4 December 2006 www.wao.gov.uk Ambulance Services in Wales 4340_WAO Amb ENG_v0_14.indd 1 29/11/06 11:00:43 Ambulance Services in Wales © Auditor General for Wales 2006 I have prepared this report for presentation to the National Assembly under the Government of Wales Act 1998 The Auditor General is totally independent of the National Assembly and Government. He examines and certifies the accounts of the Assembly and its sponsored and related public bodies, including NHS bodies in Wales. He also has the statutory power to report to the Assembly on the economy, efficiency and effectiveness with which those organisations have used, and may improve the use of, their resources in discharging their functions. The Auditor General also appoints auditors to local government bodies in Wales, conducts and promotes value for money studies in the local government sector and inspects for compliance with best value requirements under the Wales Programme for Improvement. However, in order to protect the constitutional position of local government, he does not report to the Assembly specifically on such local government work. The Auditor General and his staff together comprise the Wales Audit Office. For further information about the Wales Audit Office please write to the Auditor General at the address above, telephone 029 2026 0260, email: [email protected], or see web site http://www.wao.gov.uk 4340_WAO Amb ENG_v0_14.indd 2 29/11/06 11:00:44 Report presented by the Auditor General for Wales to the National Assembly on 4 December 2006 4340_WAO Amb ENG_v0_14.indd 3 29/11/06 11:00:49 Ambulance Services in Wales 4340_WAO Amb ENG_v0_14.indd 4 29/11/06 11:00:49 Contents Foreword by the Auditor General for Wales 8 Summary 10 There are longstanding problems with the ambulance service 11 The Trust’s key strengths have been let down by a wide range of factors 13 The problems can be resolved over time provided key challenges are dealt with 15 Recommendations 17 Performance 17 Strategy 17 Governance 19 Leadership 19 People and culture 20 Process 21 Capacity, systems and infrastructure 23 How to read this report 24 Part 1: There are longstanding problems with the performance of the ambulance service 25 Patient care could have been compromised by the Trust’s consistent failure to provide sufficiently responsive emergency ambulance services 25 The Trust has consistently failed to achieve important performance targets 25 The Trust has not achieved response time targets 27 There are consistent regional variations in response time performance 32 Emergency response time performance compares badly with English services but appears similar to Scotland 35 Poor response times have led to other emergency services transporting patients to hospital 37 There has been an increase in emergency activity in the Trust which is consistent with rural trusts in England but which does not fully explain the failure to improve performance 38 There is little information about Patient Care Services performance and there have been serious adverse incidents 40 Clinical performance needs to improve further 41 Rates of pre-hospital thrombolysis are rising but can increase further 41 We are not able to report at this stage on the extent to which improved performance might save additional lives 42 Ambulance Services in Wales 4340_WAO Amb ENG_v0_14.indd 5 29/11/06 11:00:50 Part 2: The Trust’s strengths have been let down by a wide range of factors 43 The Trust has a number of key strengths 43 The strategic framework will provide significant opportunities 44 There are examples of innovation and good practice within the Trust 46 There is significant goodwill towards the ambulance service in Wales 48 The Trust has structural stability as a national service, with national commissioning and scope for further national developments 49 The Trust has enough human and financial resources 50 The Trust’s staff are a key strength 56 The Trust has been let down by failures in a number of key areas 59 There has been no effective strategic direction for the Trust 59 Governance has not been effective in securing improvement 62 There has been weak leadership in the Trust 71 Processes are badly designed and managed 81 The Trust has poor systems and infrastructure 89 There are serious concerns about the organisational culture 102 Part 3: The problems can be resolved over time provided key challenges are dealt with 104 The problems can be resolved over time 104 Other trusts have turned themselves around 104 The draft modernisation plan sets out a direction to address the weaknesses we identified 106 External challenges need to be addressed 106 NHS reconfiguration changing demand for ambulance services 106 Ineffective interfaces with other NHS systems 107 PCS contracts are at risk from competition and internal system weaknesses 110 Managing stakeholder expectations 112 GP dissatisfaction with the service 113 Developing effective partnerships 