1. Background
1.1. Performance against waiting times standards for Accident and Emergency departments and Ambulance services
Senedd Research has published a research article on Health Performance Indicators in Wales.. The targets for time spent in Accident and Emergency (A&E) departments are:
§ 95 per cent of patients to spend less than 4 hours in all emergency care facilities from arrival until admission, transfer or discharge;
§ No patient to spend 12 hours or more in all hospital emergency care facilities from arrival until admission, transfer or discharge.
Table 1 below sets out performance against the 4 hour target.
Table 1: Percentage of patients admitted, transferred or discharged within four hours at NHS emergency departments (all-Wales), March 2017 to March 2022
Source: Welsh Government NHS activity and performance summary: February and March 2022
The call categories and targets for ambulance response times are:
§ Red: Immediately life-threatening (someone is in imminent danger of death, such as a cardiac arrest). There is an all-Wales target for 65 per cent of these calls to have a response within 8 minutes;
§ Amber: Serious, but not immediately life-threatening. These calls will include most medical and trauma cases, such as cardiac chest pains, stroke or fracture. There is no time-based target for amber calls;
§ Green: Non urgent, including fainting (recovered and alert), minor injuries or earache. There is no time-based target for these calls.
Table 2 below sets out performance against the red call target.
Table 2: Percentage of red calls which received an emergency response at the scene within 8 minutes (all-Wales), March 2016 to March 2022
Source: Welsh Government NHS activity and performance summary: February and March 2022
A broader range of Ambulance Service Quality Indicators are published by StatsWales and the NHS Wales Emergency Ambulance Services Committee. Indicators 32-36 relate to the notification to handover within 15 minutes of arrival at hospital, as well as lost hours due to delays in handover, as set out in Table 3:
Table 3: Percentage of notification to handover within 15 minutes of ambulance arrival at hospital and lost hours through delayed handover – all-Wales
|
Month |
Percentage of notification to handover within 15 minutes |
Lost ambulance hours due to handover delay |
|
October 2021 |
22.4% |
18,234 |
|
November 2021 |
22.6% |
18,160 |
|
December 2021 |
22.5% |
18,773 |
|
January 2022 |
19.9% |
22,563 |
|
February 2022 |
18.8% |
23,232 |
|
March 2022 |
18.7% |
24,479 |
Source: Emergency Ambulance Services Committee.
In November 2018, the Welsh Ambulance Services NHS Trust (WAST) published A review of calls to the Welsh Ambulance Service categorised as Amber. The Review Implementation Programme had been leading work to support time-based measures for stroke which was originally expected to be published ‘in early 2020’., but no findings have been published to date.
The performance against targets should be set in the context of a sharp increase in average daily attendances to A&E departments and emergency calls to ambulance services.
These performance issues are not unique to Wales, with recent reports of pressures across the UK in terms of waiting times for ambulances and delays in patient handover at A&E.
1.2. Healthcare Inspectorate Wales (HIW) review
In October 2021 Healthcare Inspectorate Wales (HIW) published their findings from a Review of Patient Safety, Privacy, Dignity and Experience whilst Waiting in Ambulances during Delayed Handover. They found there were generally positive patient experiences but also identified a number of areas of concern:
Our review found that the issue of prolonged handover delays is a regular occurrence outside Emergency Departments (EDs) across Wales. It is clear that these delays and variations in process between and within health boards are having a detrimental impact upon the ability of the healthcare system to provide responsive, safe, and dignified care to patients.
Whilst there are clear expectations and guidance for NHS Wales to follow, and a clear will to meet these guidelines, there are substantial challenges which inhibit efforts to consistently achieve these. Whilst handover processes at EDs across Wales were broadly similar, we found many examples of these processes being adapted for a range of reasons[…]
These reasons included differences in department layouts, staff roles and availability, and a lack of clarity around care responsibility ahead of handover. HIW noted that there is:
[…]significant collaborative work needed to resolve the issue of prolonged handover delays which are a symptom of wider patient flow issues throughout the NHS in Wales.
