Ambulance pilot removes 43 year old safety target for 16 million people
By Nick Turner
For the past few months, a total of sixteen million people living in the West Midlands, Yorkshire and the South West have been unaware that there has been no target in place to reach the most life-threatening Red-1 cases within any set time.
With growing pressures on the service, the Red-1 call category and its associated eight-minute response standard has been removed for the three trusts under a pilot scheme called the Clinical Coding review (CCR). Introduced in April last year, CCR is one of two schemes within a larger ambulance response programme (ARP) intended to help an underfunded service cope with growing demand.
Under another ARP initiative called Dispatch On Disposition (DOD), life threatening but less critical Red-2 calls that can include conditions such as stroke and fits, are now delayed for an additional two minutes for extra triaging. CCR goes further in testing completely new call categories and removing existing response targets. The results of CCR, due to be published in March, may recommend entirely removing the eight-minute response nationally. NHS England told me that:
“One of the purposes of the trial is to make recommendations for future response time standards based on our results. These recommendations will accompany the full ARP report, which will be published in the Spring. ”
Another ambulance pilot called the Clinical Response Model (CRM) has been running in Wales and was permanently rolled-out on the 27th February. Although this too placed emphasis on additional telephone triaging, it retained a commitment to an eight-minute standard throughout the pilot although in slightly modified form.The existing standard states that ambulance services should reach seventy-five per cent of life-threatening cases within eight-minutes. In the Welsh Pilot this was lowered to sixty-five per cent although they found that in practice that trusts were able to achieve more than 75%. The important difference between the two studies is that unlike its English counterpart the ARP, CRM in Wales retained basic standards as a safeguard.
Why does the 8 minute target matter?
The eight-minute target was introduced in 1974 following international recognition that the there is little chance of surviving a cardiac arrest after twelve minutes without intervention. Recently, the Daily Mail highlighted, that the CCR coding set had already scrapped the Red-2 category and these calls were now included within a much larger Amber category with no response-time requirement. Crews were now simply required to respond to Red-2 calls as “quickly as they can.” Most people will be unaware that the introduction of a more recent clinical coding set has now also removed the Red-1 call category – as a result, scrapping the eight-minute response target entirely.
The purpose of CCR is said to be to more efficiently match ambulance service response to patients’ needs. The new coding set was set-out in a little known NHS document that I stumbled across while researching ambulance performance figures. I was surprised to find that the document only referred to the “fastest response” to even the most urgent of the new call categories. I asked NHS England why no specific response-time is stipulated. They replied:
“No response time standards have yet been set….”
I asked NHS England if it could confirm if all of the three trusts taking part in the pilot at least unofficially aim to respond to the most urgent calls in eight minutes. They were again unable to commit to an eight-minute response or any specific response time:
”The three trial sites still aim to respond to the most urgent calls in the fastest possible time. We are closely monitoring response times for all call categories to ensure patient safety”
NHS England told me that no serious incidents have resulted from the introduction of the scheme.
However the stringency of the Serious Incident reporting system was questioned in 2015 by NHS England itself. Their enquiry into a secret South East Coast Ambulance initiative to delay response to NHS 111 calls, stated that:
“Serious Incident reporting by staff was the only review process offered by SECAmb; this on its own is an unreliable way of ascertaining this [patient harm], as it is a well reported fact that clinicians under report events."
The Ambulance Response Programme: A response to a crisis of underperformance
The Ambulance Response Programme initiatives CCR and DOD, were designed to address worsening performance figures that showed the system was unable to cope with demand.
By February 2016 the [eight minute] standard had been missed for Red 1 calls for nine months, with only 68% of calls receiving a response within 8 minutes. The standard for Red-2 calls was breached for the 25th consecutive month. At 60.3% this was the lowest performance since records began in 2012.
NHS England sustained heavy criticism both for ambulance response-time figures and for the number of ambulances waiting with sick patients at hard-pressed A&E units. After the worst ever queuing figures were recorded in 2015, NHS England decided to remove the ambulance queuing statistics from its Winter Situation Reports. In response, Dr Cliff Mann, President of the Royal College of Emergency Medicine said it seems as if “someone has decided to to glaze over the windscreen." Critics of CCR may question if the removal of the forty-three year old eight-minute standard is similarly intended to remove troublesome statics about the NHS in addition to improving efficiency.
