1. Introduction
Ambulance Manufacturers in Europe; The design requirements of ambulances and their parts differentiate this area of healthcare from others and highlight the complexity and difficulty of the problem. The functions and responsiveness of many existing emergency ambulance services need to improve, generally offering greater care and clinical expertise on incidents, especially for more serious or critical cases. Although ambulance manufacturers can be considered a niche area in healthcare, the ways in which ambulances are designed and equipped, and the time they can save in emergency responses, have the potential to significantly affect the chances of recovery for a suitably selected or filtered pre-hospital patient. This is especially true for ambulance-intensive critical care transfers and most especially for so-called “sub-acute” care in situ or en route. This case of an ambulance manufacturer in Europe is to demonstrate an examination of the interplay of global production-distribution relationships in the ambulance and prehospital emergency transfer markets.
Ambulances have resilience and dependability to enable a rapid response. It is not possible completely to prevent mechanical, environmental, criminal, or act-of-God events that interrupt the progress of an emergency ambulance deployment. Ambulances are specialized vehicles to meet the needs of patients and the healthcare organizations and practitioners that transfer or are conveyed by them. This text examines the current European ambulance manufacturers industry. It details the different construction methods and the types of ambulances used across Europe, concentrating on the specialist need patient transport sub-sector. Finally, it explores the strategic corporate position for a newcomer manufacturer in the industry. What broad research questions do we seek to address by this case study? Firstly, we use an ambulance service management research perspective to help formulate our research questions.
1.1. Background and Significance – Ambulance Manufacturers in Europe
The ambulance has become a vital component of modern healthcare delivery, serving as a mobile treatment room on the front line of emergency medicine delivery. The increased demand for emergency medical services presents as unscheduled acute admissions to care facilities. As such, there is a need to expand, upgrade, or replace aging ambulance fleets. With this, the market for ambulance manufacturing is growing. The majority of ambulances are built from whole-type vehicles purchased from original equipment manufacturers. The original design of ambulances developed from horse-drawn ambulances pre-dating the period of industrialization. Categorized as a “specialty vehicle,” ambulance manufacturing only emerged after World War II, and currently, the largest market for ambulances is the United States, with a significant quantity also being manufactured in Europe.
Ambulance Manufacturers in Europe; Ambulances are subject to mechanical regulatory standards and various consumer desires, but they are unique in that they are built to aid the reduction of fatalities of occupants suffering from immediate, life-threatening conditions. This is further complicated by the fact that ambulances have to navigate busy urban areas and highways to obtain emergency care for patients while meeting the increasing expectations of stakeholders, such as taxpayers, patients, emergency medical service employees, and legislators. Ambulances have historically been insulated from broader technological and regulatory changes that occur with passenger vehicles. Research as of late, however, has been performed on vehicle-EMS simulation studies, design requirements for bariatric patients, survey studies, involvement in patient outcomes, reducing worker injuries, AV research, and vehicle dynamics data collection. Though substantial biomedical research is occurring, there is very limited knowledge about how external vehicle characteristics may influence patient and provider safety and care, patient outcomes, or even if efficient designs are leading to efficient operations. This is of great concern; manufacturers may have spent hundreds of thousands or millions of dollars to produce vehicles to aid in care that may be inefficient and cost-ineffective. A deep understanding of the ambulance market and the components of design that positively contribute to higher levels of care can be utilized to refine system performance while also increasing company profitability, regardless of existing company goals. It is also possible that current manufacturers will exit the market and vehicle conversion businesses will further adapt to fill the gap with specialty vehicles. Presently, ambulance manufacturing has not been studied in depth, often focused on the product itself while neglecting the societal perspective, and thus the rationality of design decisions made. There are no reviewed papers on the subject of ambulance air conditioning, while only two published reports could be found that explore vehicle design outside of the operational envelope. Manufacturers have not necessarily proactively responded to the changing market and are currently facing challenges due to longer life cycles and more maintenance requirements for used vehicles. That may pose a modest risk due to potential new vehicle buyers not receiving the newest technologies as stipulated in requests for proposal specifications while lengthening the period more resilient conversion vehicle manufacturers can keep the doors open. The changing healthcare landscape further compounds the issue. Healthcare may be driven from vehicles in the coming years as opposed to hospitals, and in a hospital on wheels, a sound vehicle design could further enhance care at the scene or during transport. Manufacturers of ambulances in Europe, though limited, can draw significant information for research and development, which could result in a more efficient allocation of available funds, decreased vehicle design time, and increased competitiveness to join the market again.