1.3. Health and Social Care Committee Inquiry on hospital discharge
The Senedd’s Health and Social Care Committee has recently undertaken an inquiry into Hospital discharge and its impact on patient flow through hospitals. The Committee heard from a range of NHS and professional bodies, as well as the Minister for Health and Social Services.
Jason Killens, Chief Executive of WAST told the Committee that December 2021 was the worst month on record in terms of delays; 25 per cent of its available capacity (fleet) were lost in delayed handover in emergency departments, “with our crews waiting with patients in the back of their ambulances outside our emergency departments across Wales”. WAST’s submission to the Inquiry set out that the pandemic “has amplified and exacerbated the structural weaknesses already apparent in the health and care system”.
WAST also said that they saw a direct impact of delayed discharge in the inability to achieve a flow of patients through the hospital and that improvements will ultimately depend on health boards, primary care, WAST, and the social care sector working jointly to deliver care collaboratively for patients. This echoed the evidence the Committee heard from other witnesses, who also stressed the need for a collaborative approach, looking at improved support to patients in the community, reducing the need to access ambulance and A&E services.
2. Welsh Government response to the petition
On 27 April 2022 the Minister for Health and Social Services wrote to the Chair of the Petitions Committee. The Minister states that “ambulance response times are not where any of us would want them to be”, that patient handover delays “remain a significant challenge at sites across Wales, which can impact on ambulance availability”, and notes that:
A range of local and system-wide factors contribute to these delays, including reduced physical capacity within emergency departments, increased levels of demand, and pressures elsewhere in the system. These delays are often a visible symptom of wider pressures across the health and care system and require collective and collaborative action by Health Boards alongside the Welsh Ambulance Service, to promote preventative approaches, better management of people’s needs in the community and improved ‘flow’ of patients through hospital and home as soon as it is safe for them to so.
The Minister notes action taking place in a number of areas, including:
§ Recruitment of over 250 frontline ambulance staff and 36 clinicians for the clinical support desk;
§ An additional £15m funding announced in December 2021 for 111 new emergency vehicles;
§ Extending a national Same Day Emergency Care (SDEC) service across Wales, aimed at reducing the number of people requiring overnight admission for a healthcare emergency by April 2023;
§ A two-week ‘national system reset’ during March 2022 to develop ways of improving performance across the unscheduled care system.
The Minister also notes that Welsh Government have recently published Six goals for urgent and emergency care: policy handbook for 2021 to 2026, which set out priorities and actions for a “whole-system transformation of access to urgent and emergency care”. Goal 4: Rapid response in physical or mental health crisis includes the following priorities:
§ Increasing ambulance availability to ensure people who access 999 and are categorised as in danger of loss of life or with time-sensitive complaints are prioritised, receive the right kind of rapid response and are transported to the right place for definitive care to optimise their outcomes. Median (average) response times to people in the red and amber categories will improve year-on-year to April 2026.
§ Improving ambulance patient handover, ensuring no one arriving by ambulance at an Emergency Department waits more than 60 minutes from arrival to handover to a clinician – by the end of April 2025. The number of people waiting over this period for ambulance patient handover will reduce on an annual basis until that point.
The Six Goals strategy also reiterates the importance of a preventative approach , stressing the need to ensure that “People with urgent or emergency care needs can access appropriate and safe care close to home, and with as much continuity of care, as possible. Admission for ongoing care to an acute hospital bed should only occur if clinically necessary”, and stating:
The Emergency Ambulance Services Committee will oversee a delivery plan that will include focus on rapid delivery of alternative pathways and community-based solutions to safely reduce avoidable conveyance to emergency departments.
The strategy states that Welsh Government expectation is that priorities are progressed as quickly as possible in the context of the COVID-19 public health emergency, and within the milestones set. The Minister has stated that she will provide an update on progress made through the six goals programme before summer recess.
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