Safety concerns with telephone triage
There has been an absence of public consultation about these schemes and the trade-offs between safety and efficiency that they may represent. Central to Ambulance Response initiatives such as CCR and DOD are telephone triaging systems. Similar systems are being touted as the solution to meeting demand throughout the NHS. Whilst NHS England emphasises that the systems used are safe, James Pavey, Clinical Operations Manager at South East Coast Ambulance service has told me that even under existing triaging arrangements, triaging-down more than ten per-cent of calls was always considered unsafe. Mark Docherty, Director of clinical commissioning and service development at West Midlands Ambulance told me that “telephone triage unfortunately in a time critical environment is inherently difficult.” As telephone triaging lacks the benefit of a physical examination, unsurprisingly, the numbers of people re-contacting ambulance services after discharge by telephone are consistently higher than those following face to face discharge. In August 2016, ambulance trusts using the new Dispatch On Disposition triage system recorded the three highest re-contact rates: West Midlands ambulance Service 13.5%; North East Ambulance Service 12.6% and South Western ambulance Service 10.4%
Mr Docherty told me that felt that response times were “still being calibrated” under CCR. Worryingly however, he told me that:
“Some of the calls triaged down are children under Five that should have automatically been classified as urgent calls because of their age.”
He told me that this group will usually go into the highest category of response precisely because “triaging over the phone for this age group is difficult.” “Unfortunately,” he said “the age of the patient was not a triage question” under the new arrangements. He said that:
“It can be two or three minutes into a call before they realise the mistake, by which time it is too late to make an eight-minute response.”
Mr Docherty said that this was unavoidable because there are more clinically important questions required by the triage system before asking the age of the patient.
Efficiency versus greater funding as strategies to meet demand
The number of 999 calls to the ambulance service has risen at an average of 5% every year for many years. The service also bears pressures within the wider NHS. Ambulance crews cope with a lack of primary and social care and wait with sick patients at overloaded A&E departments. At the same time, the funding of the NHS has been tightened since 2010 to increases of under 1% a year in real terms. For the ambulance service this has meant insufficient investment in staff and vehicles.
The solutions to meeting demand are either to increase the training of paramedics to reduce the number of ambulances required to attend patienst or extract the last efficiencies from the system with increased triaging and targeting of care. Mark Docherty, told me that the same efficiencies brought by the new system could also be achieved by having more paramedics on double-crewed vehicles because a first-time paramedic attendance would make attendance by several vehicles unnecessary. He stated that trusts often have to back up vehicles that don’t have a Paramedic. “To become efficient”, he said, trusts “need a higher level of Paramedics, which will need a cash boost to achieve, and arguably maintain.”
He recognised the continuing importance of the existing eight-minute response standard, stating that:
“you have got to have a benchmark. The risk is that if you stop measuring something, it slips.” He added that “National benchmarks are really helpful in flagging up when trusts need additional support.” He told me however, that at the present rate, paramedic vacancies would not be filled for ten years. In the absence of additional resources, Mr Docherty believes that schemes such as CCR are necessary in order to enable trusts cope with demand.
Trusts accused of fiddling performance figures
Although it is argued that Ambulance initiatives such as DOD and CCR were unavoidable in the absence of greater funding, the continuing failure of these efficiency schemes to make up for lack of resources is confirmed by the fact that some ambulance trusts have been accused of adjusting data to meet response targets. In January this year, a report in The Times stated that:
“Ambulance trusts have been accused of routinely manipulating 999 response times by using a loophole to claim that they reached life-threatening emergencies in less than ten seconds. Ten of the country’s 11 trusts have taken advantage of NHS rules allowing them to log ambulance response times as near-zero if there was a defibrillator within 200 metres of a patient, and someone nearby was trained to use it. The rule applied even if the device was not used or unsuitable for the patient’s condition.“
While efficiency in public services is in-itself a worthwhile aim, it is both unacceptable and inadequate as the sole solution to underfunding and increasing demand. In December 2016, James Lazou, Unite's Research Officer for Health stated:
" Unite is calling for the recruitment of more paramedics so that the service can be staffed with the necessary skills to deliver the most efficient and safe service."