Tuesday, 7 October 2014

Why are Welsh ambulance response times so poor?

The Wales Ambulance Service Trust (WAST) has failed to hit and maintain its response time targets (65% of the most serious [Category A] 999 calls responded to within 8 minutes) for around 24 months in a row.

The latest figures, from August 2014 (pdf), show that 56.9% of Category A calls were responded to within 8 minutes; that rises to 66.8% within 10 minutes and 83% at 15 minutes. That means for 17% (almost 1 in 5) of life-threatening calls in Wales, an ambulance takes near double the target time to reach the patient. Summer is traditionally quiet in terms of demand for ambulance services, so these figures are particularly bad.

Although this is one of those issues which Assembly Members get very hot under the collar about, nobody's ever considered the precise reasons why the ambulance service is missing its targets so consistently. Opposition AMs huff and puff over the figures and turn it into a political football, while ministers almost never give straight answers.

Most of this is going to be guesswork and inductive reasoning with very little hard evidence to back it up. But I do believe that – concerns from the McClelland Review about management aside - some of the reasons might not be sexy enough for politicians to score points off each other in the Senedd chamber or press, but do make sense.

Where are the problems?

Before considering why response times are poor, it's worth looking at performances at a local level to see if there are any patterns we can draw conclusions from. As you can see from the map below, response times vary wildly across Wales.

Ambulance response times by local authority - August 2014
(Pic : StatsWales/Welsh Government)

Four local authorities actually hit or exceeded the target – Swansea (65.1%), Conwy (65.9%), Bridgend (69.3%) and Wrexham (70.3%). Neath Port Talbot (62.8%) and Denbighshire (63%) came close. So despite criticism elsewhere, it looks like ambulance response times in the Abertawe Bro Morgannwg local health board are significantly better than the rest of Wales.

In terms of poor responses, there are two distinct clusters.

The first cluster are rural local authorities, with Monmouthshire (50%), Anglesey (51.5%) Powys (53.3%), Vale of Glamorgan (53.5%) and Carmarthenshire (54.7%) standing out, with the likes of Pembrokeshire, Ceredigion and Gwynedd not doing much better.

The second cluster consists of Cardiff (58.1%) and the south Wales valleys. Response times in Caerphilly (44.8%), Rhondda Cynon Taf (46.4%), Torfaen (47.6%), Merthyr Tydfil (51.3%) and Blaenau Gwent (52.8%) are much, much worse than the rest of Wales. The difference between bordering local authorities like Bridgend and RCT is stark, though – as I'll come to – there may be unorthodox explanations as to why this is the case.

What might the problems be?

These aren't exactly ambulance friendly street layouts.
(Pic : Wales Online)
The quality of the road network - The poorest response times are in the south Wales valleys where there are a lot of very narrow side streets consisting of tightly-packed terraced houses, usually on steep inclines. There's often very little room to park if you live on these roads, let alone enough room to attempt to get an ambulance up them at high speed.

Local authorities which have the better response times, like Swansea, Bridgend and Wrexham, are quite car-friendly. Swansea city itself, for example, has been designed with road traffic in mind since the Luftwaffe flattened it, while Bridgend and Wrexham have large housing estates served by high-quality spine roads and dual carriageways.

So as much as AMs might want to pin the blame on the government or the WAST's management team, it could be equally down to dodgy junctions, potholes, poor car parking, ill-considered one-way systems or unnecessary sets of traffic lights and speed humps.

Perhaps consideration should be given to the creation of designated "ambulance-friendly routes" in the valleys that are cleared of any and all obstructions where practical.

Rurality and the distance travelled to 999 calls – This is something you can easily infer from the map, and it's so blindingly obvious even the harshest critic of the Welsh NHS will have to accept it as an unavoidable hazard.

The further you are from a hospital or ambulance station, the longer the ambulance will take to reach you – simple. The problem will be more acute in north west, mid and west Wales (as well as some south Walian local authorities like Monmouthshire and Vale of Glamorgan). The catchment areas for Ysbyty Gwynedd and Bronglais Hospital, for example, are huge, and often cover difficult terrain.

Farming and fishing are probably the most dangerous jobs around. Workers in these sectors are at higher risk of suffering serious accidents, and these jobs are also more densely concentrated in these areas.

Also, people who move to idyllic-looking farmhouses to retire don't factor in that – as they get older and inevitably get sicker too - ambulances might struggle to reach them at the end of gravel tracks off a picturesque winding B-road in the Welsh Desert. And air ambulances might be tied up elsewhere.

Ambulances are too heavy and too slow
- In 2013, around £9.5million was spent upgrading the Welsh ambulance fleet. Although they now carry very high-tech (and heavy) equipment – before factoring in the weight of paramedics themselves and patients – the ambulances are still glorified transit vans that can't negotiate corners particularly well and accelerate slowly. Over longer distances this will add up.

If you want an analogy, it's a bit like refurbishing the interior of a train or bus to business class standards, but the bus/train itself remaining a clapped out diesel from the 1970s.

