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The ambulance service plays a unique role. As a fundamental part of the country's emergency services, ambulance trusts operate alongside the police and fire service in addition to the rest of the NHS, and the wider health and care system.

At a national level, ambulance performance is monitored by the time it takes the service to respond to different levels of emergency care. The largest academic study into ambulances in the world, and extensive piloting with the sector, resulted in the ambulance quality standards being updated in 2017. This prioritised the sickest patients, ensuring they receive the fastest response, drove clinically and operationally efficient behaviours and put an end to unacceptably long waits by ensuring that resources are distributed more equitably across all patients.

The ambulance service has now operated for 18 months under the new framework, meaning we now have enough data to look at trends and gain a deeper understanding of performance.

An expanding service

There are 10 ambulance trusts across England. Each trust covers a large geography, covering multiple local integrated systems which include numerous hospitals with A&E departments and varying community, primary and social care provision and support millions of people.

There is a common misconception that an ambulance is simply 'a blue light taxi' or that ambulances are staffed by paramedics whose main job is to transport someone to hospital. This narrow understanding of what the ambulance service does fails to reflect the broad and evolving role the service has to play within health and care systems, particularly as services become more integrated. One challenge for the NHS is to try to shift public perception and increase understanding of the important role ambulance services can play as a front door to the NHS (particularly given many ambulance trusts also manage the NHS 111 service), in signposting and referring frequent and vulnerable patients to other services, and in delivering clinical treatment and care.

Ambulance trusts provide a range of services including;

handling 999 calls

co-ordinating and dispatching ambulances

providing clinical interventions on the scene for seriously ill patients and transporting people to hospital in an emergency

referring patients onto alternative services across health and care

multidisciplinary response teams e.g. paramedic, mental health nurse and police responses to those in mental health crisis or consultant-led response vehicles to cardiac arrests

see and treat - when a person does not require hospital care but instead a paramedic or another clinician provides treatment at the scene, which could be in someone's home or in the community

Hear and treat - when a person does not require an ambulance but a clinician is able to provide treatment and advice over the phone

Hospital transportation to help with hospital transfers and discharges

Some ambulance services are also commissioned to provide NHS 111 services that provide advice over the phone and increasingly are able to book appointments in GP surgeries or urgent care centres.

The old national ambulance standards

Prior to the introduction of the new national ambulance quality standards, ambulance performance was measured by two response time targets:

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.

Following calls from paramedics to review ambulance response times that were developed in the 1970's, the NHS embarked on a review setting up the ambulance response programme (ARP) in 2015. The objectives of the review were:

1. Prioritising the sickest patients, to ensure they receive the fastest response.

2. Driving clinically and operationally efficient behaviours, so the patient gets the response they need first time and in a clinically appropriate timeframe.

3. Putting an end to unacceptably long waits by ensuring that resources are distributed more equitably amongst all patients.

The review made changes to the 999 script to help with early recognition of life threatening conditions, in particular cardiac arrests. In addition, revisions were made to the call categories - resulting in a new triaging process that ranks the severity of the call and allows for more effective prioritisation.

The changes were piloted with two ambulance services in England and the University of Sheffield carried out a large scale study in which over 14 million 999 calls handled with the new 999 script were reviewed over an 18 month period. The roll out of the new operational model was then staggered across different ambulance services with them now all working within the new framework.

The new ambulance standards

The new ambulance standards are different to the previous targets in a few ways.

Firstly, the targets apply to all calls and not just a proportion of calls, raising the standard across the board. Secondly, the average time for responding to those in life threatening conditions has fallen from eight minutes, down to seven minutes. And thirdly, there are targets for the 90 th percentile. This point may be harder to translate to the public but what it does is ensure that calls which have missed the average response target are still responded to in a timely manor. Lastly, the changes mean that the service can dispatch the right vehicle first time and in cases such as strokes or cardiac arrests, can focus on taking patients to specialist hospitals so they can receive the best care.

All these changes are aimed at providing a more effective and safer service overall for the public.

Table 1: Ambulance quality standards

C1- Calls from people with life-threatening illnesses or injuries

A time critical life threatening event requiring immediate intervention or resuscitation.

Potentially serious conditions that may require rapid assessment and urgent on-scene intervention and/or urgent transport.

An urgent problem (not immediately life threatening) that needs treatment to relieve suffering and transport or assessment and management at the scene with referral where needed within a clinically appropriate timeframe.

None (mean indicator of 60 minutes)

Current performance

Since the introduction of the new standards, trusts have improved performance moving closer to the targets. Particular progress has been made in relation to category 1 calls.

