From the outside, the ambulance service can appear an almost inexhaustible team of heroic personalities, equipped with powerful vehicles and cutting-edge technology to be a highly mobile and capable NHS resource. An endless cocktail of glamorous TV programmes, both fictional and documentary, plus our own professional ego, contributes to a widely-held confidence in the ambulance service.
However, the service is under considerable strain. As the Nuffield Trust’s recent Winter Insight briefing finds, 'Category A' call-outs (those that are immediately life threatening) have risen by around a third over the last five years and key response time targets have been consistently missed since May 2015. As services continue to struggle to meet demand, the consequences are that some seriously ill patients are waiting even longer for help to arrive.
On the front line
Where a patient is taken to hospital, ambulance crews often face extremely crowded emergency departments, packed with patients arriving in other ambulances or those who’ve made their own way there. Busy hospital staff are not always immediately on hand to receive a patient handover, and it can be difficult to find the physical space to put patients, with insufficient wheelchairs, beds and assessment space exacerbating handover issues.
The overall effect is that ambulance crews, who have vital patient information, test results and details about treatments to pass on, are waiting for long periods until a handover can be completed. This process frequently exceeds the 30-minute handover target, and ambulance staff are tied up at hospital, instead of responding to other emergencies.
The impact of diverts
In exceptional cases, and when our hospital colleagues are so busy they are struggling to maintain patient safety in the department, a 'divert' can be arranged where ambulances instead go to neighbouring hospitals for emergency care.
The problem with this is that it’s rare that an overwhelmed hospital is neighboured by a quiet one, which can mean the units receiving diverted patients are at risk of becoming dangerously busy too, spreading the worst pressure over a larger geographical area. Diverts also impact on patients who, understandably, dislike being taken to the 'wrong' hospital when they feel more comfortable with their local one.
By the time an ambulance finishes at the hospital they were diverted to, the crew can be a very long way from their base, leaving insufficient ambulance cover to respond to further emergencies in those communities.
And if diverts or handover delays happen towards the end of a shift, it can mean the ambulance crew finishes very late. When this happens repeatedly over consecutive shifts, staff inevitably end up feeling increasingly tired and frustrated.
As alluded to in the Nuffield Trust briefing, it’s not just patients who suffer when ambulance services are constantly dealing with very high demand. It can take a huge toll on staff who feel exhausted, underpaid and insufficiently valued by their employers. The resulting low staff morale harms the ambulance service's ability to keep hold of good clinicians and underpins widespread burnout among ambulance personnel. This cycle makes it even harder for staff to feel motivated when responding to ever-higher numbers of emergency and urgent calls.
No quick fixes
In my opinion, these kinds of pressures for ambulance services and A&E are caused by increasing numbers of older people with complex chronic diseases, plus an emerging cultural reflex to “call the ambulance” to obtain a rapid medical opinion on a wide range of ailments. It’s also undeniable that a prolonged period of budgetary restraint has meant flagship NHS services such as A&E have not been adequately funded to meet current and future needs. Some A&Es have closed permanently, so remaining hospitals are additionally receiving patients from larger areas than they were originally designed for.
Despite these major challenges, the ambulance services are working ever harder to better manage demand. The increased use of 'hear and treat', where patients are given medical advice over the phone, is attempting to reduce the overall number of ambulances dispatched. However, this is inherently tricky, as callers often have complex needs which are impossible to safely manage over the phone. In other cases, ambulances manage calls with clinicians assessing, treating and making referrals for patients at the scene of the incident where appropriate, to avoid unnecessary A&E attendance.
The NHS ambulance services are working hard to care for as many patients as possible – I enjoy being part of these developments. But curing the challenges that emergency services face will not be easy. There will never be quite enough resources to do everything we would like to.
However, empowering ambulance clinicians to avoid unnecessary admissions would be a start. Frank communication is also required between all health and social care partners to ensure 999 calls, delays and diverts are kept to an absolute minimum. Ultimately it must be recognised that demand will rise, whatever is tried.
Finally, meaningful work must continue to improve and maintain ambulance staff morale. This should involve continuous recruitment campaigns and efforts to avoid the late finishes and other issues which really harm employee wellbeing.
Matt is an enhanced paramedic at South Central Ambulance Service NHS Foundation Trust. Please note that views expressed in guest blogs on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
Green M (2017) ‘Ambulance staff are working harder than ever to manage demand’. Nuffield Trust comment, 12 April 2017. https://www.nuffieldtrust.org.uk/news-item/the-nhs-workforce-crisis-may-be-irreversible