There's little the Welsh Government and Ambulance Trust can do here, and the onus is on ambulance manufacturers to create faster, lighter vehicles. Perhaps there should be more use of motorbikes and cars for first responders, while using larger ambulances solely to transport patients to hospital and stabilise complicated conditions.

There's at least 8 ambulances I can see that can't go on another urgent 999 call.
(Pic : Morriston Hospital via cardifflocalguide.co.uk)
Delayed transfers at Accident & Emergency departments – Now this is something you really can criticise the Welsh Government for. It's their job to ensure there are enough medical staff, and that hospitals are well-resourced enough, to see whoever comes through the door.

Every minute an ambulance spends outside A&E departments waiting to discharge patients is a minute that ambulance is out of action. There are acute problems in Cardiff in particular, and it occasionally happens at other hospitals, such as Morriston Hospital in Swansea and Princess of Wales Hospital, Bridgend.

With the forthcoming centralisation of specialist services in south Wales, I'll actually expect this problem to get worse, as treating capacity hasn't been dealt with. They might stand a chance of being seen by staff quicker, but as far as I can tell there'll be the same number of beds to treat them.

This is the main reason why, in my opinion, you end up hearing of extreme cases of people waiting hours for an ambulance to show up. It's simply because all the ambulances are tied up outside A&E departments waiting to offload patients.

Compassion fatigue & "false alarms" - "Compassion fatigue" is a mild form of post traumatic stress disorder that affects people who deal with harrowing things every single day (like paramedics and A&E doctors), and it even affects the general public when we're bombarded with bad news or sob stories. We eventually get used to it to such an extent we don't care anymore. How many times have we been told the Wales Ambulance Trust are over-worked, under-staffed and poorly-managed?

For medical staff this becomes cynicism and a lack of genuine compassion for patients. This in turn may lead to complacency in care and poor morale. I doubt you would ever get paramedics to admit it because the trade unions will go ballistic and on the defensive. But I'm willing to bet on some calls they'll let standards slip because they've had enough crap for one day.

Then there are people calling for an ambulance when they don't really need one, tying up more resources. It's easy to criticise people who do this as time-wasters or hypochondriacs, but it's often better to be safe than sorry. Welsh Government public information campaigns on this have clearly failed.

The McClelland review recommended that the 8 minute target be ditched.
- something AMs have conveniently forgotten.
(Pic : Telegraph and Argus)
The targets are too ambitious – Not all Category A 999 calls need to be responded to within 8 minutes. With improved medicines and treatments, things that would've once killed people – like heart attacks and strokes – are now increasingly survivable, even if a patient doesn't reach hospital in the "golden hour" (which some academics and medics have called a "myth").

That's no reason to be complacent, and there is evidence that suggests the sooner an ambulance reaches a patient who's suffering a heart attack, the greater the chance of survival (Pell, Sirel, Marsden et. al 2001).

However, just to point out how silly the 8 minute target is (as pointed out in the McClelland review), if an ambulance reaches a patient within 8 minutes and they die, they've met the target. If they reach them in 8 minutes 30 seconds and save the patient's life, they've missed the target. That's ridiculous, and no wonder paramedics must hate their job (Price, 2006) when those are the twisted standards they're held to by managers and politicians.

Echoing what was said in the McClelland review, the target should be based around the patient's outcome (for argument's sake, all Category A patients should be admitted to hospital within 40 minutes of the 999 call with a chance of survival), not a stopwatch.

What are the Welsh Government doing about it?

You've got to say that if these are the sorts of problems facing the ambulance service, then there's very little the Welsh Government can do other than implementing some of the recommendations from the McClelland report and keeping their fingers crossed.

Ditching the 8 minute target – however rational it would be - would be an absolute god-send to opposition AMs. It would probably send the Tories in particular into screams of ecstasy on the Senedd benches, as it'll be on every election leaflet in 2016, accompanied by a photo of an elderly actor/actress having a "chest-clutcher" on the stairs. So it's unlikely to happen due to politics, even if shifting the goal posts is in vogue at Cathays Park.

However, in the last fortnight or so, the new Deputy Minister for Health, Vaughan Gething (Lab, Cardiff S. & Penarth), made a major announcement on this.

The Welsh Government have earmarked around £5million towards the creation of an Emergency Medical Retrieval and Transfer System (EMTRS) service. In English, that means an expansion (you could even say a part-nationalisation) of the Wales Air Ambulance - dubbed "Flying Doctors" after the cheesy 1980s Australian drama, though it's probably more comparable to M.A.S.H. It'll operate for 12 hours a day, and will be based in Swansea and Welshpool.

The idea's that trained doctors and consultants will be airlifted to serious incidents with equipment so patients can be treated at the scene instead of waiting for an ambulance to take them to hospital to be treated. If it works, it's said 95% of the population will now be within 30 minutes of doctor-led emergency care.

The EMTRS is probably an act of desperation, but as an idea it's incredibly sensible, practical and I'm surprised it hasn't been attempted a lot sooner.


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