Ambulance Services in Wales

4 December 2006 www.wao.gov.uk

4340_WAO Amb ENG_v0_14.indd 1 29/11/06 11:00:43 Ambulance Services in Wales

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

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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

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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

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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

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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. I also depart from convention in acknowledging The report records some instances of disagreement here my gratitude to the Wales Audit Office team between parties as to certain matters. Where such who carried out the very thorough work this inquiry disagreement is not central to the conclusions I demanded. Their names are given in Appendix 1. draw, I have not necessarily sought to resolve it. The study has been completed in 148 days at a cost to the Wales Audit Office, at the time of I have undertaken this study of ambulance services writing, of approximately £170,000 (excluding in Wales under my normal audit powers. The costs incurred in the translation and publication of report is therefore, in that sense, a conventional the report). It is very unlikely that a public inquiry audit report. The circumstances under which I was could have delivered as comprehensive a report invited to conduct the study were not conventional, so economically or so quickly. For example, the however, and I have been conscious throughout public inquiry into the death of Dr David Kelly that it was intended to be a substitute for a public reported after 6 months (which is unusually rapid inquiry under the Inquiries Act. For that reason, for a public inquiry) but at a cost of £1.7 million. I took the unprecedented step for an Auditor

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4340_WAO Amb ENG_v0_14.indd 9 29/11/06 11:00:57 Summary

1 The Welsh Ambulance Services NHS Trust (the appointment and subsequent resignations Trust) was set up in 1998 through the merger of two interim Chief Executives, Mr Roger of five predecessor ambulance services. The Thayne OBE and Dr Anton van Dellen. A Trust’s Emergency Medical Service (EMS) new substantive Chief Executive, Mr Alan handles annually some 317,000 emergency Murray, took up post in August 2006; calls, attends 269,000 emergency incidents and transports 63,000 urgent patients. Its Patient d a serious adverse incident in patient care Care Service (PCS) provides 1.4 million routine services in which a patient died after being patient journeys a year to hospital for those who delivered to the wrong address; and would otherwise have difficulty getting to and from hospital appointments. The Trust employs e claims by Mr Thayne that 500 lives nearly 2,500 staff and had an annual turnover were lost avoidably as a result of the of £115 million in 2005/2006. It works closely way that the service operated. with the air ambulance charity, which provides 3 As a result of such concerns, on 11 July three aircraft. The role of ambulance services is 2006, the National Assembly for Wales changing to a more clinical focus as a provider unanimously voted to invite Jeremy Colman, of mobile primary healthcare, encapsulated in Auditor General for Wales, to lead an the Welsh Assembly Government’s emerging Inquiry into ambulance services in Wales. strategy, Delivering Emergency Care Services It proposed that the Inquiry should: and the Department of Health report in England, Taking healthcare to the patient. a look at the effectiveness of performance standards, staffing issues, financial and 2 There has been growing and widespread resource pressures, together with any other public concern about recent events related matters considered relevant; and in the Trust, in particular: b consider the implications for the future and a its consistent failure to achieve make recommendations accordingly. performance targets, particularly in south-

east Wales and some rural areas; 4 To address these points, we therefore sought to confirm the nature and extent of perceived b high profile procurement failures such as the problems with the ambulance service. As procurement of 46 ambulances that were well as that diagnosis, we focused strongly not fully fit for purpose because the Trust on the future and the plans being developed did not provide a coherent specification; by the new Chief Executive to improve ambulance services in Wales. In the spirit c severe managerial instability arising from the absence of the substantive of the NHS Concordat, we worked closely Chief Executive, Mr Don Page, and the with, and drew upon the emerging findings

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4340_WAO Amb ENG_v0_14.indd 10 29/11/06 11:01:01 of, colleagues from Healthcare Inspectorate There are longstanding problems Wales, who are undertaking a review of with the ambulance service clinical governance, patient care services and specific investigative work to assess the claim 6 The speed with which ambulance services that 500 lives were avoidably lost each year respond to emergency patients affects because of the way the service operates. their prospects of survival. Consequently, governments in the United Kingdom have set 5 We concluded that there are longstanding and internationally recognised response time targets severe problems throughout the ambulance based on clinical evidence that responding service but that they could be resolved over within eight minutes to an emergency call time provided that various internal and external improves patient care. Although there are some challenges are dealt with. The Board’s draft differences in the categorisation of emergency modernisation plan sets out a direction which calls, the Welsh Assembly Government’s current already addresses the key weaknesses targets are a lower milestone towards achieving we identified. Our work confirmed that the the same target as applies in England, which ambulance service’s poor performance was is to achieve an eight minute response to 75 more than a matter of not meeting targets, per cent of Category ‘A’ calls. In Scotland, the but also could have compromised patient target is to achieve a 75 per cent response care. Our diagnosis of the reasons for such rate to Category ‘A’ calls within eight minutes performance is that the ambulance service’s by 2008, with interim milestone targets. very considerable strengths – including the quality of front-line staff, public goodwill and 7 The Trust has generally failed to meet its the emerging modernisation agenda – have response time targets and to deliver consistent been let down by weaknesses in all the key access to emergency ambulance services aspects of good business management. across Wales. Although performance has increased in most recent years, the Trust

Current Welsh Assembly Government ambulance response targets

To maintain a monthly all-Wales average performance of ambulance services with at least: a 60 per cent of first responses to Category A’ (immediately life threatening calls) arriving within 8 minutes; b 70 per cent of first responses to Category ‘A’ (immediately life threatening) calls arriving within 9 minutes; and c 75 per cent of first responses to Category ‘A’ (immediately life threatening) calls arriving within 10 minutes; and d a fully equipped ambulance will respond to all emergency calls to a level of 95 percent within 14, 18 or 21 minutes in urban, rural or sparsely populated areas respectively. In all geographical areas that fall below the above targets, targets for improved performance will be agreed with the Welsh Assembly Government. There is a performance standard for GP urgent calls, introduced from April 1999, that in 95 per cent of cases, the ambulance should arrive at hospital no more than 15 minutes later than the time agreed by the GP for urgent patients.

Source: Annual Priorities and Planning guidance for the service and financial framework (SaFF) 2005/2006 and 2006/2007, WHC (2006) 019 Balanced Scorecard for NHS Wales 2006/2007, Welsh Assembly Government, and Health Statistics Wales (2005).

