Issues For Our NHS > Ambulance Services: Managing Demand

Underfunded ambulance trusts failing to meet even relaxed response targets

By Nick Turner

Ambulance response-time standards have been relaxed to help manage increasing demand on an underfunded service. The initiatives have come in response to record-poor performance figures.

 

Since 2012, the most urgent (Category-A) ambulance calls have been divided into Red-1 (most urgent) and Red-2 (serious but less time critical). According to a national target, trusts are required to send an ambulance within eight-minutes to at least 75% of Red-1 and Red-2 emergencies. 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.

By February 2016, the standard had been missed for Red-1 calls for nine-months with only 68% of calls receiving a response within eight-minutes. At 60.3% performance for Red-2 calls was at its lowest since 2012.

In response, a scheme called Dispatch On Disposition (DOD) increased triage time and delayed response to Red-2 calls by an additional two-minutes. Red-2 calls can include conditions such as stroke and fits.

In addition, new call categories are being tested by three ambulance trusts taking part in a Clinical Coding Review (CCR). NHS England will report the findings of the review in the spring before introducing changes nationally. Information already obtained from two of the trusts however, suggest that they are still struggling to cope with demand despite these measures.

Call categories scrapped

Under the Coding Review, Yorkshire, South West and West Midlands ambulance trusts have removed the Red-2 call category and its eight-minute response standard altogether. Red-2 calls made-up an average of 95% of all life-threatening Category-A emergencies. Consequently, 16 million people served by the three trusts have been unable to rely on the fastest response to most of the calls that would previously have had this requirement.

It has been less-well publicised that the Red-1 call category has now also been scrapped by the three trusts. A new set of call-categories are set-out in a little-known NHS document. This only refers to the “fastest response” to the most urgent new Category-1 emergencies. When asked if there was still an eight-minute standard for these calls NHS England said:

“No response time standards have yet been set….”

Contradicting this claim, Freedom Of Information requests show that the three trusts do still record performance against an eight-minute standard for Category-1 calls. In fact, South West Ambulance trust (SWAST) had been publishing figures against this standard for months in their reports.

Performance figures show continued failure to meet the eight-minute standard

The reason for NHS England’s refusal to admit that eight-minute performance is still being measured is unclear. Figures available for two trusts however, show that performance is still below the 75% target for the most urgent cases.

In January 2016 before the introduction of the new categories, SWAST responded to 68 % of Red-1 calls within eight-minutes. In February 2017 performance for the new category-1 had improved slightly to 73.96%. However, performance over the whole period from 25 October to 28 February 2017 was lower at 71. 5 %.

As the bulk of calls requiring an eight-minute response were removed when the Red-2 category was scrapped, trusts might have been expected to be able to properly meet their remaining eight-minute commitments. SWAST’s eight-minute performance has only improved slightly. Because monthly performance typically varies by a few percentage points, the degree of actual improvement may be disputed. As the new call-codes are supposed to more accurately reflect the seriousness of calls, this continuing failure is concerning.

Results are worse for the Yorkshire Ambulance Service. Response to a Freedom Of Information request dated February 9, 2016, stated that between October 20, 2016 and February 7, 2017, 65.3% of Category-1 calls received an eight-minute response. This compares to 69.4% of Red-1 calls from April 21 and October 19, 2016 - before the new codes were introduced.

West Midlands Ambulance refused to provide figures arguing that it could affect the outcome of the pilot.

Efficiency versus greater funding as strategies to meet demand

Mark Docherty, Director of Clinical Commissioning and Service Development at West Midlands Ambulance told me that any 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. This would need “a cash boost to achieve, and arguably maintain.”

SWAST’s report in January this year confirmed that the ambulance initiatives have been inadequate to meet demand on the service, highlighting the need for:

“Additional operational vehicles to increase conveying resource capacity” and “….frontline recruitment to provide the right numbers of appropriately  skilled staff….”

Unite the union has called for:

“recruitment of more paramedics so that the service can be staffed with the necessary skills to deliver the most efficient and safe service."

Safety concerns with telephone triage

Central to the ambulance response initiatives are telephone triaging systems. James Pavey, clinical operations manager at South East Coast Ambulance service has said that even under previous triaging arrangements, triaging-down more than ten per-cent of calls was always considered unsafe.

Mark Docherty said: “Telephone triage unfortunately in a time- critical environment is inherently difficult.”

Mr Docherty told me response times were “still being calibrated”:

“Some of the calls triaged down are children under five that should have automatically been classified as urgent calls because of their age.”

The age of the patient is not a triage question. As a result:

“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.”

NHS England told me no serious incidents have resulted from the introduction of these schemes but the stringency of the Serious Incident reporting system was questioned in 2015 by NHS England itself. Its enquiry into South East Coast Ambulance initiative to delay response to NHS 111 calls, stated that:

….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."