Winter pressures and the NHS Ambulance Services: ‘Doing more with less’ is not an option

ambulances queuing outside A&E at a North West hospital

Paresh Wankhade, Professor of Leadership and Management and Emergency Services Management Expert discusses the issues the Ambulance Service faces as winter approaches in his latest Comment blog:

With each passing year, the winter crisis puts a massive strain on the NHS ambulance resources with huge bottlenecks in the transfer of patients into the hospital Accident and Emergency (A&E) wards. In 2017, media carried several reports which highlighted delays on the part of ambulance crews arriving at the scene, including deaths of the patient waiting for an ambulance. Some of these arguments have been well rehearsed and have also prompted emotional debates and the cries of “52 weeks of the year crisis” in the Parliament.  I have highlighted four issues which in my view are the key flash points for ambulance services to deal with such recurrent crisis.

Address the funding-demand gap

The sustainability of an underfunded and overstretched ambulance services is though well recognised, but remains unresolved. The National Audit Office reported that between 2009-10 and 2015-16, the number of ambulance calls and NHS 111 transfers increased from 7.9 million to 10.7 million (average year-on-year increase of 5.2 per cent), and income for NHS ambulance trusts’ urgent and emergency care activity increased by 16 per cent from £1.53bn to £1.78bn between 2011-12 and 2015-16, but ambulance activity over this period (NHS ambulance calls and NHS 111 transfers) rose by a massive 30 per cent. This is accompanied by significant shifts in the demand with only 10 per cent of 999 callers having a life threatening emergency despite the average annual increase of five to six per cent in ambulance demand.  Doing even ‘same with less’ is proving difficult for ambulance trusts, something I have argued in my recent piece.

 

Move away from response time targets

Response time targets have been historically used to measure ambulance performance. Since July 2017, performance of NHS ambulance trusts is being benchmarked against four new national standards, based upon patient’s condition, now enshrined in the NHS Constitution.  However, during May-September 2018, ambulance services in England failed to meet  all the standards. A recent Parliamentary Report concluded that ‘ambulance trusts have organised themselves to meet response-time targets, at the expense of providing the most appropriate response for patients’ (p.5).  Another view that ‘commissioners, regulators and providers still place too much focus on meeting response times” reported in the National Audit Report (p.8) is deeply worrying.

Our research points to similar conclusions. We have systematically documented a range of unintended consequences  of response time targets used by the ambulance services.  We have also explored the relationship between cultures, performance measures, and organisational change to understand how organisational culture is perpetuated and found the targets to be a significant factor impeding the process of change. Ambulance services have embarked on the drive for ‘professionalisation’ but our latest research suggests that as ambulance work continues to intensify, ‘issues around dignity, staff retention and the meaning of work are becoming ever more challenging’.

 

Introduce fines/penalty for hospital delays

Ambulance handover delays to hospital A&E departments can have serious implications for patient safety and reduce available ambulance resources. The 30 minute cycle (handover and readiness for next call) is proving difficult to resolve. NAO  figures suggest that in 2015-16, only 58 per cent of hospital transfers met the 15-minute expectation in 58 per cent of cases as against 80 per cent in 2010-11, and only 65 per cent of ambulance crews were then ready for another call within 15 minutes. There are inconsistencies on the part of commissioners to penalise hospitals that do not adhere to the guidance of 15-minute transfers in absence of a fining regime. A quality indicator for measuring hospital performance in meeting the transfer-time target has not yet materialised, notwithstanding the recommendations of the Committee of Public Accounts.

Improve efficiency and productivity

The Carter Efficiency Review, published last month, highlighted concerns about huge variations in the delivery of ambulance services. It suggested potential savings of £300m a year by cutting unnecessary ambulance transfers, along with further £200m through use of more efficient models of operations and procurement.  But the review also raised fundamental questions over the need for significant investment in the ambulance sector. The shortage and retention  of paramedic staff coupled with high sickness absence rates continue to be a problem, an issue highlighted in the draft NHS Workforce Strategy. However, the review raises the clear need for investment since one of the recommendations to reduce high conveyance rates is likely to have cost implications. This will also require high quality staff engagement.