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4340_WAO Amb ENG_v0_14.indd 11 29/11/06 11:01:04 has achieved the 60 per cent average in low compliance with response time targets, only two months since March 2004 and which include Monmouthshire, Powys, Bridgend performance declined during 2005/2006. and the Vale of Glamorgan. Consequently, while The Trust has also failed to achieve: the Trust reaches 60 per cent of Category ‘A’ calls within eight and a half minutes overall, a the nine and ten minute response other patients face long waiting times for a time targets for Category ‘A’ calls; response from the service, especially in some rural areas. This has led to some adverse b response targets for a fully- incidents and could have compromised safe equipped ambulance to respond to patient care, including patients being transported all emergency calls in urban, rural to hospital by other emergency services. and sparsely populated areas; 9 Historically, the Trust has consistently, and to a c contractual performance levels agreed with large extent inappropriately, attributed the failure HCW for each Local Health Board area; and to achieve targets to increases in demand and insufficient funding to accommodate it. While the d response time targets for GP volume of emergency incidents has increased urgent calls, which have declined by 43 per cent between 2000/2001 and significantly since 2000/2001. 2005/2006, activity in terms of emergency and

In the last three financial years, England has urgent patient journeys only increased by 2.8 achieved an overall response rate of 75 per per cent between 2001/2002 and 2005/2006. cent of Category ‘A’ calls met within eight The Trust’s income increased by 73 per cent minutes, although the Department of Health between 2000/2001 and 2005/2006, while its has raised some concerns about data accuracy staffing has also increased by around 27 per in 2005/2006, and there have been some cent since the creation of the Trust in 1998. differences in emergency call classification The number of emergency patient journeys between England and Wales since April 2005. has risen at the same time that the number of For example, in Wales all children under the GP urgent calls has decreased significantly. age of two have been automatically classified The scale of increased demand in Wales as Category ‘A’. In Scotland, the percentage was consistent with that experienced by rural of Category ‘A’ calls receiving a response services in England. The Trust appears to have within eight minutes is similar to the level in been slow to develop alternative responses to Wales, at 58.5 per cent in 2005/2006. demand in the same way as rural services in England. The Trust transports a relatively higher 8 The use of averages skews the performance proportion of patients to hospital than rural data because it does not show by how much services in England, which adds to the pressure the Trust missed the eight minute target. A small on Accident and Emergency Departments proportion – half of one per cent – of emergency and the ambulance service, and contributes to calls between April 2005 and September 2006 long turnaround times for ambulance crews. received a response of between one and three hours. The national average also masks 10 Of course, the most important element of consistent regional variations, with performance the ambulance service is the clinical care it highest in North Wales and lowest in South-East provides to patients, and it is essential that this Wales. There are also some areas with extremely is measured alongside response times to give a

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4340_WAO Amb ENG_v0_14.indd 12 29/11/06 11:01:04 balanced assessment of service performance. e although many people historically, including However, there are problems with the quality the Trust, believed that the Trust is under- of the Trust’s clinical data. Roger Thayne, resourced, we found little evidence to former interim Chief Executive, claimed that support this. Our analysis suggests that 500 lives were avoidably lost each year as a the Trust has relatively high financial and result of the Trust’s relatively low performance human resources in comparison with in a number of interventions. This claim is other UK ambulance services. However, still being tested by Healthcare Inspectorate there are questions about the efficiency Wales (HIW) who will report separately on with which resources are used and people their findings in due course. HIW’s review has, deployed. Whilst we found that the Trust however, found that the Trust is developing had a comparable asset base and received the use of pre-hospital thrombolysis - an comparable capital funding in recent years, important clot-busting drug treatment used there is also evidence that the Trust requires for some patients experiencing a heart attack further capital investment to develop its - and that by the end of 2006, all paramedics infrastructure; there is significant scope to should have been trained. This should deliver improved performance from within improve the relatively low rates of thrombolysis existing resources, principally by achieving in Wales compared with the average a better match between rostered hours performance of English ambulance services. and predicted demand for services; and

The Trust’s key strengths have been f the Trust’s staff are highly regarded let down by a wide range of factors by the public, and the majority of staff recognise the need and scope for the

11 The Trust has some key strengths: Trust to modernise, and have practical ideas about how to change things. a the strategic framework is favourable and the Welsh Assembly Government’s 12 However, the Trust has been let down by emerging strategy, Delivering Emergency important failures in all the key areas of business Care Services, should open up numerous management. Although the Board and new opportunities for the Trust to play a leading Chief Executive are finalising a modernisation role in the development of unscheduled plan, there has been a longstanding absence care services and new models of care; of strategic direction. Although a five year strategy was produced in 2005, this was not b there are local examples of good supported by any clear plans for implementation, practice and innovation; reflecting wider weaknesses in business planning, and the strategy has been superseded c there is significant goodwill towards by the draft modernisation plan. In addition, the ambulance service in Wales; key stakeholders – Trust staff, consultants in Accident and Emergency Departments, other d there is overall structural stability as a emergency services, the public, Community national service that has been through Health Councils and some acute trusts – do the merger process; strategic national not think that the Trust has a clear vision of commissioning is an advantage and the the future although this may be changing as proposed merger of the Trust and NHS the draft modernisation plan develops. Direct offers significant potential benefits;

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4340_WAO Amb ENG_v0_14.indd 13 29/11/06 11:01:07 13 The Trust has, to date, consistently achieved and performance management arrangements its annual financial targets but has not done at corporate, executive and individual levels. so in a sustainable way because it has There has also been a lack of clinical leadership, been insufficiently focused on long-term partly because the Medical Director works considerations. The Trust was only able to part-time for the Trust and has a role as a break even in 2005/2006 because of unplanned ‘clinical advisor’, rather than a clinical lead. additional funding and non-recurring gains and is facing a potential deficit of £6.6m in the 16 Related to management capacity, we current financial year, with significant financial identified serious concerns about the culture pressures in future years. Despite receiving of the organisation and the way people are income and capital funding that is comparable managed. Sickness absence levels are overall with other ambulance services, we high. The numerous secondments – moving found that the capital infrastructure was weak. staff temporarily to posts other than their Capital expenditure was often rushed at year substantive post – and lack of performance end and was not supported by long-term capital management mean that roles, responsibilities planning linked explicitly to a Trust strategy. and accountabilities are not clear and decision- making is slow. This is illustrated by the failure 14 Internal and external governance has been of the Trust to address a number of known weak. At Board level, there could have been problems over several years, such as changing greater engagement and involvement in the rosters, differential levels of performance and business, exacerbated by the absence of a serious problems with the Trust’s estate. plan to deliver the strategy, poor management information and an absence of performance 17 Staff generally lack performance objectives and management. Despite a clear diagnosis of appraisal. They also reported a culture of blame the problems in the Trust and actions taken and a failure to praise staff or listen to and act on individually to tackle the problems, a risk of their ideas for improvement. This is reflected in overlap between the respective performance the perception among some staff that the Trust management responsibility of the Welsh has a culture of bullying and harassment, and the Assembly Government’s Department for increasing levels of grievances. Communication Health and Social Services Regional Office and is inherently difficult in an organisation like the principal commissioning role of HCW has made Trust, but it has been poor. This has contributed it more difficult to stimulate improvement. to the absence of systems to learn from experience and identify and disseminate good 15 There have been significant problems of practice from within or outside the Trust. leadership and managerial capacity. The rapid changes in leadership, and prolonged 18 Processes have been badly designed sickness absences of key executives, have been and managed. The basic problem is that, extremely damaging. Nevertheless, serious although overall resources appear adequate, problems with managerial capacity existed the supply of ambulance and patient care before the recent turnover: the Trust lacked services does not adequately match peaks change management and project management of demand, particularly because of inflexible capacity. This is exemplified by the serious shift patterns and deployment. This can deficiencies in procurements, such as the recent place many individual staff under extreme ambulance procurement, and weak improvement

