22 October 2014
Ross Thomson, Academic Intern, The Nuffield Trust - photo

Ross Thomson

Academic Intern
Nuffield Trust

The performance of the ambulance service has received a lot of media attention in recent months. Last week, BBC Radio 4’s The Report had a special feature, ‘Paramedics under pressure’. This report focused on the increased pressure London Ambulance Service staff are feeling, but is there more to this story? 

A nationwide fall in performance

The key measure used to assess the performance of ambulance trusts is known as the A8 target. This requires that 75% of life-threatening emergencies (category A calls) receive a response within eight minutes. Nationally:

  • there has been steady decline in the number of category A calls receiving a response within eight minutes (69% in July 2014 versus 77% in July 2011);
  • the A8 target was breached just once in 2011 and three times in 2012, but six times in 2013 and six out of seven months this year so far. 

It’s clear from these figures that there has been a significant deterioration in national ambulance service performance, particularly over the past eighteen months. Alarmingly, July 2014 represents the worst performance recorded so far, and if the pattern of previous years is followed, things will get even worse in winter.

Breaking these figures down by ambulance trust, there has been nationwide deterioration in performance, with only one trust meeting the A8 target in July of this year, the latest month for which data is available. The deterioration in performance has been greatest for the East of England Ambulance Service, who have consistently struggled to meet the target, and London Ambulance Service, which have struggled to meet the target in the past few months.

Rising demand, growing pressure

Why is performance getting worse? The general consensus is that much of the blame lies with increasing demand. Our analysis supports this view: the total number of category A calls made to ambulance services in England has risen from 2,609,675 in the year ending July 2012 to 2,961,274 in the year ending July 2014. This represents a 13.5% increase in two years, and there is a strong correlation between call volume and response times. For example, in July 2012 there were 222,614 category A calls and 77.3% of these received a response within eight minutes. In July 2014 there were 262,110 category A calls, and the A8 target was met in only 68.9% of cases.

Interestingly, the number of category A (life-threatening) calls has risen more rapidly than the total number of calls (which increased by 5% over the same period). This suggests that serious incidents are accounting for a growing proportion of ambulance workload, which will contribute to the observed decrease in performance.


Increasing demand is clearly an important cause of deteriorating performance, but it’s not the only factor at work. Another issue which has received much media attention is the time taken for ambulance crews to transfer care of their patients to busy A&E departments, which prevents crews being available to respond to another call. 

Although we’ve found that delayed handovers are a significant problem, affecting 4.7% of patients taken to A&E in December 2013 (over 19,000 people), there is no relationship between the proportion of calls meeting the A8 target and the number of delayed handovers, at least at a national level. For example in February 2014 74% of category A calls met the A8 target, and there were 16,876 delayed transfers. In February 2012, the A8 target was still met for 74% of category A calls, despite the fact that there were 20,530 delayed transfers.

In search of the full picture 

The Radio 4 feature pointed the finger at staffing levels being a particular problem in London. Our national analysis has found that the average number of ambulance staff employed in 2013-14 (17,849) is almost identical to that in 2011-12 (17,899). Although staff numbers have remained fairly constant, these figures only represent the overall number of staff and may mask changes in skill mix and level of experience. 

Despite this, given that there was a 5% increase in the total number of calls over the same time period, and in particular a 13.6% increase in the number of calls about life-threatening emergencies, it may be that failure to grow the number of ambulance staff at the same pace as demand has contributed to the reduction in performance. Although this may help explain the gradual decline in performance seen over the past two years, it does not help us to understand the particularly poor results seen in 2014.

The general deterioration in ambulance service performance presents a worrying picture. Increased demand for ambulances is undoubtedly important, and failure to increase staffing in line with demand may also be a factor. It is clear, however, that these are not sufficient to explain the whole problem. Improving ambulance service performance will depend on identifying and tackling problems throughout the emergency care system, and on properly understanding the factors responsible for poor performance.

Comments

This is a complex issue and if it was easy to solve then people much cleverer than I would have sorted it by now, however I do think there may be room to look at factors such as GP receptionist behaviour. My mother in law telephoned for an appointment, was asked why, she said she had some discomfort in her chest similar to a few weeks before when she had a chest infection. The response was that as there were no appointments left for the day she should call an ambulance which she did. Diagnosis after multiple tests was a pulled muscle. One week later the whole process was repeated again. On this occasion we intervened and refused to call one and took her the practice. Diagnosis - pulled muscle saving yet another unnecessary ambulance journey, which happened to be on the morning of the recent strike! It is not the only occasion I have been told that patients have been directed to A&E by the GP receptionist because there have been no appointments left for the day. Has anyone looked at how large a problem this is and also the impact of national campaigns to raise awareness of signs and symptoms of stroke and heart attack? I would be interested to read it if so.
Trudi Cameron (not verified)
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the way calls are triaged makes most calls appear life threatening when in fact 8 out of ten of these so called emergancies do NOT need an ambulance. senior management in london will not acknowledge this as it will result in less funding and highlight how missmanaged the service is.
andy (not verified)
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Performance for the twelve moths year end Dec 2016 in Newark & Sherwood was 51% R1 and 42 R2 a big deterioration from the same period in 2015. Demand has increased and handover times are a problem but Newark lost its A&E and now only a few ambulances are taken to Newark the vast majority 93% (FoI data) of the green cases are taken away from Newark and are transported 23 miles to Kings Mill in Mansfield 23 miles away. Now the important factor here that is lowering ambulance performance is the number of ambulances taking the less serious injuries & illnesses (green cases) 45 minutes to distant hospitals for treatment bypassing Newark hospital en route. If the handover times are affecting ambulance performance then surly the 45 minutes travelling time must be a factor also when transferring green cases?
francis towndrow (not verified)
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