NHS ambulance services

In 2019 the Care Quality Commission reported that ambulance services were relying on private providers because of lack of capacity. Some firms had failed to obtain references or carry out criminal record checks and a lack of staff training was leading to serious patient harm. More than £92 million was spent in 2018/9 on private ambulances and taxis.[3]

In May 2022 NHS England tendered a contract worth up to £30m for “auxiliary ambulance services”. This is worth £7.5m annually and is initially an eight-month contract. It covers both emergency and non-emergency ambulance crews “with the capacity to respond to callouts across categories one to four”.[4]

NHS England sets targets for response times to 999 calls, which were first established in the 1970s. Call handlers were, until 2017, given just 60 seconds to decide on the urgency of the call. The clock stopped once a vehicle reached the patient - even if it was not the appropriate vehicle.

Category A (Red 1 and Red 2) were classed as life-threatening and the national standard sets out that a vehicle should reach the scene within eight minutes for 75% of these calls . Red 1 calls are for patients who have suffered cardiac arrest or stopped breathing and require two vehicles. If onward transport is required a suitable vehicle should arrive on the scene within 19 minutes. The number of these rose from 2.5 million in 2011/12 to just under 3.4 million in 2015/16, but response times fell steadily and the 75% target was not met after 2013.[5] Green 1 required a vehicle within 20 minutes, Green 2 within 30 minutes. Green 3 required telephone assessment within 20 minutes and Green 4 telephone assessment within 60 minutes. These targets are only recommended.[6]

In July 2017 a new set of performance targets for the ambulance service were announced after a trial across four different ambulance trusts, looking at more than 1 million patients overseen by Sheffield University.[7] These are to apply to all 999 calls for the first time. Call handlers will be given four minutes to assess the urgency of the call before the clock starts. The target for the most seriously ill patients is now seven minutes. The 'clock' stops when the most appropriate response, not necessarily the first, arrives. There are condition-specific measures which will track time from 999 call to hospital treatment for heart attacks and strokes. 90% of eligible heart attack patients should receive definitive treatment (balloon inflation during angioplasty at a specialist heart attack centre) within 150 minutes by 2022. 90% of stroke patients should also receive appropriate management (thrombolysis for those who require it, and first CT scan for all other stroke patients) within 180 minutes of making a 999 call.[8] For other emergencies the target is for 90% to be seen in 40 minutes. Urgent or non-urgent calls should expect an average response time of 120 and 180 minutes respectively. Extensive trials have shown that fewer patients are classed as life-threatening and fewer vehicles are dispatched, but responses for the most urgent calls improved.[9]

Trusts asked for more resources to meet these targets, in particular the standards for the top 90% of responses. Taking patients to the "right" hospital rather than the nearest, leads to longer journeys. They were supported by a benchmarking exercise undertaken by the National Audit Office.[10]

In July 2018 eight of the ten services in England missed the seven-minute target. A review conducted by Lord Carter of Coles found that the rate of sickness of ambulance staff was the highest in the NHS - 20 days per person. Use of information technology was advancing very slowly. 25% of ambulances, of which there were 32 different types, were more than seven years old. There were large differences in costs and performance between the different trusts, some of which were attributable to local geography and the performance of other parts of the NHS.[11] Responses to the most urgent calls averaged 11 minutes in rural areas in 2018 but 7 minutes in urban areas. The worst waits were around Wells-next-the-Sea.[12]

The COVID-19 pandemic in England put huge pressure on ambulance services. In July 2021 there were 81,685 category one incidents, up 32% in July 2019, and up 16% on the previous high in December 2019. Response time performance for these calls slumped to 8 minutes 33s, against a target of 7 minutes, with a tenth taking more than 15 minutes 15s. Average response time for category two calls, still classified as emergencies and including heart attacks and strokes, was 41 minutes 4s against a target of 18 minutes.[13] In October 2021 there were around 28,900 ambulance handovers lasting longer than an hour. This was almost four times the 7,772 hour-long handovers recorded in October 2020.[14] In April one patient waited 24 hours in an ambulance - thought to be the longest ever recorded. 11,000 patients waited more than three hours for handover, with 7,000 of them taking more than four hours and 4,000 over five hours. [15]

11 July 2022 was said to be the worst night on record for ambulance services in England, with more than half of some trusts ambulance crews queued outside hospitals in very hot weather.[16] There were more than 85,000 category one ambulance callouts in July - the highest ever recorded. Category one performance averaged 9 minutes 35 seconds, the same as in March 2022 and the joint lowest on record. Category two calls took an average of 59 minutes 7 seconds.[17]