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4340_WAO Amb ENG_v0_14.indd 14 29/11/06 11:01:07 pressure, particularly at certain times of b in fleet, ambulances are inadequate day. There is little costing or benchmarking because of the problems with the information on which to draw in considering the recent procurement of 46 ambulances, distribution and use of available resources. vehicles are old, have high failure rates and spare fleet capacity has been 19 There are weaknesses in the management of insufficient. The Welsh Assembly control centres because of problems with ICT Government has recently announced systems and very low job satisfaction. We also £16m funding for new ambulances; and identified scope to improve significantly the way calls are classified in control centres and c in ICT systems, the Trust has not invested the speed with which they are expedited. PCS in key systems such as satellite navigation, systems are not fit for purpose and have resulted which has the potential to deliver in poor service to patients, serious adverse improvement in Category ‘A’ response time incidents involving patients being delivered performance. There are also problems to the wrong addresses and an information with the radio network which a major void. Clinical governance has developed procurement, the ambulance radio re- but has not yet become integrated into the procurement project (ARRP), is addressing, management of the Trust and there is scope though it has slipped and is not yet fully to broaden the understanding of front-line staff funded. And there is no standard system about clinical governance and clinical audit. for PCS even though a procurement exercise led to expenditure of around 20 Systems and infrastructure – estates, fleet and £500,000 on a system that could not be ICT – remain weak and reflect the Trust’s poor used because it was not fit for purpose. management of capital. Although there has been piecemeal development of alternative The problems can be resolved over time models of service, such as community provided key challenges are dealt with responders and Rapid Response Vehicles, the Trust’s infrastructure represents a significant 21 The scale of the challenges facing the Trust obstacle to further progress. At focus groups, suggests that their resolution will take time. In the main concern of staff was being properly the past, however, other UK ambulance services equipped to do the job, with particular problems have faced similar problems to those in Wales in the areas of estates, fleet and ICT: and have been able to turn around the situation. The Trust’s Board and Chief Executive have a in estates, the Trust has an outstanding now developed a draft modernisation plan Health and Safety Executive notice that sets out a direction to address many of relating to 19 sites; there has not been a the weaknesses we identified. Clear priorities, strategic approach to estates and this is significantly improved planning and performance exacerbated by insufficient investment and management will be needed. The strengths a lack of estate management capacity; of the Trust and its staff mean that, over

1 The Trust has four control centres that take emergency calls, allocate jobs to crews and manage the deployment of resources.

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4340_WAO Amb ENG_v0_14.indd 15 29/11/06 11:01:10 time, change can be delivered with effective f the need to develop effective partnerships leadership, capital investment in infrastructure and develop new service models and a significant improvement and development for unscheduled care, particularly of managerial capacity and organisational with Local Health Boards. culture. To deliver such an improvement in line with its emerging modernisation plan, 23 Similarly, the Trust must address a series of the Trust must address a series of important internal challenges to deliver improvement: challenges both external and internal. a the development of sound operational 22 A number of external challenges face the Trust: processes in control centres, and improving deployment, efficiency and processes a changes in demand for its services to match resources and demand; arising from changes in the way hospital services are organised mean b developing a new culture by improving the Trust will need to adapt; operational management – effective workforce planning and delivering the b interfaces with other NHS systems benefits of the expensive Agenda for need improvement, particularly: Change process which has reduced capacity and increased staff pay, and i lost ambulance hours arising from where the Trust’s inclusive meal break time lost because of problems policy does not comply with the national handing over patients to accident and agreement; the Trust needs to engage emergency departments – so called and communicate more effectively with ‘hospital turnaround times’; and staff, with faster decision making, an increased focus on learning, performance ii changes in patterns of demand management, change management arising from the new GP out- and robust programme management of-hours arrangements. processes; and it needs to develop a structure that empowers the regions to c PCS contracts are at risk from operate within a corporate framework competition and weaknesses in the of accountability and responsibility; Trust’s operational processes for PCS; c addressing a challenging financial position d managing stakeholder expectations – the Trust and HCW are currently of immediate and fundamental negotiating a Service Change and Efficiency service improvement based on more Plan, with a projected deficit of £6.6m in ambulance stations, more staff and the current financial year, but will need to more traditional ambulances, especially agree a reasonable timescale in which to in rural areas where new types of deliver the efficiency gains that the Trust service may be more appropriate; must achieve from its relatively generous e GP disaffection with the service, levels of resourcing. In addition, the Trust manifested by the reduction in GP will need to demonstrate a significant urgent activity and corresponding improvement in its capacity to access increase in emergency calls; and

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4340_WAO Amb ENG_v0_14.indd 16 29/11/06 11:01:10 2 There are significant problems with access and make effective use of the significant to emergency medical services, as shown by capital funding that is available from the performance data and the significant concerns Welsh Assembly Government; and expressed to the team by members of the public. There have been particular problems d improving the estate – the Trust has with response times in some rural areas. The significant problems with its estate and Trust should conduct a review that leads will also need to change its estates to the development of regional strategies, model to reflect and support changes in consistent with the national plan. These the overall model of service delivery. strategies should take account of specific Recommendations local circumstances, service developments and the need to deliver significant Performance performance improvements and more equitable access. The regional plans should 1 The Trust has generally failed to achieve its 60 also analyse new models of service that per cent response time target for Category A might significantly improve performance in calls, which is a significantly lower milestone rural areas, as well as the need to maintain towards achieving the same target as applies cover by double crewed ambulances. in England, whilst Wales categorises Category ‘A’ slightly differently than England. The Trust’s 3 The time ambulances spend at A&E detailed business planning should set out departments handing over patients and then how the Trust will deliver and then maintain presenting themselves for the next call remains 75 per cent performance across Wales a significant drain on capacity. A monitoring and how it will achieve a step change in system is in place to measure the length of time performance in rural areas. At the same time, ambulances remain at A&E departments. The the Trust should develop a robust, accurate Trust should take a much more proactive and balanced system of measuring and role in tackling poor turnaround times and reporting ambulance service performance monitoring real time delays that occur. that covers key aspects such as: Strategy a clinical quality; 4 The Trust has over-centralised to the extent b measures of progress in transporting that the regions have not been empowered fewer patients to hospital; to develop appropriate services and to tackle the challenges they face. Headquarters was c patient and stakeholder satisfaction; too operationally focused and consistently failed to deliver strategic change. Internal d staff morale and cultural change; communication has been a weakness. The Trust Board and headquarters should focus e finance and resources; and on longer-term strategic development and the performance management of operations, f PCS performance. while the managers in the regions should be empowered to develop and deliver the

