reasons, changes required, or No changes required i.e. acceptable.

The Panel is of the opinion that the section that they have undertaken for consideration should be sectioned, we have used throughout the Draft Paragraph Numbers, and changes are per the full text. We have also placed each Heading in the suggested order so that it will read in continuity, we hope this will assist the Executive with the proposed layout and format.

Para 707 The number of people requiring medical treatment at any music event will vary considerably as will the type of ailment. These will vary with environmental conditions and can range from traumatic injuries due to crushing, falls. Fighting or conditions such as hyperventilation, exhaustion, dehydration, sunstroke, hypothermia or hyperexia, emotional or anxiety attacks, food poisoning or the serious effects of drugs or alcohol, as well as acute medical emergencies such as heart attacks or strokes.

Para 708 At events that take place over several days, such as festivals, conditions common in General Practice are likely to predominate. In addition, people with various existing disabilities and medical conditions such as asthma, diabetes, heart, or psychiatric problems may attend events where their condition could be exacerbated.

Para 709 it is essential that all major music events have suitable arrangements for the triage, treatment, and transport of those in need.

Para 710 Previous experience suggests that approximately 0,3% to 2% of an audience will seek medical assistance during an event day. Of these around 10% will need further treatment on site, approximately 1% of this number requiring initial assistance may require subsequent referral to Hospital. It must be recognised that other factors such as ineffective welfare facilities, absence of free drinking water or the presence of other ‘on site’ hazards may dramatically increase these numbers.

Para 719 Pre-Planning the provision of Medical, Ambulance and First Aid Services in Liaison with the Local NHS Ambulance Services is important. Promoters must appoint a competent organisation to provide medical Management, or Ambulance Management or First Aid Management as the case may be. This organisation need not be the sole provider of resources at the event, but they must show suitable competence, preferably they should have suitable experience of managing similar events. The service appointed must also have the ability to CO-ordinate the activity of all other medical providers.

Para 720 A Manager from either the Medical / Ambulance or First Aid Provider should be appointed to take overall control of pre-planning in conjunction with the event organiser and relevant local statutory Organisations, either this manager or another competent person should be designated to be at the event. And respective roles and responsibilities should be set out in a medical/ ambulance /First Aid plan, and agreement should be reached wherever possible with Local NHS Ambulance Services as to the desired cover required and contingency arrangements.

Para 722 Consideration with regards to availability of Medical/Ambulance or First Aid Cover must be given for both the Build -Up and the breakdown, including the statutory regulations under the Health and Safety at work Act for Employees and Sub-Contractors. Under the Health and Safety, (First Aid) Regulations 1981. Employers are responsible for ensuring that first aid facilities are provided for their employees and for self-employed persons, and that an accident book is available on site. First Aid workers appointed to provide these facilities must have the necessary competence and training to meet the requirements of the regulations. It may be helpful to have a written agreement between the various employers involved ensuring that the first-aid facilities meet with requirements.

Para 721 at events with overnight campsites, appropriate provision should be made to have medical, ambulance, and First Aid cover available while the campsite is open. Due to the likely range of conditions requiring medical advice, organisers should also consider GP services the appointed medical provider during the times these campsites are in operation.

Para 725 where practicable, consider the development of suitable sterile routes for the exclusive use of emergency vehicles

Para 724 consider the need for medical, ambulance and first aid arrangements for any audience members queuing before the gates or doors open and also on dispersal

Para 728 the appointed medical provider should consider arrangements to ensure that emergency cover is maintained at the correct level throughout the event, according to the risk assessment. Therefore, if a casualty needs to be removed from the site by ambulance, sufficient arrangements must be in place to quickly replace that vehicle or to transport the casualty using an ambulance dedicated to off-site movement (if there is the need for ambulances on site)

Para 729 at certain events in rural districts, an area for possible Medical evacuation by helicopter may have to be considered, and a suitable landing site, either at the site, or nearby may have to be considered.

Para 750 the number, location and suitability of medical or First Aid Facilities must be planned early. If there is more than one facility, one must be designated as the main facility. This should be located who ever possible near to the edge of the site, and must have adequate access and egress for Ambulance vehicles, and suitable hard standing for the parking of a number of Ambulances. Other areas of perceived risk may be covered by secondary facilities, which must also have free access and egress for Ambulances. Consideration must also be given to First Aid and Ambulance Aid Patrol points and there suitable location in areas of perceived risk to provide immediate response in emergencies arising throughout the event area, points and patrol staff must also be suitably equipped to respond.

