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Improving performance management and staff wellbeing in NHS ambulance services

Our ambulance services deal with more than 12 million 999 calls every year. Their performance has traditionally been measured against how quickly they get to a patient, with other factors, such as quality of care, overlooked. This not only affects efficiency but also takes its toll on the wellbeing of our key workers.

Professor Paresh Wankhade
Professor Paresh Wankhade

Paresh Wankhade, Professor of Leadership and Management at Edge Hill, supports ambulance services to work optimally, both for the people they serve and those who work for them.

From a family of doctors and with a long-standing interest in our health services, he is helping ambulance trusts better manage their teams and resources. This includes recognising long-standing limitations, such as the arbitrary eight-minute response time target.

Improving operations and performance means patients are more likely to get the right support at the right time. It also helps staff feel more valued and less overwhelmed.

Professor Wankhade’s work is now taking him into the realm of other blue light services keen to bring their leadership practices into the 21st century.

The challenges for ambulance services

There are 13 ambulance trusts in the UK. Together, they have more than 33,000 full-time staff, including paramedics and call handlers. Each trust covers a sizeable and diverse geographical area.

Professor Wankhade’s research suggests that enduring management practices, combined with broader political and social pressures, have increased the challenges for our ambulance services and their staff. These include:

  • A high level of calls, growing year on year. NHS 999 receives around 12 million calls annually, with October 2021 their busiest month yet. 
  • An eight-minute response time is the primary measure of success. Paramedics’ clinical contributions and patient outcomes are largely ignored.
  • Dealing with the consequences of patients’ lack of access to other healthcare services such as GPs and adult social care. Data suggests that only around 5% of NHS 999 calls are life-threatening emergencies.
  • A traditional hierarchical ‘command and control’ structure with few leadership opportunities.
  • High levels of staff sickness – Professor Wankhade found the average absence rate for ambulance trusts (6.32%) to be the highest among the entire NHS workforce (4.2%).
  • Issues in staff recruitment and retention – job vacancies stand at around 10%, putting increasing pressure on operational staff.
A close up shot of the back of an ambulance. The ambulance is stationary in a city street with its blue lights on.

Putting the challenges into context

These challenges have shaped Professor Wankhade’s research and its subsequent ‘real world’ application. 

A key aspect of his work has been investigating the negative impact of the response time targets on staff engagement and organisational productivity.

He found that as work intensifies in a job that already demands a lot physically and emotionally – as highlighted during the Covid-19 pandemic – staff are more likely to question and evaluate whether the role is for them.

Professor Wankhade looked at how staff – many enticed by the thrill of an ’emergency response’ career – were affected by the rapid transition between ‘intense-extreme’ and ‘mundane-extreme’ cases.

He also considered how the role and identity of ambulance staff interplay with the professional culture, managerial objectives and performance management.

Shaping the Ambulance Response Programme

In 2017, NHS England implemented new ambulance standards to overhaul a decades-old system.

Professor Wankhade’s research underpinned this Ambulance Response Programme (ARP),  with professionals and leaders recognising his work as one of the important empirical investigations in the sector.

The ARP took on board Professor Wankhade’s observation that there was no evidence that response time targets supported good clinical care or staff motivation.

As a result, the new regime focuses on getting all patients the right response first time. It aims to give call handlers more time to assess patient needs based on four categories of calls – life-threatening, emergency, urgent and less urgent. The sickest patients get the fastest response.

It also recognises paramedics’ value in clinical care. The ARP encourages paramedics to treat patients with less urgent conditions at home or to call with advice. This is a shift away from paramedics being seen primarily as a hospital transport service.

Importantly, the ARP also looks to end hidden delays for patients and the inefficient use of already stretched resources. Call handlers have commonly dispatched cars to meet response time targets, despite patients still having to wait for an ambulance to get them to hospital.

While the ARP is still being embedded and refined across trusts, early findings suggest that it has boosted performance and led to more efficient operations.

Reviewing 999 responses in Wales

Professor Wankhade’s expertise also put him front and centre in a 2018 clinically-led review of the Welsh Ambulance Service’s response to 999 Amber (serious but not immediately life-threatening) calls.

He was the only academic invited to join the review team’s Expert Reference Group and also acted as adviser and peer reviewer.

The AMBER Review, commissioned by the Welsh Government, was prompted by concerns over response times. The Welsh triage system of categorising calls as Red, Amber or Green was leaving some ‘Amber’ with unacceptably long waits for assistance.

It warned that any new amber response targets would be arbitrary and potentially counterproductive – a direct recommendation from Professor Wankhade’s research.

Instead, it advised that any evaluation should also consider if patients had received the correct response and quality care, as these are factors patients value too.

The National Assembly for Wales welcomed the review. It has since seeded further developments and reforms in the Welsh Ambulance Service.

A call operator with their headset on whilst smiling. There are two other call operators sat either side of them with their headsets on.

Improving performance and staff wellbeing

The West Midlands Ambulance Service (WMAS) is the highest performing ambulance trust in the UK and has the lowest sickness absence rates.

It used Professor Wankhade’s research into the impact of response times on patient outcomes and staff resilience to help transform its operations and performance management.

WMAS now uses high-quality reporting, analysis and performance mapping tools to forecast demand and match ambulance crews. This has reduced pressure on resources – including staff – with one measure being falling sickness absence rates.

The Trust has also invested in its staff on Professor Wankhade’s recommendation. It empowers them to show leadership, moving away from the ‘command and control’ structure of old. WMAS was also the first trust to fund one of its managers through a PhD. 

Driving cultural change

Professor Wankhade and ambulance professionals are working together, using academic rigour and real-world insight to move the sector forward.  

His book Ambulance Services: Leadership and Management Perspectives – written with ambulance service leaders – is now a core text, widely used by management trainees and leaders.

The Association of Ambulance Chief Executives (AACE) has also supported a drive for evidence-based management training to boost the sector’s research capacity. It has endorsed Edge Hill’s PhD in Emergency Services Management. The first two candidates from an ambulance background are set to complete their doctorates in 2023.

Professor Wankhade’s success in driving a holistic approach to performance management in ambulance services has caught the attention of senior police and fire service leaders. Their organisations face similar pressures with increasing demands on resources and disaffected staff.

Keeping up the momentum

Professor Wankhade is grateful to Edge Hill for the opportunity to immerse himself in an area of public sector performance management that is new territory for the University and the ambulance sector. 

His research has been ranked high for impact by those who independently rate university research. But most importantly, it has led to demonstrable improvements within ambulance services’ performance management regimes.

Professor Wankhade’s research is also proving of interest in Parliament. The House of Lord’s Public Services Committee recently called him to give evidence on the challenges in accessing emergency services. 

Despite leading such influential work, Professor Wankhade considers that he’s only just scratched the surface. He is keen to learn more about how all emergency services can better work together, overcome leadership challenges and improve service delivery.

Our research means

  • People calling 999 for ambulance services are more likely to get the right support at the right time.
  • Ambulance staff feel more valued and listened to, positively impacting their health and wellbeing.
  • Emergency service leaders have the evidence and ongoing professional research to improve their operations.

Find out more about Paresh Wankhade’s research by viewing their profile on Pure:

Professor Paresh Wankhade’s research