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4340_WAO Amb ENG_v0_14.indd 17 29/11/06 11:01:13 Trust’s services to patients. To enable the a developing roles, staff and protocols to Board to achieve this necessary level of allow hear and treat and see and treat strategic leadership, it should undergo a approaches that avoid transporting programme of Board development. There patients to hospital unnecessarily; should be much clearer accountability for results delivered through the performance b expand the number of staff who management system. A communications have had additional education and strategy should support the positive training to make clinically safe development of the Trust’s culture. decisions not to convey the patient;

5 The public needs to be informed about how c reintroducing Category ‘C’ calls and a modern ambulance service works and why protocols that allow the service to refuse the changes in the draft modernisation plan to attend patients where the caller has are necessary. The public, particularly in rural had a telephone consultation and it is areas, can help ambulance staff to provide a not clinically appropriate to attend; better service. In the context of Delivering Emergency Care Services, the Welsh d monitoring the percentage of Assembly Government should develop patients transported to hospital; a patient information campaign to: e developing referral protocols with NHS Direct and GP out-of-hours services to a explain changes in unscheduled care services, including ambulance services ensure that patients access the care and their changing role; and most appropriate to their clinical needs; f expanding successful initiatives b highlight ways in which the public could help the ambulance service deliver a such as the field hospitals, set up in prompt and appropriate response, such Swansea and Cardiff at busy times, as by knowing when and how to call that provide appropriate responses to the service, what information they need demand for unscheduled care; and to provide and how it will be used. g working with health partners, develop alternative care pathways that provide 6 The Trust transports a relatively high proportion of people to hospital, despite evidence that a appropriate routes through the significant proportion of calls could be treated unscheduled care system and increase more appropriately without being transported the clinical role of the ambulance to hospital. This exacerbates pressures on service as a front-line provider of mobile A&E departments, ties up crews unnecessarily primary and diagnostic healthcare. and means that patients do not access the 7 The ongoing secondary care reviews will most appropriate care. In implementing its lead to a reconfiguration of services that modernisation strategy, the Trust should, could significantly affect the ambulance with the Welsh Assembly Government service. The Regional Planning Fora should where appropriate, develop alternative ensure that the secondary care reviews response interventions including: include a consideration of the impact of any changes on the ambulance service.

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4340_WAO Amb ENG_v0_14.indd 18 29/11/06 11:01:14 In particular, there is a need to consider 10 The Trust has experienced a very difficult the impact of reconfigured services on period, including significant external scrutiny. demand for the air ambulance service. The Trust has experienced problems in the past implementing strategies. Now that Governance it has developed a plan to move the service forward, the Welsh Assembly 8 There have been historical weaknesses in Government should provide the Trust with internal governance concerning the Trust Board, the space to work towards implementing some of which have been addressed in recent its plan as quickly as possible with a months. There is a particular need to develop minimum of distraction, particularly greater clarity of the Board’s role, responsibility over the next twelve months. and decision making. The Trust should review the roles and responsibilities of Board Leadership members to ensure that non-executives are much more actively involved in the Trust, 11 Management capacity has been poor at for example through regional non-executive all levels, with confusion about roles and roles. There should also be more robust responsibilities, and little management performance management arrangements development. The Trust should assess for non-executive members of the Board. management capacity urgently and ensure The Trust Board should also clarify which that its leadership has sufficient skills decisions the Board should take and to at all levels to manage the organisation communicate more clearly with staff the effectively. The Trust should develop a decisions taken at each Board meeting. leadership and management development programme that is linked to the performance 9 Although national commissioning is a strength, and appraisal system and addresses skills its role in performance managing the contractual shortages. It should also link the workforce delivery of the emergency service has been planning processes, which seeks to identify insufficiently co-ordinated with performance future skill needs, as the organisation management of the Ambulance Trust as an moves to more modern working practices. organisation by the Welsh Assembly Government There should be a particular focus on: and there was insufficient input from local health communities. As the Delivering Emergency a change, programme and Care Services strategy evolves, the Welsh project management skills; Assembly Government should maintain national commissioning but seek to develop b valuing staff, engaging with them regional consortia of Local Health Boards to and acting upon their suggestions inform it about the local needs that should where considered appropriate; inform the commissioning of unscheduled care services, of which ambulance services c investigating the potential of team are a key element. In respect of PCS, the leadership to improve management Trust should develop more integrated capacity at local level, particularly commissioning of transport services with through managers having social services and Mental Health services. named team members; and

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4340_WAO Amb ENG_v0_14.indd 19 29/11/06 11:01:16 d changing the management structure c incorporates an effective performance to provide the capacity and skills to management, and personal development deliver change and to manage the system for all employees where organisation effectively on a day-to- employees have personal targets day and longer-term strategic basis. and objectives that are derived from the strategy and business plan and 12 There have been problems with the assessed at least annually through organisational culture and a lack of clinical a formal appraisal process; leadership, partly because the Trust has not had a full-time clinical director. The Trust needs to d gives all executives clear and change its culture and become a reflective, measurable personal objectives learning organisation that learns from which are cascaded from the adverse incidents and focuses on clinical strategy/business plan; issues rather than transport. To develop a more clinical focus, it should move towards e strengthens accountability and full-time clinical leadership. It should also challenge within managerial take account of the views of its service and Board arrangements to users and stakeholders in order to improve deliver improvement; and consistently the quality of care it provides. f ensures there is timely reporting to People and culture the Board of progress against key strategic and operational objectives. 13 The Trust has failed to develop robust performance management processes, with 14 Despite some recent progress, levels of key staff lacking objectives and performance sickness absence remain high and compromise appraisals, and significant confusion about operational efficiency. Following Agenda roles and responsibilities. Along with a for Change, sickness absence is likely to review of the organisation structure and present even greater direct costs to the programme of Board development, the Trust. Although basic principles of policy Trust should urgently develop an integrated and approach are in place, application has performance management system that: been inconsistent and sickness rates have increased since April 2005. The Trust should a incorporate an effective business refocus on applying its sickness absence planning process that translates the management policies in a robust and Trust’s strategy into specific operational consistent fashion, and to speed up benefits business plans, linked to financial realisation in respect of the electronic staff planning and service delivery processes; record system, in areas such as manager self-service for sickness reporting and b ensures appropriate and timely direct access to sickness records. monitoring and reporting of performance to enable decisions, 15 Developing new service models will require action and intervention to take place the Trust to develop new capacity and at the appropriate time and at the skills. Workforce planning has been an appropriate organisational level; historical weakness. The Trust should

