The impact of ambulance handover delays resulting in poor response times is “clearly the biggest single risk to patients in the emergency care system of Northern Ireland,” it has been warned.
In a new report, NI’s Auditor General Dorinnia Carville detailed how Ambulance Service (NIAS) targets are being repeatedly missed, spending on private paramedic crews is increasing, and interventions to tackle the problem are having little effect or not being utilised properly.
Back in February 2023, the heads of the various Health Trusts gave a commitment that no ambulance handover at an emergency department (ED) should take longer than two hours.
Not only is this two-hour target being missed, but the number of handovers taking longer than even three hours has increased from around 400 in 2019/20 (less than 1% of total handovers) to over 11,000 in 2023/24 — or 9% of all handovers.
Read more
Over this period, handover performance has worsened at all nine hospitals here with major EDs.
The report said there were over 36,300 instances when patients may have experienced harm as a result of delays and around 3,800 occasions when patients were potentially subject to severe harm.
Between 2020/21 and 2023/24, the report found that the number of Serious Adverse Incidents which the NIAS attributed to delays in responding to patients has increased from eight to 35.
Timely handovers require adequate capacity and resources in our hospitals, especially in EDs.
However, the report noted how waiting times in EDs have increased to the extent that 21% of patients waited more than 12 hours before being admitted between July and September last year.
This is the worst quarterly performance on record in NI, which Ms Carville described as a “dramatic deterioration” in handover performance.
With ambulances being increasingly tied up at EDs, ambulance response times to 999 have also deteriorated. Life-threatening Category One calls have a target response time of eight minutes. This hasn’t been met any year since 2019/20 and in 2023/24 the average response time was more than 11 minutes.
In a bid to plug gaps in the system, the NIAS has also been increasingly relying on the private ambulance sector.
In 2019/20, the NIAS commissioned private ambulances to provide ED relief on 20 occasions. By 2023/24 this figure was 1,100. Spending in this area has jumped from £1.3m to £3.6m over this period — but handover delays have continued to increase.
Back in June 2023, the DoH commissioned a team from the Getting It Right First Time (GIRFT) project, a UK-wide programme which aims to improve patient care across the health system, to review emergency medicine in NI.
While the report was finalised in January last year, it has not been published, but the Audit Office was able to access and review the report.
It identified that the impact of handover delays on poor ambulance response times is “clearly the biggest single risk to patients in the emergency care system of Northern Ireland,” which the Audit Office said reinforces its findings.
In order to improve patient flows through hospitals, there also needs to be adequate care capacity in the community to allow for swift patient discharges, the report notes.
Auditor general Dorinnia Carville
For complex discharges — those requiring outside support arrangements for a patient — the Department of Health (DoH) has set a target that all should take place within 48 hours of a patient being declared medically fit.
The report found that 21% of complex discharges in 2020/21 were delayed for longer than this, rising to 42% in 2023/24.
In 2017, the NIAS began implementing alternative care pathways, which are aimed at diverting patients away from EDs where they can be treated elsewhere.
Despite this, the proportion of emergency calls which have resulted in these pathways being used has not increased, but fallen from 3% of calls in 2019/20 to 2% of calls in 2023/24.
In October 2020, the DoH announced its No More Silos (NMS) Action. One of the key actions of the plan related to ambulance handovers and it highlighted that EDs needed to provide physical space for assessment and triage of patients arriving by ambulance.
Part of this involved the five largest EDs accommodating at least six ambulance arrivals to be handed over as soon as possible, but the report found that Trusts “did not prioritise funding to develop ambulance arrivals and handover zones at the Royal Victoria Hospital or the Ulster Hospital.”
While £1.3m was allocated in 2021/22 and 2022/23 towards handover zones in Craigavon Area Hospital, Altnagelvin Hospital and Antrim Area Hospital, the report said “evidence indicates that the operation of these zones in practice was limited.”
Then in November 2023, the DoH launched a ‘Delayed Ambulance Handover Standard’ protocol, which required Trusts to provide an ambulance handover area to allow patient handovers to the ED team.
As the Audit report notes, however, “if handover zones are not in place and functioning as intended, the protocol is meaningless.”
Northern Ireland’s Comptroller and Auditor General, Dorinnia Carville, said having ambulances waiting outside hospitals for long periods is “both unacceptable for patient wellbeing and a waste of public resources.”
“Addressing this issue will no doubt be challenging,” she added.
“However, this report includes recommendations, and good practice from other regions, highlighting key areas for improvement.”
NIAS and the Department of Health said they “welcomed” the NI Audit Office report and added that they would consider its recommendations.
“Today’s report underlines the seriousness and scale of the pressures facing health and social care services,” a spokesperson for the Department of Health added.
“The Department of Health recognises the risk of harm to patients who are delayed at handover on arrival at the emergency department and the impact this has on NIAS’s capacity to respond to the next emergency call in the community.”
They added: “Although some progress has been made in delivering changes to services to meet the needs of patients and service users, there is no quick fix and addressing the current situation will require sustained long-term effort, additional recurrent funding and support across the political spectrum.
“The Department is determined to find better ways to work as a system to tackle these complex issues. That is why the Minister initiated a series of winter planning workshops to identifying solutions to the system flow issues that we collectively face.
“The Minister attended the first of these events on 4 March and was encouraged by the engagement and enthusiasm from HSC leaders across the system. The Department expects to see better outcomes in advance of next winter, including improvements to ambulance handover times.”
NIAS said it apologised to patients who experienced long wait times.
In a statement a spokesperson said: “These current challenges are as a result of the pressures faced across the entire Health and Social Care system and which are manifested most in the pressures at EDs and patient flow through hospitals.
“These pressures have resulted in prolonged turnaround times for ambulances at EDs, which impacts upon our ability to respond to emergency calls within the community.”
The spokesperson added that they continue to work with other health departments to find solutions. “NIAS operates a clinical triage system to ensure that the most clinically ill or urgent calls receive the most immediate response,” the spokesperson continued.
“Unfortunately, this means that those patients whose needs are less clinically urgent will face delays in ambulance response.”