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.

Trust	Total ambulance arrivals	Total delayed 30-60 minutes	Total delayed over 60 minutes	% delayed 30 mins or more
UNITED LINCOLNSHIRE HOSPITALS TRUST	5,067	1,317	910	44.0%
THE QUEEN ELIZABETH HOSPITAL, KING’S LYNN FT	2,011	469	330	39.7%
EAST LANCASHIRE HOSPITALS TRUST	4,400	1,218	363	35.9%
MID ESSEX HOSPITAL SERVICES TRUST	3,055	752	180	30.5%
THE PRINCESS ALEXANDRA HOSPITAL TRUST	1,769	451	69	29.4%
SHERWOOD FOREST HOSPITALS FOUNDATION TRUST	3,486	878	131	28.9%
EAST KENT HOSPITALS UNIVERSITY FOUNDATION TRUST	6,552	1,536	335	28.6%
WORCESTERSHIRE ACUTE HOSPITALS TRUST	4,896	1,082	314	28.5%
KETTERING GENERAL HOSPITAL FOUNDATION TRUST	2,868	578	214	27.6%
THE DUDLEY GROUP FOUNDATION TRUST	3,999	934	162	27.4%
NORTH WEST ANGLIA FOUNDATION TRUST	4,658	715	561	27.4%
SOUTHPORT AND ORMSKIRK HOSPITAL TRUST	1,994	267	278	27.3%
UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE TRUST	5,191	1,325	88	27.2%
COLCHESTER HOSPITAL UNIVERSITY FOUNDATION TRUST	3,234	584	276	26.6%
PORTSMOUTH HOSPITALS TRUST	4,087	553	531	26.5%
SOUTHEND UNIVERSITY HOSPITAL FOUNDATION TRUST	3,181	510	318	26.0%
MEDWAY FOUNDATION TRUST	4,084	847	183	25.2%
WEST SUFFOLK FOUNDATION TRUST	2,249	446	109	24.7%
COUNTY DURHAM AND DARLINGTON FOUNDATION TRUST	2,868	427	276	24.5%
NORTHERN LINCOLNSHIRE AND GOOLE FOUNDATION TRUST	3,376	675	124	23.7%
BLACKPOOL TEACHING HOSPITALS FOUNDATION TRUST	3,453	516	289	23.3%
ST HELENS AND KNOWSLEY HOSPITALS TRUST	3,490	542	269	23.2%
BRIGHTON AND SUSSEX UNIVERSITY HOSPITALS TRUST	4,212	823	152	23.1%
ROYAL SURREY COUNTY HOSPITAL FOUNDATION TRUST	1,702	359	34	23.1%
STOCKPORT FOUNDATION TRUST	3,284	515	239	23.0%
WEST HERTFORDSHIRE HOSPITALS TRUST	2,961	471	208	22.9%
BOLTON FOUNDATION TRUST	3,345	407	350	22.6%
IPSWICH HOSPITAL TRUST	2,614	453	126	22.1%
CHESTERFIELD ROYAL HOSPITAL FOUNDATION TRUST	2,435	497	36	21.9%
YORK TEACHING HOSPITAL FOUNDATION TRUST	5,013	588	481	21.3%
MAIDSTONE AND TUNBRIDGE WELLS TRUST	4,132	757	118	21.2%
WIRRAL UNIVERSITY TEACHING HOSPITAL FOUNDATION TRUST	3,229	399	281	21.1%
THE HILLINGDON HOSPITALS FOUNDATION TRUST	2,520	455	68	20.8%
WRIGHTINGTON, WIGAN AND LEIGH FOUNDATION TRUST	2,873	324	258	20.3%
LONDON NORTH WEST HEALTHCARE TRUST	5,696	899	243	20.0%

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.