Designing a new model for air ambulance helicopter services

Air ambulance helicopter services are a critical part of how we respond to health emergencies in New Zealand.

The demand for air ambulance helicopter services has been rising and is expected to continue to rise. The current air ambulance helicopter fleet has an average age of 29 years. There are increasing aviation and clinical compliance requirements and many of the helicopters currently in use for medical emergencies are smaller, single engine helicopters which do not allow full access to the patient for treatment. Also, these single-engine helicopters do not meet Civil Aviation Rules, which limits flying over urban areas (eg, flying into hospital helipads). Over time these will need to be replaced with more modern double-engine helicopters.

The National Ambulance Sector Office (NASO), the district health boards (DHBs) and the air ambulance sector recognise the existing operating model is not sustainable.

That’s why the Ministry of Health, the Accident Compensation Corporation and DHBs, through NASO, have taken the first step towards ensuring every community has access to an effective air ambulance helicopter service, with the development of a 10 year modernisation programme for the country’s air ambulance services.

The intent is to build a national integrated network that covers all of New Zealand, is well linked with other emergency services, is available around the clock, is safer and is more appropriately clinically resourced. This will contribute to improved patient outcomes.

Southern region air ambulance service

Two existing air ambulance helicopter providers in the South Island – Helicopters Otago Limited and GCH Aviation Limited (Christchurch) - have formed a joint venture to continue serving their local communities throughout the Southern region. The Southern region covers all of the South Island and Stewart Island, the Chatham Islands and Auckland Islands when required.

The new provider - Helicopter Emergency Medical Services New Zealand Limited (HEMS) - has entered into an agreement with the National Ambulance Sector Office (NASO) and will begin operating in the region from 1 November.

HEMS will be supported by existing trusts: Otago Rescue Helicopter Trust, Canterbury West Coast Air Rescue Trust, Lakes District Air Rescue Trust and Nelson Marlborough Rescue Helicopter Trust. Funds raised by each trust will continue to support services in their area.

HEMS will work to modernise operations, increase efficiencies and continue to improve patient outcomes.

The contract will cover helicopter pre-hospital retrieval and inter-hospital helicopter transfers for medical and injury services across the Southern region. All existing bases will remain and continue to service local search and rescue needs. The bases, which are located in Nelson, Greymouth, Christchurch, Te Anau, Queenstown and Dunedin, will remain.

A 24/7 service, with dedicated clinical crew available, will be run from the Christchurch and Dunedin bases. The remaining bases, with the exception of Te Anau, will provide dedicated services from the base for 12 hours each day, with on-call services overnight.

Te Anau will retain its base with on-call services similar to what are currently offered but will also be well-covered by enhanced services in Queenstown, or from Dunedin if a large hospital is required for treatment.

In Queenstown there will be permanent dedicated cover available for the first time and both Queenstown’s and Greymouth’s single-engine helicopters will be replaced by twin-engine helicopters from November 1. These helicopters will be more technically advanced and provide more room for treatment during flight.

The providers will purchase two new twin-engine helicopters during 2019. These will be the most modern helicopters available in the South Island and will give clinical staff more room to provide comprehensive care on board, ensuring patients needing urgent clinical attention can get that care while being transported to the most appropriate hospital for their needs. They will be based in Dunedin and Christchurch, where most call-outs occur.

New technology on those aircraft combined with exclusive use air routes will enable missions to be flown safely in conditions that previously restricted the use of air ambulance helicopters. This is a significant benefit to communities in the South Island that rely on the air ambulance service.

New provider for Central region air ambulance helicopter service announced

Five existing air ambulance helicopter trusts in the North Island have formed a joint venture to provide services in the Central region. The new provider, which will be known as Central Air Ambulance Rescue Limited (CAARL), has entered into an agreement with the National Ambulance Sector Office (NASO) and will begin operating in the region from 1 November.

The Central region covers the North Island from Wellington up to the Waikato, including the East Cape, Bay of Plenty, Hawke’s Bay, Taranaki, Manawatu and Wairarapa. The contract will cover pre-hospital retrieval and inter-hospital helicopter transfers for medical and injury services across the Central region. All bases will continue to service local search and rescue needs.

The five trusts are the Eastland Helicopter Rescue Trust (EHRT), Hawke’s Bay Rescue Helicopter Trust (HBRHT), Philips Search & Rescue Trust (PSRT), Taranaki Rescue Helicopter Trust (TRHT) and the Life Flight Trust (LFT). The trusts will work together to modernise operations, increase efficiencies and continue to improve patient outcomes. They have a long history of working with their communities and this new arrangement will enable them to build on their existing strengths and relationships.

