Ambulance response times

In July 2017, NHS England announced a new set of performance targets for the ambulance service. The new standards are set out in the addendum to the Handbook to the NHS Constitution. The redesigned system is a triage system, which focuses on a patient's clinical needs and aims to ensure that the highest quality and most appropriate response is provided for each patient first time.

Ambulance services are measured on the time it takes from receiving a 999 call to a vehicle arriving at the patient's location. Under the new system, all calls will be triaged into four categories according to the patient's condition. Ambulances will now be expected to reach people with life-threatening illnesses or injuries in an average time of seven minutes. The 'clock' will only stop when the most appropriate response arrives on scene, rather than the first.

How have response times for Category 1 (life-threatening) calls changed over time?

Category 1 ambulance calls are those that are classified as life-threatening and needing immediate intervention and/or resuscitation, e.g. cardiac or respiratory arrest. The national standard sets out that all ambulance trusts must respond to Category 1 calls in 7 minutes on average, and respond to 90% of Category 1 calls in 15 minutes.

Between April and July 2018, the average response time target was not met, however the 90th centile target was met. In July 2018, the mean Category 1 response time was 7 minutes 37 seconds and the 90th centile response time was 13 minutes 15 seconds.

Around 8% of incidents fall under Category 1, and it covers a wider range of conditions than the former Red 1 category (which only included cardiac arrest patients who were not breathing and did not have a pulse, and other severe conditions). Performance against the previous target, that 75% of Category A (immediately life-threatening) calls should receive a response within eight minutes, had been declining over the past few years and was last met in January 2014.

Updated August 2018.

How have response times for Category 2 (emergency) calls changed over time?

Category 2 ambulance calls are those that are classed as an emergency for a potentially serious condition that may require rapid assessment, urgent on-scene intervention and/or urgent transport. For example, a person may have had a heart attack or stroke, or be suffering from sepsis or major burns. All ambulance trusts should respond to Category 2 calls in 18 minutes on average, and respond to 90% of Category 2 calls in 40 minutes under the new standards.

The intent for Categories 2, 3 and 4 is to ensure that patients in these categories who require transportation receive a conveying resource in a timeframe that is appropriate to their clinical needs. Therefore, if a patient requires transportation in an emergency, the clock will only stop when the conveying resource arrives.

Between April and July 2018, both the average and 90th centile response time targets for Category 2 calls were not met, and response times increased. The mean response time increased by 2 minutes 26 seconds, and the 90th centile response time increased by 5 minutes 29 seconds.

Updated August 2018.

How have response times for Category 3 (urgent) calls changed over time?

Category 3 ambulance calls are those that are classified as urgent. They are problems (not immediately life-threatening) that need treatment to relieve suffering (e.g. pain control) and transport or clinical assessment and management at the scene. The national standard states that all ambulance trusts must respond to 90% of Category 3 calls in 120 minutes. There is no target for the average response time.

Response times for Category 3 calls have increased over time. In April, the mean response time was 50 minutes and this increased to 1 hour 7 minutes in July. The 90th centile target was met in April with 9 out of 10 incidents responded to in less than 1 hour 56 minutes, but this increased to 2 hours 39 minutes in July.

Updated August 2018.

How have response times for Category 4 (less urgent) calls changed over time?

Category 4 ambulance calls are for incidents that are not urgent but need assessment (face to face or telephone) and possibly transport within a clinically appropriate timeframe. According to the national standard, 90% of Category 4 calls should be responded to within 180 minutes.

Response times for Category 4 calls have increased over time. The 90th centile target was met in April 2018, but by July 9 out of 10 incidents were responded to in 3 hours 22 minutes. The mean response time also increased by 19 minutes over the same time period.

Updated August 2018.

About this data

On 13 July 2017, the Secretary of State for Health accepted NHS England's recommendation to implement new ambulance performance standards. The new standards had already been successfully piloted in three areas of England and clinical experts agreed that they would improve patient outcomes. They were progressively rolled out across the rest of England and since April 2018 all 11 Ambulance Services have provided data on the new systems indicators.

Ambulance Trusts use one of the approved triage tools to allocate incidents to one of the new response categories as quickly and accurately as possible. The response categories are as follows:

Category 1: Life-threatening
Time critical life-threatening event needing immediate intervention and/or resuscitation e.g. cardiac or respiratory arrest; airway obstruction; ineffective breathing; unconscious with abnormal or noisy breathing; hanging.

