Number of ambulance diverts from A&E doubled this winter

Analysis finds A&E units closed to ambulances almost 500 times in just three months this winter.

Press Release

Published: 07/04/2017

Updated: 07/04/17

Urgent response time targets only met in six out of last 49 months

The number of times hospital A&E units in England have had to close their doors to ambulances has almost doubled this winter compared with the previous three, new research from the Nuffield Trust health think-tank reveals today (see note 1).  The authors say that the extra time paramedics are having to spend on the road as a result is a factor in the service’s inability to meet its targets for urgent requests for an ambulance.

Hospitals have implemented these ambulance diverts almost 500 times this winter, almost double the average of the previous three winters, and the extra time crews are having to spend on the road is not helping the ambulance service’s ability to meet its response time targets.

Prof John Appleby, Chief Economist and Director of Research, Nuffield Trust

The authors of the report, ‘Winter Insight 3: The Ambulance Service’, say the efficient performance and smooth running of the ambulance service are vital to the operation of every part of the health service, from care homes to general practice to hospital care.  

The research finds that pressures facing the ambulance service are growing at an even faster rate than those facing hospitals.  In the last five years, for example, the number of category A calls (the most serious) resulting in an ambulance arriving at the scene of an incident has increased by 7.4% year on year (from 2.5 million in 2011/12 to 3.3 million in 2015/16) – whereas over the same period there has been an average annual increase of 2.1% in the number of emergency admissions to hospital, and a 1.6% average annual increase in the number of attendances at A&E.

As a result, in a new analysis of ambulance trusts’ performance against targets, the report reveals that despite their importance, the three main urgent response time targets (see note 2) have been met in only six out of the last 49 months, and none have been met since May 2015.   The most recent figures published, covering January this year, show that just 67% of ‘Red 1’ calls for ambulances (which include those for cardiac arrest patients who are not breathing and do not have a pulse), and only 58% of Red 2 calls (which are serious, but less immediately time-critical), received a response within eight minutes – significantly off the target of 75%.

Of the 233,472 Category A Calls received in January this year, at least 95% should have had a response within 19 minutes – but in fact 29,000 calls did not receive a response within this time, meaning only 88% of responses met the target.

The report sheds new light on the reasons ambulance trusts are finding it so difficult to meet these response times.  Although organisations such as the National Audit Office (see note 3) have provided extensive evidence of the long waits ambulances face before being able to hand over their patients at A&E departments, there has been little focus to date on what is often the ultimate outcome of these delays - the decision by a hospital in ‘exceptional circumstances’  to implement a ‘divert’ from its A&E, when ambulance trusts are instructed to take patients to other hospitals instead (see note 4).  Our analysis shows that while these diverts were implemented an average of 249 times over the three winters 2013/14, 2014/15 and 2015/16, 478 were instigated over the same period this winter, a virtual doubling (see note 5). 

Five hospital trusts accounted for over half of all the 478 diverts reported this winter – four in the North of England commissioning region (Pennine Acute Hospitals, Northumbria Healthcare, County Durham and Darlington, South Tyneside), and one in the Midlands (Worcestershire Acute Hospitals).

In the report, the College of Paramedics explains the effect of these diverts on ambulance services:

“Diverts from A&E departments have an impact on paramedics’ ability to reach seriously ill and injured patients in an appropriate time frame.  While we are sympathetic to hospitals that are forced to implement diverts so that they don’t reach dangerous levels of overcrowding, in non-urban areas in particular the extra time taken to reach more distant A&E departments is significant.  There is a ‘double whammy’ in that not only do crews have to drive further away once a divert is implemented – once that’s happened, an ambulance crew will then also need to travel further to get back to their own area to respond to the next emergency call.”
Richard Webber, National Spokesperson for the College and practising Senior Paramedic.