113 Internal challenges need to be addressed 113 Developing sound operational processes 114 Developing a new culture 118 Addressing a difficult financial position 123 Improving the estate 128 Ambulance Services in Wales 4340_WAO Amb ENG_v0_14.indd 6 29/11/06 11:00:50 Appendices Appendix 1: Methodology 131 Appendix 2: Expert Panel 135 Appendix 3: Response time performance by Local Health Board area 138 Appendix 4: Priorities for improvement identified by Trust staff participating in our focus groups 161 Appendix 5: Extract from District Audit report, Commissioning Emergency Ambulance Services (2001) 164 Appendix 6: Comparison of funding for the Trust and other UK ambulance services 166 Appendix 7: Sickness absence 168 Appendix 8: The Trust’s response to our recommendations in respect of links to the draft modernisation plan 170 Appendix 9: Hospital turnaround times 178 Appendix 10: Category ‘A’ response time performance by LHB area at the sixtieth, seventy fifth and ninety fifth percentiles 184 Ambulance Services in Wales 4340_WAO Amb ENG_v0_14.indd 7 29/11/06 11:00:51 Foreword by the Auditor General for Wales The long standing problems of the ambulance of front-line ambulance staff, public goodwill service in Wales can be resolved – over time. The towards the service, the national structure and draft modernisation plan of the Welsh Ambulance the emerging modernisation of ambulance and Services Trust Board addresses all the crucial unscheduled care services across the UK. challenges that need to be faced to turn the service round. Successful delivery of that plan in both In addition, things have already started to change the short and longer term will be fundamental to within the Trust, with particular progress in respect establishing an efficient and effective ambulance of internal governance. It is also important to note service for Wales, and will also address those of my that the Trust’s co-operation with the WAO team recommendations that fall to the Trust for action. during this Inquiry has been exemplary throughout - I am most grateful to all who assisted us – and The Trust needs leadership and strategic direction the fact that the Trust’s management has made and to address detailed matters of internal efficiency. significant progress in the development of the A particular challenge will be to find ways to improve modernisation plan at the same time as dealing the match between supply of ambulance services with the impact of this inquiry is to their credit. in each area of Wales and the demand for them throughout the day, and to establish what changes This report confirms, however, that the problems to working practices are needed to achieve that. of the ambulance service in Wales are long standing and deep seated. Its strengths The ambulance service is not a self contained have been let down by problems of strategy, operation and must be seen as an integral part leadership, governance, process, infrastructure of the way the NHS delivers clinical services and systems, people and culture. to patients. Effective management of the ambulance service therefore includes effective Severe as the problems are, other ambulance management of its external relationships. Major services in Britain have been in a similar position external challenges that need to be faced include and have been able to turn themselves round accommodating changing demand for ambulance given time. For that reason I am able to reach an services arising from reconfiguration of NHS optimistic conclusion about the ultimate prospects services, ineffective interfaces with other NHS for the success of the ambulance service in systems and developing effective partnerships. meeting the needs of the people it serves. There are grounds for optimism about the ability In accordance with the established convention of the ambulance service to meet all these for my reports I have agreed with the Accounting challenges over time because despite the much Officer for the Welsh Assembly Government’s talked-of problems it has some very important Department for Health and Social Services strengths. The current level of funding for day to and with the Chief Executive of the Trust, as day operations (as distinct from capital investment) Accountable Officer for that body, that the facts in is adequate. Other strengths include the quality the report relating to matters for which they have Ambulance Services in Wales 4340_WAO Amb ENG_v0_14.indd 8 29/11/06 11:00:55 responsibility are correct and that the balance of General’s report of holding eight public hearings their presentation is fair (although they could not, throughout Wales, and in presenting the results of naturally, be expected to confirm the accuracy of the study I have deliberately set out the evidence evidence from third parties). All of the judgements much more fully than is usual in my audit reports. made and conclusions drawn are mine alone.