Putting system-thinking to the test in tackling handover delays

Saffron Cordery profile picture

01 July 2022

Saffron Cordery
Interim Chief Executive
NHS Providers


Daren Mochrie profile picture

Daren Mochrie
Chair
Association of Ambulance Chief Executives


The whole health and care system must work as one to tackle the root causes of handover delays for patients coming to hospital by ambulance.

Delays in transferring patients from an ambulance to a hospital have risen exponentially over the past year. In April 2022 there were over 41,000 delays of over 60 minutes, up more than 450% in 12 months. This equates to 71,000 hours lost, with a significant risk of harm to patients, even though the proportion being taken to hospital by ambulance has fallen thanks to successful initiatives such as 'hear and treat' and 'see and treat'.

The current reality is that crews are often waiting with patients in hospital corridors or outside, hearing urgent calls to which they are unable to respond.

   

These delays mean that too often crews are not able to respond to 999 calls from critically ill patients. Instead they are being held in 'stacks' of hundreds each day – as ambulance control room teams strive to prioritise overstretched resources. The current reality is that crews are often waiting with patients in hospital corridors or outside, hearing urgent calls to which they are unable to respond. For the patients in the back of ambulances, it can be many hours before they receive definitive assessment, treatment and admission where needed. We know this is unacceptable and is leading to an increasing number of serious incidents.

In addition to the direct impact on patients, this is incredibly demoralising, even traumatising, for many staff involved. This is particularly the case for those in the control room with no available crews to send to people clearly in need, and for the clinicians reaching patients after lengthy delays since the first call for help.

For trust leaders, patient safety is an absolute priority. Everyone in the sector recognises the need for ambulance crews to be able to hand over patients quickly so they can get back on the road answering emergency 999 calls. We need to go further than this, however, to ensure there is a shared recognition of both the root causes of handover delays and how to solve them. This is a very real test for health and care services working together in local "systems". 

Handover delays are often viewed as a problem relating to the interface between ambulance services and hospitals. They are, in fact, a symptom of much wider pressures, including the ongoing delays in discharging medically fit patients from hospital. At the end of April, 62% of the 20,155 patients who were medically fit to be discharged, remained in hospital. Due to stretched and underfunded services in domiciliary and intermediary care, and a lack of social care provision, patients cannot be discharged safely. And so the pressure grows.

Hospitals are struggling to deal with rising urgent and emergency care demand while making crucial progress on reducing the care backlog.

   

There are other capacity constraints contributing to the delays. Hospitals are struggling to deal with rising urgent and emergency care demand while making crucial progress on reducing the care backlog. Mental health services are also under incredible strain, with latest data showing that 1.6 million people are in contact with secondary care services. Some may still be waiting to be seen. The number of children and young people in this position is almost three times higher than when records began.

Tackling handover delays is the most immediate and pressing challenge facing health and care services. It demands increased collaboration, as enshrined in the Health and Care Act. In practice, this means trusts, together with partners in local government and primary care, looking at the challenges and seeking solutions through a system lens. There is an urgent need to address workforce shortages and expand social care capacity alongside securing reforms for social care that put it on a sustainable footing.

Trusts also need the support of regulators, acknowledging that, in times of crisis, risk needs to be shared more proportionately across systems. Focusing only on individual provider accountability will not help to solve handover delays.

Greater recognition of ambulances as 'critical assets' may help systems to unlock the solutions they need. By that we mean staff and equipment with very limited availability which deliver specialist clinical skills and are the only resource that can manage the care required. Recognising ambulances as critical assets would mean they are protected in the same way hospitals work to protect their intensive care beds. This relies on there being adequate capacity across the system but a shift in mindset would be a helpful start.

Trusts are already playing a key role collaborating with partners to help people stay well and intervening early to prevent crises.

   

A whole system approach also presents opportunities for a greater focus on prevention. Trusts are already playing a key role collaborating with partners to help people stay well and intervening early to prevent crises. The ambulance service has a crucial role in this, working alongside their system partners. This approach offers a real prize for patients and communities, with services catching more problems 'upstream' before they happen and easing the pressures across the system that lie behind the handover delays.

There is no quick and easy fix to handover delays. If there were they would have been eradicated long ago. But as NHS England finalises its forthcoming urgent and emergency care strategy, there is an opportunity to harness the potential of trusts working in systems to make a real difference for patients and staff.

This blog was first published by the Independent.

About the authors

Saffron Cordery profile picture

Saffron Cordery
Interim Chief Executive
@Saffron_Policy

Saffron is NHS Providers interim chief executive, part of the senior management team and sits on our board. She has extensive experience in policy development, influencing and communications and has worked in the healthcare sector since 2007. Before moving into healthcare, Saffron was head of public affairs at the Local Government Association, the voice of local councils in England. Her early career focused on influencing EU legislation and policy development, and she started working life in adult and community education.

She has a degree in Modern Languages from the University in Manchester, for ten years was a board member and then chair of a 16–19 college in Hampshire and is a trustee of GambleAware, a leading charity committed to minimising gambling-related harm. Read more

Daren Mochrie profile picture

Daren Mochrie
Chair

Daren Mochrie took up his role as Association of Ambulance Chief Executives chair in August 2020, having previously served as the chief executive of North West Ambulance Service NHS Trust (NWAS) since May 2019.

Having worked for the NHS since the age of 17 he has extensive experience of managing ambulance services in both rural and urban settings. Daren is a registered paramedic, holds a master's degree in business administration from Napier University, Edinburgh and was one of the first paramedics to gain a diploma in immediate medical care, Royal College of Surgeons, Edinburgh.

In 2013 Queen's Birthday Honours, he was awarded the Queen's Ambulance Medal for distinguished service to the UK NHS Ambulance Service. Prior to joining NWAS, Daren was chief executive of South East Coast Ambulance Service. Previously he had been director of operations for the Scottish Ambulance Service and the lead for ambulance provision in the 2014 Commonwealth Games in Glasgow. Daren has also held the position of specialist advisor with Care Quality Commission (CQC), leading several CQC inspections of ambulance trusts in England.

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