Ambulance service ‘must do better’ as stroke patients face unacceptable waits
Patients in Wales who suffer strokes and heart attacks are continuing to experience unacceptable waits for an ambulance to arrive, a review of so-called Amber calls has found. But the review concludes these failures are not being caused by the current cli
Which patients are classed as Amber?
In October 2015 a new clinical response model was adopted by the Welsh Ambulance Service which drastically reduced the number of 999 calls subjected to a timed target.
It meant only the most seriously life-threatened patients, known as Red calls, had to be reached within eight minutes.
The Red category includes patients who are in cardiac arrest, choking, not breathing, unconscious and/or about to give birth.
According to latest figures just 5% of all 999 calls to the Welsh Ambulance Service are classified as Red.
That means most of the Welsh Ambulance Service’s time is taken up with less serious calls, known as Amber, and the least serious Green category.
Amber calls make up 65% of the service’s overall workload and contain a range of serious illnesses and injuries.
They include patients who have suffered strokes, had a heart attack, suffered chest pain, experienced breathing problems, suffered fits and/or suffered a trauma.
None of these is subject to timed targets – a move which has upset charity groups like the Stroke Association, who believe time is of the essence when the condition takes hold.
How well is the ambulance service dealing with Amber calls?
In the past two years the overall number of 999 calls the Welsh Ambulance Service receives has risen by 11%.
That means pressure on the service is more intense now than it has ever been.
There were 536,260 incidents classed as Amber between April 2016 and March 2018.
More than half (59%) of patients waited less than 20 minutes for an ambulance and 87% waited less than an hour.
But according to figures, where a “tail” of long waits still remained, many involved elderly people who had fallen but not suffered significant harm.
Nevertheless, it meant that more than 1,000 patients faced waits of 10 hours or more for a crew member to turn up.
A wait of 54 hours for one Amber call was recorded in north Wales in December 2017, as well as a wait of 43 hours in the ABMU area in February.
The median time for an Amber call has fluctuated from 16.5 minutes in October 2017 to 34.4 minutes in February 2018 at the height of the winter pressures.
The report states: “Waiting for an ambulance, even for a short time, can cause anxiety and frustration, especially if the patient is on their own.
“And information provided by the call handler, such as ambulance arrival time and what to do while waiting, could reduce uncertainty in a stressful situation.
“The Welsh Ambulance Service should consider actions to reduce anxiety while patients were waiting, with 97% of the public saying they would like to be told the approximate ambulance arrival time.”
Why are some Amber patients waiting so long for an ambulance? One of the biggest issues the ambulance service is facing is delays in handing over patients to hospitals.
According to NHS Wales guidance, 95% of patients should be transferred from an ambulance to a hospital within 15 minutes, with any time over that being classed as a delay.
But this target has not been met for the past two years.
Since April 2016, 122,266 hours have been lost due to these handover delays, with ambulance personnel experiencing record-breaking problems over the winter period last year.
Cwm Taf University Health Board – covering Rhondda Cynon Taf and Merthyr Tydfil – is currently the only health board in Wales to allow ambulances to admit their patients straight into A&E, freeing up vehicles to respond to other calls.
Commissioner Stephen Harrhy says he would like this model seen at other sites, but will assess them on a “hospital-by-hospital” basis.
Meanwhile, sickness levels in the ambulance service are still higher than any other NHS trust or health board in Wales, which is also impacting negatively on response times.
Are patients coming to harm as a result? The review found that while some patients had poor experiences of their care – such as significant delays – they were not at an increased risk of harm.
It concluded that the current response model is “fundamentally sound” and does not need to be changed.
However, the report did find an increase in the number of “serious adverse incidents” recorded.
These are described as events where the consequences to patients, families and carers are so significant – or the potential for learning is so great – that a “heightened level of response” is justified.
From April 2016 to March 2018, there were 90 serious adverse incidents reported – 28 in 2016-17 and 63 in 2017-18.
What do the critics say? Commenting on the review, Llinos Wyn Parry, director of the Stroke Association in Wales, said she believed ambulance crews should have a response target for stroke
patients.
“We’re concerned that without a target for getting stroke patients to hospital, we won’t see an improvement in the emergency stroke care received in Wales,” she said.
“England has set a target of getting 95% of stroke patients scanned and treated within 180 minutes of phoning an ambulance.
“We would like the results of this approach examined and a similar system developed for Wales so stroke patients are able to get rapid access to the treatment they need.”
What do the experts say?
Chief Ambulance Services Commissioner Stephen Harrhy said: “The Welsh Ambulance Service is experiencing a significant increase in call demand year on year.
“Sometimes people are waiting too long to receive a response for a variety of reasons involving the whole NHS system, and this is not acceptable.
“However, the review has found that the principle of the clinical response model – of getting the sickest patient and getting the right response to that patient – is supported by both the public and staff, and is the right direction of travel.
“There needs to be a better understanding of why demand is increasing, the role of other services in driving this demand and the management of this demand as part of the wider health system.
“I am assured from this review that the majority of patient outcomes are not affected by ambulance response times alone.
“This is not to say that some patients have not had negative experiences and I am determined that these will be reduced.”
Welsh Ambulance Service chief executive Jason Killens said: “The review has brought into focus the need for improvement across the unscheduled care system, as well as within the ambulance service, to ensure patients receive an appropriate response to their needs as quickly as possible.
“The good news is that the review found that the clinical response model is fundamentally sound, which is something we welcome.
“However, we recognise that we have more to do in ensuring we have sufficient resources available to meet the needs and expectations of all our patients, some of whom are waiting longer for help than any of us would like.
“Looking ahead, work on improvement rests not just with us as an ambulance service. While we need to give serious and sustained focus to our attendance levels and our ability to meet the demands on our service, we welcome the finding that the system also needs to make improvements, particularly in terms of the delays we encounter at hospitals when trying to hand over our patients.
“There’s more to do in ensuring our staff are using the full breadth of their skills in treating patients safely in the community, and for health boards in developing a range of community services, so that we take to hospital only those patients who really need to be there.
“What’s important about the review is that it has highlighted a number of opportunities for us, and the NHS in Wales more generally, where we can do more for our patients by working together.
“We will be working with our commissioners, the Chief Ambulance Services Commissioner and the community across Wales to make sure we provide the best possible services to people who rely on us in times of need.”