emergency care

Published: 29/07/2004, Volume II4, No. 5916 Page 26 27

Drastic measures were needed to turn around zero-starred Essex Ambulance Service trust.

Jay Bevington, Aidan Halligan and Ron Cullen explain how it was achieved

Essex Ambulance Service trust has achieved a remarkable turnaround in a very short space of time, moving from zero to two stars in 12 months.

Sixteen months ago people waited longer for an ambulance in Essex than anywhere else in England. The trust significantly failed to achieve Improving Working Lives practice status and received the worst Commission for Health Improvement report in the county.

CHI concluded that while 'the trust has staff who are committed to providing high-quality care to their patients...they do not generally feel supported in their work. Urgent attention is required to address the existing management control and command structure which results in instances of bullying.' The trust was accused of being inward facing, downtrodden and under-resourced. Staff felt demoralised and lacked any confidence in their management.

In one year the CHI action plan has been completed and key targets are being met. Its category-A ('lifethreatening') responses within eight minutes were at 76.5 per cent during June (compared to 74.5 per cent in June 2003) and, at the other end of the scale, its response doctors' urgent call response times within 15 minutes were at 96 per cent in the same period (compared to 86 per cent a year ago). The leap in performance on doctors' urgent calls is a significant achievement, as many ambulance trusts continue to struggle with the 95 per cent target.

The trust also managed a rapid turnaround on Improving Working Lives, achieving practice status in July 2003. Furthermore, last year's national patient survey found that 94 per cent of patients in Essex thought the service they received from ambulance crews was either excellent or very good.And colleagues in the health community describe it as being much more positive and upbeat.One member of staff commented: 'Even staff who have previously been very cynical are starting to say it is the best time to be in the ambulance service.'

So how has the transformation been achieved? As part of the trust's work with the NHS Clinical Governance Support Team we interviewed staff to find out what they thought had made the difference, based on their own experience.

First, the turnaround has not happened through being cautious. Fundamentally, the trust did not want to become simply a better-performing ambulance trust by fixing the many known problems. Instead, it wanted to transform itself into an emergency care trust. This meant combining traditional ways of working with new roles and more collaborative working - for instance, providing out-of-hours care and developing emergency care practitioners.

Following the success in training the first 12 nationally funded emergency care practitioners, the trust has received funding from its local workforce development confederation to train a further 16 paramedics. The training consists of classroom-based learning at Hertfordshire University with a series of clinical placements in both acute and primary settings.

The trust now leads on emergency capacity planning and on reforming emergency care for Essex and has developed its own model for delivering out-of-hours services, which it provides for more than half of the county. It also continues to develop a positive relationship with NHS Direct, which is co-located with the trust and the social services duty team.

An organisation cannot move forward unless people have confidence in those leading the transformation.

The trust board recognised that management capability was vital and significant changes to its senior management team were made, beginning - crucially - with new chief executive Anthony Marsh, a young, relatively inexperienced manager.

Everyone we spoke to said he has made an enormous difference.He leads the organisation with an enticing vision, high levels of energy, enthusiasm and approachability, huge personal commitment and praise for the work of others. One person said: 'Anthony gets many e-mails from staff about issues and personally responds to each of them in a way that doesn't undermine the other managers...Because he actually talks to staff face-to-face, everyone knows what is going on and feels able to put their views forward.'

A new chair was also brought in to oversee the strategic development of the trust. Richard Bourne, who did not have a strong NHS background, brought new ways of approaching change and ensured the whole board worked together to formulate, agree and then promote the transition to an emergency care trust.

Support from non-executive directors meant the whole management team was able to articulate and enthuse over the new vision. A number of other senior management appointments were made.

In describing the team, one middle manager commented: 'There are no mavericks or people with personal agendas. No-one is obsessed with their own ego.' There is also a strong sense of shared ownership and mutual support in the team. One director stated: 'My colleagues look out for areas of my portfolio and I feel that I can contribute to theirs.We are all extremely supportive of each other.'As a highly effective team, the directors have won the confidence not only of staff, but also other organisations in their health community, which have responded by ensuring that the trust has access to necessary funds for investment.

The philosophy behind the turnaround was a relentless focus on the needs of patients and staff, led from the top.Mr Marsh explains: 'Both are equally important. If you do not have staff on board, you're not going to deliver. If you have both, you have an absolute recipe for success.'

In practice this has meant striking at the heart of what really matters to the workforce: improved staffing levels, protecting meal breaks wherever possible, increased training opportunities, and buying new emergency vehicles and equipment.

Buying uniforms had previously been a low priority for the trust, which meant that staff often felt undervalued and unprofessional wearing increasingly shabby work clothes. The trust bought new uniforms for all staff, designed by the staff themselves.

'It helped the sense of professionalism and a shared sense of identity, ' says Mr Marsh. 'But it was also about someone listening, recognising a problem and taking immediate action...It cost a fortune, but it was worth it.'

Much effort goes into getting the balance right between supporting staff and performance management. There is close attention to what is required to achieve the key targets, and people are very clear about what is expected of them in terms of performance. One member of staff said: 'We have become a trust that can deliver what we say we will.'

The trust has also focused on communications, promoting transparency and staff involvement in key strategic decisions, especially at times of crisis. For example, staff briefings, written personally by the chief executive, go out with each individual's pay packet and all levels of management strive to be highly visible.

There is also a union member on the board.

As a result, staff talk frankly and feel more able to make a positive contribution to improving the organisation. Furthermore, media coverage of the trust is extensive and generally highly favourable.

No-one claims the organisation is perfect. The cost of going so far so fast has been heavy pressure on senior managers.Mr Marsh says that as the service expands the trust requires more 'leaders'with the 'experience and expertise to continue to make improvements'.

As one executive director said: 'Managerially We are very light. I do not question capability, but I do question capacity.We will not run out of desire, but we could run out of energy.'

Getting help from the clinical governance support team

The performance development team, part of the clinical governance support team, was formed to help the recovery of trusts awarded zero stars in the annual performance assessment ratings and to support those with adverse Commission for Health Improvement clinical governance reviews.

For more information on CGST e-mail jay. bevington@ncgst. nhs. uk

Key points

Essex Ambulance Service trust has achieved a rapid transformation, having last year received the country's worst CHI report.

The trust transformed itself through new roles, collaborative working and developing its own model for out-of-hours services.

Staff have new confidence in the management team, led by young, relatively inexperienced chief executive Anthony Marsh.

Dr Jay Bevington is associate director of the Clinical Governance Support Team's board development team.Professor Aidan Halligan is deputy chief medical officer and NHS director of clinical governance.

Ron Cullen is CGST director and Department of Health head of strategy for healthcare quality and standards