One of the most basic expectations people have of the NHS is simple: if they dial 999 in an emergency, they want to know an ambulance will arrive quickly.
Service users across Wales will measure us and measure our success on how quickly we turn up – Jason Killen, former Chief Executive, Welsh Ambulance Services University NHS Trust.
A timely ambulance response is one of the most visible indicators of NHS performance. Yet in recent years, that expectation has been increasingly difficult to meet. Ambulance delays, long waits outside hospitals, and rising demand have put the system under intense pressure. This has been the subject of scrutiny at the Senedd, including the work of the Health and Social Care Committee.
This article looks behind the blue flashing lights to explore how new reforms aim to shift the focus from speed alone—where ambulance services have struggled to meet urgent response targets —to patient outcomes and safer care.
A system under pressure: Is help still on the way?
For the most serious “red” emergencies — such as cardiac arrest — response times for an ambulance remain a major challenge. In May 2025, only half of red calls received an ambulance within the 8-minute target. Performance varied across Wales, from 46.0% in Powys (the lowest) to 53.7% in Aneurin Bevan (the highest) – well below the national target of 65%.
The Welsh Ambulance Services University NHS Trust (WASUT) told the Senedd’s Health and Social Care Committee in May 2024, one of the biggest causes of slow ambulance response times is hospital handover delays. In December 2022, over a third of ambulances were unavailable because crews were waiting to hand patients into hospital care. A year later, the 2023/24 WASUT report confirmed that the problem had barely improved. Ambulances are often seen queuing outside emergency departments, unable to return to the community.
Former Chief Executive of WASUT highlighted the knock-on effect, noting that WASUT loses around 20–25% of its fleet capacity each month due to system-wide NHS bottlenecks. He explained that thousands of patients remain in hospital beds despite being medically fit for discharge, which blocks new admissions – a problem explored in detail by the Health and Social Care Committee in its June 2022 report.
At the same time, nearly 10,000 patients cancelled their own ambulance calls in December 2023 and made their own way to hospital — not because they no longer needed help, but because the wait felt too long.
Health Secretary Jeremy Miles MS has acknowledged these delays cause “avoidable harm”.
The Health and Social Care Committee concluded that simply adding more ambulances to the fleet cannot resolve the crisis. It acknowledged that the pressures stem from deeper systemic issues and recognised that queuing ambulances are a visible symptom of a wider system under strain. However, the Committee emphasised that WASUT must “play its part in ensuring it is effectively managing its own resources.”
From Sirens to Solutions: a strategic shift in ambulance services?
Senedd scrutiny has highlighted the need for WASUT to further develop its role – not just as a provider of patient transport, but as a key frontline healthcare service. In response, WASUT has expanded its clinical role – delivering more care at the scene, supporting mental health, and reducing unnecessary hospital admissions.
The Welsh Government is also reshaping how ambulance services are measured, following recommendations from the Health and Social Care Committee. Reforms introduced in July 2025 mark a fundamental shift focused on patient outcomes and clinical quality, rather than simply response times.
Key issues identified by the Committee:
- Over-reliance on a single time-based target: The 8-minute target for red calls hadn’t been met consistently since July 2022. The Committee questioned whether speed alone was a fair measure of care and called for a formal review.
- Lack of differentiation within emergencies: Previously, all life-threatening calls were treated the same. The Committee supported a more nuanced approach, with earlier clinical triage and more precise categorisation.
- A need for clinically meaningful performance measures: The Committee was told that the ambulance service is evolving from a transport provider to a frontline healthcare service. It stressed the need to evaluate this shift in terms of clinical value and impact, stating performance must be assessed in terms of patient outcomes.
- Inadequate focus on harm caused by delays: Delays can result in serious harm. The report found that 1 in 10 patients experienced moderate or severe harm — or even death — as a result of long waits.
- Hospital handover delays: The Committee described this as the single biggest challenge and called for better discharge planning and investment in adult social care.
A new Ambulance Performance Framework
Launched in July 2025, the new framework introduces new categories for 999 calls:
- Purple calls: now cover cardiac or respiratory arrest – where the heart or breathing has already stopped. These are the most critical emergencies. Patients must be reached within 6–8 minutes, but the main measure of success is whether the patient’s heartbeat is restarted and remains stable until hospital arrival. It shifts focus from just speed to clinical outcomes, aiming to improve survival rates (currently less than 5% in Wales).
- Red calls: still cover life-threatening emergencies like major trauma or critical illness – where the patient is at high risk of cardiac or respiratory arrest. The target remains 6–8 minutes, but the emphasis is on preventing arrest by reaching patients before their condition worsens.
The first results under this new model, published in August 2025, show promise but that challenges remain. In July, there were 814 purple and 4,449 red calls. Median response times were still slower than the 6–8 minute goal, but cardiac arrest survival rates improved.
New roles, new resources
The reforms are supported by:
- Community first responders: trained volunteers who provide on-scene assessments and early care, helping paramedics prioritise.
- Clinical navigators: paramedics and nurses in control rooms who monitor waits, re-triage calls, and deploy the right resource.
- Expanded defibrillator funding: boosting survival chances in cardiac arrests.
The goal is to save ambulances from being sent to every incident. This means ensuring that the most appropriate resource — whether a community responder, clinical navigator, or scheduled transport — is dispatched based on the patient's needs, helping preserve ambulance availability for the most critical emergencies.
Further refinements
In addition to separating the most urgent red calls, the Health Secretary also announced further changes to how 999 calls are categorised:
- Orange calls: A new orange category - which will be introduced this winter, will create a middle tier for time-sensitive conditions like suspected strokes. These cases require a fast ambulance response and clinical care, but crucially, the definitive treatment happens in hospital. The new system prioritises rapid assessment and transport to specialist care. Although no time target will be attached to the new orange category the average and longest response times will be recorded.
- Amber, Yellow and Green calls: these categories are under review. Amber calls - which account for round 70% of all 999 activity, cover serious but not immediately life-threatening cases, through to non-urgent issues. Patients in these categories are often referred to other services or scheduled transport, reinforcing the point that not every 999 call requires an ambulance.
Beyond the stopwatch: how to build trust in the road ahead?
The measure of success for Welsh ambulance care is shifting. It’s no longer just: “How fast did the ambulance arrive?” but “did the patient survive? Was the right care delivered? Could hospital admission be avoided?”
These questions are being tracked through new Ambulance Quality Indicators (AQIs), measuring outcomes, experience, and efficiency. But a communications challenge remains. The public are likely to still equate speed with safety. The Health and Social Care Committee warned that unless expectations are reset, people may see delays as failure — even when patients receive better care.
The Committee has urged clearer public messaging, insisting that confidence in the ambulance service is a cornerstone of trust in the NHS. Wales faces a delicate balance: reassuring the public while reshaping services around outcomes rather than stopwatch targets.
Ambulance care in Wales is no longer just about the race against the clock. It is about safe treatment, whilst using resources wisely. As the Welsh Government redefines what success looks like in ambulance care, the story of what happens after you dial 999 is becoming more nuanced and increasingly complex.
Article by Sarah Hatherley, Senedd Research, Welsh Parliament.
