Concerns about stroke patients making their own way to hospital

Despite a drop in the number of patients being taken to hospital by ambulance, the service covering Staffordshire and Stoke-on-Trent is still failing to meet response time targets and facing challenges including handover delays.

Senior representatives of West Midlands Ambulance Service (WMAS) said the number of “self-presenting” patients arriving at hospitals by their own means, instead of travelling by ambulance, has started to increase. And they were particularly worried about those with more severe conditions taking this route.

The service is calling for an independent review of resources in a bid to improve its performance. Members of Staffordshire County Council’s Health and Care Overview and Scrutiny Committee backed this call at a meeting this month.

Vivek Khashu, strategy and engagement director at West Midlands Ambulance Service (WMAS) spoke of the number of self-presenting patients attending hospitals. “A lot of organisations report that’s started to increase”, he said.

“The other thing that’s been changing is of those who self-present, a lot of people report they’ve got more dependency and would be sicker. Our activity is coming down over a sustained period because we’re finding alternative pathways for patients – how patients are choosing to vote with their own feet and how they’re interacting with the system does merit exploration.”

Mark Docherty, who was executive director of nursing and clinical commissioning at WMAS before he retired earlier this year, said: “The ones we’re really worried about are the ones who self-present with very serious conditions; the people who should have gone in by ambulance had the ambulance service been able to provide a quicker response. We know that some patients who have a stroke are making their own way.

“If they drive themselves, that’s hugely dangerous. Even if they’re driven, if something catastrophic happens on route, they’re on their own.

“What we would ideally like is a more responsive service for people that absolutely need an ambulance. And better alternatives for people that don’t need either an ambulance or an acute hospital.

“Things always get more challenged over the winter – not just handover delays but response times, activity and nature of patients. The question for me is why we cannot get back to the pre-Covid performance that we saw.

“If you think of handover delays we thought were bad pre-Covid, we would be delighted if we got back to the pre-Covid levels. We can’t explain the whole reason why we can’t get back as a system to how we were performing pre-Covid.

“If we rewind to pre-Covid, your average ambulance was doing seven or eight jobs in 12 hours. The Staffordshire average now is 3.2, so we’ve lost huge productivity and that has a massive impact on performance.

“One thing we are pursuing with commissioners is doing an independent review of what resourcing needs to be in order to get much better performance. We last had an independent review in 2009 and we know even from that that it’s really difficult to guarantee fast response in all rural areas at a price that’s reasonable for a cash-limited system.

“We want to get an independent review that presents scenarios – what it could look like within the current resource and what would it need to look like in order for better performance at pre-Covid-type levels. The commissioners have already sort-of indicated that they don’t anticipate the issue of handover delays suddenly improving.

“It feels like we’ve got to work with this one. If we’ve got to work with it we’ve got to make sure it’s resourced appropriately.”

Ambulance handover delays are currently on the rise this year, the committee heard, and the service experienced high levels last winter. Mr Khashu said: “Members will know that there has been a very difficult situation when it comes to handover delays and we are on an upward trajectory in that regard, which is a matter of concern.

“You can see the effect the lost hours have had on response times across the patch. In Stoke-on-Trent and Staffordshire, prior to the beginning of January 2021, we were there or thereabouts on the response time standards and they have deteriorated as the lost hours increased and improved as they have come down.

“The Government moved the Category 2 (response to time-critical medical emergencies such as heart attacks or strokes) standard to 30 minutes for this year. The country isn’t meeting the standard.

“North West Ambulance Service were there or thereabouts, we’ve been not far behind them and the rest of the country has been considerably some way down. We’re the higher end of response times, but we’re not currently meeting the 30-minute standard.”