Ambulance waiting times for stroke and suspected heart attacks have quadrupled in four parts of England since before covid-19 – whereas others have only grown by half – underlining the severe impact of long accident and emergency handovers.

The variation in category 2 waiting times – which cover serious conditions, such as stroke and suspected heart attacks – is revealed in detailed data on waiting times at local clinical commissioning group level. You can explore the data for local areas across different measures in the dashboard below.

The data was obtained through freedom of information requests.

Response times have leapt across England over the past two years, particularly for category 2 and 3 incidents, but the data makes clear that the steepest increases are in areas where hospitals have the biggest handover delay problems (see tables below of highest and lowest increases).

Of the 10 patches with the largest increases in average category 2 performance between 2018-19 and 2021-22, four are served by major hospitals which make up NHS England’s “cohort one” of trusts selected for the worst handover problems; and four more are on government’s list of 15 which accounted for the most long handover delays last winter. 

Cornwall’s category 2 mean response times, already long before covid, are now 55 minutes greater than the next longest; and more than seven times the shortest, in North Cumbria. The category 2 target is 18 minutes. Recent data seen by HSJ shows Cornwall has 50 per cent more hours lost to handover delays than the next-worst. 

There is also a clear regional pattern.

Ambo gif

Looking at average category 2 performance, the West Midlands had the best response times before covid, but accounts for four of the 10 areas with the biggest increases, up as much as 351 per cent since pre-covid in Birmingham and Solihull. Despite the increases, the West Midlands areas still have better response times than many in other regions (see tables below/dashboard).

Recent West Midlands figures show handover delays continued to increase in October in Worcestershire and Shropshire, while there has been some improvement since the summer in Birmingham and Staffordshire.

Several of the most affected ambulance trusts stressed to HSJ that staff were working hard to provide quicker responses; that handover delays were the main cause; and that they were collaborating with local NHS and social care services to try to reduce them.

In addition to the West Midlands, the rest of the 10 most deteriorated are in the South West (two), East of England (two), London (one) and the North West (one).

The South West and East of England regions have recorded the largest increases in so-called super stranded patients’ – those people who remained in hospital for 21 or more days – between winter 2019-20 and 2021-22, probably due to delayed discharges. The rise in discharge delays since pre-covid – and in turn, the crisis in social care – is cited by most as the largest cause of increased handover delays, along with staffing problems in health and care.

Some of the longest response times from October 2021 - June 2022 – as well as in the South West – were in Lincolnshire and Leicestershire, overseen by East Midlands Ambulance Service (see table below). Although they did not increase as steeply as some others, they were already very long before covid.

Best performers

At the other end of the scale, none of the 50 areas with the biggest growth in response times are served by South East Coast ambulance or North East ambulance services, and only one (Portsmouth) is covered by South Central.

These three regions are known for having significantly fewer handover delays, and have also faired marginally better on super stranded patients.

South East Coast covers six of the 10 areas with the lowest increases in category 2 average responses, all up around 40-50 per cent from 2018-19 to 2021-22.

SECAmb interim CEO Siobhan Melia told HSJ its handover delays were relatively good, thanks to “a combination of good working relationships on the ground across the acutes and at executive/CEO level, good grip and oversight from integrated care boards, and an agreement for immediate handover where appropriate (when in surge) across Kent, Surrey and Sussex”.

The areas with the shortest waits are spread fairly widely around England though, across the North West, West Midlands, South Central and South East. The shortest — North Cumbria — is believed to be because the North West service bases a dedicated resource in this very rural/remote area. 