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4340_WAO Amb ENG_v0_14.indd 20 29/11/06 11:01:16 produce a detailed workforce plan that b include in its strategy proposals for includes objectives and timescales, and linking control and NHS Direct if the takes account of enhanced paramedic proposed merger proceeds, and roles and the modernisation plan, systems to allow local service provision as well as the capabilities of existing to be taken into account in telephone staff to move into new roles. assessment and referral where this is the most appropriate pathway; and 16 In common with many other ambulance services, Agenda for Change has been implemented at c urgently resolve the inconsistencies in significant cost to the Trust without yet deriving gazetteers used in control rooms so that any modernisation benefits. Meal breaks remain there are compatible gazetteers in all a drain on capacity and the Trust is currently control rooms in Wales. operating an inclusive meal break policy which appears to conflict with the national Agenda for Change agreement. The Trust now 18 Staff do not feel valued or listened to by needs to work closely with staff and their Trust managers, despite the evidence that representatives to deliver rapid benefits from they are very strongly valued by the public the implementation of Agenda for Change. In of Wales. The Trust should communicate particular, the Trust should urgently resolve more regularly and directly with individual the meal break issue to ensure compliance employees, as well as with the Trade with the national agreement on Agenda Unions. Management development for Change and that meal breaks do not should address the need to recognise compromise capacity through crews driving and praise staff and to ensure that all long distances back to base stations. employees realise that the Trust recognises their contribution and commitment. 17 There are significant problems with job satisfaction, stress and sickness in control Process centres, which deliver a vital function within an ambulance service. There are also 19 There has been a failure to monitor or manage inconsistencies between the gazetteers PCS costs and performance, with five different in use in the various control rooms, which systems in operation, none of which is fit lead to data quality problems and can lead for purpose. The Trust should urgently: to problems identifying the source and a review contracts to establish the service location of calls. The Trust should: that their PCS clients want and develop common core standards of service; a develop a clear strategy to develop the control function, provide b develop a standardised PCS appropriate technology and a suitable management system; working environment, listening carefully to the views of staff on c establish appropriate management improving the control function; arrangements that ensure proper accountability for service management and delivery; and

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4340_WAO Amb ENG_v0_14.indd 21 29/11/06 11:01:19 d develop accurate costing information to meet statutory obligations. The Trust should ensure that the service operates within benchmark its estate function with a view its income levels and is competitive. to providing sufficient capacity to meet the challenging estates agenda. Drawing 20 Rosters, both for EMS and PCS, do not take on previous reviews, the Trust should account of demand, which has compromised develop a clear estates strategy that is service quality. The current rosters provide more consistent with the modernisation plan. capacity than is required overall, but not enough capacity at peak times. In some areas, rosters 23 Although there have been recent improvements, are eight years old and do not reflect recent the Trust has had significant weaknesses in changes in the demand profile or the context in terms of the performance information collected which the ambulance service provides services. and performance management systems. In PCS rosters tend to focus on the hours of 8am to particular, the information has been retrospective 4.30pm and therefore do not support the needs and does not provide ‘real time’ management of the NHS or its patients. The Trust should information to enable managers to make urgently review its rosters and undertake decisions at the appropriate time. The Trust fundamental changes to ensure that services should review its performance information are arranged around the needs of patients. requirements and develop appropriate Management Information Systems that: 21 Problems in procurement have led to significant wasted money and the acquisition of assets a provide real-time performance that have compromised the Trust’s ability to information about the delivery of perform, although there have been some recent their modernisation strategy; improvements in process. The Trust should designate an executive with responsibility b capture the right information for all procurement. It should also actively that the Trust needs to manage liaise with other ambulance services in the its various services (EMS, PCS, UK to learn from their procurement and to HR, Fleet, Estates etc); avoid duplication. The Trust should also bring in external procurement expertise for c are derived from the strategy the highest-risk procurements to support and business and financial the restoration of confidence and rigour planning processes; in its procurement function. Procurement d enable the Trust to carry out plans should be explicitly linked to national sophisticated demand modelling, strategy and modernisation plans, and both temporal and geographical; any investment, capital or revenue. e are consistent across the regions 22 The Trust has experienced significant to ensure that the Trust not only problems with the buildings that make up has regional management and its estate. It is subject to an ongoing Health performance information but also and Safety Executive improvement notice has a corporate overview; and and has not invested sufficiently, either in maintenance or the estates function, to develop a strategic approach to the estate and to

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4340_WAO Amb ENG_v0_14.indd 22 29/11/06 11:01:20 f provide reports at timely intervals the way it uses its capacity to improve for both managers and the efficiency, building in safeguards to avoid Board, and which are part of the any ‘levelling down’ of performance. performance management regime. 27 The Trust has consistently met its statutory 24 Although there have been a number of adverse financial targets over recent years but there incidents in which the other emergency is evidence that it has not done so in a services have transported emergency sustainable way, including a draft SCEP that patients to hospital due to unacceptably long predicts a £6.6m deficit for 2006/2007. There is response times, there are no established evidence that the service is adequately revenue systems to share learning from these funded and efficiencies can eventually result incidents. Through the Joint Emergency from modernisation and matching resources Services Group, the Trust should develop to demand, but that this will require capital a protocol to learn from serious incidents investment, particularly to develop a modern involving transportation of emergency and integrated communications infrastructure. patients by the police and fire services. Working with the Welsh Assembly Government and HCW, the Trust should 25 There are concerns about the adequacy develop robust business cases for all capital of clinical information available to the Trust. investments, including performance gains The Trust should identify and implement and revenue savings over a reasonable an audit process for key clinical areas and achievable timescale. The Welsh which will produce reliable information Assembly Government and HCW should about the outcomes of patient care, and rigorously assess these business cases should use the adverse incident reporting using the Gateway Review, or similarly robust arrangements already established by process to ensure their fitness for purpose the Welsh Assembly Government. and explicit link to the overall strategy.

Capacity, systems and infrastructure 28 Fleet management has been poor with no national fleet manager and evidence that 26 The Trust appears to have sufficient overall current arrangements are not delivering value revenue and staff resources, although there for money, particularly the recent ambulance are questions about the efficiency with which purchase. A new fleet manager has recently resources are used and people deployed. been recruited. The Trust should conduct However, there is little costing or benchmarking a fundamental review of its fleet needs information to help the Trust assess how and methods of delivery in the context of capacity might be used more effectively. The modernisation plan. The review should Trust, using its developing information produce a clear decision on how best to on unit hour utilisation, should carry out use the recently-purchased ambulances. more detailed work to cost services. Taking account of its modernisation planning and the development of the Strategic Change and Efficiency Plan (SCEP) for 2007/2008, it should also review

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4340_WAO Amb ENG_v0_14.indd 23 29/11/06 11:01:22 How to read this report ii Failures in key areas Lack of strategic direction The conclusions of this report can be read at Ineffective governance a glance in the Table of Contents and, in more Weak leadership detail in the Summary. The main body of the Badly designed and managed processes report is organised in exactly the same way as Poor systems and infrastructure the Summary in sections as described below. Organisational Culture

1 Part One: Performance: evidence 3 Part Three: the prospects for about the Trust’s services resolving the problems

i Emergency ambulance services i Modernisation plan

ii Patient Care Services ii External challenges

iii Clinical performance iii Internal Challenges

2 Part Two: Diagnosis: the reasons for the Trust’s performance

i The Trust’s strengths Strategic framework Examples of innovation and good practice Significant goodwill towards the service Structural stability as a national service Enough resources Its staff

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4340_WAO Amb ENG_v0_14.indd 24 29/11/06 11:01:23 Part 1: There are longstanding problems with the performance of the ambulance service

