Delays across the NHS are no longer exceptional events. For many care providers, they are now a routine operational reality. Ambulance waits of many hours, sometimes extending into days, delayed access to urgent diagnostics, and prolonged waits in emergency departments are increasingly common. These delays are not simply inconvenient. For older people, those living with frailty, dementia, osteoporosis or multiple long-term conditions, delayed urgent care can result in avoidable harm, deterioration and, in some cases, death.
For providers, this creates an uncomfortable and often distressing position. You hold responsibility for people’s safety and wellbeing, yet you are increasingly reliant on a health system that cannot always respond in a timely way. Providers are left managing clinical risk in environments that are not designed to replace urgent healthcare. The question many are now asking is not whether delays exist, but how to respond to them safely, lawfully and proportionately, while avoiding being held responsible for failures that sit outside their control.
This article examines how providers can navigate NHS delays in urgent situations, using a real-world scenario as a lens, and sets out what good practice looks like from both a care and a regulatory perspective.
A scenario many care home providers will recognise
A resident falls. A fracture is suspected. The resident is in pain, immobile, distressed, and at risk of deterioration. An ambulance is called, but the response time is given as 48 hours.
This is no longer an outlier. Providers across the country report similar cases. While alternative falls response services exist in some areas, a suspected fracture is time-critical. A delay of this length is clinically unsafe and should not be accepted as normal.
At this point, the provider is carrying significant risk. Staff must manage pain, maintain dignity and safety, prevent secondary harm such as pressure damage or delirium, communicate with family, and escalate concerns, while being acutely aware that outcomes may later be scrutinised by commissioners, safeguarding teams or regulators.
Systemic pressure, not care home provider failure
It is essential to recognise and articulate that these delays stem from systemic pressures rather than individual or organisational neglect. Ambulance delays are closely linked to overcrowded emergency departments and delayed hospital discharges. Thousands of people who are medically fit to leave hospital remain in beds because of gaps in community provision. This often results in the usual scapegoating of social care as cited in the media by officials, which many providers do not agree with. The more likely cause of delays is the underfunded and under-resourced public sector commissioning of adult social care in the community, which in turn prevents ambulances from handing over patients and responding to new calls.
The Care Quality Commission has described the urgent and emergency care system as effectively gridlocked, with people harmed by delays beyond frontline staff’s control. Care providers are increasingly absorbing risk created elsewhere, often without the clinical authority or resources to mitigate it fully.
This context does not remove a provider’s duty of care, but it is critical to understanding where responsibility lies. Regulators are not expecting providers to replace the NHS. They expect providers to recognise when risk has escalated beyond what can be safely managed in a care setting and to act accordingly.
Practical steps care home providers can take
- Understand and use local response pathways appropriately
Providers should be familiar with local urgent community response options. In some areas, ambulance services work alongside fire services, community responders and specialist falls teams to provide rapid assistance where hospital transport may not be required.
These services can be invaluable for non-injurious falls or situations where a person needs help getting up, assessment and reassurance. However, providers must be clear that they are not appropriate when a fracture is suspected or confirmed. Accepting a lower-level response in a high-risk situation may expose the resident to harm and the provider to criticism.
- Manage immediate risk while awaiting clinical input
While awaiting emergency services, providers remain responsible for minimising harm. This includes:
- Keeping the person warm, comfortable and reassured
- Avoiding movement or repositioning where a fracture is suspected unless clinically advised
- Monitoring pain, consciousness and signs of deterioration
- Taking steps to prevent secondary harm, such as pressure damage, dehydration or distress
Pain should never be ignored, but providers should avoid repeatedly administering PRN medication without clinical advice, particularly when this may mask deterioration. If delays are prolonged, urgent clinical advice should be sought to support safe pain management.
- Re-escalate and request clinical re-triage
Ambulance triage decisions are not fixed. If a delay is unsafe, providers should re-contact 999 and request re-triage. This should be done clearly and assertively, stating:
- That a fracture is suspected or confirmed
- That the person is in pain, immobile or deteriorating
- That remaining in the setting without urgent transfer is unsafe
Providers should explicitly request escalation to a senior clinician where appropriate. Accepting a 48-hour delay in a time-critical situation without challenge may later be difficult to justify from a safeguarding or regulatory standpoint.
