NHS England has announced a new set of performance targets for the ambulance services.
Although the proposals are wide-ranging and affect a number of targets and measures, headlines have focused on the changes to the definition of “life-threatening”, i.e. those cases which require an emergency vehicle to arrive within 8 minutes.
This follows an 18-month pilot study carried out in the London and South Western Ambulance Service from January 2015, which hoped to tackle the problem of ambulances being dispatched on “blues and twos” to so-called “life-threatening” calls but where it turns out that no hospital treatment was actually needed – estimated to happen in 25% of cases.
Why the change?
Previously, 999 calls were categorised into those which were “immediately life-threatening”, and those which were not.
Of the “life-threatening” cases, “Red 1” and “Red 2” cases were the most serious and required a response within 8 minutes, although call-handlers had 60 extra seconds before the clock started to assess “Red 2” calls. “A19” cases required a response within 19 minutes.
However, studies were showing that while 10% of 999 calls were actually genuinely life-threatening, 40% of calls were classified as such. Clearly something was going wrong with the way in which the information was received, assessed, and processed.
Another problem identified was that, in the rush to meet the 8 minute target, ambulance services would send whichever vehicle was most likely to reach the patient in time, regardless of whether it was the right response. On the same day that the new system was announced, newspapers were reporting on criticisms made of the East of England Ambulance Trust for sending single-crewed Rapid Response Vehicles (RRVs) to 999 calls even where an ambulance was required, compromising care, patient safety, and patient dignity.
This so-called “hidden wait” – where the clock stops but the patient has to wait, sometimes for hours, to receive treatment from an ambulance or be transferred to hospital – is one of the issues which NHS England hope will be tackled by the changes.
What is new?
Under the changes, 8% of calls will be classed as life-threatening, with a target of 15 minutes’ response in 90% of cases.
48% of cases will be classed as an emergency, with a target of a response in 40 minutes in 90% of cases.
34% of cases will be classified as “urgent”, with a response time of 120 minutes, and 10% of cases will be classified as “non-urgent”, with a response time of 180 minutes.
It is anticipated that a number of cases which currently would fall within the 8-minute target will now attract a 40-minute target – but the urgent and non-urgent cases now have a target response time, which was not the case before.
Perhaps most significantly, the clock will stop only when the most appropriate response arrives on scene, rather than the first medical professional.
However, it is not clear exactly how these changes will be implemented. The public announcements have not included the criteria for deciding whether a case is “life-threatening” or an emergency. There will need to be training at every level of the call handling and dispatch system, as well as for the paramedics and medical professionals who respond to calls, but the timeframe for implementation and training has not yet been announced.
There are also practical obstacles, as call handlers will still be reliant on information provided by untrained members of the public. If a heart attack or stroke could be classified as either life-threatening or an emergency, the extra time for assessment will surely help. But sometimes it simply isn’t possible to work out over the phone whether a complaint of “chest pain” is actually a heart attack or something more benign, and so there will always be a need for ambulances dispatched “just in case”.
NHS England has also announced new “condition-specific measures” which will track time from 999 call to hospital treatment for heart attacks and strokes, with the aim of seeing 90% of eligible heart attack patients receiving appropriate management in a specialist centre within 150 minutes, and 180 minutes for stroke patients. It is not yet clear, however, how the jump will be made from data collection to targets.
“It’s not about relaxing standards”
After months of headlines about the difficulties facing the NHS, there may be those who greet this announcement with some scepticism. Rather than working to meet the targets, are NHS England simply moving the goalposts?
This is clearly a criticism which NHS England expected to receive. The announcement of the pilot scheme was accompanied by “expert advice from senior clinical experts” which set out the reasons why the scheme was advisable and would not endanger the lives of patients. The announcement of the wider implementation of the scheme stated that the proposals were “well structured, methodical and evidence based”, with “significant input from senior ambulance clinicians”.
The review of the pilot scheme, carried out by Sheffield University’s Centre for Emergency and Urgent Care Research (CURE), concluded that the new system allowed ambulance services to use their resources more effectively, although the results are perhaps more modest than hoped for. 6.5% of the most serious 999 calls received a faster emergency response, and more patients were allocated the correct vehicle first time. The study estimated that there was the potential for a gain of 10,243 resources per week, which would be available to respond to other incidents, with fewer vehicles being assigned to calls and then cancelled before arrival. Other proposals tested did not produce a quantifiable change in outcomes, but were thought to have provided “a period of stability” at a time of increased demand.
Most importantly, there were no reports of any serious or adverse patient incidents associated with the new scheme, even where call handlers were given longer to assess the call before dispatching a vehicle.
These figures offer some reassurance to those with concerns. It is also significant that there is broad support for the new system from those who know, including the Stroke Association, the British Heart Foundation, the Association of Ambulance Chief Executives, and the College of Paramedics.
No organisation as large, complex, and pressured as the ambulance services can be fixed overnight. There may well be cases where the system fails, or where the pressure to achieve targets is expressed in ways which are not necessarily in the best interests of patients or those who work in the front line.
Nevertheless, in a system that remains substantially unchanged since 1974, it may be time for a change. Whether the optimists or the cynics are proved right, remains to be seen.