1.1 In this Part of the report we examine the to achieve important targets overall and there evidence about the operational performance are significant variations between regions in of the Trust in recent years. In summary we Wales. The Trust’s response time performance find that the service provided to patients compares badly with England but appears and users has been generally poor. similar to Scotland. The increase in emergency activity that has occurred in Wales does not 1.2 The Trust’s two main activities are emergency account for the failure of the Trust to improve ambulance services and patient transport performance. As a consequence of the Trust’s services for non-emergency cases, the latter poor performance, other emergency services of which is known within the Trust as Patient have had to transport patients to hospital, Care Services (PCS). Both these services which presents potential risks as the staff of need to be performed within an over-arching these services may not be adequately equipped framework of clinical governance. In this section or trained to deal with these situations. we show that the Trust’s consistent failure to provide responsive emergency ambulance The Trust has consistently failed to services could have compromised patient achieve important performance targets care, that the Trust has minimal information about the performance of PCS, despite serious 1.4 The Trust allocates the emergency calls adverse incidents involving patients being it receives into two main categories: taken to the wrong addresses and that, overall, ■ clinical performance needs to improve. Category ‘A’ – immediately life threatening incidents; and

Patient care could have been ■ Category ‘B’ – other emergency calls. compromised by the Trust’s consistent failure to provide sufficiently responsive 1.5 The Trust’s Emergency Medical Services emergency ambulance services also respond to ‘urgent’ calls which are requests, usually from a GP, to transport a

1.3 Time is of the essence in emergency ambulance patient within an agreed time limit. The Welsh services. In recognition of this Ministers Assembly Government has set a series of throughout the United Kingdom have set targets to measure how quickly the Trust specific performance targets for the time taken responds to emergency incidents. These are by ambulances to reach various categories of based on clinical evidence, recognised in the patient. Those targets are not arbitrary but reflect National Service Framework for Coronary evidence as to the clinical outcomes of speed Heart Disease, that responding within eight of response. The Trust has consistently failed

2 The Trust formerly employed a third Category ‘C’, neither serious nor life threatening, but ceased using this categorisation during the second quarter of 2006.

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4340_WAO Amb ENG_v0_14.indd 25 29/11/06 11:01:28 minutes to patients suffering heart attacks 1.7 We did not audit in detail the systems for increases their prospects of survival. Although recording clock start and stop times, but there are many other important measures of did identify some concerns about the way the performance of an ambulance service, in which this key performance information particularly clinical outcomes and performance is collected, validated and reported: indicators, the speed of response to the most serious incidents is a vital measure. ■ reporting the proportion of calls where a response arrives within a set time fails to 1.6 Consequently, in 1999, the Welsh Assembly capture by how much the response exceeds Government set a target that the Trust should the target time; the Scottish Ambulance respond to 75 per cent of category A calls within Service reports its average response time eight minutes. This target is consistent with in minutes and seconds to present what the 75 per cent target that has been measured it considers a more balanced view of its in England since 2001/2002. However, since response time performance; an alternative April 2003 the Assembly Government has set approach, which does capture the tail of milestone targets, of 60 and 65 per cent, to the response time, is to measure at the support the achievement of the 75 per cent 95th percentile; in our sample of Category standard. There are also targets to respond to 70 ‘A’ emergency incidents where the Trust per cent of Category ‘A’ calls within nine minutes provided a response (April 2005 – September and 75 per cent within ten minutes. There are 2006), the sixtieth percentile was achieved additional targets for the Trust to provide a in eight and a half minutes, while the 95th fully equipped ambulance to 95 per cent of all percentile was achieved in twenty two emergency calls within 14, 18 and 21 minutes in and a half minutes (Appendix 10 provides urban, rural and sparsely populated Local Health these figures for each Welsh LHB area); Board (LHB) areas respectively. The Trust also has a target to arrive at hospital no more than ■ the postcode and address databases 15 minutes later than the time agreed by the GP (gazetteers) used in the Trust’s four in 95 per cent of instances for urgent cases. controls to locate incidents are not Box 1 describes how the clock starts and stops standardised, do not recognise all when the ambulance control receives the call postcodes and do not conform to the and when the response arrives at the scene. British Standards for address databases;

Box 1: Starting and stopping the clock to measure emergency response times

When the ambulance control receives a call, the clock starts when the dispatcher has obtained three key pieces of information from the caller: • a verified location; • the caller’s telephone number; and • the primary complaint. The clock stops when the ambulance arrives at scene and the crew log their arrival with control.

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4340_WAO Amb ENG_v0_14.indd 26 29/11/06 11:01:29 ■ linked to the problem with the gazetteers, were attributable to data error. However, this the reliance on post codes and telephone raises questions about the validity of some numbers to locate and categorise calls of the other response times reported. to LHB areas, can lead to anomalies where a location is in one LHB area but The Trust has not achieved has a post code or telephone number for response time targets the neighbouring area – this can affect reported performance by LHB area; and 1.10 The Trust has increased its performance against the 8 minute Category ‘A’ response time target, ■ analysis based on percentages of rising from 51.4 per cent in 2001/2002 to 57.7 calls receiving a response within per cent in 2004/2005, but with a decline in eight minutes by LHB area can be performance to 57 per cent in 2005/2006. skewed by the very low total volume of Despite this general improvement in performance emergency calls in some LHB areas. since 2001/2002, Figure 1 shows that the Trust has achieved 60 per cent performance 1.8 East Radnor and the Borders Health Focus across Wales in only two individual months Group wrote to us with concerns about actual since April 2004 (in July 2004 and April 2005). response times for people in that part of Powys. Because of the weaknesses of measuring 1.11 Figures 2 and 3 also show that the Trust performance using averages, we analysed has not achieved the Welsh Assembly actual response times throughout Wales. Government’s 9 and 10 minute Category ‘A’ Current performance targets for the Trust are response time targets, since these targets based on responding within a certain period were introduced in April 2005. Monthly to emergency calls but do not set explicit performance has ranged from 59 to 66 per maximum response times. In our sample of cent of Category ‘A’ calls within 9 minutes, 529,000 emergency incidents (both Category lower than the 70 per cent target, and from ‘A’ and ‘B’ calls) across Wales covering the 65 to 72 per cent of Category ‘A’ calls within last two years (April 2005 – September 2006), 10 minutes, below the 75 per cent target. we found that 0.5 per cent (2,541) received a response of one hour or more, of which: 1.12 The Trust is also required to deliver particular response time targets and continuous ■ 2,264 emergency incidents received improvement in each LHB area. In 2005/2006, a first response after between the Trust delivered contractual performance one and two hours; and levels, agreed with Health Commission Wales (HCW), in 9 of the 22 LHB areas. Appendix 3 ■ 277 emergency incidents received a first shows performance trends in each LHB response after between two and three hours. area between April 2001 and June 2006.

