When ambulances queue at hospital EDs, waiting to offload and transfer rather than racing to the next call, it’s more than a logistical inconvenience —it’s a symptom of a stretched, fragmented, and failing system. Recent data, political commentary, union activism and media reporting show the problem has been worsening across every state and territory, and becoming more visible. It’s increasingly recognised not just as a hospital or paramedics’ issue, but as a systemic failure with real implications for patient safety, workforce morale, and health system credibility.
In South Australia, the latest figures highlight this tension quickly starkly. In September 2025, 4,557 hours were “lost on the ramp” across Adelaide’s public hospitals, which was a dramatic rise from 3,106 hours a year earlier, as reported publicly.
Viewed through the national lens, ambulance ramping is a symptom of deeper distortions. Constrained inpatient capacity, exit block (patients who cannot leave hospital because of lack of post-acute, community or aged-care services), disjointed care pathways, and insufficient integration between acute, primary, and aged care systems. The consequences of this disorienting cocktail of deficiencies then ripple outward. This results in delayed care, overburdened paramedics, increased clinical risk, and growing public frustration.
In this article we look at how ramping plays out in different states, surface structural drivers, and propose strategic directions for healthcare leaders to consider —because this is not merely a paramedic problem, but a system design challenge requiring cross-leadership across silos.
Snapshot by State: Common Themes, Varied Intensities
While data consistency is a limitation (definitions of “ramping” or transfer delays differ across jurisdictions), the patterns are consistent: every state is under strain and many are considerably worse than they were five years ago.
New South Wales
NSW has seen improvement in some hospitals, for example, St George, Blacktown, Campbelltown and Liverpool have reported substantial gains in transfer times over the past year.
Yet more broadly, emergency departments remain under pressure, and paramedics report that ramping is eroding system responsiveness outside of the metropolitan hubs. The gains that are seen suggest targeted interventions can move the needle, but they must be scaled systemically.
Queensland
Queensland’s challenge is perhaps among the most acute. The state has not met its 30-minute offload target for transfer of care for nearly a decade.
In some hospitals, nearly half of patients are reported to now wait beyond 30 minutes for transfer. The number of calls requiring ambulance response is also rising, which compounds the logjam. Queensland’s situation illustrates how growing demand can directly exacerbate structural bottlenecks.
Western Australia
Western Australia recently broke some records. In September 2025, ambulances spent more than 7,257 hours ramped —a new high. Here, the state’s low hospital bed base (relative to population) further exacerbates the problem. Public discourse has shifted toward accepting that until deeper fixes occur, ramping must be “made safer.” Health sector unions have proposed plans including the rapid addition of aged care beds, guaranteed staffing, and diversion protocols.
South Australia
As already noted, ramping in Adelaide remains stubbornly high despite efforts. The state government has introduced 120 transitional care beds, but the AMA cautions that such beds are a stopgap, not a durable solution. The SA Health “Ambulance Ramping Review Report” further recommends strengthening clinical accountability (e.g. a senior ED clinician directly assessing offloading vs ED waiting) and a risk-based patient flow strategy across the continuum of care.
In a recent coroner’s inquest in South Australia, ramping was formally recognised as contributing to loss of life, prompting 18 recommendations to not only to reduce ramping, but to make temporary conditions safer (including improved observations, alarm systems, dedicated ramp areas).
Tasmania, ACT, Northern Territory
While less frequently cited, these jurisdictions are not immune. Tasmania, for instance, is reporting significant delays in ambulance response times, with average waits rising from ~18.5 minutes to over 30 minutes in some areas. The smaller populations and greater rural distances place additional strain on paramedic networks and ensuring the continuity of services, making even modest increases in demand much more harder to absorb.
Structural Drivers: Why the System is Buckling
What emerges from the data and rhetoric is a consistent set of structural problems, many of which have been recognised for years, yet few seem to have been meaningfully addressed at scale. To move beyond anecdote to strategy, we must grapple with these structural drivers that’re behind ramping, because fixing ramping in isolation is like trying to keep mopping up the floor without stopping the leak.
Exit block & post-acute capacity gaps
One of the most cited causes is “exit block”: patients who no longer require acute hospital care but have nowhere to be discharged, for example, due to shortages in aged care, rehabilitation, home care, or supported housing. These stranded patients consume inpatient beds that should turn over more rapidly, reducing throughput from ED to wards, and creating a bottleneck for new arrivals.
So unless post-acute and community services expand in tandem, hospitals will continually struggle to reclaim capacity.
Demand growth & complexity
Ambulance demand has reached record levels (4,443,102 incidents in 2023–24 nationally). Many patients now arriving via ambulance have complex comorbidities or social care needs, and not necessarily the classic acute emergencies. This contributes to longer ED stays, more intensive resource requirements, and more frequent interactions across services.
Capacity misalignment & under-investment
In several states, investment in hospital beds, ICT (information systems), and infrastructure has not kept pace with population growth, aging demographics, or clinical expectations. WA’s historically low hospital bed stock per capita is a glaring example.
Even where new capacity is created (e.g. the transitional beds in SA), we often see that it lacks sustainability or integration with the broader care ecosystem.
