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 by the time it takes from receiving a 999 call to a vehicle arriving at the patient's location. Under the new system, all calls are triaged into four categories according to the patient's condition. Ambulances are now expected to reach people with life-threatening illnesses or injuries in an average time of seven minutes. The 'clock' only stops when the most appropriate response arrives on scene, rather than the first.
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.
The average Category 1 response time improved from 7 minutes 37 seconds in April 2018 to 6 minutes 54 seconds in May 2018. The 7 minute target was met in March, April and May of this year. However, the average response time worsened in June 2019 to 7 minutes 11 seconds. The 90th centile target is consistently being met, reaching 12 minutes 28 seconds in June 2019.
Around 9% 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 and was last met in January 2014.
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 2018 and June 2019, both the average and 90th centile response time targets for Category 2 calls were not met. Response times fluctuated but worsened overall. In June 2019, the mean response time was 22 minutes 26 seconds and the 90th centile response time was 46 minutes.
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 worsened over time. In April 2018, the mean response time was 49 minutes 11 seconds and this increased to 1 hour 9 minutes in June 2019. The 90th centile target was met in April 2018 with nine out of ten incidents responded to in less than 1 hour 55 minutes, but this increased to 2 hours 45 minutes in June 2019.
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 fluctuated over time. The 90th centile target was met in April 2018 and May 2019, but was missed during the intervening months. The worst level of performance occurred in July 2018, when the average response time was 1 hour 36 minutes and 90% of Category 4 calls were responded to in 3 hours 33 minutes. In June 2019, the mean response time was 1 hour 22 minutes and nine out of ten incidents were responded to in 3 hours 8 minutes.
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 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 8 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, covering 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, covering conditions such as stroke and fits.
For more information please see NHS England's Ambulance Quality Indicators.