The report reveals that the continually increasing pressure on the ambulance service is having a worrying impact on its staff.  Analysis of responses to the most recent annual NHS Staff Survey (see note 6), published last month, shows that the morale of ambulance staff appears to be much poorer than those employed in other parts of the health service.  For example:

  • When asked whether there are enough staff to enable them to do their job properly, a striking 61% of ambulance staff disagreed, with only 21% agreeing - but among all NHS acute and community Trust staff, 46% disagreed and 32% agreed.
  • When asked to agree or disagree with the statement, ‘senior managers here try to involve staff in important decisions’, among all acute and community Trust staff 34% agreed and 34% disagreed - but only 20% of ambulance personnel agreed with the statement, while 55% didn’t.

What’s striking is the impact all the pressures on the service are having on ambulance staff themselves. Managers in the NHS and politicians need to make improving the ambulance service’s poor morale and its ability to meet targets an urgent priority.

Prof John Appleby, Chief Economist and Director of Research, Nuffield Trust

Commenting on the findings, report lead author Prof John Appleby, Nuffield Trust Chief Economist, said:

“There’s rightly been a lot of focus recently on the delays ambulance crews face in being able to hand over their most seriously ill patients at A&E – but what our research today has uncovered is the huge increase in the number of times this winter ambulance trusts have been told that they must take patients to another hospital altogether, because an A&E unit simply doesn’t have the capacity to accept any more patients.  Hospitals have implemented these ambulance diverts almost 500 times this winter, double the average of the previous three winters, and the extra time crews are having to spend on the road is not helping the ambulance service’s ability to meet its response time targets.

“What’s striking is the impact all the pressures on the service are having on ambulance staff themselves.  Even allowing for the inherently stressful nature of the job, our analysis of the results of this year’s NHS Staff Survey shows they feel significantly more pessimistic than other staff in the health service about their ability to do their job properly and provide a good service.  Managers in the NHS and politicians need to make improving the ambulance service’s poor morale and its ability to meet targets an urgent priority”.

Notes to editors

  1. Nuffield Winter Insight:  Briefing 3, The Ambulance Service.  Prof John Appleby, Mark Dayan.  Nuffield Trust, April 2017.  The first two reports in the Winter Insight series examined bed occupancy rates and the performance of the NHS 111 service.
  2. The ambulance service in England at present works to three main response time targets.  These have changed over time, but currently Category A calls are split into Red 1 and Red 2 calls. The former are the most time-critical, and cover cardiac arrest patients who are not breathing and do not have a pulse, and other severe conditions such as airway obstruction.  Red 2 calls are serious, but less immediately time-critical, and cover conditions such as stroke and fits. 
    The targets for Red 1 and Red 2 calls are for 75% or more of responses to be at the site of an incident within 8 minutes.  For all Category A calls, the third target is that 95% or more calls should receive a response within 19 minutes.
  3. National Audit Office: NHS Ambulance Services.  26 January 2017.
  4. In exceptional circumstances, and only after consultation between local trusts, commissioners and the ambulance service, hospital emergency departments sometimes find it necessary to temporarily stop accepting ambulances and instead divert them to other A&E units locally.
  5. Figures are taken from NHS England’s Weekly Winter Sit Reps.  In order to provide an accurate like-for-like comparison with previous winters, figures for A&E diverts have been taken each year from the period 1st December to the last day of February, the only period common to all four years.  Numbers of diverts for the four years are as follows:
  6. 2013/14:               225   
    2014/15:               258
    2015/16:               265
    2016/17:               478

    Since 1st March this year, an additional 37 diverts have been recorded  (figures to 12th March).

  7. NHS England, Staff Survey 2016.  7 March 2017.
Updated 07/04/2017

NHS England’s reported figures for A&E diverts for the period 1st December 2016 – 28th February 2017 contained an error showing 15 extra diverts for Worcestershire Acute Hospital Trust on Boxing Day.  The correct figure for Worcestershire is 63 diverts during these three months. For England as a whole the total is therefore reduced from 493 to 478 diverts during that three month period.  This does not change the report’s conclusion that this year’s figure is a virtual doubling of the average for the previous three years (average for previous three years is still 249).  

In addition, NHS England have informed us that while they had planned to continue publishing Winter Daily Situation Reports until today, 7th April, as stated in our press release, in fact they ended the dataset on 12th March.

These figures have now been updated in this press release and briefing.