Para 749 at events with a defined stage, suitable barriers should be erected in front of the stage, so that a pit area is defined. Ambulance Aid or First Aid staff in suitable numbers should be allocated to this area, a clear unrestricted area should be designated towards either the side or rear of the stage, it should have clear access, and egress for Ambulances without the ambulances having to enter the crowd area. The Rear or side of stage medical area must have access to drinking water facilities and a suitable quantity of plastic non-reusable drinking cups, and should be suitably equipped to deal with injuries on a initial attendance basis. It is essential that stewards in this area work in liaison with the Designated Medical Staff in recovering casualties. Medical staff and Security Stewards must also be equipped with suitable preferential cooling sprays, and be instructed in their correct and proper use.

Para 751 Detailed maps or plans of the whole site and the surrounding roads and access points, with the positions of each medical facilities and welfare facility clearly marked should be included within the medical/Ambulance/First Aid Plan. These will be needed prior to any considered License application.

Para 723 Information on the location of First Aid or Medical Facilities must be available to all those attending. Provide adequate signage and consider printing the location of First Facilities on tickets or flyers advertising the event. In addition all stewards must be made aware of the nearest facility and the method of calling for assistance to any casualty they may come across.

Para 752 at outdoor events, if a suitable permanent structure is not available, there must be provided suitable mobile units or marquees of adequate size with appropriate flooring. These facilities must be connected to a suitable supply for electric lighting, which must include a suitable emergency electrical supply in the event of main supply or generator failure, which should automatically kick in' if the main supply fails. A suitable Staff - patient toilet with disabled access should be supplied next to each medical designated facility sited, and there should be a supply of wholesome drinking water, and a suitable electrical supply or other means to boil water for hot refreshments, or boiling water for medical needs.

Para 730 At all events communications are extremely important. At small events radio channels may be shared at larger events there will be a need for a separate Medical Radio Channel connecting the Medical Control with all Ambulance Aid Staff, First Aiders, and other Medical Staff. The use of multi channel radios is a prime consideration. A protocol for the use of radio equipment, including consistent call signs, and the channels being used and by whom must be agreed before the event and should be included in the overall plan. A separate channel should be allocated to security, organisers and officials, and any other persons on site such as car park attendants. With Multi-channel radios, calls for assistance can be routed through each individual control, and in extreme cases of emergency the radio handset can be changed to another appropriate channel to obtain the correct assistance.

Para 732A there must be facilities for the re-charging of radio batteries and an ample supply of spare batteries for radios should be available. The major breakdown of site communications is due to battery drain.

Para 732 All radio communication should be controlled and coordinated. If there is a local NHS Ambulance service present on site, they should be also be provided with a suitable radio to communicate with the on-site medical control and any emergency liaison team that is on site.

Para 731 if there is more than one medical facility on site, there should be a designated main medical facility with an external telephone line, that does not, go through a switchboard, and a list of appropriate telephone numbers. All other medical facilities should have an at least an internal telephone or radio link to the main position.

Para 733 At all large events, a communications plan detailing medical communication links should be produced as part of the overall plan as well as the medical plan. And this should be held at both the medical site control, and each person engaged on medical duties should be given a written copy, and a further copy should be provided as part of the plan to the Local NHS Ambulance Control.

Para 727 Only in exceptional circumstances should any vehicles or ambulances are allowed to enter into audience areas. Ambulances should not move from a designated position except on instructions of their control, unless comprised on the grounds of safety. The event control should maintain a log, which should include any decisions or actions taken by the manager of the medical provisions and the reasons for those actions, including the times of incidents reported and any calls from crews for assistance, together with the location required. And any difficulties encountered in attending. These will assist in the reporting of accidents and injury to workers and audience members under RIDDOR.

Para 738 The decision on the level of medical provision and whether an Ambulance Service will be directly involved, or not, at any particular event will depend on a number of specific factors and will have to be based on a perceived risk assessment, this includes:

Range of possible major incident hazards at or associated with the event; (structure collapse, civil disorder, crushing, explosion, fire, chemical release, food poisoning, availability of experienced First Aiders and experienced ambulance staff.

