The ambulance service has received a lot of media attention recently for missing its emergency response targets. This is despite the Welsh Government investing in the Welsh Ambulance Service Trust (WAST) to increase the number of ambulances and frontline ambulance staff. The Welsh Government has also transferred responsibility for commissioning emergency ambulance services to a new Emergency Ambulance Services Committee, to provide greater clarity in this process. Even still, the statistics show emergency ambulance response times continuing to fall below target levels, particularly for the 8 minute emergency response targets. So what is the story behind these emergency response time figures, and what’s being done to tackle them?
The 8 minute response target
The ambulance response time targets are based on UK Government National Service Framework standards. The 8 minute target is based on standard 5 of this framework and on evidence that death becomes more likely where there are delays in administering cardio-pulmonary resuscitation and defibrillation to people suffering a heart attack. The Welsh Government has set two ambulance response targets:
- 65% of all calls categorised as ‘life threatening’ to receive an emergency response within 8 minutes on an all-Wales basis and
- 60% of all calls categorised as ‘life threatening’ to receive a response within 8 minutes on a Unitary Authority basis.
It is worth noting, however, that the McClelland review found that the 65% target was:
[…] a very limited way of judging and incentivising the performance of ambulance services. Speed is particularly important for some conditions such as cardiac arrest but there is little clinical evidence to support the blanket 8 minute national target.
WAST was hitting these targets in the first half of 2012, but since June 2012, WAST has only achieved the 65% target once, in October 2013. The following graph shows how the percentage of emergency responses arriving at the scene within 8 minutes has consistently remained below the 65% target, while there has been a general downward trend: 
While the number of Category A calls that result in an emergency response has increased by 3.1% between 2012 and 2014, the number of Category A calls receiving a response within 8 minutes has decreased by 13.6%. This suggests that while there’s been a slight increase in demand for Category A calls, there’s been a considerably larger decrease in performance against the 8 minute target. 
Across Wales, the 8 minute ambulance response times have fallen short of the 65% target by 1.3 percentage points in 2012 (average figures for January to December), 9.4 percentage points in 2013 and 10.6 percentage points in 2014. As the following table shows, while ambulance services were reaching their target in 2012, performance was consistently lower in 2014. Only in Bridgend was the percentage of ambulances meeting the 8 minute response target higher in 2014 than it was in 2012: 
As the data from January 2015 illustrates, it is particularly in valleys areas that ambulance response times have fallen short of the 60% emergency response target: 
Drawing on the distinction used in England between Red 1 (immediately life threatening) and Red 2 (life threatening but less time-critical) calls, WAST provide some reassurance that, in January, the ambulance service reached 62.8% of the more serious calls within 8 minutes. This still falls short of the 65% all Wales target. According to WAST, the decrease in the proportion of emergency responses meeting the 8 minute target can be explained by increased demand and delays in hand over times to hospitals, increasing patient acuity and dependency, a reduction in resources in areas of higher activity, and barriers to the improvement of the current healthcare system.
Responding to the 8 minute response time challenge
Given these challenges, WAST has been the subject of a number of Wales Audit Office reports, an inquiry by the Assembly’s Audit Committee, and the McClelland review. The Welsh Government strategy Delivering Emergency Services (2008), sets out a modernisation workstream seeking to turn the ambulance service “into a major provider and partner in the delivery of unscheduled care services”. WAST’s own modernisation programme sets out to develop a high quality service, and to “respond quickly to patients with immediately life-threatening conditions, with four minutes being the norm for cardiac, stroke and serious trauma cases”. The plan is to achieve this by developing staff, making better use of technology and by modernising buildings and the ambulance fleet. More recently, the Welsh Government has highlighted the 'perverse outcomes' prompted by targets, and report efforts to move the NHS to a system delivering healthcare outcomes. The Health Minister has asked his “Department to prioritise the development of unscheduled care [outcome] measures including both the ambulance service and A&E departments”, and had agreed to publish the NHS Outcomes Framework in January 2015: The purpose of the NHS Outcomes Framework is to measure delivery across a wider area than just the acute hospitals to reflect the structure and accountability of the Welsh Health Boards. WAST has been conducting a public engagement exercise aimed at developing its responsiveness to the public, thereby contributing to developing a more sustainable and cost effective service. No details have yet been released on how an outcomes framework may operate.
Article by Shane Doheny, National Assembly for Wales Research Service.
