The North West Ambulance Service has failed to meet a number of its call-out targets as it heads into a Covid winter.
Last month, amid a big spike in 999 calls and the first pressures of a winter exacerbated by the pandemic, the service was among the worst-performing nationwide in terms of patient waiting times following a call-out.
The NHS England figures do not reflect on the standard of care patients received on paramedics' arrival and NWAS bosses, who have implemented a range of measures to improve performance, say November's performance has been better.
In October, although patients requiring ' category one' care - for life-threatening injuries and accidents - were responded to in an average of just over eight minutes, this was still above the seven-minute target and higher than last year's average.
However, figures for 'category two' call-outs - emergency patients suffering, for example, a stroke or chest pain - show an average wait of nearly 46 minutes, much longer than any other service in the country. That compares to 26 minutes last October.
The aim is to respond to these calls within 18 minutes.
The England average last month was 25 minutes. NWAS was the worst-performing in this category and the next highest time was in the North East, where the service recorded an average of 32 minutes.
Category three call-outs - for urgent situations such as abdominal pains - should be responded to at least nine out of 10 times within two hours.
In October, the nine-out-of-10 figure for NWAS was five hours and 36 minutes.
In October 2019, the service got out to these patients in one hour and 29 minutes on average. This year, it was two hours and 18 minutes.
The England average last month, meanwhile, was one hour and 10 minutes. NWAS was the worst-performing in this category; the next longest wait was one hour and nearly 58 minutes, again in the North East.
Earlier this month, the North West Ambulance Service declared a major incident after staff were overwhelmed, with reports of up to 12 vehicles queuing outside A&E departments in Greater Manchester.
The service has launched its own investigation but has already said they saw 36 per cent more calls than they would have expected. Bosses have implemented a number of measures with the aim of preventing a recurrence.
Although the major incident was undoubtedly an isolated event, the delays outside hospitals are not. In just one week in October, for example, 104 hours were lost across three hospitals to delays in patient hand overs from paramedics to Emergency staff.
And the Manchester Evening News has spoken to medics who say the causes are 'system-wide', with this year's winter pressures exacerbated by Covid-19 testing obstructing the 'flow' of patients through hospitals.
This overcrowding, at times leading to corridor care, is thought to contribute in delays to handover time - the gap between arrival at hospital and the patient being passed to into the care of Emergency department medics - resulting in less resources to respond to new 999 calls.
Medics say these factors are exacerbating a service also dealing with more patients than usual; here was a 9 per cent increase in 999 calls in October compared to the same month last year.
The Manchester Evening News has spoken to paramedics reporting growing pressure during their shifts, which are often 12 hours long, compounded by staff absence due to self-isolation.
One paramedic said: "We always get winter pressures from October to January but on top of that there's Covid and the workload is more.
"I've never known it to be this busy before. Sometimes I get home and cry. We're all human and we deal with a lot of emotional things. But you just have to carry on. It's a very physical job that we do. People get tired but we all cart on, we all know we've got patients to deal with and that's really important. We always put them first."
NWAS have recruited an extra 180 call handlers and support staff since the first wave of the pandemic - with plans to recruit a further 123 this winter, including clinicians to give medical advice to crews on the road. They are also adding 100 ambulances to their fleet.
What the North West Ambulance Service says...
Ged Blezard Director of Operation at NWAS, said: "The North West Ambulance Service is consistently one of the busiest ambulance trusts in the country, nevertheless, in October demand rose by more than 15pc compared to the month before.
"We took almost 148,999 calls, which also represents a 9pc increase on October 2019.
"Of those calls, more than 9,000 were category 1: life threatening incidents, requiring the most urgent response.
"NWAS dealt with the most category one incidents out of any ambulance service in England, during the month of October."
He said an increase in demand for the most serious incidents may unfortunately mean longer waits for other patients, adding: " Coronavirus also created staffing challenges with a number absent or self-isolating.
"The trust is working extremely hard to mitigate these pressures."
He said they had recruited people into the call centre and were putting more ambulances on to the roads, adding: "We have pulled additional support from our patient transport service and from additional private providers and St John Ambulance.
"We have also invested in our Clinical Support Hub as we try to treat people over the phone reducing the number of incidents that require and ambulance response, and we lead the way on this nationally.
"We are pleased to see that these actions have had an effect on our performance this month. In addition to this, we would like to thank the public who have heeded our messages about when they should call us, and using other services, including 111 online."
