1/25 New report from @AACE_org on the impact of ambulance handovers on patients. @Independent story here:
independent.co.uk/news/health/am…. Thread below on the broader context and why everyone in the NHS needs to help rebalance current levels of risk to protect patients.
2/25 In the words of one senior national NHS leader last week “we have all become used to the ambulance service being the brilliant bedrock of the urgent and emergency care pathway. Always providing a fantastic, rapid, quality of care whatever the level of pressure”.
3/25 But, over the last few months, the pressures on ambulance services across the country have risen significantly. It’s striking that this is universal – all ten ambulance services in England have been on high alert for a very long, and continuous, period of time.
4/25 If you run a system close to, or above, its capacity limits all the time, small shifts in demand can cause major problems. Performance statistics show, despite staff continuously going above and beyond the call of duty, there are huge pressures across the ambulance service…
5/25 …Pressure on 999 call answering times. Pressure on ambulance response times – the time it takes an ambulance to reach a patient requiring treatment. Pressure on ambulance handover delays – the time taken for ambulances to hand over patients to a hospital.
6/25 It’s important to unpack the impact on patient safety / quality of care and the scale of risk in each area as each has its own dynamics. But, together, they add up to a major increase in the scale of risk being carried by ambulance services, which is a real concern.
7/25 Inability of ambulance services to answer 999 calls promptly is a particular problem because the patient risk is untriaged. The NHS doesn’t know whether the 999 call is for a heart attack or stroke needing immediate attention or is for a non-life threatening condition….
8/25 …that’s why there's such emphasis on answering 999 calls promptly and avoiding 999 call queues. The NHS literally has minutes to save someone’s life if they are having a heart attack / severe bleeding so any delay in answering immediately puts lives at risk.
9/25 Longer ambulance response times can have several impacts. For the most serious cases, they can literally be the difference between life or death/serious harm. Cardiac/respiratory arrest need rapid intervention & effective treatment. That’s why there are clear standards…
10/25 …for category 1 (the most serious incidents) ambulance response times. Current performance statistics show that, despite huge staff effort at the frontline, the average response time in October was nine minutes 20 seconds against a standard of seven minutes.
11/25 Delays for category 2 calls – including strokes & suspected heart attacks – also have real consequences for patient safety. Conditions worsen and avoidable harm increases. Pain continues/deepens. Patient experience/risk – e.g. lying on floor for extended period – worsens…
12/25 ...Again, despite huge effort at the frontline, the average response time for category 2 calls in October was 53 minutes 54 seconds against a standard of 18 minutes. This is clearly very difficult but also shows the effort going in to prioritise category 1 calls.
13/25 Longer and higher numbers of ambulance handover delays have two consequences. As the new @AACE_org report clearly shows, long handover delays run the risk of increased patient harm. Evidence shows patient safety risk reduces once the patient enters hospital.
14/25 But the other risk of ambulance handover delays, that we don’t focus on often enough, is that an ambulance waiting outside a hospital can’t be on the road seeing other patients who need treatment. There is an important opportunity cost risk of tying up ambulance capacity.
15/25 These risks are inter-related. The current scale of ambulance handover delays means that there is insufficient ambulance capacity to cope with demand. Ambulance response times, particularly for non life- threatening conditions, can extend to many hours….
16/25 …So patients will, understandably, sometimes make multiple calls to 999 to find out when an ambulance will arrive. Anecdotal evidence from one trust said that 999 call volumes have risen by 25% but four fifths of this extra call volume were calls seeking updates.
17/25 Ambulance staff are working incredibly hard to cope with these pressures. They are doing a brilliant job. Triaging 999 patients to prioritise patients by clinical need. Trying to keep the category 1 and 2 response times as low as possible to protect patients from risk…
18/25 …Treating as many people as possible in their homes to reduce the number of people taken to hospitals that are very busy – national leaders say hospital conveyancing rates are actually down. Providing the best possible care to those waiting for hospital handover.
19/25 The load on ambulance staff is currently enormous. Some of the ambulance staff stories in the media last week were very distressing, as were the patient stories. All NHS leaders I’ve spoken to are very grateful to ambulance staff for their reaction to such extreme pressure.
20/25 Taken together, this represents a significant, recent, unprecedented, shift in patient risk. Risk in the health and care system is no longer appropriately balanced with ambulance services now bearing a disproportionate and very worrying level of risk. This is why…
21/25 …It is now important for every system, and every NHS leader, to ask what they can do to help rebalance this risk. A key concept for now, and for this winter, will be “where is the patient safety risk in my system greatest and what can I and my team do to help reduce it?”
22/25 There’s an understandable focus on backlog recovery in the NHS. But these pressures, and their impact on patients, also show the vital importance of an appropriate focus on the urgent and emergency care pathway as well. As many, including @RCEMpresident, have been arguing.
23/25 And it's important to recognise that all parts of our health and care system - GPs, community services, mental health, hospitals and social care as well as ambulances - are currently under very significant pressure. In mid November. Before the traditional winter peak.
24/25 Important to also balance pressures with some positives. Great to see current high levels of interest in people wanting to train to be paramedics. Opportunities for paramedics to support primary care: see this @NHSProviders inspired story from today theguardian.com/society/2021/n…
25/25 Similarly, opportunities from connecting paramedics more easily to community services to avoid hospital admissions. And new review headed by @clairefuller17 on care at place level offers great opportunity to harness ambulance services to manage demand more effectively.