1.9 There were also 115 incidents recorded as having a first response after more than three hours. We queried these with the Trust and, following further investigations, the Trust claimed that these long response times

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4340_WAO Amb ENG_v0_14.indd 27 29/11/06 11:01:31 Figure 1: The percentage of Category ‘A’ emergency calls receiving a response within 8 minutes within Wales (shown in green) compared with the Welsh Assembly Government target of 75 per cent (blue) and varying milestone target (red)

75 Welsh Assembly Government target

60 Welsh Assembly Government milestone target Percentage 55

Jul 04 Jul 05 Jul 06 Apr 04 May 04 Jun 04 Aug 04 Sep 04 Oct 04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05 May 05 Jun 05 Aug 05 Sep 05 Oct 05 Nov 05 Dec 05 Jan 06 Feb 06 Mar 06 Apr 06 May 06 Jun 06 Aug 06

Source: Health Commission Wales and Welsh Assembly Government Service and Financial Frameworks 2004/05, 2005/06 and 2006/07

Figure 2. The percentage of Category ‘A’ emergency calls receiving a response within 9 minutes within Wales (shown in green) compared with the Welsh Assembly Government milestone target of 70 per cent (red)

70 Welsh Assembly Government milestone target

60 Percentage

Note: The Welsh Assembly Government introduced the 9 minute targets in April 2005

Source: Health Commission Wales and Welsh Assembly Government Service and Financial Frameworks 2005/06 and 2006/07

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4340_WAO Amb ENG_v0_14.indd 28 29/11/06 11:01:32 Figure 3: The percentage of Category ‘A’ emergency calls receiving a response within 10 minutes within Wales (shown in green) compared with the Welsh Assembly Government milestone target of 75 per cent (red)

75 Welsh Assembly Government milestone target

60 Percentage 55

Note: The Welsh Assembly Government introduced the 10 minute targets in April 2005.

Source: Health Commission Wales and Welsh Assembly Government service and Financial Framework 2005/06 and 2006/07

Figure 4: Declining performance (shown in green) against response time targets to respond to 95 per cent of all emergency calls (Category ‘A’ and ‘B’) within 14, 18 and 21 minutes in urban, rural and sparsely populated areas (red)

100

75 Percentage 70

2001/02: Q12001/02: Q22001/02: Q32001/02: Q42002/03: Q12002/03: Q22002/03: Q32002/03: Q42003/04: Q12003/04: Q22003/04: Q32003/04: Q42004/05: Q12004/05: Q22004/05: Q32004/05: Q42005/06: Q12005/06: Q22005/06: Q32005/06: Q4

----- Total Trust ----- Target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

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4340_WAO Amb ENG_v0_14.indd 29 29/11/06 11:01:35 1.13 As well as specific response time targets for transported to hospital where this is clinically Category ‘A’ calls, the Trust has to meet targets appropriate, and the move away from time for the time it takes a fully equipped ambulance targets for Category ‘B’ and ‘C’ calls in England. to attend all emergency calls, reflecting the fact that the initial response may come from a 1.14 At the end of 2005/2006, Figure 4 shows that the community responder (a lay person trained to Trust provided a fully equipped ambulance to all provide an initial response to an emergency) or emergency calls within 14, 18 and 21 minutes for a single-manned rapid response vehicle which urban3, rural and sparsely populated areas in 85 may need back-up from a fully equipped double- per cent of cases, against a 95 per cent target. crewed ambulance in a serious emergency. The Figure 4 also shows an ongoing deterioration in DECS project includes a workstream looking performance against this target since June 2001. at data definitions and targets, which will need to consider the appropriateness of the ‘fully 1.15 Providing a timely service to patients designated equipped ambulance’ target for all emergency as ‘urgent’ by their GP is extremely important. calls in the light of changing models of service, We heard a number of times that such patients moves to reduce the percentage of patients are often sicker than those calling 999 for an ambulance and need a timely response according to their doctor’s instructions. However,

Figure 5: There has been a serious deterioration in performance against the target for 95 per cent of GP urgent calls to arrive at hospital no more than 15 minutes later than the agreed time, which is worse in Wales (red) than in English rural trusts (blue) 100

95 National Target

70 Percentage

50 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06

Source: Wales Audit Office, based on Department of Health KA34 data and Welsh Assembly Government, Health Statistics and Analysis Unit.

3 For the purposes of this measure, Cardiff is the only unitary authority area in Wales designated ‘urban’. The definitions are based on population densities. In England, there are two categorisations – urban and rural, with targets of 14 and 19 minutes in Wales. 12 unitary authority areas are designated ‘rural’ and 9 ‘sparsely populated’.

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4340_WAO Amb ENG_v0_14.indd 30 29/11/06 11:01:36 Figure 6: North Wales has consistently performed better than the other two regions against targets to respond to Category ‘A’ calls within 8 minutes

100

Percentage 60

WAG SaFF milestone target WAG SaFF target Central & West Wales North Wales South East Wales

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Case study A: The problems of providing traditional ambulance services in Powys

There are very serious and justifiable concerns about the adequacy of ambulance services in Powys. Providing more traditional ambulance services is unlikely to meet the needs of patients in Powys, which is over one hundred miles in length and which does not have a district general hospital within its boundaries. The Trust only responded to 43 per cent of Category ‘A’ calls in Powys within eight minutes in 2005/2006 . Emergency patients needing support in Accident and Emergency departments are generally transported to district general hospitals in Shrewsbury, Hereford, Abergavenny and Swansea. The long distances involved in reaching incidents, long turnaround times at hospitals, and deployment of crews to respond to incidents they pass on their way back to Powys, means that a single emergency incident can tie up a crew for several hours. Poor deployment planning can mean that this capacity is not replaced because of urgent needs elsewhere, leaving the people of Powys extremely short of cover. Minor injuries units within the county are rarely content to take patients from 999 ambulance calls. Doing more of the same is unlikely to produce sufficient improvement in service quality for the people of Powys. Although the Trust will need to look carefully at predicted demand for emergency ambulances and shift patterns, new community- based models of service have the potential, backed up by emergency ambulance services and the air ambulance, to improve response times and the quality of service. Similar challenges exist in other very rural areas, such as Monmouthshire, where response times are very long.

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 31 29/11/06 11:01:38 Figure 7: Some unitary authority areas had much higher performance against Category ‘A’ 8 minute response targets than others in 2005/2006

75 Welsh Assembly Government and English 75% target

60 Welsh Assembly Government milestone target

50 Percentage

Conwy Cardiff Powys Flintshire Torfaen Wrexham Swansea Newport Caerphilly Bridgend Gwynedd Ceredigion DenbighshireMethyr Tydfil Pembrokeshire Carnarthenshire Blaenau Gwent Isle of Anglesey Monmouthshire Neath Port Talbot Vale of Glamorgan Rhondda Cynon Taff Regional Key: Central and West Wales (yellow) North Wales (pink) South East Wales (red) Note: The bars shown for each unitary authority area reflect the range between the highest and lowest quarterly performance Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure 5 shows that performance against the There are consistent regional variations target to arrive at hospital no more than 15 in response time performance minutes later than the agreed time for GP urgent calls has declined significantly between March 1.16 Despite the overall and consistent failure of 2000 and March 2006, from 86 per cent to the Trust to achieve important performance 69 per cent over the six financial years from targets across Wales, some parts of Wales 2000/2001 to 2005/2006. Interestingly, this have services that respond more quickly than period has also seen a 17 per cent decrease in others. The Trust is split into three operational GP urgent activity, at a time when emergency regions. Figure 6 shows that the Category ‘A’ activity rose by around 30 per cent. Figure 5 responses times within 8 minutes has varied also shows that, in 2005/2006, the Trust had between regions. The North Wales region has lower GP urgent performance than all but one responded to at least 60 per cent of Category of the rural ambulance trusts in England. ‘A’ calls within 8 minutes in 16 of the 20 quarters between 2001/2002 and 2005/2006. Neither the Central and West nor South East regions has ever achieved a quarterly performance of 60 per cent on this measure over the same period.

