Published: 28/02/2002, Volume II2, No. 5794 Page 24 25 26 27 28
I joined South Yorkshire Ambulance Service trust as chief executive in March 2000.My brief was to get the organisation back on track in the context of some significant challenges.
These included a deficit of£1m on a budget of£17m - 5 per cent of turnover - the worst deficit of any trust in the region, poor response-time standards and a dilapidated vehicle fleet.
Additionally, the press and the public were on the trust's back, and other NHS organisations locally were unimpressed and unengaged.
I had faced similar challenges as a chief executive elsewhere in the NHS - at South Humberside health authority, North Nottingham HA and West Lindsey trust, Lincolnshire. I felt reasonably comfortable about taking on this job.Yet nothing had really prepared me for my first few days with South Yorkshire ambulance service. In taking on this assignment, there were few positive things to build on other than a very insightful and rightthinking new chair and a supportive board of non-executive directors.The workforce was very committed but disillusioned.
The overwhelming feeling on my first day was that I had left the NHS and joined the armed forces. I genuinely thought I was in the wrong place when I arrived at my first meeting with the operational managers and was the only one not in uniform.
I was clear from the outset that the trust should continue to have strong links with non-NHS emergency services, but even clearer that its true destiny lay in much fuller, creative integration with the NHS.
That debate was being had, as it turned out, within both the Department of Health and the Ambulance Service Association.A report by the ASA published last year said: 'The ambulance services wish to improve the care they provide for patients by integrating much more closely with other healthcare providers in the NHS, and by expanding their clinical role in caring for patients.'
1In April last year, Gisela Stewart, then a junior health minister, told Parliament: 'The ambulance service's primary role is the provision of effective and responsive pre-hospital emergency care in a modern and integrated health service.'
But I believe some ambulance trusts still do not sign up to real membership of the NHS.
This, of course, is closely connected to the culture of uniform and rank which has been the identity of the ambulance service in the UK for many years, with all that that entails.
Different parts of the NHS, managed by different organisations, have to connect if the patient's experience of emergency care is to be positive and if demand and access are to be handled effectively across the board.Yet here I was in March 2000 knowing that many of my NHS chief executive colleagues privately giggled at the image of the resplendently uniformed 'chief '. Indeed, I was the subject of much mickey-taking for several months, with people asking me why I wasn't wearing my uniform - silver trimmings and all.Some chief executives really did believe that I would wear a uniform as a matter of course, so entrenched is the image and expectation.
One thing became instantly clear: that the organisation would only survive and prosper by undergoing major cultural change. I realised that it would be a long and difficult journey, and that something powerfully symbolic and destabilising had to be done straightaway.
At the end of the first day I recruited Maurice, the trust's joiner (a very shrewd observer of human nature), to help me take down the flag poles that lined the entrance to the trust headquarters.Next, we moved the flags and other regalia from the boardroom and other offices.Most of the images were of men in uniforms working alongside the police and fire service at disaster-planning events.This is a crucial role, but few images represented anything to do with patient care.
Change was going to be a slow and painful process.The benefits of NHS-ising were promoted continuously with the entire workforce over several months:
Better care for patients through working with the rest of the NHS to provide integrated care.
An organisational culture that was not based on rank or status but on equality and the inclusion of all staff in decisionmaking processes.
Opportunities for staff to build meaningful networks within the NHS in terms of training and development, and to see career progression within the context of the wider NHS.
Managers picked up quickly that uniforms and rank markings were not valued any more and some stopped wearing uniform within days; others resisted stoutly for months.Throughout this period, I never directly asked anyone not to wear uniform but allowed peer pressure to bring about the change.
Now, no managers wear uniforms.There is no underestimating how difficult this was for some who found it hard to 'manage'without them.One or two had to run the gauntlet of partners suspicious about the change of attire, and several had to bridge a big gap in their wardrobes between T-shirts and dress uniform.
I gained the board's support at an early stage to adopt the NHS logo and drop the crown badge (on stationery, for example), but the decision was not actioned until some nine months later, so sensitive was the issue.
At last, the board took the opportunity of a massive fleet replacement programme, costing the trust£5m, to introduce the NHS lozenge to all our vehicles and to remove the crown badge.
The physical identity at least became identical to that of the rest of the NHS.Many people have said to me what a big and pleasant surprise it was to see the new ambulances and fastresponse vehicles going about their business, badged with the emblem of their true identity and as trusted parts of the NHS.