Siloed governance & fragmented accountability
Hospitals, ambulances, primary care and aged care often operate under different agencies and/or funding lines, limiting the development of meaningful incentives for integrated planning. Even though ramping is a cross-system problem, accountability is often compartmentalised. Additionally, reporting standards for ramping vary by state, making national benchmarking and shared learning difficult.
Workforce constraints and morale
Paramedics, emergency physicians, nurses and allied health professionals are working under extreme pressure and systemic constraints. Fatigue, burnout, and escalating demand diminish responsiveness and flexibility. Ramping wastes paramedic availability, because an ambulance stuck at a hospital is an ambulance that’s unavailable for new calls, which creates cascading delays.
Leadership Imperatives: What Healthcare Executives Can Do
Given that ambulance ramping is a systemic issue, “solving ramping” requires leadership beyond the ambulance service itself. Below are several strategic imperatives and recommendations for healthcare executives, system planners, and policymakers to consider.
Adopt a system-wide view of flow & risk
Ramping must not be framed as an ambulance-to-ED problem, but as a flow problem across acute, subacute, and community services. To tackle this, health leaders should:
- Map patient trajectories across the care continuum, identify current choke-points (e.g. discharge planning, diagnostics, social care), and embed risk-based decision prioritisation.
- Use real-time analytics and clear dashboards to monitor flow bottlenecks, predict pressure points, and trigger early interventions (such as when surge capacity is required) before the ED becomes overwhelmed.
- Empower senior clinical decision makers (e.g. ED lead physicians) to oversee offload decisions dynamically, helping to balance risk across waiting patients and ambulance arrivals (a recommendation that has already been made in SA).
Invest in post-acute & community services in tandem with acute capacity
Expanding hospital beds without ensuring downstream discharge capacity is like filling a bathtub when the drain is blocked. Health leaders must:
- Initiate and drive accelerated investment in aged care, rehabilitation, home-based care, and transitional care beds, as aligned with local demand.
- Think beyond boxes to innovate models such as hospital-at-home, virtual care, community rapid response teams, and enhanced GP integration to reduce avoidable hospital presentations.
- Leverage alternate care pathways (such as observation units, and urgent care in primary care settings) to redirect lower acuity cases away from the ED.
Harmonise governance, accountability & incentives
To break existing silos and disconnects, we must:
- Create cross-agency governance bodies including hospital, ambulance, primary care and aged care leadership to coordinate investment, data sharing, and flow strategies.
- Standardise ramping definitions and reporting across states and incorporate ramping metrics into national health performance frameworks (for example, via aligning with the National Minimum Data Set reporting requirements).
- Design financial incentives and/or risk-sharing models that align rewards with flow outcomes (e.g. shared savings when ramping reduces, penalties for excessive offload times) rather than continually focusing on isolated departmental budgets.
Embed safety mechanisms & mitigations
While long-term fixes roll out, healthcare leaders should strive to make ramping safer rather than accept it by:
- Developing protocols and clinical pathways for care delivery within ambulances (e.g. extended paramedic scope) when transfer delays are inevitable, to mitigate clinical risk where possible.
- Allocating dedicated “offload zones” or buffer spaces adjacent to EDs to de-congest ambulance paths whilst maintaining clinicial staff oversight.
- Conducting audits and root cause analyses of instances where delays contribute to adverse outcomes, as South Australian coroner’s recommendations highlight.
Champion a culture of innovation & continuous improvement
Unfortunately this is not a “once and done” fix, because leadership must foster ongoing innovation and iteration:
- Pilot and evaluate process improvement initiatives with rigorous measurement and scaling of successful models.
- Encourage cross-jurisdictional learning. States that have shown improvement on offload metrics (like parts of NSW) should be closely studied and their models readily adapted elsewhere.
- Invest in workforce resilience programs: mental health support, flexible scheduling, and professional development to retain staff who are under pressure.
Advocate for collaborative federal-state reform
Many transformation levers reside in funding, structure, and national policy frameworks. Therefore it is imperative that healthcare leaders:
- Push for a refreshed National Health Reform Agreement that embeds flow and ramping metrics, with shared funding models that support cross-sector investment.
- Seek bipartisan commitment to long-term health system infrastructure solutions (beds, ICT, care pathways), rather than episodic, election-driven fixes.
- Advocate for transparency in reporting, national benchmarking, and funding tied to performance and flow outcomes.
Conclusion: From Crisis to Collective Purpose
Ambulance ramping is not a discrete problem, it’s just another symptom of a deeper systemic problem that’s been created from misaligned incentives, capacity constraints, fragmentation across care settings, and governance inertia. For healthcare leaders, the path forward is not about pouring more resources into ambulances or EDs in isolation, but about redesigning service flows, bridging acute and community care, rethinking capacity, and aligning accountability across sectors.
In many states, pockets of improvement show that meaningful progress is indeed possible. But scaling those gains and sustaining them requires the kind of leadership that transcends portfolios, that unites stakeholders, and that keeps focus on flow, safety, and patient-centred outcomes. If we continue to treat ramping as an ambulance and paramedic problem, we will be continually chasing delays. But if we treat ramping as a symptom of health-system design that must evolve, we do stand a chance of pivoting from this crisis towards a more responsive, integrated, and sustainable health system.
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