Stretcher cases

The ambulance service has the worst managers in the NHS who are failing in everything from community links to patient safety, according to a new poll. Mary-Louise Harding analyses the results

As if being slated in last year's star-ratings was not bad enough, this spring ambulance trust senior managers are once again reeling.

Nearly 9,000 ambulance service paramedics, technicians, administration and clerical staff took part in the NHS-wide staff survey carried out by the Commission for Health Improvement (now the Healthcare Commission). The poll delivered a clear and damning verdict:

ambulance service senior managers are the worst in the NHS.

An analysis by HSJ of answers to key questions on senior managers' performance (see box) found that eight out of the 10 worst-managed trusts were ambulance services.

A third of ambulance staff who completed the survey gave managers the red card in key areas. These can be summed up as internal and external leadership, and a patient-centred approach to everyday operations and service modernisation (see box).

English ambulance trusts achieved a score of just under seven-and-a-half out of a possible 100 for staff perceptions of senior management overall (see table for score methodology).

Staff slammed, in particular, their managers' efforts to build links with the communities they serve, with the overall ambulance score for this question returning a score of -4. The staff verdicts on managers' competence at providing a vision for future organisational direction was also shockingly low (see table).

HSJ understands that the Department of Health 'top team' is particularly concerned about ambulance trusts' performance.

Their worries are reflected in the survey results on senior managers, and the higher-than-average number of respondents who report having seen more than 10 errors in the last month that 'could hurt patients' (staff from 28 of the 31 ambulance trusts in England ticked this box).

The extent of ambulance staff disengagement is demonstrated by the fact that under a third from a total of 31,446 eligible ambulance staff responded to the survey. Trusts that performed well tended to also have a high response rate.

But a straw poll of key figures in ambulance and emergency care reveals a service that is struggling valiantly to meet its key performance targets and modernisation priorities, but continues to complain of underinvestment.

'[The results] reflect the fact ambulance services have been, and are, up to their necks in dealing with key performance targets, leaving little capacity to look at all the other things they should be focusing on in the round, ' says Ambulance Service Association chief executive Richard Diment.

'Although there is now a focus through Improvement Programme for Ambulance Services, trusts operate on a thin management structure and tend to be run as mean and lean operations, ' he explains. 'There needs to be a recognition that we have to create the headroom and capacity in the system to allow structured release time for everybody in a given period.'

Others argue that, on top of pressures to meet response-time targets, major reforms such as Agenda for Change, the change in out-of-hours provision following implementation of the new GP contract, and efforts to meet acute emergency care targets, are having a disproportionate impact on ambulance trusts.

And while all these things have brought a highly welcome focus on the role that ambulance services can play in the drive to upgrade pre-hospital care, noone anticipates an easy ride.

'My reading is that what we are doing is pushing ambulance services into major change with our work on emergency care networks and so on, and the workforce doesn't like being pushed, ' says emergency care czar Professor Sir George Alberti. 'We are looking at ways of tackling this with the ASA and trusts themselves.'

As a consequence of changes such as the introduction of clinical governance arrangements, their role in direct healthcare has increased. Such change needs strong leadership, but, following many trusts' savaging in last year's star-ratings, around a third of ambulance chief executives have been replaced in the last 18 months.

As any leadership guru will agree, consistency is crucial.A look at the short-term management history of the NHS's worst-performing trust in the staff survey underlines this.

West Yorkshire Metropolitan Ambulance Service trust's chief executive Trevor Molton has been on sick leave for 16 months. The trust has had two interim leaders in the last 12 months, and the current incumbent, Diane Whittingham, works at the trust just one day a week.

It has an interim finance manager, until very recently it had an interim HR director, and it has had to appoint an almost entirely new board over the past year.

'While We are disappointed with the results of the survey, We are not surprised by the findings, ' the trust said in a statement to HSJ.

'We have experienced major change at senior level over the last 12 months. The current senior team recently visited every site within WYMAS and is already implementing plans to be visible and available to staff.'

For ASA president Peter Bradley, chief executive of the London Ambulance Service trust, which came a clear first among its ambulance peers in our management analysis, there needs to be a focus on breaking down silo barriers within the ambulance service and between it and other parts of the NHS.

'[The improvement programme for ambulance services] can be a catalyst for working together, ' he says. 'I want to try and work with them to look at organisations that performed well and break down competitiveness to facilitate sharing best practice.'

Mr Bradley is widely acknowledged to have transformed LAS from an organisation mired in staff-vsmanagement rancour to a forward-thinking, modernising service: 'The key is listening to staff, ' he says.

'Be honest and apologise when you do not deliver. People want to see that you're on their side.'

Key survey questions

To what extent do senior managers:

set out a clear vision for the organisation;

support new ideas for improving patient services;

focus on meeting patient needs;

build strong relationships with the community;

build strong, co-operative links with other organisations.