In January 2019, six out of the 10 trusts exceeded the target for category 1 calls. Nationally, the average response time was 7:08mins - 8 seconds over the target. The average 90 th percentile response time was 12:20 minutes; 2 minutes and 40 seconds quicker than the target.

As shown in figure 1, national performance has been improving since the new standards were introduced.

The national average response time for category 2 was 22:58 minutes in January 2019. Performance against the category 2 response times is more varied, with only two trusts exceeding the target. The difference between the shortest and longest response time is over 18 minutes - same as the average response time target for category 2. Instead of being quick to criticise the ambulance service for current performance, we must be cognisant that it was always going to take time, investment and additional staff to deliver the quality standards across the board.

Current challenges for the ambulance sector

Similarly to the rest of the health and care sector, the ambulance service has struggled due to large increases in demand, a lack of funding and widespread workforce shortages. The service experiences higher levels of sickness absence than other services and ambulance staff are more likely to be physically assaulted or experience verbal abuse when working.

Whilst demand, money and recruitment and retention challenges are in some way consistent across ambulance trusts, there are a range of factors that can impact the operational model and performance of an ambulance service.

There is variation in terms of:

the size of the different geographies

population count

population profile - in particular around age

how rural or urban the geography i.e. spread of densely populated cities and more sparsely populated areas

the number and spread of A&E departments

the different health and care systems e.g. the number and type of specialist services, the performance and flow in local acute hospitals

the quality of community services, care homes and primary care

other emergency services including the fire service and police service.

A number of these factors are related to the demand and quality of other NHS services - things that are often out of the ambulance service's control.

One of the most challenging things for ambulance trusts in terms of planning and deployment of vehicles is when staff and vehicles are held up handing patients over to acute hospitals. These 'handover delays' happen when hospitals are running at capacity and there are no beds available. These delays result with the risk to patients being extended from the hospital, out into the community, as ambulances are unable to be re-deployed to people waiting for an ambulance; meaning people have to wait longer due to other parts of the health system.

The direction of travel

Despite demand for ambulances increasing significantly in the last year, there has been a range of developments in conjunction with the new quality standards which would indicate that performance of the sector may improve over the next few years.

Funding

In the middle of 2018 the government announced an investment of £36.3m in the ambulance service for the 70 th birthday of the NHS. The investment will provide 256 state of the art ambulances as well as providing some trusts with money to grow their workforce to help them meet the growing demand for their services.

Workforce

To boost recruitment, the sector has expanded the training routes to qualify as a paramedic, including paramedic courses, a degree in paramedic science and apprenticeship degrees. In 2018 it was also announced that paramedics will be eligible to train as independent and supplementary prescribers, diversifying and unlocking the potential of the ambulance service. New care models and the development of more integrated ways of working between community and primary care services may also open up new partnerships for ambulance staff to support these endeavours.

There was also good news in the 2019 NHS staff survey for the ambulance service, which could be positive in terms of retention. The ambulance service continues to struggle with staff engagement indicators, being worse than in any other sector in the NHS, but the service bucked the downward trend and has seen year on year improvements recently.

System working

Ambulance trusts play a unique role in local health and care systems. Covering multiple systems with varying degrees of maturity, they can offer a joined up perspective at a regional level.

Increased system working, new care models and a system focus on avoiding costly inpatient care have already seen an expansion of the role of the ambulance service in some regions.

As demand for the NHS continues to rise we must recognise the potential the ambulance service offers in helping keep people out of hospital.

The long term plan plans for the sector are encouraging with key changes around emergency mental health care provision to be rolled out across ambulance trusts. For those that are commissioned to provide a NHS 111 service, will be expected to work with systems to ensure that NHS 111 is the central point of contact for those experiencing a mental health crisis within the next 10 years.

Conclusion

The outlook for the ambulance service is positive with improved staff engagement and morale an important marker for the direction of travel, alongside renewed focus on ambulance services playing a key role as 'an integrator' within local systems.

The recent review of response targets has been cornerstone for change. Sufficient investment, growing the workforce, and upgrading the fleet of ambulances will help trusts continue to make progress against the new quality standards.

Meanwhile, as the NHS carries out a clinical review of targets in acute care, national policy leaders need look no further than the review of the ambulance quality standards as a template. Clinically led, the review team placed patient safety was of paramount importance - extensive piloting prior to roll out, rigour and full engagement with trusts are all success criteria that should be shared and replicated.

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The ambulance service: understanding the new standards

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The ambulance service plays a unique role. As a fundamental part of the country's emergency services, ambulance trusts operate alongside the police and fire service in addition to the rest of the NHS, and the wider health and care system.