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Start the clock: Ambulance target overhauls explained


By Carolyn Wickware
19 July 2017

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Last week, Healthcare Leader reported that ambulance response time targets should be reduced to seven minutes for urgent calls as part of a raft of changes to the ambulance response standards.

Last week, Healthcare Leader reported that ambulance response time targets should be reduced to seven minutes for urgent calls as part of a raft of changes to the ambulance response standards.

In a letter to the health secretary, Sir Bruce Keogh told Jeremy Hunt that the current response standards, which were put in place 40 years ago, are ‘hopelessly unsuited to modern medicine’.

He said: ‘A stroke patient, for example, will gain little benefit from a paramedic on a motorbike when what they need is an ambulance that can rapidly convey them to a specialist treatment centre.’

The new changes, first proposed by Sir Bruce in 2015, were first implemented in pilot sites that year and monitored by the University of Sheffield. The pilot sites covered 14 million calls to test a new operating model and the new set of targets.

The university found that there were no incidents or patient safety concerns attributable to the new targets.

Jump to each section to find out more:

What are the changes to the Ambulance Response Programme?

What will this mean for patients?

What has the reaction been?

What are the changes to the Ambulance Response Programme?

Four types of changes are being put in place: changes to the way 999 calls are triaged, response times, what ‘stops the clock’ and additional clinical outcome standards.

Triage changes

The new programme implements a ‘nature of call’ system introduces three standardised pre-triage questions to increase the early recognition of cardiac arrest. Sheffield University has estimated that up to 250 additional lives will be saved in England every year as a result of this measure.

Those answering the calls have also been given more time to make a decision about what the best course of action is for the patient by pushing back when the clock starts ticking down the required response time.

The new proposals ‘start the clock’ for the most urgent cases either when the problem is identified, an ambulance is dispatched or 30 seconds after the call is connected – whichever comes first. Previously, the clock started ticking as soon as the call was connected. This gives the triage team more time to identify the problem while also ensuring that serious calls are identified as soon as possible.

Less urgent calls have up to 240 seconds to triage a patients before the clock starts, when before they had just 60 seconds.

Response times

Once the clock starts ticking, all calls now have to be responded to within an allotted time. Before, patients in the two most urgent categories had to be seen to within eight minutes, while non-urgent calls had no target.

Now calls can fall into four categories, with the most urgent cases needing an ambulance onsite in seven minutes and less urgent calls having between 18 and 180 minutes to see the patient, depending on their illness.

How the clock stops

The clock only stops when ‘the most appropriate response arrives’. For example, if a patient requires transportation, only an ambulance able to transport the patient will count. Previously, the clock stopped when any first responder arrived on the scene, including paramedics on motorbikes when the patient needed transportation.

New clinical outcome standards

Serious heart attack patients will be expected to receive definitive treatment (balloon inflation during angioplasty at a specialist heart attack centre) within 150 minutes of making a 999 call. NHS England has said they expect 90% of patients to meet this standard by 2022.

For stroke patients, NHS England plans to measure the proportion of patients that complete their care pathway within 180 minutes of making a 999 call, with an expectation that 90% of patients will meet this standard by 2022.

Currently, an estimated 75% of stroke patients complete their pathway of care within that time.

What will this mean for patients?

The new programme aims to get rid of ‘hidden waits’ when the vehicle that first arrives isn’t suited to treating the patient effectively or efficiently. According to NHS England, a quarter of all patients who require hospital treatment have the clock stopped by a vehicle that is unable of taking them anywhere.

This will also free up other vehicles that are all sent to the same patient in a ‘race to stop the clock’. Currently, three or even four vehicles may be sent to the same 999 call to be sure of meeting the response target, meaning that across the country one in four are stood down before reaching their destination.

According to analysis of data gathered from the ambulance trials, the new standards mean that up to 750,000 calls a year that currently go into a queue will get an immediate response.

Also, by implementing response targets for every 999 call, frail or elderly patients should expect to see a clinician faster. Currently, half of all ambulance calls, around five million a year, are classed as ‘green’ and not covered by any national target. Response times for these patients have been under pressure, with some patients waiting six hours or more. It will also help to make patients in rural areas less disadvantaged than they sometimes are currently.

What has the reaction been?

The reaction to the proposals has been cautiously welcomed, considering no timeline has been announced for when these proposals are to be implemented nationally.

NHS Providers has said the new standards will ‘save lives’. The director of development and operations at NHS Providers, Ben Clacy, said: ‘Ambulance services have been coming under great pressure in the face of growing demand. It is a great credit to them that they have engaged with this challenge in such a positive way, resulting in improvements that will be of enormous value for patients and the wider NHS.’

Yvonne Rispin, chair of the NHS Clinical Commissioners National Ambulance Commissioners Network (NACN) and director of ambulance/111 commissioning for the North West added that the changes are ‘an important step in enabling the ambulance service to provide patients with the best care possible, within an appropriate timeframe, while also making the most effective use of its resources in the face of rising demand’.  

But the Nuffield Trust director of research, John Appleby, said the ‘shake-up’ is being proposed as the NHS is under financial pressure, facing workforce issues, and a growing demand for care, ‘all of which make it harder for the health service to meet its targets’.

He said: ‘Our recent analysis of the ambulance service showed that pressures facing the ambulance service are growing at an even faster rate than those facing hospitals, and morale in the service is strikingly low.’

GMB national secretary for public services, Rehana Azam, added that ambulance services ‘need to tread incredibly carefully’ with the new proposals.

She said: ‘Extending the time to consider calls can't be used to try to do more with less.

‘Measures to reduce the pressure on our members are cautiously welcome, but there are multiple reasons for ambulance response times getting worse, including rising demand triggered by cuts to preventative social care.’

What do you think about the new measures? Comment below or tweet us your views @HCLeaderNews.

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