On 3 November 2022, the House of Lords is scheduled to debate the following topical question for short debate:

The Lord Bishop of London to ask His Majesty’s Government what progress they are making on ensuring swift ambulance handovers, as set out in ‘Our plan for patients’, published on 22 September 2022, given the decision of ambulance workers across 11 trusts to ballot for strike action.

1. Are ambulance handover targets being met?

Ambulance handover refers to the process of moving a patient from an ambulance to an accident and emergency (A&E) department upon arrival at a hospital.

The NHS standard contract for 2022/23 states that handovers should take place within 60 minutes, with 95% taking place within 30 minutes and 65% taking place within 15 minutes. The NHS Confederation explains that “the clock begins [on this target] when an ambulance arrives outside an A&E department and stops when a clinical handover has been fully completed to A&E staff”. This target was introduced in March 2022 and adjusts the earlier target, which required handovers to take place within 15 minutes, with none taking more than 30 minutes.

The Association of Ambulance Chief Executives (AACE) publishes monthly statistics on ambulance responses, including handover times. Its statistics for August 2022 found that:

  • There were 42,000 cases of patients waiting longer than an hour for handover. It noted that although this was a decrease of 4,000 from the previous month, it was the “third highest volume on record”. It was 15,000 higher than August 2021 and more than twice the series average (17,000).
  • 66,000 hours were lost due to missing the 60-minute target and 138,000 lost if tracking the 15-minute target. The report stated that, based on the 15-minute target, it was the fourth highest figure on record, despite having decreased from 152,000 to 138,000: “this is the equivalent of 110,000 job-cycles lost in August, or 148 patients who could not be attended every hour of every day”.
  • More than 300 patients and crews waited for over three hours (10,501 in total) each day in August. There were 16 delays of 10 hours or longer each day, a total of 522 across the month. It said that “while these are not the highest figures to date, they represent a considerable volume of patients and crew, with a subsequent impact on health and resource”.

The NHS Confederation states that delays, particularly over 60 minutes, can cause harm to patients, increase pressure on staff and affect the ambulance service attending to other emergencies:

[Delays] can cause potential harm to patients, as shown by the Association of Ambulance Chief Executives report released in November 2021. It found that more than eight in 10 patients who were delayed beyond 60 minutes were assessed as potentially having experienced some level of harm, and that nearly one in 10 experienced severe harm.

Further to this, delayed handovers result in poorer ambulance response times, as ambulances sit queuing outside of A&E departments unable to attend patients waiting in the community. Not only does this increase pressure on clinical staff, it also causes pressure on ambulance call handlers, as distressed patients and their families call to get updates on their wait time. This can lead to thousands of additional (duplicate) calls, placing even more pressure on ambulance services.

Based on its August 2022 figures, the AACE estimated that around 35,000 patients experienced potential harm as a result of long handover delays in August, with just under 4,000 of these experiencing potentially severe harm.

2. What can be done to improve handover times?

In its September 2022 policy paper ‘Our plan for patients’, the government spoke of the importance of improving ambulance response times, including handovers:

Ambulance services are often the frontline of the NHS for those who most need help urgently. Supporting ambulance services to operate more effectively is key to our plan for this winter and next. For ambulances to operate successfully, the whole urgent care pathway needs to be improved, including discharge. In winter 2021, 45% of ambulance handover delays occurred in 15 hospital trusts.

We want shorter response times for category 1 and category 2 incidents [the two most serious types of incident], enabled by quicker handover of patients so ambulances can get back on the road and respond to 999 calls.

To improve response times, the government said it was:

  • reducing the time lost to ambulance handover delays so that ambulances can get back on the road swiftly, including an expectation that all hospitals will have clear escalation arrangements for when delays occur and can deploy hospital ambulance liaison officers if needed
  • facilitating ambulance trusts to support each other during the busiest periods, including by rolling out a new digital intelligent routing platform and where necessary sharing call handling
  • exploring establishing a new ambulance auxiliary service

Responding to a written question on the issue on 27 September 2022, the then minister of state at the Department of Health and Social Care, Robert Jenrick, set out the steps NHS England was taking to address handover delays:

NHS England has written to all trusts and systems to ensure that actions are taken to prevent ambulances waiting for longer than 30 minutes before transferring patients to the A&E department. This includes immediately moving patients who have completed emergency medical care from A&E to maintain capacity for new patients.