Para 740 the recommended minimum number of First Aiders at small events where no special risks are considered likely is 1 per 250 or part of, for the first 3,000 attending. No event should have less than 2 first Aiders. The recommended minimum number of Qualified Ambulance Aiders (experienced) First 2,000 ratio of 1 per 500 or part of + 1 for the next 1,000 these may substitute First Aiders, when an equipped Ambulance is in attendance.

Para 741 at indoor venues or stadium First Aid Facilities are likely to have been agreed and established. There is still a requirement to carry out an assessment for each and every different type of event that is undertaken in such premises.

Para 742 at higher risk events, long concerts or large events held in Public roads. Special arrangements may have to be made which may involve special standby arrangements involving the NHS Ambulance Service. In such cases the competent organisation providing Medical Management should liaison with the Local NHS Ambulance Emergency Planning Officer to agree the type of cover that may be required in addition to services provided at the site. Substantial notice may be required and the EPO should be contacted at an early stage of planning.

Para 743 The risk assessment may indicate the need for the provision of a Registered Medical Practitioner (Doctor) to be on site. A suitable Experienced Medical Practitioner may also act as Medical Incident Officer (MIO) for the management of medical resources at the scene in a case of a major incident.

Para 745 At Lengthy events with a high risk of substance abuse, consideration should be given to any requirement for psychiatric care and the involvement of Drug Advisors.

Para 746 where the risk assessment indicates, State Registered Nurses may be required to care for patients on site.

Para 753 A number of competent First Aiders should staff each medical facility and, as appropriate, medical workers, ambulance staff and nurses. Consideration must always be given to the deployment of some staff to various points within audience areas. At all large outdoor events ensure that a proportion of such staff is strategically positioned, so that they may patrol a defined area. All Medical staff must be clearly identified as such, and the mix must always include experienced elements. All patrols or mobile staff must be in constant radio contact with their Medical Controller, so that they may be re-deployed or called back. Staff should be rotated on a regular basis, including rest or refreshment breaks, and rota duties away from high noise levels. A means for Medical staff to obtain refreshment and rest should be provided adjacent to the Medical Facility.

Para 756 Medical Accommodation on site (Larger Events)

Medical Practitioner; A ‘Qualified Medical Practitioner’ is a medical practitioner (Doctor of Medicine) who is registered with the General Medical Council in the UK. This Doctor should have experience in dealing with emergencies in pre-hospital or an accident and emergency environment, and be familiar with the operation of the Ambulance Services and voluntary Aid Societies in attendance. He should have knowledge or be briefed on NHS Ambulance major incident plans, and in addition have attended a course in pre-hospital emergency care within the last three years. He/she should also be briefed on all arrangements made by the appointed medical manager, and should liaison with and be aware of local casualty receiving hospitals arrangements prior to the event commencement. (Doctors have clinical responsibility for all patients seen and must have relevant membership and are insured with a medical defence union)

Qualified Nurse; A ‘qualified Nurse is a nurse whose name is entered in the relevant part of the professional statutory register maintained by the UK Central Council for Nursing, Midwifery and Health Visiting (or its successor). The qualified Nurse should have post graduation and experience in Trauma, pre-hospital, Accident and Emergency, Cardiac, etc.

Paramedic; A ‘Paramedic:’ is a member of an ‘Ambulance Service’ who has extended training above Qualified Ambulance Technician or Qualified Nursing levels. And is considered competent by a certificating body in Ambulance Aid, and who has the clinical experience certificated by a Medical Consultant to deal with advanced treatment and monitoring of emergency patients. This person must bear authorisation from their employer, and be insured formal-practice in an employed capacity, and they must have immediate access to the appropriate level of specialist equipment required to perform their duties. Paramedics in law are only authorised to use their skills in an emergency or under the directions of a Medical Practitioner.

Ambulance Technician; A Qualified Ambulance Technician is a member of an ‘Ambulance Service’ who has trained and been considered competent by a certificating body in Ambulance Aid, and who has the considered experience to deal with accident and emergency patients. They must have access to appropriate Ambulance Aid Equipment and be insured formal-practice in an employed capacity, and be authorised to use their Ambulance Aid Skills when required.