Removing the physical signs of the old culture cleared the way for change in other ways.We have begun to turn the financial position around - the books are balanced - and response-time standards are being met consistently.When I joined the trust,47 per cent of category A calls (potentially life-threatening illnesses) were responded to in the target of eight minutes.Now, it is consistently over the target of 75 per cent.All category B calls are now responded to within the target of 14 minutes, compared with 65-75 per cent when I started.The response rate to urgent calls from GPs has also improved, and more than 90 per cent of these patients are in hospital within an hour of the time agreed with the GP.
This would not have been possible without improving management capacity and changing the culture of management - a tougher task than changing its appearance.As a result of much negotiation and persuasion in the local health community and its neighbours, I have replaced the top team, recruiting NHS managers from outside the ambulance service and encouraging some people with vast experience of the ambulance service into other parts of the NHS where they can both learn and educate.This was crucial.
What we had had was inaccessible authoritarian management and a culture of disempowerment. Its consequences, apart from isolation from the rest of the NHS, included the suppression of the staff 's potential for creativity and engagement in improving the whole organisation as a caring service. If I measured the trust as it was then against the staff-empowerment principles of the NHS plan and Shifting the Balance of Power , with all their emphasis on re-engineering services for patients through the insights and involvement of those closest to them, we were failing miserably.
We have made a start and things have changed, but we need to be vigilant about sustaining the momentum of improvement.
John Kotter, the one-time Harvard Business School professor of leadership, said that most attempts to transform organisations fail in the end because management loses the plot on one or more of eight basic conditions for success.
2For our purposes, the most crucial are the need to form a powerful 'guiding coalition'of key stakeholders within the organisation, committed to helping with change; to articulate and communicate a clear and compelling vision of where the organisation is going and why; to empower people to act on the vision; and to consolidate and reinforce the change.
My view is that we have attracted people's attention to the need for change, achieved increased awareness of our collective roles in caring for patients, and repositioned the trust as a more equal and participative member of the health community.We have improved management capacity and capability and developed a wide coalition of people who are really committed to, and working towards, a clear vision for the future.
The coalition between the trust, its front-line staff and the trade unions has been powerful in bringing about the changes.
Maximum effort has gone into facilitating staff and trade union involvement, particularly focusing on front-line operational staff.
It took staff and trade unions a long time to realise that managers were serious about involving them in decision making.But we brought together a forum of front-line staff and unions and involved them in drawing up the specification for the new vehicles and in working out new rotas.A union representative from Unison or the Transport and General Workers'Union now sits in on interviews for management vacancies.Successful outcomes on these two major organisational issues have produced a wave of enthusiasm for involvement.
We certainly want to observe Kotter's advice about empowering staff, so clearly expounded also by health secretary Alan Milburn.But this is an organisation that has traditionally done the opposite, and things will not be put right overnight.
The efforts of a pushy, committed individual achieving some early successes are not the same as embedding cultural change.
One hopes that the trust is on course to achieve the latter, but we must be careful to reinforce the gains we have made.
The trust was perceived to be failing more conspicuously in financial and performance terms than cultural ones.But I have no doubt that cultural backwardness was the main factor, stifling talent and making recovery difficult.Having achieved progress with the 'must be dones', there is still a regression risk. It will be difficult to sustain both financial health and good performance as one tends to work against the other.Part of our emerging strategy will no doubt be to balance cost containment with excellent performance standards, while innovating and improving as the role of the trust evolves.
The centre for health economics at York University has expressed concern that in the NHS 'insufficient attention will be paid to the sometimes nebulous concepts of trust and culture in a headlong rush for the more tangible appeals of measurement, monitoring and coercive control mechanisms'.
3Though South Yorkshire Ambulance Service was not the prime target for this remark, it certainly could have been. l
REFERENCES
1 Nicholl J, Turner J, Martin D.The Future of Ambulance Services in the United Kingdom .The Ambulance Services Association, 2001.
2 Kotter JP. Leading Change: why transformation efforts fail.Harvard Business Review , March-April 1995: 101-109.
3 Talfryn H, Davies O, Mannion R. Clinical Governance: striking a balance between checking and trusting.Discussion Paper 165.York University's centre for health economics, 1999.
Ray Shannon is chief executive, South Yorkshire Ambulance Service trust.
Key points
An ambulance trust with a deficit of£1m in 2000 and poor response times has balanced its books and exceeded response-time targets.
A hierarchical, military culture has been changed into a more participative one.
Union representatives now sit on the interviewing board for management jobs.
These changes have allowed the trust to become more integrated with the NHS as a whole.
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