New ambulance service standards announced

NHS England has today (Thursday, 13 July) announced a new set of performance targets for the ambulance service which will apply to all 999 calls for the first time.

  • National response targets to apply to every single 999 patient for the first time
  • Faster treatment for those needing it to save 250 lives a year
  • An end to “hidden waits” for millions of patients
  • Up to 750,000 more calls a year to get an immediate response
  • New standards to drive improved care for stroke and heart attack
  • World’s largest clinical ambulance trial updates decades-old system

The new targets will save lives and remove “hidden” and long waits suffered by millions of patients, including reducing lengthy waits for the frail and elderly. The new system is backed by the Association of Ambulance Chief Executives, the Royal College of Emergency Medicine, the Stroke Association and the British Heart Foundation amongst others.

Call handlers will change the way they assess cases and will have slightly more time to decide the most appropriate clinical response. As a result cardiac arrest patients can be identified quicker than ever before, with evidence showing this could save up to 250 lives every year.

The redesigned system will focus on ensuring patients get rapid life-changing care for conditions such as stroke rather than simply “stopping the clock”. Currently one in four patients who need hospital treatment – more than a million people each year – undergo a “hidden wait” after the existing 8 minute target is met because the vehicle despatched, a bike or a car, cannot transport them to A&E.

Ambulances will now be expected to reach the most seriously ill patients in an average time of seven minutes. The ‘clock’ will only stop when the most appropriate response arrives on scene, rather than the first.

This will free up more vehicles and staff to respond to emergencies. Currently, three or even four vehicles may be sent to the same 999 call to be sure of meeting the 8 minute target, meaning that across the country one in four are stood down before reaching their destination.

According to independent analysis of what has been the world’s largest clinical ambulance trial, the new standards mean that up to 750,000 calls a year that currently go into a queue will get an immediate response. Academics at Sheffield University found that the changes are safe, with no safety issues identified in more than 14 million 999 calls handled over the 18 month trials.

The changes also introduce mandatory response time targets for all patients who dial 999. 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, who are often frail and elderly, have been under pressure, with some patients waiting 6 hours or more. It will also help to make patients in rural areas less disadvantaged than they can currently be.

To ensure these changes improve care for seriously ill patients, we are introducing condition-specific measures which will track time from 999 call to hospital treatment for heart attacks and strokes, where a prompt and appropriate response is particularly critical. By 2022, we will expect that 90% of eligible heart attack patients will receive definitive treatment (balloon inflation during angioplasty at a specialist heart attack centre) within 150 minutes. Nine out of 10 stroke patients should also receive appropriate management (thrombolysis for those who require it, and first CT scan for all other stroke patients) within 180 minutes of making a 999 call. That currently happens for less than 75% of stroke patients. Data collection will begin immediately so the new targets are achieved in the coming years.

The overhaul follows calls from paramedics for the modernisation of a service developed and introduced in 1974, as well as criticism of the current system from the National Audit Office and Health Select Committee.

Sir Bruce Keogh, NHS England’s National Medical Director, who commissioned the Ambulance Response Programme in 2015, said: “Patients across the country deserve to benefit from the significant improvements seen in the trial areas, from ambulances reaching cardiac arrests in London 30 seconds faster to the one minute improvement on stroke responses in the West Midlands. These changes, together with ambitious new clinical standards for heart attack and stroke patients, will end the culture of ‘hitting the target but missing the point.’ They will refocus the service on what actually counts: outcomes for patients.”

Professor Keith Willett, NHS England’s Medical Director for Acute Care, said: “Our core priority will always be patient safety, but paramedics are rightly frustrated that under the current ‘stop the clock’ system they are frequently dispatched to simply hit targets. This has led to the inefficient use of ambulances, with the knock-on effect of ‘hidden waits’.

“This is not about relaxing standards but updating a decades old system to respond to modern needs. In most 999 calls we know the best clinical outcome for patients is not about the fastest response by the nearest vehicle, but the most appropriate one. These are changes which have been called for by paramedics, and the evidence shows that they will save lives.”

