BEHIND THE HEADLINES: Is our ambulance service in Wales in crisis?

DELIVERING the very definition of frontline care to patients, ambulance services are rightly subject to a high degree of scrutiny.

Attending patients in often extreme situations in terms of their health - where time is of the essence in providing initial treatment and transferring them to hospital for that to continue - is a high profile, high pressure responsibility.

It also makes the ambulance service, for better or worse, the most regularly kicked of NHS political footballs, fair or unfair game for AMs and MPs to squabble over publicly.

Wales' ambulance service is regularly squabbled over, for reasons that hit the headlines on an almost weekly basis.

The past couple of weeks have provided rich pickings, with another set of poor, albeit slightly improved, emergency response time figures, followed by the revelation - exclusively revealed in the Argus - that staffing shortfalls mean private ambulances must be used to respond to some emergency calls in South East Wales at weekends this month.

Throw in the threat of industrial action by members of some staff unions, and it is little wonder the spotlight shines harshly at the moment.

Politicians have had plenty to say, and before the end of September there will likely be more robust debate in the Senedd.

Toward the end of June, health minister Mark Drakeford informed AMs that he had told Welsh Ambulance Service NHS Trust (WAST) chiefs and trade unions he expected "an urgent improvement over the next three months."

That followed publication of a particularly dismal set of emergency response time figures for May, when Wales-wide just 54.1 per cent of responses to category A emergency calls arrived on scene within the standard eight minutes.

The target is 65 per cent, but this has proved particularly elusive in the past couple of years, being achieved just once.

In Gwent in May, fewer than half (49.1 per cent) of category A calls received an on scene response inside eight minutes, but in individual areas some results were much worse. In Blaenau Gwent it was 40 per cent, in Monmouthshire 42.4 per cent, and in Torfaen 45.9 per cent.

Things have improved. In July, all-Wales performance against the eight-minute standard was 58.3 per cent. In Gwent it struggled to up to 52.2 per cent, and while performance improved in all five of Gwent's council areas, in some it was negligible.

Professor Drakeford then, will be able to say performance has improved, but opposition AMs will be lining up to ridicule any suggestion that the situation is stabilising.

Another issue he will have to address is the use this month of private ambulances to help with responses to emergency calls at weekends in the South East Wales region.

This is the first time the private sector has been called upon in Wales to help with emergency responses, due to a shortfall in staff to fill weekend rotas, and the issue has been seized upon by opponents of the Welsh Government.

The trust is recruiting extra staff as part of a recruitment drive which has recently seen the appointment of more than 80 extra staff into the workforce, including in the Emergency Medical Service, Patient Care Service, Urgent Care Service and NHS Direct Wales, and a number of paramedics who graduated in July, are also expected to be operational from December.

Whether the current weekends shortfall is a workforce planning issue, or hints at something deeper in terms of staff morale and disquiet is difficult to fathom.

The Welsh Conservatives' shadow health minister Darran Miller AM has called for a statement on the issue from First Minister Carwyn Jones, though the task is likely to fall to Professor Drakeford, while Welsh Liberal Democrat leader Kirsty Williams AM has urged the Labour administration to "come clean on the NHS in Wales."

ANOTHER issue demanding clarification is why the eight-minute response time target is still being used as a monthly performance measure 16 months after the McClelland Report into problems within the Welsh ambulance service, suggested it be scrapped.

It took almost a year for WAST and the Welsh Government to announce the testing of new measures of performance from April this year, putting stronger emphasis on the quality of patient care and outcomes.

Speed remains a key factor for paramedics attending suspected heart attacks and strokes, linked more to ensuring patients reach the appropriate hospital for scans and treatment as quickly as possible.

Ambulance service performance in dealing with patients with fractured hips is also being measured differently, focusing on pain management and pain relief.

Work with heart attacks is focusing on a particular type, known as a STEMI, in which a blood clot develops in a blood vessel in the heart.

The aim is to develop a target including elements such as arrival at the scene, patient assessment, preparation for and delivery of a clot-busting drug, and how many patients receive this within an hour.

Five months on, there has been no published indication as to progress, while details of performance against eight-minute target - branded as "useless" by staff union Unison Cymru and described in the McClelland Report as a "very limited" way of judging performance - are still issued every month.

ANOTHER issue affecting ambulance service performance in Wales, one that again has proved difficult to manage, is handover times at A&E departments.

Ninety per cent of patients should be switched to the care of hospital staff inside 15 minutes.

Thousands of ambulance crew hours are lost every year in Wales by handover delays, and A&E departments in Gwent, particularly at the Royal Gwent in Newport, have struggled with this.

Handover times consistently suffer during busier winter periods, but even at other times, they can fall well short of the target.

A&E at the Royal Gwent, always a busy department, has achieved an average of around 50 per cent of handovers within 15 minutes this year, while at Nevill Hall, the 70 per cent mark was reached in May and June.

The result can be several ambulances backed up outside A&E, because crews cannot formally hand over patients.

In Gwent, additional nursing staff have been deployed in A&E units, specifically to receive and care for ambulance patients when the department is congested.

Aneurin Bevan University Health Board has also led a pilot scheme through which GPs have been placed in ambulance control, to direct on-scene crews on whether or not patients need to be taken to hospital.

It has also run its own 'save A&E for when you need it' campaign alongside Wales-wide awareness drives, encouraging patients to use emergency services appropriately, to ease pressure on ambulances and hospitals.

UNION disquiet at ambulance service management in Wales, and in other parts of the UK, surfaces periodically.

Last week the GMB, which represents around 1,000 Welsh ambulance staff, announced that its members had voted in principle for industrial action.

Unite, another union representing ambulance staff in Wales, has also asked its 500 members in the service if they would support such action.

Formal balloting will be required, and the GMB is also looking for a vote of 'no confidence' in WAST management. But that the matter has gone this far is yet another headache for management and the Welsh Government.

Long hours, meal breaks and training are among the key areas of concern.