Warning 999 calls 'downgraded' amid ambulance strain

The number of 'purple' 999 emergencies has doubled from 9,591 in 2018 to 19,558 last year, with 6,841 in the period from January to the end of April this year.

These are the most urgent incidents, where a patient is considered to be in an immediately life-threatening condition. Around half suffer a cardiac arrest.

From 2018 to 2020, there were fewer than five 'purple' incidents a year where the response time exceeded 60 minutes.

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By last year this had climbed to 22, with a further nine in the first four months of 2022.

For the next most serious 'red' callouts, the number of incidents where the response time exceeded 60 minutes has soared from 111 in 2018 to 510 last year, and 783 alone in January to the end of April this year.

There has also been a steady increase in the annual total of 'red' incidents, from 67,535 in 2018 to 93,483 last year, and 28,782 by the end of April this year.

The colour codes are based on a five-tier triage model introduced by the Scottish Ambulance Service (SAS) in November 2016, which grades incidents green, yellow, amber, red or purple based on risk.

Research carried out by Stirling University previously found that the system was associated with 20 per cent increase in survival for the most critically ill patients during its first full year of use.

Average, median and 90th percentile* response times are all up (*for example, 90% of purple callouts reached within 16 minutes 41 seconds)

However, there are fears that the severe pressures now engulfing the ambulance service are leading to some calls being coded at a lower risk threshold than they deserve, only to be escalated later.

The information on response times relates to the colour code assigned to an incident by the time paramedics arrived - not necessarily its initial colour.

Jamie McNamee, a Glasgow-based paramedic and Unite convenor who first joined the Scottish Ambulance Service in 1986, said: "An amber call is a serious call, and a yellow call is deemed not to be that serious, but the anecdote at the sharp end is the amber call is becoming the new yellow call. That's where it gets worrying.

"Make no mistake, people such as myself look at the yellow basket and think 'there's some really sick people in there'.

"But because they're trying to target the most seriously unwell, some of these people in the yellow basket have been waiting 24 hours for an ambulance.

"There's absolutely no doubt in my mind that people in these yellow basket calls have suffered adverse events.

"By that, I mean by a significant deterioration in their condition, or indeed they may not have made it to the hospital."

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In September last year, the Herald revealed that an investigation had been launched into the case of 65-year-old Gerard Brown, who died at home in Glasgow after waiting 40 hours for an ambulance.

Mr Brown, a cancer survivor who weighed just six stone and had a history of alcohol-related health problems, had suffered cuts in a fall, was dangerously dehydrated, and required oxygen treatment.

The investigation by the Crown Office is ongoing, but it is understood that the initial 999 call by his building's concierge was downgraded.

Problems date back to around 2015, when it became clear that the emergency service was increasingly unable to meet demand.

In Glasgow alone, it was estimated that there was shortfall of around 20 ambulances per shift.

The Scottish Government pledged to fund the additional vehicles needed, but this is being rolled out gradually as new staff are trained.

Mr McNamee said this has been partly complicated by a switch from vocational in-house training to three-year university courses, which means it take longer "to get the numbers up" on the ground.

The FOI data shows average response times for 'purple' callouts were 30% longer at the beginning of 2022 compared to 2018, with average response times for 'red' callouts up by 72%.

One 'purple' patient, categorised as being in an immediately life-threatening situation by the time paramedics arrived, had first called for an ambulance over six hours earlier.

"The big issue for us right now is the backlog in hospitals," said Mr McNamee.

"Because that ties up our ambulances outside A&E and it doesn't matter how severe a 999 call is, we can't respond."

A&E departments across Scotland have been gridlocked for the past year, despite the number of people turning up at emergency departments actually remaining below pre-pandemic levels.

Tens of thousands of patients have spent more than 12 hours on A&E trolleys - some waiting days - because there are no hospital beds available.

With A&E departments full, ambulances are forced to "stack" outside for hours waiting to offload patients.

NHS Greater Glasgow and Clyde warned this week that over 90% of its beds were full. Anything over 85% bed occupancy is considered unsafe.

On average more than one in 10 beds across NHS Scotland are occupied by a patient ready to be discharged, but unable to leave hospital - typically due to a lack of social care.

The number of beds being lost to delayed discharge increased by 50% between May 2021 and May this year.

At the same time, Covid rates have been higher over the past year than at any point in the pandemic.

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This has resulted in record numbers of doctors and nurses absent due to the infection - reducing the number of beds which can be safely staffed - as well as record numbers of Covid positive patients in hospital who must be treated in separate wards from non-Covid patients, even if they are not sick with the virus.

This means beds can be unoccupied but unavailable to new admissions because they are on a ward designated for Covid patients.

There are fears the situation could worsen in winter with a potentially record-breaking resurgence of influenza, similar to that already underway in Australia, as the same isolation protocols apply to patients who test positive for flu.

"It doesn't bear thinking about," said Mr McNamee.

One control room operator, speaking to the Herald on condition of anonymity, said the increase in red and purple callouts was also linked to people "getting sicker as previously planned operations and procedures are not being done and conditions are worsening".

But they added that the ambulance service is also dealing with an increase in mental health and welfare incidents being passed over by the police, and a "risk averse" NHS 24.

They said: "Non-clinical call takers are using a poor software system then speaking to nurses walking the floor about a patient's condition.

"Those nurses nine times out of ten request an ambulance. This practice is having a significant impact on ambulance delays and ambulance service workload.

"You can almost set your watch when things start getting busy and it is usually as GPs are starting to close around 4pm-6pm on Mondays and Fridays, but this is also when NHS 24 primarily kick in and again you can see the screens and calls filling up with NHS 24 codes.

"Their processes and the size of NHS 24 compared to SAS means that they produce a lot more calls than we can deal with, resulting in patients being delayed."

Sandesh Gulhane, a GP and Scottish Conservative health spokesman, said ambulance response times are “spiralling dangerously out of control".

He added: “The enormous rise in the number of hour-plus wait times for red call-outs is especially shocking and unacceptable.

“There’s a reason why the target response time is eight minutes – because these emergencies include suspected heart attacks and strokes.

“So there’s no question that many lives will have been needlessly and tragically lost as a result of these delays."

The Scottish Ambulance Service stressed that its current median response time for purple emergencies is seven minutes and 10 seconds, and that 30-day survival rates for the most critically ill patients are at their highest ever level.

A spokesman said: "The longer response times regarding purple and red calls relate to where calls have started as a lower call category, for example amber or yellow, and were then subsequently upgraded.

"Our response times are comparable with other ambulance services across the UK, however we continue to relentlessly look for opportunities to improve them and have recently recruited 540 extra frontline staff.”

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A Scottish Government spokesman said the pandemic has "heaped pressure on our ambulance service and wider NHS".

He added: “Since 2018/19, despite the challenges, including serving some of the most rural areas in the UK, the number of Purple incidents responded to in under 10 minutes is up by over 70% with over 99% of their highest priority calls responded to in under 30 minutes.

“Our increased investment has seen record recruitment of 540 additional ambulance staff in 2021/22 with further recruitment planned for this year, ensuring the Service is working as efficiently as possible.

"Staff cover levels have shown a sustained improvement over the last few weeks which has allowed SAS to step down from the highest level of their escalation plan.”