Category 2: Emergency
Potentially serious conditions (ABCD problem) that may require rapid assessment, urgent on-scene intervention and/or urgent transport.

Category 3: Urgent
Urgent problem (not immediately life-threatening) that needs treatment to relieve suffering (e.g. pain control) and transport or assessment and management at scene with referral where needed within a clinically appropriate timeframe.

Category 4: non-urgent
Problems that are not urgent but need assessment (face to face or telephone) and possibly transport within a clinically appropriate timeframe.

The Addendum to the NHS Constitution requires all ambulance trusts to:
- Respond to Category 1 calls in 7 minutes on average, and respond to 90% of Category 1 calls in 15 minutes.
- Respond to Category 2 calls in 18 minutes on average, and respond to 90% of Category 2 calls in 40 minutes.
- Respond to 90% of Category 3 calls in 120 minutes.
- Respond to 90% of Category 4 calls in 180 minutes.

The previous response time commitments were set out in the NHS 2010/11 Operating Framework. They stated that:
- 75% of Category A (immediately life-threatening) calls should receive a response within eight minutes.
- If a Category A patient requires transport, this should arrive within 19 minutes of the request for transport being made, 95% of the time.

From June 2013, the former Category A call category was further separated into Red 1 and Red 2 calls:
- Red 1 calls were the most time critical and covered cardiac arrest patients who were not breathing and did not have a pulse, and other severe conditions.
- Red 2 calls were serious but less immediately time critical and covered conditions such as stroke and fits.

For more information please see NHS England, Ambulance Quality Indicators.

Comments

It would be interesting to correlate these results with the number of ambulance unit hours being produced nationally and by each trust over the same time series.

Ambulance trusts, in common with all other NHS trusts, have had to build, since 2011, towards an annual CIP of 17%-20%.

Average annual growth in the NHS budget has fallen from 4% (1948-2010) to 0.7% (2011-2016). Hospital CIP and deep cuts in adult social services have led to inability to discharge vulnerable adults and, in turn, to huge growth in ambulance handover times at EDs.

The prolonged freeze on NHS staff pay has squeezed both nurses and paramedics out of the system. For the first time in my 42 year career, there is a national shortage of paramedics.

Alan Murray (not verified)
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It would be interesting to correlate the apparent fall off in response with the increase of workload as a result of:

a) increase of 999 calls per annum
b) increase in workload coming in from the 111 service

General call volumes to the 999 service appear to rise 8-12% per annum.

Additional load on the ambulance service as a result of having the 111 service directly transfer work in to the ambulance call taking system as 'already triaged' and 'ready to dispatch' may, in some cases, be responsible for an additional increase in workload in the order of 15-20%

Mike Tubby (not verified)
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It would also be interesting to see the correlation between ambulance wait times over the same period to discharge patient into A&E's. Increased pressure on A&E's also plays a part. There is obviously from what Alan and Mike say many facets to these figures although the media will no doubt show it in more black and white terms. I also wonder about the impact moving from 2 stretchers on a vehicle to one, had on the number of ambulances required although this was long ago. Obviously much better care, but logistically there must have been an impact.

John Dale LLB(Hons) (not verified)
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Hi Mike, are you suggesting the 111 system has had an increase in patient journeys over and above what NHS Direct created?

John Dale LLB(Hons) (not verified)
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Dear Sir, I am more interested in the 25 to 30% of responses that did not meet the 8 minute target. Do you have any figures on the average response times in this respect and is there any marked difference between urban and rural response times? Many thanks.

Peter Burgess (not verified)
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Thank you for all of your comments and suggestions for further analysis. Some of these suggestions are being looked at in some of our other work, so keep an eye out on both of our websites for findings http://www.nuffieldtrust.org.uk/ and http://www.health.org.uk/
With regard to the question on average wait for the 25-30% of people who are not treated within 8 minutes. NHS England ambulance data does not publicly provide that data specifically, but does have data on the median, 95th and 99th centile for time to treatment for category A calls over time. There is variation across the three, with a general upward trend. I tweeted a rough graph here https://twitter.com/noracookeodowd/status/775314501763825664
Hope this helps.

Nora, QualityWa... (not verified)
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And where exactly did the 8 minute target time come from? Was this simply plucked out of the air by someone, or does it have a theoretical basis? Perhaps someone can throw some light on this.

Derek Smith (not verified)
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