Independent researchers from Sheffield University studying the pilot sites have shown patient care has been maintained with no safety concerns or adverse patient outcomes identified. Elements of the new ambulance programme are already being trialled within England’s ten ambulance trusts, and will now be introduced as a permanent change during Autumn this year.

Juliet Bouverie, Chief Executive of the Stroke Association, said: “We support the recommendations of the Ambulance Response Programme. It is vital that all stroke patients get to a stroke unit as quickly as possible in order to get lifesaving treatment to minimise the impact of their stroke. Under the current system, the first responder to a stroke patient could be on a motorbike – but this vehicle can’t transport the patient to hospital meaning they have to wait even longer for a second ambulance to arrive. By allowing ambulance call handlers a little more time to determine what is wrong with a patient, it ensures that stroke patients can be identified and that the right vehicle – a two crew ambulance – can be sent out immediately to get the patient to hospital quickly and safely so that they can be treated at a stroke unit.”

Simon Gillespie, Chief Executive of the British Heart Foundation, said: “When someone suffers a cardiac arrest, heart attack or stroke, it is absolutely vital that emergency services attend as quickly as possible to improve their chances of survival and reduce the risk of long-term disability. In the case of a cardiac arrest, by-standers should start CPR immediately and continue until the emergency services arrive.

“Following promising trial results, when the new system is introduced more widely we would expect emergency services to attend these life-threatening events more rapidly to ensure that every victim has the best chance of survival. The BHF will work with the NHS to monitor how well the new system works in practice and that the potential to save more lives is realised.”

Anthony Marsh, Chief Executive of the West Midlands Ambulance Service that took part in the ambulance response programme trials, said: “Since introducing these changes, our ambulances are now reaching stroke patients a minute quicker than before, helping them get to hospital and receive vital treatment as rapidly as possible. Response times fell across all of our response categories during our involvement in the trial, and we have no doubt that implementing these changes has significantly improved the service we can offer our patients.”

Taj Hassan, President of the Royal College of Emergency Medicine, said: “The changes to the Ambulance Response Programme’s system of call prioritisation are to be welcomed and will help save lives. Slightly extending the initial time in which call handlers must assess the urgency of the situation will allow for a better diagnosis of the problem, without reducing the speed of response to those most in need of urgent medical attention.

“Response times will be more appropriate according to the patient’s need, and trials have suggested that ambulances could arrive up to three minutes quicker to the most serious incidents – time which can make the difference between life and death.  For instance, in a scenario where only one ambulance is available to respond, taking a few more seconds to assess the situation could make sure that we are not sending that ambulance immediately to someone with a broken leg, when it could be going to someone who may be bleeding out and in need of critical care.

“By using the new system nationally, NHS England have calculated that there will be up to 14,500 occasions each week in England where an additional ambulance is freed for response to the most serious of cases, which will ensure that those in most need get to an emergency department quicker. It is especially pleasing to see that the approach taken to development has been so well structured, methodical and evidence based. It has produced a new system that will truly add to the number of lives saved in those precious early few minutes following a 999 call.”

Martin Flaherty, Managing Director of the Association of Ambulance Chief Executives, said: “The introduction of the new ambulance response standards is positive for patients and ambulance services alike. Our control room staff and paramedics out on the road have welcomed the new system which has been developed with significant input from senior ambulance clinicians. We know it is safe because it has been rigorously tested using over 14million 999 calls, with no safety concerns.

“We can also see clearly how the quality of care will improve for all patients because the new standards will mean greater availability of our limited resources, especially for those with life threatening conditions who need us there fastest. It is a common-sense approach that is long overdue and AACE is pleased to have played a significant role in its introduction.”

Gerry Egan, Chief Executive of the College of Paramedics, said: “The College is fully supportive of the Ambulance Response Programme and appreciates the opportunity to have been involved. It is vital to patient care that paramedics are targeted to the most appropriate patients and the extra time to triage a call resulting in less stands downs reduces stress all round.”