12 hours on ambulance frontline with ‘the one service which cannot say no’

Pulling out of a busy south London A&E in the middle of a 12-hour day shift in mid-August, paramedics Harriet Walton and John Chilvers are one of the only free crews in London.

With July’s ambulance response times for the most urgent 999 calls the worst on record and 152,000 ambulance crew hours lost to delays in June, this summer has exposed the extent of the problems facing the ambulance service, with all 10 trusts put on “black alert” in what is traditionally a quieter season.

Response times have collapsed – with some patients waiting several hours following a 999 call and 4,000 patients estimated to have come to severe harm due to handover delays in June – prompting health leaders to warn that the delays are the “biggest” safety risk facing the NHS.

As news of the crisis dominates headlines, The Rustwire was given exclusive access to join two London Ambulance Services senior paramedics.

Grappling with the consequences of a broken social care system and a backed-up NHS, they say they the pressure is mounting because they are “the one service which cannot say no”.

‘A last resort’

The start of the shift is eerily quiet and the pair from Brixton Ambulance Station begin their day with an unusual silence from the dispatch team. 

But the 20 minutes of stillness is just the calm before the storm as the first Category Two alert comes in – a man with a severe mental health condition in crisis.

Blue lights turned on, and we soon arrive at the door of the patient.

Ms Walton, who is aged just 21, and Mr Chilvers 27, speak calmly to the man who is agitated, incoherent and delusional, but the pair work quickly to assess the risk he poses to himself. 

As his behaviour escalates, they are reluctantly forced to call for police assistance and an advanced paramedic to help take the man to hospital.

The differing priorities of the police force and paramedics are clear as the officers question whether it’s possible to leave the man.

A mixture of drugs and his worsening mental health means he must be assessed at hospital but without access to a number for his community mental health team, A&E is the only option.

The decision to call the police to restrain the man is not taken lightly but he ticks all the markers on his own care plan for needing hospital assessment. 

It is a difficult situation to watch, as he is eventually restrained by six officers and taken with his head down into a caged police van.

The paramedics are able to calm him and he is taken to King’s College Hospital A&E which is near The Maudsley mental health hospital. 

A dissonance of beeps, alarms, shouting and scurrying clinicians meet the team at an ambulance bay at the hospital, which is already full with three ambulances waiting to hand over patients. 

While he waits, the patient deteriorates again.

Three hours have passed between the first dispatch call to when he is eventually handed over to A&E teams – and these calls can happen at least once a day.

Covid hasn’t gone away

Upon leaving King’s College emergency department, a hospital announcement warns that one ambulance has already been waiting for four hours to hand over a patient and another has waited for two.

One crew who had taken over from another were yet to see any patients that morning and instead started their shift watching the doors of an A&E ambulance bay for a chance to hand over. 

Just 250 ambulances were available that day. Although that is more than the 156 from the night before, that figure is almost half of what is needed, The Rustwire understands.

At 12pm we are the only ambulance available for dispatch in the city. 

The calm of the morning becomes a distant memory as another “Cat Two” call comes in – a Covid-positive patient struggling to breathe. 

The pandemic hit the NHS like a big red bus this summer at a time when calls to ambulance services have gone through the roof.

While the country continues to “live with Covid” the virus is still creating demand.

As a bystander, it is unnerving to enter the house of a Covid-positive patient, but Harriet and John are unphased and assess the woman.

Although her Covid symptoms are nothing to worry about, an underlying health condition forces the crew to take her to A&E.

The wait is quicker this time, but the King’s A&E is busier, with patients everywhere, while the same ambulance crew we left behind 90 minutes ago are only just leaving.

Fighting wider failures 

Paramedics, by the very nature of their job, come into contact with all facets of life and see first-hand how deprivation and social inequalities shape people’s health.

After two years of pent-up health issues and as the NHS tries to tackle its mammoth backlog, they see patients who are seriously ill and who need urgent care because their condition has been left unaddressed.