 

Conclusion

There are no easy fixes and addressing the winter pressures will necessitate strong and visionary leadership by ambulance chiefs and cooperation from other health care partners, in a political climate dominated by Brexit. A ‘whole systems’ approach is crucial to deal with this crisis. The Dalton Review called for successful leaders to act as a ‘systems architect’ to use their entrepreneur skills to explore innovative organisational models, as set out under the NHS Five Year Forward View. The Carter Review necessitates ambulance leaders to make right business and spending decisions which will impact the NHS. Devising an effective public education campaign to minimise misuse of ambulance resources and managing public expectation, will be a good starting point.

How to reboot Britain’s fractured emergency services

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pixelaway/shutterstock

 

Professor Paresh Wankhade, Edge Hill University

The Grenfell Tower fire and recent terrorist attacks in Manchester and London have put the spotlight on spending cuts for emergency services.

In Manchester, an independent review into the emergency response was ordered in the aftermath of the bombing to look into the “the strain of spending cuts” on police. The city mayor is also investigating the fire service after crews were apparentley “held back” from helping the victims.

Whatever the outcome of these investigations – and others like them – I believe the problems go far beyond staff numbers and resources. The only way forward is to engage in a full system “reboot” to get better results.

The problems are legion. For starters, the emergency services are far too fragmented. There are huge differences across the emergency services when it comes to size, funding and organisational structures with no overarching body for coordination.

Disconnected ministerial oversight also creates uneven and localised outcomes in performance. And the government’s approach to the problem is vague and unclear. The Policing and Crime Act 2017 has brought important changes to the governance of the police and fire and rescue services – but ambulance services remain independent of these provisions. It places a duty on police, fire and ambulance services to work together which currently remains undefined.

Ambulance demand is growing at an annual rate of about 5.2%. Managing such levels of demand and maintaining the quality of patient care is unsustainable and it is no secret that ambulance services across the country are struggling to meet their performance targets. The police are witnessing a reduction in recorded crime but are increasingly dealing with cases relating to cybercrime, child and sexual exploitation and mental illness. Meanwhile fire services have seen a massive reduction in fire call-outs. But these organisations continue to be performance-managed and target-driven – and current models of service delivery do not reflect these changes.

The focus for the emergency services remains on performance metrics and stringent target regimes. Alongside this is the influence that staff associations and unions have on determining the scale and pace of reforms. Workforce issues such as stress remain largely neglected and recruitment and retention of black, Muslim and ethnic minorities (BME) continues to be a challenge.

Issues around Post-Traumatic Stress Disorder (PTSD) and other illness – which are common among emergency workers – are not being fully addressed and ambulance staff sickness is highest within the NHS. Media reports also increasingly highlight cases of harassment and bullying within the emergency services.

There are no easy fixes for all these problems but emergency services do need a “road map” to help them navigate the shifting political landscape and the changes to training and performance regimes. Here are five ways to improve the emergency services and better equip them for the future.

Leadership reform

There needs to be a move from isolated chiefs calling all the shots to a more collaborative culture. This is because front-line staff and managers should have confidence in their own leadership and decision-making skills while dealing with other 999 services during major incidents and during interactions with the public.

Promote collaboration

A top-down bureaucratic approach to force the merger of police and fire services is unlikely to work and should be abandoned if it proves costly and does not bring results. Proposals for merger and reorganisation of the fire services need to be reconsidered, along with the feasibility of a national or regionally organised police force like in Scotland.
Further reforms should allow pooling organisational and management oversight.

Similarly, the role of the ambulance services within the emergency architecture should be spelt out more clearly, since they derive their funding from the National Health Service budget. They work more as the emergency arm of the health services rather than the health arm of the emergency services.

Adapt to changing demands

There is a clear need to understand how usage is changing – and to support staff to respond to new challenges. This will help to improve workforce motivation and reduce the cost of ill health by building a “resilient” organisational culture.

Academic partnerships

Developing partnerships with academia will be useful in building modern and professional organisations and to further improve the research base in the “Blue Light” services.

