A year ago, Mersey Regional Ambulance Service trust was faring very badly - until an interim chief executive changed the culture of decision making. By Alexis Nolan

By the time you read this, Alan Murray will no longer be interim chief executive of Mersey Regional Ambulance Service trust; the trust will have merged with three others to create North West Ambulance Service trust and he will have moved on. But like all good managers, he leaves a valuable legacy, despite being in position for only 11 months.

In 2005-06, Mersey Regional Ambulance Service lost its two stars and was labelled the poorest performing ambulance trust in England. In July 2005, its compliance with the key standards to respond to 75 per cent of life-threatening calls within eight minutes and 95 per cent within 14 minutes (or 19 in rural areas) was 70.5 per cent and 92.9 per cent respectively - and declining.

Only 51.1 per cent o GP urgent admissions - often the sickest patients the service has to deal with - were being admitted within the time specified by the GP, against a 95 per cent target.

'There was reliable evidence that GPs had lost confidence in the service and were using the 999 system to ensure their patients received timely attention,' says Mr Murray.

By mid-April this year, the trust's performance had been transformed. Compliance with the 75 and 95 per cent standards for life-threatening emergencies had risen to 75.4 per cent and 97.8 per cent respectively. Urgent performance had risen to 92 per cent. Mr Murray is proud to point out that these improvements were achieved against a background of rising activity over the previous year: 4.3 per cent for emergencies, 10 per cent for GP urgent admissions and 15.4 per cent for sub-acute transfers.

And there is a standout patient outcome statistic when you look at the corresponding improvement in return of spontaneous circulation (ROSC) following cardiac arrest in the final quarter of 2005-06.

'Against a national average of 13 per cent ROSC at the hospital door, Mersey Regional Ambulance Service's performance rose from 16 per cent to 26 per cent,' says Mr Murray. 'In human terms, against this one measure, 69 additional patients were given a chance of survival.'

Fast work

The changes are understandably welcomed by trust chair Ken Hoskisson, who is surprised by the speed of progress since a new strategy was put in place for the trust last July.

'We never thought that our turnaround strategy would achieve such impressive results so quickly,' he says. 'The changes in the management approach and culture have been extraordinary and have transformed the standing of the trust with our colleagues in the emergency care community.'

Cheshire and Merseyside strategic health authority director of performance Helen Bellairs says the SHA has been similarly impressed by the 'scale and speed' of transformation.

'The new management approach has not only demonstrated its ability to address some deep-seated performance problems quickly and effectively,' she says. 'It has also introduced state-of-the-art information-management techniques that are already proving their value in the delivery of emergency care to the local community.'

Mr Murray, a management consultant and former ambulance trust chief executive, was commissioned by Mersey Regional Ambulance Service trust, the SHA and local primary care trusts last year to conduct a strategic review.

At the heart of this report was the recommendation that the trust adopt a comprehensive approach to performance measurement and management, drawing on best practice and supported by 'performance dashboard' software.

His July report clearly struck the right chord and he was invited to become interim chief executive, tasked with implementing his own recommendations.

Demand led

His immediate actions included restructuring and simplifying the management arrangements, based on demand analysis and the use of emergency ambulance unit hours.

In October, the trust board signed off an 18-month strategy called Time to Make a Difference, which set out goals for delivering clinically effective responses to emergency and urgent patients and improving appropriateness for 999 callers who did not need an ambulance response.

This was supported by a trust-wide e-learning package which used industry research to demonstrate the relationship between rapid response and good patient outcome.

'We have given frontline managers in the organisation a role,' says Mr Murray. 'Their role has traditionally been ill defined. There has been a fairly centralised approach, referring upwards for permission to act and sometimes acting and then not getting support from above. We have looked to change that.'

The development of a performance-management framework is the foundation for the trust's improvement. The trust worked with NHS Health and Social Care Information Centre to get advice on best practice in performance management processes and with Lightfoot Solutions for information analysis and the dashboard software.

The trust went through a review process to ensure performance improvement could be understood and rolled out at every operational level, that there was clear communication from the executive team and that the right key performance indicators would be used.

The rollout of the programme began in late November with middle managers running through training sessions on the software and how to interpret data and also on how to undertake effective performance review meetings. Once this was achieved managers were given a coach to provide one-to-one feedback.

'I would have said six months ago that I would have preferred to start out by delivering coaching skills to managers but now I say what we did was right,' says Mr Murray. 'The aim was to get the attention of managers and then follow up with coaching skills. These coaching events not only helped support the learning cycle for individual managers but also helped their respective teams gain an insight into where critical problems were occurring.'

