Ambulance handover times in England have shown signs of improving, but a new report suggested there is still a long way to go before performance targets are reached.
An analysis by the Association of Ambulance Chief Executives warned that there was "no room for complacency" as delays transferring patients from ambulances to hospitals continued to cause "significant harm" to patients.
It's over a decade since handover delays were the focus of a major collaborative report — 'Zero Tolerance: Making ambulance handover delays a thing of the past' — from the NHS Confederation and the Association of Ambulance Chief Executives (AACE). When it was published in 2012, the Department of Health stipulated that handovers must occur "within 15 minutes" of an ambulance's arrival at A&E, and that a "zero tolerance" approach to delays should be embraced.
A Decade of "Staggering" Delays
Even a decade ago, in 2011-12, handover delays were described as "staggering", when one in five handovers took over 15 minutes. By 2017-18 over half (53%) exceeded the target, with 3% taking over an hour. But over the last decade the number of handovers taking more than 15 minutes had increased by a factor of three, to 61%, with the number taking over an hour more than doubling, to 8%.
In 2022-23, 68% of all hospital handovers took longer than 15 minutes and 14% were taking over an hour. Gradual increases in 2022 saw "unprecedented" volumes peak in December when around three quarters of handovers took 15 minutes or longer, and around a quarter took more than an hour.
In December 2012 there were an estimated 5226 handover delays of more than an hour across England, but by December last year this had reached 66,000, according to the report.
Martin Flaherty, managing director of AACE, commented "The situation a decade ago was highly concerning, with a fifth of handovers taking longer than 15 minutes – yet today that figure is more than two-thirds, with delays beyond an hour almost unheard of in 2011, yet now up to 14% of all handovers."
Millions of Hours Lost
Ambulance crews "lost" nearly two million hours while waiting to hand over patients to A&E staff in England last year, the analysis found, with 868,000 hours lost due to handover delays of an hour or more.
The number of patients risking potential additional harm as a result of these delays was an estimated 440,000, or over 1 in 10 of the patients who required ambulance transport to an emergency department during that time.
Compared with the 12 months to March 2019, the same period to March this year saw an increase of 436,000 hour-plus delays – a 521% increase, alerted the authors.
In a 2021 report, 'Delayed hospital handovers: Impact assessment of patient harm', AACE pointed out that "the longer patients wait in an ambulance as part of the handover process, the greater the risk of them experiencing additional, sometimes serious harm – and even death". The report also emphasised the impact of delays on staff who felt drained, abandoned, worried, and demoralised following long waits with sick and injured patients.
"These delays mean that ambulance crews are not always able to respond to 999 calls from critically ill patients," commented Saffron Cordery, deputy chief executive at NHS Providers. In addition to the direct impact on patients, this is incredibly demoralising, even traumatising, for many staff involved."
Situation "Precarious" Despite Improvements
The Association said longer delays had shown "signs of receding" since the start of the current financial year but still "remain very high", and it warned that potential harm to patients and the drain on vital ambulance resources remained "significant".
The drop in the number of handover delays was a "positive short-term trend", but one that needed to be sustained for some time to bring levels back in line with those seen even two years previously.
"Many trust leaders are working effectively to reduce handover delays by focusing on culture, dedicated risk management and collaboration with partners, highlighted Ms Cordery. "Too often, though, mounting pressure is undermining best efforts."
"We remain in a precarious position," cautioned Mr Flaherty, "and there is no room for complacency." Although there was still considerable work to do to prevent handover delays, he believed that the problem was "not intractable".
The authors said the report represented a "hopeful line in the sand" and called for an even greater focus on improvements that would "reduce and eradicate delays, prevent more patients from coming to significant harm, and stop the drain on vital ambulance resources".