1.2. Research Objectives – Ambulance Manufacturers in Europe
The central objective of this research is to understand the changing trends in ambulance manufacturing in European markets, as these forces are also influencing manufacturers. The specific objectives of the planned research are: to investigate dynamics that occur in this part of the market, identify major players in this area, explore connections between vehicles and the manufacturers of their equipment, and to learn the current state of the company and the way it is seen by third parties. This case study will use the company as the principal subject of the analysis, but further research will include an analysis of the entire market and placing the Polish company among the European producers of specialist vehicles.
The objective of the study is to learn about the latest trends in the production of vehicles for the transportation of people with disabilities and the equipment necessary for them, as well as to define the position of the company in this trend in terms of its mission and evaluation of strengths and weaknesses. Achieving this objective is related to a more detailed research proposal for the company, which can take place within the framework of a diploma thesis, as well as to learn about the innovation of the companies by implementing new solutions in the fields of economy, ergonomics, and safety. The hope is that the pilot research and the preliminary hypotheses set out in it will help to verify this thesis. Of particular interest to the authors of this study is the market for ambulances, in which the production of both entities is very important due to its ability to carry disabled people.
2. Ambulance Industry Overview – Ambulance Manufacturers in Europe
2.1. Global Ambulance Market Trends – Ambulance Manufacturers in Europe
Prehospital emergency medical services (EMS) have received increasing attention from researchers around the world. Due to technological advances and state-of-the-art emergency medical principles, patients outside the hospital have a higher chance of surviving and better outcomes. The field of prehospital emergency care is moving towards careful attention to patients and personnel, and more European countries are adopting laws to provide high-quality prehospital care. The ambulance industry and vehicle manufacturers are important components of efficient prehospital medical services. To provide high-quality prehospital care, the medical equipment, support features, working posture, and accessibility of various types of medical support equipment need to be well-designed for paramedics. Truck manufacturers can satisfy the requirements of national and international laws and standards in the design of ambulances, using their knowledge to build and mass-produce vehicles more efficiently. This study investigates the key factors and environment in the European ambulance market. In-depth interviews were conducted to clarify the required niche manufacturing management strategy. The results of the study are specifically addressed to industrial automotive manufacturers, truck manufacturers, and SMEs hoping to be involved in European markets.
2.2. European Ambulance Market – Ambulance Manufacturers in Europe
In 2017, the European ambulance market was worth €836 million, with nearly 12,000 new vehicles produced. The EU market for high-end ambulances, mostly made-to-measure for individual customers, is led by a small number of specialist coachbuilders and modified vehicle suppliers. Prices and volumes suggest that the market may suffer from symptoms similar to those identified in other niche industries. However, this niche ambulance market has not been analyzed at length so far. This analysis focuses on a small Italian company. The analysis is organized as follows: the following section presents the European landscape for ambulance manufacturers in detail, focusing the analysis on the main European countries where ambulances are produced. The next section describes the company: its products, its production process, and the supply chain. Another section describes the approach used to model the pricing policy. Propositions of the model are formulated in a subsequent section. Concluding arguments are drawn in the conclusive section.
3. ICU Automative: Company Profile- Ambulance Manufacturers in Europe
Founded in 1993 in Västerås, in central Sweden, ICU Automotive AB is a private limited company. The company has passed through several different stages, but the same key players have remained from inception until today. The original name was In Car Utilities, and the company’s purpose was to work with advanced instrumentation design for land, sea, and air vehicles. Core values such as innovation and attention to industrial design have been regulating the managerial decisions from the start. When the company was restructured into the current form, ICU Automotive, in 2003, this originally simple task had grown to focus on the design of medical interiors specifically created for common M1 type ambulances.
