A senior paramedic has described the relentless pressure facing the Welsh Ambulance Service as it deals with one of the busiest periods in its history.
Dermot O'Leary, who covers Conwy and Denbighshire, said the service has had to deal with a "tidal wave" of patients over recent weeks, particularly since Wales went into alert level zero in August.
He said crew members are having to deal with excessive amounts of non-urgent calls for treatment, such as chronic knee or back pain, as people struggle to access their local GPs. He said this issue is having a knock-on effect on reaching those most in need.
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The experienced medic, who is also a duty operations manager for the region and is responsible for staff welfare, admitted the biggest frustration his colleagues face is handover delays, where ambulances spend hours waiting outside A&E unable to offload their patients into the department.
In August the Welsh Ambulance Service recorded its second worst response times to immediately life-threatening 'Red' calls since new targets were introduced in 2015. Just over half (57.6%) of these calls arrived on scene within eight minutes last month - way below the target of 65% which has not been met for over a year.
On Wednesday Health Minister Eluned Morgan admitted current pressures on the Welsh Ambulance Service are "worse than anything we've seen", but rejected calls from the Welsh Conservatives to declare an emergency.
"[These pressures] are not new and they've been going on for some significant time. We had hospital delays prior to Covid, and we had issues about our response times which were well documented in the public environment," he said.
"But what we're seeing now is an increase in, for want of a better phrase, non-availability of other services and other pathways to us that we would have disposed patients to, as a result of Covid.
"Staff are doing the best they can with the resources we've got against the pressures that we're facing now. But if you have 50 or 60 calls and you don't have 50 or 60 ambulances, then there inevitably is going to be a delay, unfortunately."
During the first wave of the pandemic when lockdown first hit, Dermot said that their call volume went "through the floor".
"There were no issues in A&E, waiting rooms were empty, the patients you were talking were the ones who needed the ambulances and you'd have no issues with offloading," he recalled.
He said the second wave was expected to be the same as the first, but call volumes were sustained and never really subsided.
"Then in the third wave - and especially as the 'staycations' increased and the footfall in north Wales increased - so did the volume of calls," he recalled.
"In my area of Denbighshire we've got some fantastic scenery and facilities on our doorstep; beaches, mountains and so on. And quite rightly everybody, if they can't go overseas, stayed in places like this. But call volume for 'Red' alone in the north region was at least 50 or 60 ahead of our next busiest area - and that includes places like Cardiff and Swansea."
Dermot added that even though many aspects of life were returning to normal, the same cannot be said for the Welsh NHS which is still having to contend with both Covid and routine elective care.
"As 'normality', shall we call it, has returned slowly, a lot of the facilities and services that were there pre-pandemic aren't back on line yet," he said.
"And we tend to become the default position. So if someone can't get an appointment with their GP, they phone an ambulance. If somebody can't get the advice or the help and support they need, they phone an ambulance.
"Our 111 service has just gone through the roof as well, so overall the ambulance service has been trying to manage an ever-growing tide [of patients]. Every single call that comes into the 999 system just puts pressure on the control rooms as well.
"The ambulance service should be there for heart attacks, strokes, trauma; the bits that an ambulance service is perfect for. What we're not there for, and what we're not designed for, is providing long-term medical care to people because other services aren't available."
Dermot said staff across the Welsh Ambulance Service are feeling an ever-growing frustration towards handover delays. The service's director of operations Lee Brooks said in the second week of September alone in excess of 3,700 'ambulance hours' were 'lost' across Wales outside hospitals.
He added that a significant reduction in the number of community hospitals and residential homes in Wales has also contributed to demand soaring on acute care.
"[In the past] you'd do 999 calls, but you'd get a little bit of downtime and have a little break between things. When you arrived at hospital there was no such thing as a wait - you went in with your patient, you went into the cubicle or room, you offloaded them and away you went. Those days unfortunately are gone," admitted Dermot.
"Every single one of the hospitals we go to these days you end up waiting - and that's not having a pop at the hospitals as they've got their own pressures and their own issues.
"But the ambulance service provides emergency medical treatment and help to the people of Wales. In order to help us do that we need to be able to effectively reach a patient in a timely manner, get to A&E if that's where all the specialist help is going to be, and offload in a timely manner so that we can be back out and ready to go for the next call."
Dermot said it would be wrong of him to comment on general staff morale, but added that the issues on demand need to be tackled NHS-wide.
"It's got to be everybody within the healthcare system from the hospitals, to GPs, right down to people themselves who have got to take ownership and responsibility," he said.
"If we all start thinking in terms of 'do I really need to do this?' or 'should I do that?' as opposed to the default 'yeah, I'll phone an ambulance' I think we'd have fewer problems."
As Covid-19 is still a major part of their workload, Dermot said it was not unusual for an ambulance to be taken out of action for as long as an entire day to be deep-cleaned.
"We have a process where if there's been what we call an AGP - or aerosol generating procedure - carried out on the back of that vehicle (so cardiac arrests and stuff like that where there's a lot of spray, blood or body fluid) then the backs are closed down, equipment used is bagged and tagged, and then we have arrangements to move it to one of our 'make-ready depots' just further on north-east Wales where they will then do the cleaning and then ship it back.
"So it is possible you'll lose an ambulance for - depending on the time of day, of course - possibly 24 hours."
Ahead of the typically hectic winter period, the Welsh Ambulance Service is seeking help from the military to drive its vehicles.
Dermot admitted: "It's a difficult road to go down, but the trust have a real dilemma on their hands. We can't continue if we don't have staff to be able to man and drive the ambulances, and if a way around it is to get help from the military then it needs to be done.
"We have a duty of care to people and if we have to deliver that care by any means, then we need to do it."
Dermot, who added that abuse against frontline staff has risen considerably over recent months, urged people to call for an ambulance only when they really needed it.
"Choose wisely and take responsibility for your own health," he added.
"If you've got coughs, colds, sneezes and so on, 999 is not the way. If you think you need a course of antibiotics, and your GP is unwilling to give them to you, it's for a good reason. Phoning an ambulance for those sorts of things isn't going to help anybody.
"We quite often will get calls for toothache, cat scratches, problems that have been there for weeks, months, possibly even years. We need to be freed up for the people who have stopped breathing, gone into cardiac arrest, or there's been a horrific accident and there are two or three people trapped in the car."
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