Performance Watch: Ambulance handover delay hotspots revealed

Ambulances queuing outside hospital front doors are a stark visual metaphor for the extreme pressure on the NHS – but also a good indicator of where the system is most stretched and patients potentially most at risk.

Handover speed gives a good indication of flow through the system. Indeed, NHS England warned trust leaders in November that handover delays “must be recognised as a system wide responsibility”.

Wrightington, Wigan and Leigh hospital chief Andrew Foster wryly commented on Twitter earlier this week that it was “time to open up an ambulance trust with the lovely fleet of 14 parked outside the front door”.

The accompanying picture is an alarming sight, and not an isolated one. Performance has deteriorated over December. 

One in 10 ambulance handovers were delayed by 30 minutes or more in the week NHS England began its winter SitRep reporting of the data (27 November to 3 December). By the week beginning on Christmas day (and reported yesterday), this had risen to one in six, according to NHS Providers’ winter tracker.

Our trust level analysis of the first five weeks of NHS England’s SitRep data (see table below) reveals the depth of the problems facing the system and the areas struggling most.

A quick health warning on the data itself: much of it is not validated and is provided, and published, at speed. It may include some inaccuracies. But statistical experts consulted by HSJ believe it gives a good overall picture of the system’s problems.

This winter’s SitRep data records weekly updates on total ambulance numbers; handover delays over 30 minutes and handover delays over one hour. The target is 15 minutes, so ambulances can be back on the road, ready to respond to further calls, 15 minutes later.

No comparable data was produced last winter, but it was in 2014-15. Nuffield Trust senior analyst Liz Fisher told HSJ their analysis suggested the number of ambulances waiting more than 30 minutes to handover patients “is around double this winter” compared to three winters ago.

She added: “This winter there have been an average of around 1,800 per day so far compared to an average of around 990 in the whole of winter of 2014-15. Plus, the indications are that this has been increasing over recent weeks, so it shows the strain the system is under this winter.”

The most challenged trusts

Our table below shows the 35 trusts that reported that 20 per cent or more of their ambulance handovers were taking over 30 minutes (don’t forget the data health warning).

A few things are apparent:

• Three of the five most challenged trusts (United Lincolnshire, Princess Alexandra and East Lancashire) on delayed handovers were also on a list of consistent accident and emergency four hour underperformers published by HSJ in September.
• Four of the five Essex hospital providers (Southend, Colchester, Princess Alexandra and Mid Essex) appear in the top 20 most challenged on handovers – underlining the issues in a long troubled health economy.
• Providers from Kent and Lincolnshire – two other highly challenged health economies – are also on the list, underlining the relationship between handover delays and systemwide issues.

One senior provider source said the data showed how severely strained the system was. But the source stressed trusts were doing all they could to minimise delays and that without the planning put in place for winter these difficulties would probably have been worse.

It would be fair to conclude that none of the trusts on this list will come as a surprise to system leaders. NHS Improvement has previously told Performance Watch that it is working on “bespoke support” for the consistent poor performers, many of which are in this table.

The areas concerned, however, all have deep rooted issues and will certainly not be turned around in the next few months.

But the depth of the problems facing these trusts does raise questions about how system leaders plan to keep the most challenged hospitals from completely going off the rails in the short term as the pressure mounts in the coming months.

Delayed discharges remain a stubborn problem

As well as the handover issues at the front door, high bed occupancy rates laid bare the congestion within hospitals, and most likely in discharges as well.

Health Foundation senior policy fellow Tim Gardner told HSJ: “The bed occupancy data suggests delayed discharges could be a bigger issue than last winter, although we won’t know this until the official data comes out.”

While some progress has been made in cutting the delayed discharges, official data indicated that the system missed a target to cut the delayed transfer of care rate to 3.5 per cent of its bed base by September and clear 2,400 beds by winter.

“Bed occupancy was at 86.7 per cent on Christmas day, 3.1 per cent higher than last year, and then went up to 90 per cent on Boxing day, which suggests hospitals have really struggled to get people out of hospital before Christmas.”

The system appears to be clogged up at every juncture and as chief economist John Appleby ominously warned: “The sobering reality is that winter for the NHS has hardly started.”

• This piece was updated at 4pm on 5 January to remove Queen Elizabeth, King’s Lynn, from the list of most challenged trusts for delayed handovers which were also on a list of consistent accident and emergency four hour underperformers published by HSJ in September. It was not one of the consistent underperformers.