New management skills

Addressing staff morale and retention and setting performance criteria that make sense will be central to improving the services. The obsession with a target-chasing culture should give way to broader sets of measures to reflect the new challenges and changing organisational realities. We need a new set of collaborative leadership and management skills to inspire a shared purpose across a network of organisations to respond quickly to current and future problems.

The ConversationThis is an important moment for the emergency services. The steady rise in the 999 demand along with shrinking budgets are seen by many as two of the key challenges which are unlikely to go away in the near future. There is an urgent need to restart Britain’s limping emergency services and bring about real “transformational” change. But it requires determination, imagination and leadership – or the 999 services will be facing their own emergency situation.

Professor Paresh Wankhade, Professor of Leadership and Management with expertise in emergency service management, Edge Hill University

This article was originally published on The Conversation. Read the original article.

Increasing Ambulance Demand: Need for a Strong Leadership and Positive Culture

The growing pressure on the NHS ambulance services as a result of increased ambulance demand has been a subject of media attention in the recent weeks. This is also accompanied by a growing academic interest in the examination and exploration of work intensification in prehospital care settings. Staff retention and staff recruitment is proving to be difficult and the shortage of paramedic staff is becoming a national problem.

Ambulance services are witnessing a period of turbulence. Amidst the progress on the professionalisation of the paramedic agenda, individual trusts are facing challenges in form of staff attitudes towards meeting performance targets, coupled with rising demand, fear of loss of contracts and private competition. Historically and in the new commissioning framework, performance (and payment) of individual ambulance trusts is still guided by the achievement of the eight-minute response time target. This has implications for patient safety, high sickness absence rates amidst increasing ambulance demand.

It doesn’t come with much surprise that the recent inspections reports from the Care Quality Commission (CQC) have highlighted some of the issues discussed above. The latest report for the North West Ambulance Services NHS Trust published last week reported regional variation in the culture across the trust:

“Staff in some areas felt very positive about the culture, but in other areas, they felt that there was a high degree of pressure and the focus was on performance targets rather than care for patients (p. 39).”

The report also highlighted staff vacancies across all areas of urgent and emergency care services and the overall vacancy rare was 5.7%. (p.3)

The increasing pressure to meet performance targets was also picked up in the CQC inspection report for the South East Coast Ambulance Service NHS Trust in September 2016:

“However, many staff reported a culture of bullying and harassment. Much of these reports stemmed from style of contact and lack of support during sickness…Staff also attributed the bullying and harassment culture to the organisation drive towards attaining performance targets. In particular the pressure placed on middle and junior managers, many of whom have not had developmental support to deliver their role”(p.31).

The CQC report highlighted a culture of operating in a crisis by ‘ fire-fighting’ and a lack of step down process and medium and long term planning led to a lack of sustainable change.

The CQC inspection report for the London Ambulance Service NHS Trust in November 2015 while giving the Service a ‘good’ rating for its care of patients, highlighted a number of areas of concern and judges the Service to be ‘inadequate’ overall and recommended to place the Service into special measures. It reported (p.2) that the trust was operating with a shortage of trained paramedics in the light of a national shortage and due to paramedics leaving its service for a number of reasons including better pay elsewhere.  Paramedics from Australia and New Zealand were recruited to address the shortage. The report expressed significant concerns about a reported culture of bullying and harassment in parts of the trust:

“Bullying and harassment was a major concern for the organisation. Several frontline ambulance staff perceived that they were bullied by managers; and an independent, external review into bullying and harassment in the organisation found that the problem was widespread.” (p.5).

It’s worth mentioning here that in the latest inspection by CQC, it has been reported4 that the trust has focused on bullying and harassment with workshops, and holding conversations instead of resorting to formal processes (p.3). Issues of bullying and harassment could be reported via ‘pulse’, an internal website staff could access, and there was a telephone line to report any incidents of this nature (p.20).  The bullying and harassment policy had been revised, relaunched and is now called ‘dignity at work’.

While these initiatives need to be welcomed, issue raised above have significant management and leadership implications for devising appropriate employment practices across the ambulance trusts. It raises questions about whether it is possible and sustainable to motivate staff and/or retain and recruit new ambulance staff while moderating these negative influences. Development of strategies to prevent significant levels of sickness and occupational health issues, to combat prevalence of general and specific ambulance specific stress factors needs immediate policy and management attention.