Callouts to people whose primary problem is not a health issue but is instead a result of poor social housing, inadequate care homes or care packages are common.

The ambulance service, which is meant to be for emergencies first, is just another part of the NHS picking up the slack of a broken system.

During our third call, we visit a man with learning disabilities, who is bed bound and visibly unwell.

This was not the harrowing story of a neglected care home resident but an example of a caring environment where the man’s young care worker shone.

Discussing his patient with the paramedics, the carer lamented the red tape and funding problems that have prevented his patient from being moved into a home which can better support his needs.

Like so many within the care industry, he is considering leaving the job over unsustainable wages.

As the NHS face unprecedented pressure, good care staff can often be the difference between taking a patient to hospital and keeping them at home.

‘No beds left’

We end the shift with a woman who has multiple health conditions, a mental health diagnosis and a complex social situation. 

As we’re let into her home, she’s in a vulnerable state and crying in pain. 

She is the last patient of the day, and we ferry her to Lewisham A&E, where eight ambulances and several police cars are queuing outside. The corridor is littered with 12 patients in chairs, others are wheeled in on trolleys, every cubicle is full and there are no beds. 

The site could have been mistaken for a police station with the number of officers accompanying drunk patients and people in mental health crisis. 

One officer says he spends at least two shifts a week at the A&E.

Luckily the patient with us is “fit to sit”, and we’re able to hand her over to hospital staff, leaving scores of patients and ambulance crews in our wake.

Exhausted after 12 hours, I leave with a renewed appreciation for our frontline NHS staff.

“We cannot say no”

“999 is for life-threatening emergencies”, Harriet and John tell The Rustwire after their gruelling 1-hour shift.

The pair say this with no judgement of their patients, their job is to attend regardless of the person at the end of the call. They are passionate about their roles and want to help people in their time of need.

However, like many paramedics, much of their time is being spent on calls which are not lifesaving.

Most of the calls attended that day were labelled “category two” with patients listing symptoms of “breathing difficulties”, “chest pain” and “numbness”.

However, for at least three of the calls outs, members of the public might rightly question whether the patients needed an ambulance.

John says: “A lot of our problems are caused by social care and the underfunding in it. The A&Es are busy because they can’t move people on to the wards and the wards are full because they can’t get people into social care”

He adds: “We’re the one service which cannot say no” he adds.

“If someone calls 999 and says they’re having breathing problems we have to go. You just don’t know [because] there’s so many patients we go to and if we got there ten minutes later they would’ve been dead.”

Calls from people who don’t need an ambulance put more pressure on call centres. During the height of the heatwave in London, the wait for some 999 calls to be answered reached 10 minutes, The Rustwire understands, whereas the target is for calls to be answered within 60 seconds.

Each ambulance dispatched to a patient who could make their own way to A&E, or could wait for a GP appointment, is one ambulance that cannot be sent to a dying patient.  

After two years of pent-up health issues delayed from treatment due to the pandemic, some patients are seriously ill and need urgent care because their condition has been left unaddressed.

“Covid is on the rise, hospitals are so busy, GPs are so busy, so people are calling an ambulance to have a clinician see you at home, I think we’re fighting the effects of so many people who weren’t going to hospital their appointments were cancelled, and their health suffered and so now we’re seeing the effects of people not being seen.”

“We’re seeing loads of conditions picked up late, cancers being picked up late, people suffering from high blood pressure, so more people having heart attacks and strokes,” says Ms Walton.

Both paramedics outline the need for more funding.

Mr Chilvers adds: “We need more funding. For those life-threatening emergencies to whom we are not getting there quick enough. For stroke patients millions of neurons are dying every minute we don’t get you to hospital and the later we get you to hospital the longer it will take for your recovery.

“If we get to you several hours later, you might not get the movement in your hand back and we’re not getting there for these people. These people that have waited a long time there will be people that are really ill and people that are fine. Actually, the majority can wait a bit longer.”