North by North West: Ambulance crisis being shrugged off

Ambulance response times for the most serious 999 cases have soared over the last six months, leading to an increase in serious incidents, patient harm, errors, stress levels and burn-out among crews.

The recent, deeply distressing case of Bina Patel from Tameside, is only the thin end of the wedge.

For whatever reason, ambulance trusts and their staff have struggled to communicate these problems in a way that truly alarms the public, NHS leaders and politicians enough to prompt action.

Held up at ED

Ambulance staff told NxNW one of their main frustrations is a perceived lack of support from the rest of the emergency system.

North West Ambulance Service has to plan its resources within the funding envelope it is given by commissioners, which assume that ED handover times are 30 minutes or less – a target which is increasingly missed across the NHS.

This means turnarounds that take longer than 30 minutes, where they are not offset by shorter handovers, automatically make NWAS under-resourced against planned provision.

For most of the last three years, turnarounds averaged about 32 minutes in the North West, but this has shot up since last summer, reaching 45 minutes in December 2021.

With almost 50,000 hospital attendances that month, that represents around 12,000 hours when crews should have been out on the road and available to respond to new emergencies, but were instead tied up at ED.

Not only does this create massive patient safety risk – for those needing an ambulance response – but ambulance units are one of the most expensive resources in the NHS, so it’s also a horribly inefficient use of resources.

Back in October, NHS England told acute trusts to “immediately end” handover delays, but without any clear way to achieve this, and four months later the proportion of handovers which take more than 60 minutes is still triple the pre-covid level.

Problem hospitals

Some hospitals, despite being extremely busy, seem to recognise the problem. Paramedics can almost always rely on the Royal Blackburn Hospital, for example, for a quick turnaround.

Several of the problem EDs are in Greater Manchester, where the Royal Oldham and Fairfield General consistently account for a huge proportion of ‘delayed admissions’, where crews are not only held up but actually prevented from bringing patients inside.

This means crews are unable to cohort multiple patients in a corridor under the watch of a single crew, which still isn’t good, but frequently happens at other sites and allows more units back on the road.

There is a sense from NWAS staff that Oldham and Fairfield have got used to using ambulances as an extension of their ED, and are reluctant to have any of the risk passed on to them. The situation isn’t helped by a lack of physical capacity and poor estate configurations.

It would be wrong to pin all the blame on ED staff, who are often faced with overwhelming levels of demand, and sometimes lack support from decision makers on the wards, who may in turn lack support from people up the chain or within the discharge process. Flow is, of course, a whole-system issue.

Apparent solution abandoned

In 2018, NWAS secured funding from commissioners to work intensively with six to eight hospitals on reducing handover delays, in a project called Every Minute Matters.

The project did seem to be making an impact in 2019, bringing down handover times while those at other hospitals increased, but it was abandoned and defunded when covid hit, as it wasn’t deemed a priority.

Oldham and Fairfield, along with the Royal Bolton, Manchester Royal Infirmary, Tameside General and North Manchester, were not part of the scheme, and it has yet to be revived or replaced by anything which sounds significant enough to make a difference.

Handover delays are a red-rated issue on NWAS’ risk register, which notes under “gaps in control” that “not all NW hospitals have signed up to the Every Minute Matters collaboration”.

NHS England, which oversees local commissioners, said measures were being put in place in Greater Manchester to smooth out ambulance flows when delays emerge, while a handover checklist is being implemented into every emergency department.

It added that Oldham, Fairfield, as well as Bolton, have been asked to provide improvement plans and are being given support, as well as ongoing work to address some of the estate and configuration issues.

It also pointed to £6m of additional funding which NWAS received over the winter period – although this appears to have been needed for increased day-to-day spending, rather than being available to invest in an extension of Every Minute Matters, or transformation work on a similar scale.

The Northern Care Alliance, which runs the Oldham and Fairfield sites, said handover times are “discussed routinely at board level” and it is working closely with NWAS to make improvements.

It suggested the issues are exacerbated by a bed deficit of 150 beds at Oldham, and added: “We have regular, open communication with NWAS at all levels and are committed to using every opportunity to listen and seek advice wherever possible.

“We are spreading learning from some of our systems and processes being deployed at Salford Royal emergency department, where positive ambulance turnaround times have been experienced, cited recently as best practice by GM and NHS England partners.”

According to staff spoken to by NxNW, these efforts have yet to be felt on the front line.