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More from @ChrisCEOHopson

2 Nov
1/14 Brilliant visit to @SurreyDownsHC, part of @SurreyHeartland ICS today. Very impressed with the excellent progress they have made in actually integrating services on the ground, delivering better care and improving outcomes. Thread below with what particularly impressed me.
2/14 Impressed with the way that the @SurreyDownsHC’s vision for integration starts with concrete action to improve services. Of course governance, finances and structures are important. But they start with a data driven understanding of the needs of their population…
3/14 …And they then put the relevant professionals together to work out how they can improve the relevant service or pathway. Strong emphasis on enabling right collaborative relationships between different people from different disciplines and organisation to drive improvement.
Read 14 tweets
1 Nov
1/5 Thanks for everyone's responses to my thread / your contributions to this important debate. They show how complex this issue is and how there are strong views here, understandably. Three quick thoughts in response to some of the comments that have been made.
2/5 A. The patient perspective is, of course, vital. There will be many patients who will feel very strongly that they have a right to be treated by staff who have been vaccinated. Equally, there are some staff who feel very strongly it is their right not to be vaccinated...
3/5 ...One of the complexities here is that there is a potential conflict between people who believe, equally strongly, that their fundamental rights are at stake and should not be breached. B. Thinking further about the patient perspective and the NHS looking after patients...
Read 5 tweets
1 Nov
1/13 Possible Government will announce approach on mandatory NHS staff vaccination this week. Consultation has now closed. A complex issue. Tweet thread follows, based on conversations with, and intelligence from, trust leaders. There are differing views in trust sector…
2/13 Our intelligence suggests c2/3 of senior trust leaders - hospitals, mental health, community & ambulance - favour mandation & 1/3 don't. Everyone agrees there are two risks to manage here, not one. Not just the risk of covid/flu cross infection from unvaccinated NHS staff….
3/13 …It’s also about managing the risk of losing unvaccinated staff when the NHS is at full stretch and carrying 93,000 vacancies. The issues currently facing social care providers illustrate the very significant scale of risk to care / patient safety if we get this wrong.
Read 13 tweets
2 Sep
1/19 Media reports suggest Govt now finalising health & care part of spending review and we're heading for a potential £5 billion NHS funding gap next year. We've issued a new report today with @NHSConfed showing why frontline NHS needs £10bn extra next year. New thread follows.
2/19 Bit of background context first. The NHS budget for five years, including next year and the year after, was set in June 2018, before covid. Over the last two years the Government has suspended those plans and given the NHS the extra money it needed to deal with covid…
3/19 ...Last year NHS received £18bn extra on top of original plan. In 1st half of this year NHS received an extra £7bn with more to come for 2nd half of year. According to Monday's Times (thetimes.co.uk/article/nhs-bo…) Govt now wants to return to pre-covid budget plan next year...
Read 19 tweets
12 Aug
1/10 Important new joint report with @AACE_org on ambulance services released today.

Report: nhsproviders.org/media/691897/r…

Blog by @daren_mochrie & me here: hsj.co.uk/quality-and-pe…

News story by ever wonderful @AliJaneMoore here: hsj.co.uk/service-design…

Quick ( 🤣) thread follows.
2/10 It’s a very good time to talk about ambulance services given the unprecedented pressure they have been under for the last two months. This is a clear warning sign that we have to address the underlying demand / capacity mismatch ambulance services face. Risks increasing..
3/10 ...Growing risk of ambulance staff burnout given constant pressure. And growing risk of harm to patients because, despite best efforts of frontline staff, demand/capacity mismatch means ambulance services can't always provide quality/speed of care they want & need to.
Read 10 tweets
11 Aug
1/12 NHS monthly stats due out tomorrow. Although the number of covid hospital cases is significantly lower than many were predicting/fearing, the NHS is still under huge pressure due to a combination of six factors. Stats will show this tomorrow. Shorter thread (🤣) follows!
2/12 Particularly important to understand that every part of NHS is under pressure. Hospitals, ambulance, community & mental health services and general practice / primary care. Many CEOs saying that although the shape of the pressure is different, it feels as busy as Jan/Feb…
3/12 …Striking that some CEOs are saying that their trust is under the highest pressure they have ever known. Don’t measure overall NHS pressure by looking at covid-19 caseload. Vital to look at all demand and capacity pressures, particularly the latter at the moment.
Read 12 tweets

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