- Involve the GP or out-of-hours service early
GP involvement is often pivotal. A GP can provide assessment, advise on pain management, confirm whether hospital transfer is required, and facilitate escalation with ambulance services. Written or clearly documented clinical advice that urgent hospital transfer is necessary can carry significant weight.
This also demonstrates that the provider has sought appropriate clinical input rather than managing the situation in isolation.
- Alternative transport only with clinical agreement
In exceptional circumstances, and only when clinically agreed to be safe, providers may need to consider alternative urgent transport options, such as patient transport services or, rarely, a private ambulance.
Providers should never attempt to move someone with a suspected fracture without explicit clinical advice. Any decision to use alternative transport must be proportionate, clearly justified and carefully documented.
When delay becomes a safeguarding concern
Where access to urgent care is significantly delayed and the person is at risk of avoidable harm, it may be appropriate to treat the situation as a safeguarding concern.
This is not about assigning blame to emergency services. It is about recognising that a vulnerable person is exposed to escalating risk due to a system failure and that additional oversight or escalation is required.
Appropriate routes may include:
- The local authority safeguarding adults team
- The Integrated Care Board urgent care lead
- NHS 111 with a request for clinical escalation
Escalation helps protect the individual and ensures the provider is not left to bear intolerable risk alone.
Documentation as protection, not bureaucracy
Clear, contemporaneous documentation is essential. Providers should record:
- The time and circumstances of the incident
- All contacts with emergency services, including reference numbers
- Clinical advice received and from whom
- Observations of pain, mobility and deterioration
- Actions taken and the rationale for decisions
Good documentation shows that risks were recognised, escalated and managed appropriately, even when outcomes were affected by system-wide failure. It protects residents, staff and organisations.
Avoiding the blame trap
Regulatory concern rarely arises from delays alone. It arises where providers appear passive, poorly documented, or slow to escalate.
Providers should avoid:
- Normalising extreme delays
- Leaving residents in unmanaged pain
- Attempting unsafe movement without advice
- Failing to challenge clearly unsafe response times
What regulators expect is professional curiosity, proportionate escalation and evidence-based decision-making in the person’s best interests.
A shared system problem
Care providers are increasingly bearing risk that properly belongs within the wider health and care system. This is neither sustainable nor fair. Providers should continue to raise these issues collectively through representative bodies, commissioners and system partners.
In the meantime, providers must protect the people they care for now. Acting early, escalating clearly, seeking clinical input, documenting thoroughly and using safeguarding routes when necessary are how providers protect residents, staff and services in a system under strain.
A resident with a suspected fracture should not have to wait two days for an ambulance. Providers are right to challenge this, and they should feel confident doing so.
References:
- Care Quality Commission. State of Care 2022/23. CQC, 2023.
- NHS England. Urgent and Emergency Care Recovery Plan. DHSC, 2023.
- National Institute for Health and Care Excellence (NICE). Falls in older people: assessing risk and prevention (CG161).
- Royal College of Emergency Medicine. RCEM Report on Ambulance Handover Delays, 2022.
- British Geriatrics Society. The Care of Patients with Fragility Fracture, 2021.
- UK Health Security Agency. Safeguarding adults in health and social care, guidance.
- Care England. Hospital discharge and social care capacity briefings, 2022–2024.
Lucy Corner is Director of Cornerstone Care Solutions Limited, a UK-based consultancy working across health and social care to support providers dealing with risk, complexity and system pressure. Cornerstone supports organisations in periods of challenge and change, helping them stabilise services, strengthen governance and make safe, defensible decisions when the system around them is under strain.
Lucy is a dual registered nurse (Adult and Mental Health) with postgraduate qualifications in leadership and management. Her work spans community, residential, nursing and specialist services, and regularly involves safeguarding, serious incidents, regulatory engagement and escalation where system failures place people at risk. She works closely with providers, commissioners and national bodies, bringing a practical, frontline-informed perspective to policy and operational decision-making.
This article reflects Lucy’s professional experience and perspective. It does not constitute clinical advice.