Northern Ambulance Alliance: New model for emergency services collaboration?

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Professor Paresh Wankhade (Business School) analyses the latest announcements about ambulance alliance and its implications:

Interoperability between the emergency services (the police, ambulance and fire) is an important but highly contested topic of research. The governance of these ‘blue lights’ in England is complex given these services come under different departments and are structured differently largely as a result of the relatively ad-hoc nature of their historical development. Currently there are 11 ambulance trusts, 44 police forces and 55 fire and rescue authorities in England.

Collaboration between emergency services is neither novel nor new. Many emergency services are already working with each other, and other public bodies to provide better services while improving efficiencies. In September 2015  the Government published the consultation document ‘Enabling closer working between the Emergency Services’ aimed at promoting better coordination of emergency services in England.  In January 2016, the government published the ‘Summary of consultation responses and next steps’ to the Consultation intending to legislate to:

  • Introduce a high level duty to collaborate on all three emergency services, to improve efficiency or effectiveness;
  • Enable Police and Crime Commissioners (PCCs) to take on the functions of fire and rescue authorities (FRAs), where a local case is made;
  • Where a PCC takes on the responsibilities of their local FRA, further enabling him or her to create a single employer for police and fire personnel;
  • In areas where a PCC has not become responsible for fire and rescue services, enabling them to have representation on their local FRA with voting rights, where the local FRA agrees; and
  • Abolish the London Fire and Emergency Planning Authority and give the Mayor of London direct responsibility for the fire and rescue service in London.

The proposed governance arrangements contained within the consultation document present a number of challenges and has received mixed responses, and the consequent legislation was rushed through in the Parliament. Some of the proposals in the latest consultation are not original. In 2013, the government commissioned report  Facing The Future  led by Sir Ken Knight, former government Fire and Rescue advisor, had reviewed the efficiencies and operations in the fire and rescue authorities in England. The report had further proposed the merging of fire and rescue services with the possibility of the PCCs taking on the role of fire and rescue authority after due evaluation.

The Association of Ambulance Chief Executives (AACE) has welcomed the intention of the Government backing to keep ambulance services as part of the NHS, while reaffirming its support for closer collaboration and more innovative blue light working between the three emergency services. The Keogh Review and the NHS Five Year Forward View also acknowledge the role and contribution of the ambulance services to the Government’s urgent and emergency care strategy. The overall attendance of fire services incidents has shown a decline of more than 40% over the last decade. Recorded crimes (other than fraud) are showing a downward trajectory since its peak in 2003-04. But ambulance demand has shown a steady increase of almost 10% over the last five years.

Ambulance

While their position within the blue-light architecture is still being decided, the latest announcement by the North East, North West and Yorkshire Ambulance Service Trusts to launch the ‘Northern Ambulance Alliance’ to improve efficiency gains (Highlighted by the Carter Efficiency Review, 2016), presents opportunities for exploring new innovative organisational forms and management structures, to bring about a new model for regional collaboration in absence of a national initiative.

A statement issued by the new NAA clarifies that the move is not a merger, but ‘an attempt by all three organisations to work closer together to standardise care, identify savings through collaborative procurement, and be better placed to tackle the fast moving change agenda.’ The move opens greater opportunities to access new, modernisation funding streams such as the transformational funding collectively, while allowing greater synergy for working with other blue light partners. It has been also stated that the three trusts remain completely separate entities and will be regulated independently.

The alliance has been quick to dismiss the fears about potential amalgamation and job losses but questions have already been raised including:

  • Implications for future joint appointments and re-categorisation of new roles and responsibilities;
  • Whether staff will be rostered to work within the geographical boundaries of the other trusts in the Alliance
  • The claim to improve quality and service delivery for all patients in the North of England remains to proven;
  • Whether performance and quality standards will be assessed and monitored collectively across the North of England in future; and
  • Importantly, the impact on devolution schemes which are at different stages in the North, remains unclear.

This new model can help drive regional collaboration and blue light interoperability but concerns about potential job losses, its impact on patient safety and service delivery will have to be quickly addressed to give it any meaningful chance of success and building a sense of confidence in the proposed Alliance.