Nearly all Swedish ambulances have a full interior designed by ICU Automotive. The company’s key goals and parameters today revolve around maintaining its position as the leading design company in the field of function-optimized and user-friendly ambulance interiors. ICU Automotive has developed a thoroughly tested and fully compliant airbag system for Land Rover ambulances and is now negotiating with the vehicle manufacturer to standardize Land Rover ambulances with this system as standard. Moreover, ICU Automotive has introduced a threat-activated locking system with both electrical and mechanical backups to speed up the loading and unloading of major incident casualties and secure the working position of the ambulance crews if there is a risk of patient hostility. ICU Automotive is also responsible for the complete design of the only purpose-built front-wheel-driven ambulance in the European market. This vehicle has a smooth and height-adjustable rear end for the stretcher and a reinforced suspension for heavy commercial use, primarily in the UK, but also for the European market.
At the authentic start-up stage, the company made revenue on average of 1.2 million to 1.5 million, and the company had roughly 10 employees. Ten years later, ICU made significant growth and had a tenfold increase in the design of a new purpose-built environmental ambulance, a concept known as WARS. At this stage, ICU grew to almost 30 employees and realized more than 60 million in materials. The main market focus was different EU fleet customers who wished to upgrade their existing in-service ambulances; with that uplift, they could extend their lifespan by another 10 to 15 years under existing EU regulations. However, unfortunately, in the EU market around 2008, due to the financial crisis, the WARS project was discontinued. In 2016, the directors focused on transferring their long and experienced market solution from transit to Mercedes Sprinter. Now, in 2022, we expect to create a European market that is able to sell 300-400 Sprinter ICUs.
3.1. History and Milestones – Ambulance Manufacturers in Europe
In July 1975, three brothers set up the company to produce accessories for motor vehicles. The first products produced were ski racks aligned with tow bars. In 1987, the company was established to develop a catalytic system to reduce vehicle emissions and to manufacture and sell the product. It is recognized by the state and the Department of Transport for its willingness to participate in research and development for environmental protection and in the search for hydrogen use as a future energy source. It is the originator of all the steps that have enabled the transformation of vehicles to gaseous hydrogen or electric propulsion. In 1992, its shareholders did not manage to come to an understanding of their future activities and decided to dissolve the companies.
The company was sold and the liquidation was begun. The future teams went to the Employment Office. The general manager, issued from a banking education, decided to face everything and gain control of the assembly company. It was a hard period when the local markets dropped by half and demanded SUVs instead of cars. Many ambulance manufacturers disappeared in this area too, and cars lost their market shares in favor of Vermières-type ambulances. After several ups and downs, the latter, who entered the manufacturing steering department, decided to reintroduce the brand and to market what are now known as vehicles, which are vehicles manufactured based on market research. If an automobile garage sets itself up as a coachbuilder, its characteristics are twofold: design and manufacturing, to meet the needs of a customer calling for one-off models or prototypes. The company has already manufactured automobiles from a car and has since then held different collaborations. These collaborations have enabled us to achieve the accomplishment of correcting several records. At first, the company had to face the shortage of orders for vehicles to be adapted.
The market research finally came out: what was needed were ambulances. For starters, we didn’t waste time directing the manufacturing of ambulances. An R&D department was set up to clear the way for the design department. The company began manufacturing type A1 ambulances (mortality transport) and then type B ambulances (for disabled people in wheelchairs). It was during this period that the ambulance operations were given a new entity. It has since been split off from the company and became a completely separate department, although it kept the same general direction.
3.2. Product Portfolio – Ambulance Manufacturers in Europe
The product and services category is critical for an organization or company to deliver a unique customer value proposition through its business model. For ICU Automotive, product manufacturing is an integral part of the business model. By manufacturing all kinds of ambulances – from advanced life support ambulances to standard basic transport units – the company offers customers all over the world innovative designs. The internal focus of the design integrates internationally approved products with internally conducted research, which offers a safe and patient care-centric vehicle.
