Thread by @ChrisCEOHopson

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.