Words by Hilary Pillin, UEC Strategy Advisor, AACE
Hospital Handover Delays (HHDs) are the most significant issue facing the urgent and emergency care system today, and we know they adversely affect many staff – those of you working on the frontline, waiting inordinate amounts of time outside ED with your patients, or turning up to see patients who have been anxiously waiting your delayed arrival; those of you working in control rooms, seeing patients’ calls stacking up, getting repeated calls for the same patient, having no resource to send to those in need and having to make difficult decisions about who gets an ambulance first; and those of you working in patient safety teams, handling the investigations for Serious Incident reports and complaints, trying to explain to distraught patients and relatives why your service was unable to give them the care they needed and deserved in a timely way.
Many of these cases are heart-wrenching. I sit in meetings with paramedics, managers, and executive directors where it is not uncommon now for tears to be shed due to the sheer frustration and angst about what these delays mean for patients and their loved ones.
This is not what anyone who joined the ambulance service ever wanted to see happening. But it is now a daily reality so what are we in AACE, and other healthcare leaders, doing about it?
Sadly, this is not a new problem. HHDs have been an unacceptable issue for more than a decade. The National Audit Office in 2011 reported: “…only around 80% of handovers meet the 15-minute standard”.
Today, in May 2022, only 40% of handovers meet the 15-minute standard. AACE published a report with the NHS Confederation in 2012, ‘Zero Tolerance – making handover delays a thing of the past’, which included a series of recommendations to address the issue.
Nevertheless, HHDs have continued to be a significant and worrying issue since then. In 2012 they were deemed unacceptable. Leading up to the COVID-19 pandemic the numbers of delays were alarming; but now, they are seriously shocking.
These delays have continued to increase over the years, and significantly, the lengths of time ambulances are being held outside ED have been increasing. In the past year, (April to April) the volume of delays in handovers taking over an hour increased by 459%. In the month of April 2022, we had 600 patients who waited for more than 10 hours in an ambulance outside ED, and we had three patients waiting 24 hours.
This is not a winter issue – nor is it specifically a problem of increasing demand on 999 – a year ago, we were taking around 400k patients to ED; in April this year, we took 346k. That has been a steady downward trend for several years now.
In November 2021, AACE produced a report highlighting the potential harm being caused to patients being held in ambulances outside ED. This was the first time anyone had attempted to measure and articulate the impact on patients. This was not an easy report to publish, but we felt we had to highlight the reality behind the data.
Behind every number and every ‘ambulance hour lost’ is a patient, and this sometimes gets lost in the desensitisation to, and normalisation of, poor performance data when in a system under pressure. We also reported how this problem is adversely affecting the health and wellbeing of ambulance staff and we were able to include some reflections from some of you about your experiences of HHDs.
In the report we acknowledge and emphasise that the problem is not one the ambulance service can resolve alone, and that it is a multi-factorial, system-wide issue. We called on Integrated Care System (ICS) leaders to consistently measure and monitor harm arising from delays in patients being able to access emergency care, so as to highlight and proactively address the risks. NHS England and Improvement (NHSEI) has since written to all ICS CEOs stating that these risks need to be discussed and balanced collaboratively with all key providers, and steps put in place to reduce HHDs happening.
AACE also stated that all HHDs over an hour should be eliminated once and for all, as an urgent target. We also requested an independent, thematic review by the Health Services Investigation Branch (HSIB) – which they have commenced, publishing an interim bulletin on 16th June; and we called on the Care Quality Commission (CQC) to include HHDs in their inspections of local health systems, which they have now been doing.
The CQC held a Patient Safety event on 26th May, attended by 250 leaders from across health systems and providers. This concentrated on HHDs and patient experiences in moving through the system, and AACE was able to present some specific patient stories, which brought the impact into sharp focus.
As HHDs, and the subsequent delays in reaching patients who have called 999, are a consequence of pressures right across the health and social care system, there is no single solution to this problem. Nor is it within the gift of a single sector – whether ambulance, acute, primary care, community, or social care – to make changes that alone will result in the significant improvements required – although we do know that it is not a persistent problem at all hospitals. Some have acknowledged the risk to patient safety and although not easy, have adopted a ‘zero tolerance’ to having HHDs on their patch, thereby inevitably taking a share of the risk within their own setting.
So, the risk needs to be one that is recognised and addressed at ICS level, coordinating measures that need to be implemented by all providers. It also requires the Department of Health & Social Care to be proactive in addressing the social care capacity issue.
There are a lot of steps being taken – building on the ambitions of the NHS Long Term Plan that was launched in 2018, prior to the pandemic – to better integrate services and patient pathways and reduce pressure on emergency hospital services by boosting out-of-hospital care provision. The ambulance sector has been transforming response models for several years now, increasing our ability to provide more appropriate responses to 999 calls – such as Hear, Treat & Refer, and See, Treat & Refer, and accessing alternative care pathways that avoid patients going to hospital when they do not need to. This has led to fewer patients being taken to EDs. But all of these are changes in practice that take time to implement and coordinate across multiple providers at scale and are hampered by workforce capacity issues across all sectors. They will make a difference in the medium to long term if these can be replicated consistently across the country.
Right now, we have a situation that demands something more immediate, and we hope that Government ministers will soon see fit to intervene. AACE and others such as the Royal College of Emergency Medicine (RCEM) have spelled out that patients are coming to serious harm on a daily basis and that the situation is unacceptable and unsustainable.
AACE continues to raise the need for urgent, collective action with NHS England and Improvement (NHSEI) and ICS leaders, to drastically reduce HHDs so our ambulance clinicians can do the invaluable job they signed up for, and patients will no longer come to undue harm because they cannot receive definitive care in time.
In the meantime, AACE welcomes the support that our colleagues in RCEM, NHS Providers and NHS Confederation are providing to us in terms of us all saying this is a huge issue that must be resolved urgently.