Through product profiling, a company can assess the value that is created through its offerings. The company offers a global image of ambulance types: 1) Type A: Legend III F Ambulance, 2) Type B: M1 (ILS) Ambulance, 3) Type C: Bariatric (BEV) Ambulance, 4) Type D: Campers and Kombis Campervan / DayVans. Aside from the smaller producers in Europe, the above creates a segmented European market. The ambulance market is, in general, highly underserved and regionalized, so there is always potential for manufacturers to choose specific healthcare franchises outside their immediate environment. A compete and win approach is deemed best. There is also a shortage of expert ambulance builders and expert automotive converters, so a jump in volume of manufacturing should result in a volume saving where raw material purchases are concerned. The most effective weapon for the company to use in the current focus market is to build relationships for the future and remove market frictions. It highlights the multiple points of difference illustrated by products, after-sales service levels, and underlying expertise provided. A realm of added value emerges from shifting the ambulance/cost factor to ambulance/value.
4. Competitive Landscape – Ambulance Manufacturers in Europe
Ambulance manufacturing is a growing business in Europe and has great economic potential. Some of the manufacturers are global in operation, while others are local market players. Considering the European market, a few major players have a dominating market share, while small players struggle to compete. Some are still focusing on the local market, where their existence also helps to form a monopolistic nature. It has been observed that in this market, players mainly compete on product innovation and customer comfort, where pricing is also a very competitive aspect. However, in the long term, pricing doesn’t make a big impact for large service providers.
Moreover, brand name value plays a vital role, as people or service providers prefer ambulance suppliers who have more experience and a good reputation in the market and who satisfy all the prerequisites highlighted by the government. As for ICU Automotive, being a new entrant in the European region, it is planning to make strategic alliances to boost its sales and distribution network. It needs to study the industry and consider the competitive landscape and the role of different target countries to design a suitable strategy.
The existing players have a fair market share and offer a great variety to customers in terms of design and shape. The recent innovation in the vehicle they have made is an electrically powered vehicle, which is a shift towards more environmentally friendly products. Market entry barriers exist, as the big firms have already established great distribution channels, making it difficult for ICU to break into that part of the market. Health consumer preferences play a role, as people prefer ambulances that are padded for patient comfort and are spacious with built-in medical equipment, making them more attractive. Moreover, the previous experience or feedback of an organization directly impacts how it wants to make purchases. The trends are such for strategic alliances, where companies work together and respond to buyers to combine products and services. Networking allows manufacturers to create and exploit dynamic capabilities.
4.1. Key Players in the European Market – Ambulance Manufacturers in Europe
Analysis of Ambulance Manufacturers in Europe: A Case Study of ICU Automotive
Despite the growing opportunity of ambulance manufacturers, the European market is comprised primarily of smaller niche players. Six companies were identified as the most significant manufacturers present in Europe. Laerdal, Medix, and Optare lead the market for intensive care units (ICU) ambulances, mainly serving the neonatal ICU and pediatric ICU. Moreover, AS Smit, Médical Réalisations, and VCS dominate the market of the non-intensive care ambulances (multifunctional, and support for advanced life support and basic life support ambulances). There is a growing trend within the industry of healthcare providers partnering with mid-sized manufacturers when developing their new ambulances. This could reflect developing loyalty among the buyers, especially in a market that is becoming more competitive as manufacturers enter the European market.
We have observed substantive marketing efforts directed at the European operator (end user, otherwise known as private ambulance service company, tier 1 emergency service, etc.). This focus is not only an effort to develop a portfolio of customers in the mid-tier band who can tailor their vehicles in line with manufacturing capabilities, but also to respond to a rise in white labels as contracts with larger purchasers are attracting bidders of alliance companies as consortia who pitch as a single unit. Although niche companies do not enjoy the same market reach or economies of scale as the big operators, they have a better ability to adapt and flex output to meet demand. This is the consequence of a market shift towards value-for-money propositions of making and doing deals in direct response to customer needs, and this has become significant enough to attract a new brand of competitor within the ambulance market, as we have seen evidence of far eastern vehicle importers entering the mix. These companies believe that they could use their substantial core manufacturing expertise to adapt to the highly demanding challenge at little extra cost since their core competencies lie with engineering unique solutions. At present, there is no sign that a far eastern vehicle importer has ever entered the top-end luxury market, which has been dominated by the European heavyweights as the sector can supposedly deliver better returns once they attain credibility in the market.
