Staff in the Welsh Ambulance Service are "dead on their feet" from the pressures of Covid-19 and soaring numbers of 999 calls, two of its most senior bosses have warned. Director of operations Lee Brooks and director of paramedicine Andy Swinburn claim while the performance of the NHS trust is nowhere near where they want it to be, many of problems with the day-today running of the service are being caused by factors out of their control.
Latest figures from the Welsh Government show that ambulance staff reached barely half (51.1%) of 'Red' calls, those deemed immediately life-threatening, in the target time of eight minutes in March - the second worst on record. Wales' poorest-performing health board was Hywel Dda UHB, which covers Pembrokeshire, Carmarthenshire and Ceredigion, where just 43.2% of ambulances arrived within the eight-minute target. The target of 65% has not been reached in more than 18 months.
"The out-turn is not the out-turn that any of us would want. There are still large numbers of patients in our community, not just in the Red category but in the Amber category as well, who are waiting longer than any of us would want for an ambulance response," admitted Mr Brooks.
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"At the start of March we had some very positive signs from a pandemic perspective. The volumes [of calls] were on their way down, staff were coming back to work, and we had actually removed our pandemic protocol for triaging 999 calls. But then, of course, the BA2 variant [of Omicron] came along. It meant that we began to see an increase in Covid-related absenteeism that peaked right at the back end of March."
Mr Brooks confirmed that by the end of March more than 220 staff were off in one go, which equates to around 7% of the operational workforce. While he said this was "very much felt" by the service, it was still significantly lower than the peak of sickness absence in January 2021 when 411 were off (13%). To help during the winter months the military were drafted in to drive some vehicles, but they were withdrawn at the end of March.
"It was not an easy decision to use the military for a third time and that cannot be the long-term option," he added. "But we saw reductions in community waits during that period, so it was the right thing to do. Now we're in a position where we no longer have them and have to absorb more pressure. It means some patients are being told that ambulances are not available to them and have to find other means of getting to hospital - and that's regretful."
One of the things that has most concerned Mr Brooks in recent weeks is the sharp rise in the proportion of calls being classified as 'Red' which has doubled from around 5% to 10% over recent months. Many of these have been related to severe breathing problems caused, in part, by Covid. "At the point of triage occurring, those that are contacting us are sicker than they were before," he added.
In March, almost 39,000 emergency calls were made to the Welsh Ambulance Service, an average of 1,256 calls per day. Mr Brooks said his biggest concern was an increase in repeat calling which can be attributed, in the main, to longer waits in the community for ambulances to arrive. He added: "The volume has felt relentless. It's key that members of the public are only calling us back if there is a change to the patient's condition or if they are going to make alternative arrangements. What you could be doing is preventing somebody else who may have a life-threatening need from actually getting that contact with a call handler."
Andy Swinburn, director of paramedicine based in north Wales, said the workforce were "exhausted" and had gone "above and beyond" over the last two years to keep communities safe. "Without wishing to be too melodramatic, they're dead on their feet. However all the parts are health economy are feeling the same pressures we're feeling. For instance, people have not been able to get an appointment with their GP and they've put it off and put if off until eventually their low-level complaint becomes a much higher level of complaint which then trips into 999."
Mr Swinburn said the current pressures on the Welsh Ambulance Service are the most challenging he'd experienced in his three decades in the career. He added that handover delays - where patients wait more than 15 minutes to be transferred from an ambulance into A&E, were crippling their ability to respond to urgent calls in communities. He added: "If you rock up at the front doors of any emergency department in Wales you're probably going to see a plethora of vehicles parked outside waiting to offload. We've made no secret of that - if anything we're shouting it from the rooftops."
In the first quarter of 2022 (January-March), a staggering 70,171 hours were "lost" due to handover delays. This was more than three times the amount recorded in the same period in 2021 (21,598), 2020 (25,929) and 2019 (21,250). Mr Brooks said this was down to patients being unable to "flow" through the NHS system due to a shortage of available hospital staff and beds, and hold-ups in discharging patients when they're medically fit and ready to go home.
Commenting on the record handover delays, Mr Brooks explained: "What that means for me, really bluntly, is that I'm starting with a quarter of my capacity gone - and we're starting to move towards that being a third. The stark reality is that it does put us into a position where the provision of a safe ambulance service is a problem. Who would have thought we would be talking about a patient waiting in an ambulance for more than a day to access the emergency department? That is shocking and it's just not the right place for a patient.
"I think some staff have started to resign themselves to this being the way ahead, which I think is incredibly sad because you can never accept that the lengths of delays in accessing the emergency department should be here to stay. We have seen some of our staff suffer trauma because they've seen the consequence of the delays to the patient they're with, and because they are hearing of the calls that are waiting in the community that they've been unable to respond to.
"[Handover delays] also have an impact on staff's experience of work. It drives crews way outside of periods where they're meant to have a break, and they work longer than they need to."
Despite these problems, both men agreed that Wales was one of the best in the UK at managing patients in their communities and preventing them from needing an unnecessary trip to hospital. But they said emptying hospitals for only those who need to be there is "really, really key". They added that the national rollout of the NHS 111 service will also help to direct people to the most suitable care to meet their needs.
The Welsh Ambulance Service has also been busy recruiting, doubling the size of its clinical support desk team, diverting its staff to do more clinical work remotely, and enlisting more support from St John Ambulance. They also added that there remains an appetite to work for the NHS with "no shortage" of applicants for roles. Some 100 emergency medical technicians (EMTs) are set to be introduced to the roster next month after a period of training.
"There's no doubt that our reputation has taken a knock at this moment in time. Whenever there are pressures on the unscheduled care system every media outlet in the country shows a picture of an ambulance when, in fact, we're just one part of a much bigger chain," Mr Swinburn added. "While people are potentially having less confidence in us being able to deliver a service when they need, in those times of crisis when people need help they'll still dial 999."
Mr Brooks added: "I would like to reassure the public that we are advocating for the patients in the community who are waiting for help. They are the patients we are most concerned about. We are doing as much as we can to absorb as much of the pressure as possible - but the levers that are available to us are not plentiful.
"If Covid behaves for us and we don't see new variants, if we see an improvement in attendance by our existing staff as a consequence, and if we see our new EMTs coming in next month, that will improve the picture for us. However the single greatest area we'll see in terms of improvement is the reduction of lost hours at the emergency department - that is the reality. There do need to be meaningful and effective plans to start to bring those figures down before I can speak with confidence that there will be turnaround in these response times."