CAARL will provide air ambulance helicopter services from bases in Hamilton, Wellington, New Plymouth, Hastings, Taupo, Gisborne, Tauranga and Palmerston North. The Rotorua region will be well-covered by the bases in Taupo, Tauranga and Hamilton, with the response times to incidents estimated to be the same or faster than under the current model.

The trusts will phase in additional twin-engine helicopters over the next 12 months. This will give clinical staff more room to provide comprehensive care on board, ensuring patients needing urgent clinical attention can get that care while being transported to the most appropriate hospital for their needs.

Agreement reached for Northern region air ambulance helicopter service

The Northern region’s two existing air ambulance helicopter service providers have formed a joint venture to provide one consolidated service across the region. This will be for pre-hospital medical and injury emergencies and inter-hospital transfer services.

The National Ambulance Sector Office (NASO) has entered into an agreement with the Auckland Rescue Helicopter Trust (ARHT) and Northland Emergency Services Trust (NEST). The new trust will announce its name once outstanding contractual matters have been worked through, which will be before 31 March 2019. The existing trusts will continue to provide services until that time.

ARHT and NEST have provided support services for each other for more than 30 years and this new arrangement will enable them to build on their existing strengths. For communities it will ensure that their air ambulance service will be more sustainable and equitable, providing greater benefits for their local populations.

The Northern region contract covers the area north from Counties Manukau, including Northland, Waitemata, Auckland and Counties Manukau District Health Board regions. The new provider will continue to support Starship Hospital’s paediatric intensive care facility as appropriate, and will include Coromandel for pre-hospital emergency admissions.

The location of the air ambulance helicopter bases at Whangarei, Auckland and Whitianga will remain unchanged. The 24/7 service will be based on a mix of on-site and on-call aviation and clinical crewing that match service demand.  The allocation of clinical crew will be based on actual service utilisation, which currently shows most air ambulance helicopter services are required during the day. Future decisions on the allocation of crew will be informed by improved data collection and monitoring to ensure helicopters and crew are available when and where they are most needed. 

Improving patient outcomes

Patients are at the centre of defining what an effective new service model looks like and we want the best possible outcome for every patient who uses the service.

The availability of qualified clinical crew, the type of helicopter and the destination are important considerations in achieving improved clinical care and therefore improved patient outcomes. While the distance between the helicopter base and the emergency scene is important, many bases currently have a time lag between the call out and getting the clinical crew on board before they can take off, because the crew are not dedicated to the service. This adds to the response time.

A good air ambulance service has four key elements: time, clinical crew, equipment and destination. With these working together well, patient outcomes will be improved. When the new service is introduced, everyone will have access to an air ambulance helicopter service that has all these elements working well.

What are we doing?

Moving from single-engine to twin-engine helicopters will ensure flights are safe for both patients and crew and regional variability in clinical outcomes is reduced. 

Why twin-engine helicopters?

  • Clinical safety, patient safety, community and crew safety
  • Greater space to provide clinical care
    • Can carry two clinical crew and helicopter crew (or full clinical crew for IHT) and ensure full access to patient – head, trunk and all limbs
    • Can carry more medical equipment, safely restrained in a useable location
  • Meets Civil Aviation rules for flying over populated areas
    • Safety – two engines if one fails, enabling the helicopter to find a location to land safely
Image comparing the smaller single-engine helicopter with a twin-engine helicopter, which is larger and has more useable clinical space.
Helicopters shown are models of Squirrel (top, single engine) and BK117 (bottom, twin engine) popular in New Zealand.

Older single-engine helicopters will be replaced by two-engine helicopters. These will allow room for two clinical crew with full access to the patient, with space for more medical equipment on board. In the new service, there will be dedicated crew at helicopter bases. Currently this is not the case, which often results in delays while clinical crew are called in from their road ambulance duties to attend an emergency air ambulance helicopter call out.

The current service has 17 bases from which helicopter air ambulances fly from. This is high by international standards. The request for proposal proposed this be reduced to 14, as well as reduce the number of service providers (currently 10).

  New Zealand NZ (Proposed) Queensland NSW Scotland
Comparative helicopter air ambulance fleets
Length 1,600 km 1,600 km 2,030 km 556 km 410 km
Width 400 km 400 km 964 km 1,047 km 310 km
Land Area 268,000 sq km 268,000 sq km 1,800,000 sq km 809,000 sq km 80,077 sq km
Population 4.69 million 4.69 million 4.69 million 7.54 million 5.295 million
Bases 17 14 10 5 2
Helicopters 21 Estimated 19 14 9 3
Providers 10 3 1 2 2

No decisions have been made regarding where helicopters will be based. There will be coverage across the country. The locations will be determined through the request for proposal process but it is important to note there will be an improved nationwide helicopter service that can provide better clinical support for patients.

In regions which experience fluctuations in population due to seasonal tourism, the Providers will be expected to manage this by allocating resources (helicopters and staff) to meet anticipated demand.