Intermediate or Trainee Ambulance Technician. Or Emergency Medical Technician.

Is a member of an Ambulance Service, who has attended an appropriate course in Ambulance Aid, but who has not received the required experience or post graduation? These staff may undertake duties of an emergency nature but only whilst under the direct supervision of a Qualified Ambulance Technician. They may undertake duties of a non-emergency nature without such supervision. They should have access to appropriate Ambulance Aid equipment and be insured for mal-practice in an employed capacity, and be authorised to use their Ambulance Aid skills when required.

First Aider: A ‘First Aider’ is a person who holds a current certificate of first aid competency issued by either one of the Voluntary Aid Societies. Or certain other bodies or Organisations, where the final examination is undertaken by a Registered Medical Practitioner and is classed as a Public First Aid Certificate. The First Aider should have prior training and experience in providing first aid at crowd events.

Ambulance Aid is the care and treatment prior to and during the course of transportation, in the case of certain ambulance qualifications, this may exclude the care and treatment of Accident and Emergency patients.

First Aid, the completion of a Health and safety at work or four-day ‘First Aid Course’ does not necessarily qualify a person as competent to administer first aid to members of the public.

First Aiders under 18 years old should not work unsupervised

Ambulance Staff should not be under 21 years of age

All staff should be physically and psychologically fit to carry out assigned roles.

All Staff engaged on medical duties should be readily identifiable and should wear appropriate uniform and protective clothing as appropriate.

The appointed Medical Manager should be responsible for checking all staff qualifications, and ensuring that any sub-contracted staff, and any directly contracted staff are insured for the duties that they are undertaking. Including malpractice as appropriate, and that they have the required employer/organisation authorisation to undertake such duties as they are qualified to undertake or carry out. Employer and Public Liability Insurance’s should also be verified. A written Health & Safety Policy must also be available.

All other paragraphs should be deleted including the tables at the end of the section, as all relevant matters have been either absorbed in the final suggested document, or have been found to be not relevant.

Medical provision at events must be adequate, and based on the perceived risk. The appointed Medical Manager or Ambulance Consultant should be competent and have the ability to assess the risk. If to many details are given as a guide, then the panel feel that promoters, and organisers may be inclined to attempt to undertake the duties of ‘the appointed Medical Manager / Consultant. When they have not either the required experience or the competency to provide a suitable independent plan based on the perceived risks.

(a) The Competition Act 1998 in that any proposed changes in the Pop Code must allow for fair competition, without placing undue conditions on any particular sector that may wish to provide services. (Chapter 1 3.1. -3.2 Section 2(2)

(b) The present Governments future considerations for the Possible State Registration of all persons engaged on Ambulance duties, which is presently in a continual consultative process. It is anticipated that within the next 18 months proposals may be laid before the Government for such State Registration concerning all Ambulance Aid Staff.

(c) The Secretary of States for Health’s view has been that it is not policy for NHS Ambulance Services to be involved in matters that are outside of their, or that are likely to effect their, statutory duties under the National Health Acts. Or to interfere to any significant extent, with the performance of its NHS work (Section 5(9) of the 1990 Act

(d) Whilst NHS Ambulance Services have a statutory duty to undertake Emergency Planning for major incidents, and to ensure that those plans take into account any event that may be likely to become a major incident. Unlike the Fire Service, or Police, NHS Ambulance Services have no statutory involvement in local authority licensing arrangements for events, music or dancing, although they may give some advice if requested.

That advice must however be impartial, and should not include any insistence that NHS Ambulance Services provide any services, or commitment. NHS Ambulance services have no power to insist that event organisers pay them to provide cover or advice.

NHS Ambulance Services likewise have no statutory authority to inspect private ambulance services or to demand details of their personnel. (Ref. JMS/EAS-97FS.DOH-01) (POH (1)1678/1287)

(e) ‘An Ambulance Service’ is; - Any ambulance operator, who is providing ambulance transport services to or from a place of medical treatment to a sick or injured person, in a vehicle which is specially designed for the purpose of caring sick or injured persons. (It need not be a service provided solely by the state)

Display an appropriate Road Fund License.

Ambulances should be: -

(These are United Kingdom and European Definitions drawn from legalisation)

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