Emergency services collaboration: role and future of the ambulance services?

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Collaboration between emergency services is neither novel nor new. Many emergency services are already working with each other and other public bodies to provide better services while improving efficiencies. It was however argued that the present levels of coordination and collaboration are uneven and not as well developed as they might be. In September 2015, the UK Government published the consultation document ‘Enabling closer working between the Emergency Services’ aimed at promoting better coordination of emergency services in England. Early this year, the responsibility for fire and rescue policy was transferred to the Home Office from the Department of Communities and Local Government (DCLG). The Government also published its response to the consultation in January 2016. The Summary of consultation responses and next steps sets out legislative proposals to:

  • introduce a high level duty to collaborate on all three emergency services, to improve efficiency or effectiveness;
  • enable Police and Crime Commissioners (PCCs) to take on the functions of fire and rescue authorities (FRAs), where a local case is made;
  • where a PCC takes on the responsibilities of their local FRA, further enabling him or her to create a single employer for police and fire personnel;
  • in areas where a PCC has not become responsible for fire and rescue services, enabling them to have representation on their local FRA with voting rights, where the local FRA agrees; and
  • abolish the London Fire and Emergency Planning Authority and give the Mayor of London direct responsibility for the fire and rescue service in London.

The latest consultation response assumes both the desirability of PCCs taking over the leadership of fire services and the ‘single employer’ form of merger to promote greater efficiencies. Arguments for and against the proposals to bring together the fire and police services under the remit of PCCs have been well rehearsed in the media. The consultation response does not specify the exact nature of collaboration between the ambulance services and the police and fire services. Other than suggesting a legal duty to collaborate, the role and responsibility of the NHS ambulance trusts in determining their legal duty remains unclear and has not attracted much attention and scrutiny.

The Association of Ambulance Chief Executives (AACE) has welcomed the intention of the Government backing to keep ambulance services as part of the NHS, while reaffirming its support for closer collaboration and more innovative blue light working between the three emergency services. The Keogh Review and the NHS Five Year Forward View also acknowledge the role and contribution of the ambulance services to the Government’s urgent and emergency care strategy. This view was also echoed by several speakers at the recent Ambulance Leadership Forum 2016.

Whether ambulance services see their future as part of NHS or whether there is a drive to integrate-fully or partially with other emergency services, there will always be the need for two functions currently provided by the ambulance services namely, (i) a means of supported transport of patients in the community to services provided in health care facilities and (ii) responsive, professional, timely outreaching emergency diagnosis and management service. These are the core of current ambulance services and will be the core of any future service(s). What is likely to change is the means of delivery and the professionals that delivers the service. Technology will enable better remote triage; increasingly skilled practitioners will use better decision support mechanisms to deliver more sophisticated heath care.

There is however a significant change in the profile for demand for the ambulance services as compared to the police and fire services. The overall attendance of fire services incidents has shown a decline of more than 40% over the last decade. Recorded crimes (other than fraud) are showing a downward trajectory since its peak in 2003-04. But ambulance demand has shown a steady increase of almost 10% over the last five years. Ambulance services are also no more the sole employer(s) of the paramedics, many of whom now work outside the NHS ambulance settings such as the GP surgeries, out-of-care facilities and with private ambulance providers. With a shortage of paramedic staff, managing such levels of demand and quality of patient care is clearly unstainable and it is no secret that ambulance services across the country are struggling to cope up with increased activity and meet their performance targets.

This is a changeable moment for the ambulance services. Steady rise in 999 demand and shrinking budgets are seen by many as two of the key challenges which are unlikely to go away in the near future. While their position within the blue-light architecture is still being decided, it presents opportunities for exploring new innovative organisational forms and management structures to bring about real reforms and transformational change. There has never been a greater need for an open and honest conversation between the ambulance leaders, policy makers and other stakeholders to debate the role and future of the ambulance services we all love and care about.

Interoperability between Emergency Services: A Missed Opportunity?