10-hour waits for a tenth of calls

The local data analysed by HSJ, provided by ambulance trusts under freedom of information rules, also revealed:

  • The highest average category 2 average response – against the 18-minute target – was in Cornwall, which averaged 2hrs30mins over October 2021 to June 2022. In March 2022, its mean response hit more than four hours, and 90th centile hit 10 hours.
  • Category 2 90th centile response times – the time which 10 per cent of patients wait above – exceeded five hours in several areas between March and July this year. These include Cornwall, Lincolnshire, Essex and Bristol, North Somerset and South Gloucestershire. 
  • On category 3 calls – which are for conditions which require urgent response and likely transport to hospital, but are not immediately life threatening, mean performance in Cornwall, parts of Essex, and Bristol, North Somerset and South Gloucestershire topped eight hours. Category 3 response times have also been rising steeply in Lincolnshire and Nottinghamshire, and these were among the highest in July 2022 – the most recent month HSJ has data for.
  • Category 1 response times – for the most serious incidents – have held up better, as ambulance services have sought to protect them at the expense of others. However, mean category 1 response hit 18 minutes in Cornwall in March (around twice typical pre-covid times) and 16 minutes in South Lincolnshire in May.

Local response times dashboard

Open dashboard in new window 

 

Reasons for local variation

The increase in handover delays – in turn linked to delayed discharge, staffing, lack of community services and social care’s collapse – is the stand-out reason for areas with the steepest increase in response times.

However, insiders cited a range of others reasons which play a part in local variation:

  • In some areas, ambulance services have lost more staff, either temporarily – for example to covid absence, which particularly hit paramedics – or to people leaving for other roles, especially in urban areas and close to big cities;
  • Where ambulances/crews are based — for example, North Cumbria has a dedicated resource based there, because it is so remote from other parts of the patch; 
  • Trusts’ capacity planning not keeping pace with changes in demand in some patches, leaving them without enough staff and vehicles; 
  • Moving staff around to match demand is difficult due to employment practices in the sector;
  • Some patches suffer as they are neighbouring areas with big handover delays, which draw in their ambulances;
  • Travel time and centre-periphery effects – responses are nearly always faster in urban areas, while incidents in the centre of cities get a faster response than the edge;
  • In addition to this, after ambulances go to hospitals – which are often in cities or towns – they are more likely to remain in the same area afterwards, meaning there is less capacity for rural patients. This is a dispatch issue;
  • A focus on targets with mean average performance can create a perverse incentive to put more resource into areas where services can achieve faster response, at the expense of dealing with the longest waits;
  • Varying conveyance rates;
  • More use of specialist clinicians in ambulance teams can increase treatment at the scene and use of alternative pathways, rather than conveyance to hospital, but can also take more time;
  • Local events and weather, and local variation in covid demand/public concern about it;
  • Capital underinvestment can mean vehicles are not ready for use when shifts start, and this has increased over the covid period;
  • Use of electronic record systems is said to have slowed crews in some areas.

Further responses

Several ambulance trusts, stressing the importance of handover delays, provided charts showing the striking correlation between hours lost at emergency departments and category two response times:

South West: Handover delays and category 2 response times  

SWambocorrelation

West Midlands: Handover delays and category 2 response times

WMambocorrelation

A WMAS spokesperson said: “We are working incredibly hard with all of our NHS and social care partners to prevent these delays, looking at new ways to safely hand over patients quickly so that our crews can respond more rapidly and save more lives.”

An East of England Ambulance Service Trust spokesman said: “The trust has been working hard to respond to high demand across the region, including in Mid and South Essex, where we have increased the number of ambulances, ambulance drivers, and clinical staff to help ensure patients are reached as quickly as possible.

“We are also working closely with local hospitals to improve handover times, including a new ambulance handover unit at Southend University Hospital, which will mean ambulances can be released more quickly. We’re also directing patients to community healthcare services, when appropriate, to reduce hospital demand.”

A South Western Ambulance Service spokesman said: “Our ambulance clinicians strive every day to give their best to patients, but our performance has not returned to pre-pandemic levels, partly due to handover delays at emergency departments… We are working with our partners in the NHS and social care, to do all we can to improve the service that patients receive.”

In relation to long response times in Lincolnshire, East Midlands Ambulance Service Trust said: “We are really sorry that patients in our communities are waiting longer than we would like for an ambulance response, due to the wider pressures across the NHS and social care systems which are causing handover delays… Handover delays are not solely an ambulance or hospital-only issue and concern, and we continue to work very closely with our system partners to address these challenges.”

Source

Data obtained by HSJ

Source Date

2022

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