The next step was to link the sector manager work to frontline and executive managers.

The blame game

Mr Murray says the aim is to take up as little management time as possible. For example, sector managers' meetings with frontline managers last 60 minutes, focusing on three issues planned in advance. 'They are decision-oriented; not information but action,' says Mr Murray. To help focus managers' minds on personal action and help rid the organisation of what Mr Murray calls 'a culture of upward referral', the trust has introduced two acronyms to drive home the message. The first is IDA: issue; decision; action. Picking up on planned meetings focusing on a small number of issues, the imperative is then to make a decision, act on it and then evaluate the impact.

It may sound simple, but Mr Murray says it is not necessarily easy to change entrenched mindsets. 'In the past I have tried using terminology like 'no-blame culture'. I have rejected that ultimately because it confuses people. They get confused because of the difference between honest mistakes and negligence.

'What we have called it here is an improvement culture. We are not looking for blame but improvement. You won't be punished for making an honest mistake, but the other side of the coin is that you have to be prepared to discuss mistakes so that you and others learn. It's almost a badge of honour: a person who never made a mistake never did anything.'

Easy as...

The second acronym is ABC: authority; beneficial; compliant. The theory is that to judge whether someone can make a decision they need to judge whether it is in their authority to do so, whether the decision would be beneficial and whether it is compliant with external legislation and internal policies.

Again, the practice should be simple. 'If it's yes, yes and yes, just do it,' says Mr Murray. 'They would be expected to press ahead and take that action and, in exchange, be supported to the hilt by their senior managers.'

One example relates to a middle manager review in Cheshire - with the decision and action taken at sector level between a sector manager and their operational service managers. The problem was under-use of the Northwich rapid response vehicle - a solo paramedic in a car - because of an inappropriate pager profile for advanced paging of calls.

The identified solution was a reprofiled pager to capture incidents within a radius of Winsford rather than Northwich. The action was the pager reprofiled through the emergency medical dispatch centre manager, and the effect was a greater capture of 999 calls and the rapid response vehicle responding to 20 per cent more incidents.

Mr Murray says the response to the introduction of the performance-management system was surprisingly rapid. Within weeks a 'buzz' had come into the organisation. 'People began to believe they were going to be allowed to make decisions. People become creative. They started to enjoy work again and use their imagination.'

Another important issue has been funding - or rather the lack of it. Mr Murray says that all the work done over the last year has been 'within the existing funding envelope'. Not only that, but the changes have created approximately£1.2m of added value in-year by getting more from the same.

Shift cover has improved from 85 per cent to 97 per cent within the existing set-up by using new production methods. Over a full year this would equate to a capacity growth of 56 whole-time equivalent staff, or£1.6m.

Vehicle-related lost unit hours have been cut by 90 per cent, equating to 1.62 whole-time equivalent staff over a full year, or£50,000.

Reducing call cycle times initially by 90 seconds equates over a full year to six whole-time equivalent staff, or£180,000.

Adult education

Another way the performance framework has had an impact is to clarify how managers and staff should relate to each other. With managers and staff expected to use their initiative and take responsibility, they have had to be treated with respect.

'We put it into very simple terms. If people are treated as adults and with respect in their own homes and out of hours social activities then they have a right to expect the same thing at work,' says Mr Murray.

'We have said to all managers they must talk to their staff on an adult-to-adult basis. If they do they will evoke one of two responses: either people will step up and take responsibility seriously or they won't.

'If there's no respect coming back, they have got to persist in adult-to-adult discourse with staff and if staff persist in not taking responsibility they have the responsibility to deal with that, but only if they follow that basic rule.'

Another crucial element in this is that staff believe managers are focused on clinical outcomes that can be improved through the performance framework and not on key performance indicators for their own sake.

'People don't join the ambulance service to achieve statistical standards, but they do need to understand the importance of these to outcomes. Getting to the patient in time to make a difference is about improving clinical outcomes.

'In talking to staff on stations and out at hospital it's very necessary to have leadership talking the same language as we do: patients and outcomes rather than spreadsheets and statistics.'

As for Mr Murray, he becomes another statistic: one fewer chief executive in the reorganisation of ambulance trusts, PCTs and SHAs. But he's far from bitter. He believes Mersey Regional Ambulance Service trust is in better shape and that this will help to get it off to a better start. Mr Murray has been working with John Burnside, chief executive of the new trust, to align the work achieved in Merseyside with a strategic direction for the new organisation. Mr Murray will return to his consultancy business and look for his next challenge.