Outcomes we are seeking

  • Effectiveness: to provide patients and communities with equitable access to care with the right skills, in the right place and at the right time.
  • Efficiency: to efficiently task air ambulances to appropriately meet patients’ social and clinical needs.
  • Risk reduction: to manage the safety risk posed to patients and staff in the use of an aeromedical service capability.

Not included in the current request for proposal

The new service will cover accidents and incidents that require an air ambulance helicopter due to the need for medical support. If someone needs to be rescued but doesn’t have any need for medical support, (ie, a search and rescue mission), this service will continue to be coordinated through the Rescue Coordination Centre (RCCNZ) and/or the New Zealand Police and did not form part of this request for proposal.

It is also important to note that air ambulance services involving fixed wing aircraft (aeroplanes) are not included. In New Zealand approximately 75 percent of inter-hospital transfers use small aeroplanes, with helicopter services providing over 97 percent of pre-hospital (that is, emergency) transport services and around 25 percent of inter-hospital transfers.

Procurement approach

The approved procurement approach for the service is as follows:

Procurement Round One was published on GETS on 26 March and closed on Monday 7 May 2018. There will be a three year contract plus one optional year – 2018–2021/22. The aim is to:

  • improve patient outcomes
  • meet all safety requirements (removing single-engine helicopters from the service, increase clinical crew, and ensure appropriate fatigue management processes are in place for aviation crew that meet Civil Aviation Rules)
  • gather information to support the completion of a comprehensive design of the future service and inform the second procurement process
  • consolidate regions from the current 12 to three, aligned to the district health board regional structure
  • provide greater value for money by improving the efficiency of the service through better use of clinical and aviation resources.

Procurement Round Two will require further Cabinet approval before it can commence. It will be a five year contract plus five year extension – 2021/22–2031/32. A key objective of the second procurement will be to actively manage the swap out of ageing air ambulance helicopters to a higher and specified standard.

Historically communities provide support and local Trusts arrange commercial sponsorship for their local air ambulance services. This procurement is structured so that these types of arrangements will continue for the duration of resulting contracts.

Project governance

A project governance group has been established with representatives from ACC, the Ministry of Health, district health boards (including an aeromedical clinician) with international aeromedical clinical input. This provides the governance required to ensure any future service model integrates and coordinates both emergency retrievals and inter-hospital transport.

Market engagement and design

NASO has designed the future solution with stakeholders.

As part of the engagement phase, four structured regional meetings were held in June 2017. These were attended by 150 participants, including district health board planning and funding and operational managers, clinicians across a range of professions, air providers, Trusts, consumers and other government agencies such – Fire and Emergency New Zealand, New Zealand Police, Civil Aviation Authority, New Zealand Search and Rescue, and the New Zealand Rescue Coordination Centre.

Following on from these regional meetings, four issues workshops were held in in September 2017. These covered financial, technical, operational and clinical issues to identify the key things that needed addressing. More than 100 people from across the sector attended these workshops.

The project approach and timeline is as follows:

  • Stage 1: Initiation (October 2016 – March 2017) [completed]
  • Stage 2: Pre-procurement (October 2016 – March 2017) [completed]
  • Stage 3: Structured Market Engagement (Co-design) (April – February 2018) [completed]
  • Stage 4: RFP Process (March 2018 – 7 May 2018) [completed]
  • Stage 5: Implementation.

Please contact if you have any questions.

Ten year story (developed with funders, clinicians, patients and providers)

The request for proposal is the first step in a 10 year modernisation programme for the country’s air ambulance services aimed at ensuring every community has access to the air ambulance helicopter.

Click to enlarge |

Theme: Safety

  • 2018–19: Eliminate single engine helicopters; increase staffing to meet safety standards
  • 2020–25: Planned helicopter modernisation, including crew training, fit-outs and aircraft maintenance standards
  • 2026–27: Safe and appropriate aircraft and crew maintained

Theme: Funding

  • 2018–19: Gather information on Trust/community funding, cost of asset base and increase government funding to begin investment
  • 2020–25: Continue investment; improve administration of Trusts and determine role; assess value of a national sponsor
  • 2026–27: Sustainable transparent funding

Theme: Data

  • 2018–19: Improved data collection and analysis of service
  • 2020–25: Improved, information led, infrastructure planning
  • 2018–25: National coordination of tasking (pre-hospital emergency and inter-hospital transfers)
  • 2026–27: Nationally coordinated, integrated Air Ambulance Service

Theme: Clinical

  • 2018–19: Finalise clinical standards; implement national clinical governance across tasking and service provision
  • 2020–25: Implement clinical standard (training and mix of staff) – based on evidence, integrate road and air service
  • 2026–27: Patient centred outcomes; 3Rs – right treatment, right time, right place
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