NHS England is providing targeted support to some of the hospitals facing the greatest delays in the handover of ambulance patients into the care of hospitals, to identify short and longer-term interventions. In 2020/21, £450mn was invested to upgrade A&E facilities in over 120 National Health Service trusts to increase capacity, reduce overcrowding and minimise delays in ambulance handovers.

In 2020, NHS England published a document which outlined a number of ways ambulance and acute trusts could self-assess opportunities to reduce ambulance handover delays and “improve flow across the ambulance-hospital interface”. For example, it recommended they assess whether “hospital and ambulance staff have a clear and shared understanding of what each stage of the handover process involves and its purpose”. The document also contains links to other practitioner-focused resources on the issue.

In February 2022, the NHS Confederation set out its analysis of the issue and how trusts can avoid delays. Based on the data, it stressed that it did not see it as a universal and “insurmountable problem”. However, it did state that the issue required a whole-system approach:

Ambulance handover delays are not an ambulance issue, they are a whole-system issue and require a whole-system response. Systems need to understand what ambulance handover delays are telling them about their system, as well as the risks to patients, particularly the ‘unseen’ patients waiting in the community. Systems should have handover delays in their risk registers and work with all system partners to mitigate those risks.

Although accepting there was a “long-term problem to resolve nationally”, it argued that some trusts had got their approach right. It said ambulance handovers needed to be tackled alongside other system issues, including demand management, the interface with primary care, risk management and patient flow. It found common themes among trusts that had “proactively tackled” the issue included:

  • taking ownership of the patient
  • strong relationships between local partners
  • sharing data
  • leadership and taking a zero-tolerance approach
  • tackling wider issues around flow

Responding to a House of Commons statement in July 2022 about ambulance pressures during the summer heatwave, the shadow cabinet minister for mental health, Rosena Allin-Khan, criticised the government’s resourcing of the health service:

We have already seen ambulance wait times soar and pressure on staff spiral, all while the NHS struggles to find the essential staff needed to deliver patient care. I am sure that everyone across the House will agree that our frontline workers are truly amazing. But if nurses and doctors are so overworked and do not have the time and resources to take care of themselves in this heat, the care that they can give patients will be impacted […] mismanagement and underfunding have left our health service unable to cope, which not only has an impact on patients but hurts staff.

3. Has industrial action been announced?

Unions representing ambulance staff are currently voting on strike action. The GMB union is balloting more than 15,000 ambulance workers across 11 trusts in England and Wales and Unite is balloting 3,000 workers across England. Both ballots are due to close around the end of November 2022.

The unions have blamed pay and work pressures. They state that workers are “angry” at the current pay offer of 4%, in light of high inflation, the rising cost of living and previous pressures on their pay. They said the decision was not being taken lightly, but that workers were now desperate. The unions also highlighted concerns about low staffing levels alongside high workloads, and the effect this had on patient safety. For example, Rachel Harrison, the GMB acting national secretary, said:

Delays up to 26 hours and 135,000 vacancies across the NHS mean a third of GMB ambulance workers think a delay they’ve been involved with has led to a death. Ambulance workers have been telling the government for years things are unsafe. No one is listening. What else can they do?

The government has urged ambulance staff not to go ahead with the strikes and to “consider the impact on patients”. The Department for Health and Social Care told the BBC that NHS England would “work with providers, professional bodies and trade unions to agree the safe level of cover during any industrial action”.

4. Read more

Statistics and information on other measures of ambulance performance, such as response times, can be found in the following publications:

In addition, other resources highlighting concerns with ambulance services include:

Cover image by Ian Taylor on Unsplash.