Mergers and acquisitions by large manufacturers could disrupt this value proposition if the companies no longer retain their agile production and design units that allow rapid system redesign, which will attract increased commercial interest as the private suppliers start trading hands in the near future. It is currently possible to tailor more niche vehicles and establish relationships with the end users if we trade valuable information, such as customer lines, territory details, and other forms of client preferential details with the unstructured manufacturer. This is key as data would be sold; the buyers will change as customer demands become clear. This marketplace will be launching in the near future, and it will target smaller, independent assemblers or designers who currently produce a limited number of low volume, specialist ambulances with complex auxiliary conversions. At a trade point, information allows two different companies to customize their vehicle designs to customer requirements.
4.2. Strengths and Weaknesses of ICU Automative – Ambulance Manufacturers in Europe
Based on the previous reiterations, we can now sum up the strengths and weaknesses of ICU Automotive. The company’s strength lies mainly in its innovation in design, which is very difficult to imitate. It is important that innovation precautions are taken; we will see how these measures are executed in the company. ICU Automotive has a very good brand name, both in terms of history and perception, and a very good product mix that responds to different customer needs. The possibility to work with the biggest vans is very positive in particular as it covers the majority of ambulance requests in the single main EU market and gives an extra appeal of reliability. The fifth point is to efficiently respond to any demand from the market. ICU’s R&D division offers the capability to make tailor-made ambulances and guarantees prompt development based on newly available vans. The sixth point is that the company uses patents for products and processes. The outlook on industrial property is very positive, which shows that the company has the patents on their major processes and products, leading to a competitive advantage with a limited imitation process from other competitors. ICU Automotive has a limited ratio of short-term debt to long-term debt, which increases resilience to financial troubles in the short term.
However, this financial stability is focused on two major partnerships that are able to maintain a constant flow of orders that respond to capacity. The only major problem in ICU Automotive is its limited presence in the English market, which is the second biggest European ambulance market. The country has an open-market policy that is sensitive to innovation, so it could be a good target for the company’s export strategy. It is important to point out that, in general, it is a capital-intensive business, mainly due to the high investment in R&D; vehicles are built on automatic lines that require high upfront capital investments. Ambulance bodybuilders with a large turnover have an EBIT in the margins of 5%–10%, which gets even larger for major players. From the director’s statement, we can see the focus of the company in the direction of a clear new strategy through the identification of new customers with an innovative product range. The analysis of the company is important to give a deep understanding of the company’s performance. The perception of the customer arises from these factors and can directly impact loyalty in the end. Overall, the company is seen as a perspective in recent memories, further focusing on the strategic path of the company.
5. Conclusion and Future Outlook Ambulance Manufacturers in Europe
In conclusion, the European market for ambulances poses a wide range of opportunities and challenges for manufacturers. Organizations face a very dynamic healthcare landscape where technological advancements, demographic changes, and future readjustments in regulation harmonization will enlarge the need for customized products and services. Hence, assets such as innovation and adaptability become crucial to face the challenges of an increasingly volatile business environment. Transportation services playing a pivotal role in healthcare are closely and directly affected by market dynamics. The organization manages, as a result, to strategically generate value and to competitively position itself in a global market. Moreover, various trends associated with ambulance production, including custom-fit manufacturing and advances in telemedicine, could shape the future of this market.
Our findings suggest valuable future research opportunities regarding ambulance production, which could help innovatively expand, diversify, and unite available knowledge. First, it would be highly interesting to explore the extent to which ambulance interior designs, including the use of sustainable materials, can endorse or hamper patient health and recovery. Moreover, embedded digital health and big data opportunities, although booming, might still be underused in an ambulance healthcare setting, deserving a thorough examination. The Internet of Things might further play an important role in such discourse. In depth, findings concerning the use of digital health in the ambulance healthcare context could therefore be of importance to a wide variety of stakeholders. Third, it could be of value to combine digital health technologies and an expertise or focus on waste management, eventually bringing cradle-to-grave or cradle-to-cradle prosecutions regarding ambulance waste.