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Professor Paresh Wankhade (Business School) analyses the latest Interoperability proposals offered by the government:

The governance of the emergency services in England is complex and the three main emergency services (ambulance, police, and fire & rescue) are structured differently, largely as a result of the relatively ad-hoc nature of their historical development. In September 2015, the UK Government published the consultation document ‘Enabling closer working between the Emergency Services’ aimed at promoting better coordination of emergency services in England. The government argued that the present levels of coordination and collaboration are uneven and not as well developed as they might be.

Earlier this month it was formally announced that fire and rescue services will be transferred to the Home Office from the Department of Communities and Local Government. However the Chief Fire Officers Association has sought clarity on issues pertaining to transitioning policy, provisions to meet national emergencies, in-depth risk assessment framework and sustainable budgeting principles to separate fire budgets from police and other Home Office Budgets.

This week the government published the ‘Summary of consultation responses and next steps’ to the Consultation after receiving over 300 responses. The Government intends to legislate to:

  • Introduce a high level duty to collaborate on all three emergency services, to improve efficiency or effectiveness;
  • Enable Police and Crime Commissioners (PCCs) to take on the functions of fire and rescue authorities (FRAs), where a local case is made;
  • Where a PCC takes on the responsibilities of their local FRA, further enabling him or her to create a single employer for police and fire personnel;
  • In areas where a PCC has not become responsible for fire and rescue services, enabling them to have representation on their local FRA with voting rights, where the local FRA agrees; and
  • Abolish the London Fire and Emergency Planning Authority and give the Mayor of London direct responsibility for the fire and rescue service in London.

The proposed governance arrangements contained within the consultation document present a number of challenges and has received mixed responses. The Local Government Association (LGA) raised concerns in their response to the consultation document. It contended that the changes would be a distraction from existing patterns of cooperation and could indeed undermine existing arrangements where the boundaries between the fire & rescue services and PCCs are not coterminous. Government’s proposals to allow PCCs to take responsibility for their local fire and rescue services was dubbed as ‘dangerous’ by the Fire Brigades Union (FBU).

It is worth noting that some of the proposals in the latest consultation are not original. In 2013, the government commissioned report ‘Facing The Future’ led by Sir Ken Knight, former government Fire and Rescue advisor (and Visiting Professor at Edge Hill Business School) had reviewed the efficiencies and operations in the fire and rescue authorities in England. The report had further proposed the merging of fire and rescue services with the possibility of the PCCs taking on the role of fire and rescue authority after due evaluation.

The latest consultation response assumes both the desirability of PCCs taking over the leadership of fire services and the ‘single employer’ form of merger to promote greater efficiencies. There are concerns that that giving a wide range of powers to a single individual will necessarily provide greater benefits than having an elected body with those powers. The merger process can have its own unintended consequences and there is enough academic evidence to suggest that such a process is likely to have an adverse impact on individual staff and organisational capacity to deliver intended benefits. Moreover, the requirement and mechanisms for the PCCs to have access to an informed, independent assessment of the operational performance of the fire services remain to be finalised.

The proposals while suggesting a legal duty to collaborate, do not clarify what would constitute evidence of a failure to collaborate, who would be allowed to institute proceedings should this allegedly happen and what would be the penalty for non-compliance. The role and responsibility of the NHS ambulance trusts in determining their legal duty remains unclear and efforts should be made to reflect their role within these proposals and in future legislative changes including possible impact on the governance of the ambulance services.

One key pubic message emerging is that the government wants the police, fire and ambulance services in England to share control rooms to improve their response to 999 calls. But this is already happening in many parts of the country (such as in Bootle in Merseyside) without a formal merger/integration. The long standing question of addressing the issue of different professional cultures in the three emergency services remains unattended in these proposals. Lack of specific proposals to improve strategic leadership across these organisations in brining transformational change can seriously hamper bringing real change in attitudes and culture(s) within the blue-light services.   There is a danger that the current process may lead to a ritualistic compliance and perverse consequences.

The consultation process was the first real opportunity to look into the important question of improving interoperability between the three main emergency services. By limiting the scope of the consultation to seek views on the proposed integration of police and fire & rescue services and giving power to PCCs to take on the functions of the fire rescue authorities, a golden opportunity has been lost for having an honest and frank discussion about the future of our emergency services.