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4340_WAO Amb ENG_v0_14.indd 32 29/11/06 11:01:39 1.17 Figure 7 illustrates the range of quarterly response times have eroded public confidence performance in responding to Category in the ambulance service in these areas. It is ‘A’ incidents in each unitary authority area inevitable that geographical factors and low during 2005/2006. Figure 7 shows that some population density should present difficulties but unitary authority areas have high levels of we found little evidence that the Trust has sought performance. For example, in Conwy 72 to to mitigate these problems through seeking 74 per cent of Category ‘A’ calls received a to develop new models of service delivery. response within 8 minutes; in Swansea, 69 Case Study A shows how rurality and geography to 72 per cent of calls received a response have affected response times in Powys. within 8 minutes; and in Denbighshire and However, the very poor performance in Bridgend Wrexham, the equivalent figures were 65 to 70 shows that rurality is not the only cause. per cent and 65 to 73 per cent respectively. 1.19 There has also been consistently better 1.18 Conversely, Figure 7 shows extremely poor performance against the overall response time response times in some unitary authorities. target for all emergency calls (both Category In Bridgend, Monmouthshire, the Vale of ‘A’ and Category ‘B’ calls) in North Wales than Glamorgan and Powys no more than 50 per cent the other two regions. The all-Wales trend of Category ‘A’ calls received a response within has been in a gradual decline (Figure 4), but eight minutes in any one quarter of 2005/2006. Figure 8 shows that performance in North We received evidence from residents of these Wales has been in line with the Welsh Assembly areas, and their representatives, about their Government target, while there has been a concerns in respect of response times. Such marked decline in South East Wales and, to a lesser extent, Central and West Wales.

Figure 8: Performance against response time targets to respond to all emergency calls (Category ‘A’ and ‘B’) within 14, 18 and 21 minutes in urban, rural and sparsely populated areas has been consistently better in North Wales than the other two regions 100

80 Percentage

Central & West Wales North Wales South East Wales target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

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4340_WAO Amb ENG_v0_14.indd 33 29/11/06 11:01:42 Figure 9: Percentage range of quarterly performance in 2005/2006 responding to Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes according to service classification in each unitary authority area of Wales

100

95 95% target

80 Percentage

Conwy Powys Cardiff Flintshire Torfaen Wrexham Swansea Newport Bridgend Caerphilly Gwynedd Ceredigion Denbighshire Methyr Tydfil Pembrokeshire Isle of Anglesey Carnarthenshire Blaenau Gwent Monmouthshire Neath Port Talbot Vale of Glamorgan Rhondda Cynon Taff Regional Key: Central and West Wales (yellow) North Wales (pink) South East Wales (red) Note: The bars shown for each unitary authority area reflect the range between the highest and lowest quarterly performance Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

1.20 The response rates for all Category ‘A’ and 1.21 There is also regional variation in performance ‘B’ emergency calls vary considerably, both against the target to arrive at hospital no more in standard of performance and consistency, than 15 minutes later than the agreed time for between unitary authority areas. Figure 9 GP urgent patients – 57 per cent arriving within illustrates the range of quarterly response 15 minutes of the agreed time in the south east time performance in 2005/2006 for the Trust region, compared with central and west, 75 per responding to Category ‘A’ and ‘B’ emergency cent, and North Wales, 81 per cent. Figure 10 calls within 14,18 or 21 minutes according shows the range in quarterly performance by to service classification in each unitary unitary authority area, with the Trust arriving authority area of Wales. At the extremes, within 15 minutes of the agreed time in between incidents in Conwy consistently received a 45 and 53 per cent of cases in Monmouthshire, response between 97 to 98 per cent within 44 and 60 per cent of cases in Blaenau Gwent, the time target set by the Welsh Assembly and 41 and 60 per cent of cases in Torfaen. Government, whereas Category ‘A’ or ‘B’ emergency calls in the Caerphilly unitary authority area received a response between 64 and 81 per cent within the target time set by the Welsh Assembly Government.

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4340_WAO Amb ENG_v0_14.indd 34 29/11/06 11:01:43 Figure 10: Quarterly performance range for GP urgent calls arriving no more than 15 minutes later than the agreed time in 2005/2006

100

95% target

70 Percentage 60

Conwy Powys Cardiff Flintshire Newport Torfaen Gwynedd Wrexham Swansea Bridgend Caerphilly Ceredigion Denbighshire Methyr Tydfil Pembrokeshire Isle of Anglesey Carnarthenshire Blaenau Gwent Monmouthshire Neath Port Talbot Vale of Glamorgan Rhondda Cynon Taff

Regional Key: Central and West Wales (yellow) North Wales (pink) South East Wales (red) Note: The bars shown for each unitary authority area reflect the range between the highest and lowest quarterly performance Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Emergency response time performance children under the age of two. Our analysis of a compares badly with English services sample of 471,000 emergency calls during the but appears similar to Scotland period April 2005 to September 2006 shows that, overall, there would have been only 0.6 1.22 As Wales is predominantly rural, we compared per cent more Category ‘A’ calls in Wales had its performance with the former rural ambulance it applied the same call categorisations as services in England.4 Wales has used a call England (Figure 11). On this basis, we do not prioritisation since September 2003 and there think that the differences in call categorisation have been differences in emergency call between England and Wales invalidate classification between England and Wales since comparisons of response time performance. April 2005, for example in Wales all children under the age of two have been automatically 1.23 Figure 12 shows that the 23 rural services in classified as Category ‘A’. Overall, 80 per cent England responded to between 69 and 88 per of call classification categories result in identical cent of Category ‘A’ calls within 8 minutes in call prioritisation in England and Wales. The Trust 2005/2006 compared with the figure of 57 per estimates that Wales classifies an additional 6 cent in Wales, although a recent review found per cent of calls as Category ‘A’ than it would some incorrect reporting, related to clock start if it applied the English definition relating to and stop times, in six English services of which

4 In response to the recommendations of the Department of Health report, Taking healthcare to the patient, Ambulance Trusts in England have recently undergone a series of mergers and have reduced from 31 to 12 services, with Staffordshire working towards merger with West Midlands.

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4340_WAO Amb ENG_v0_14.indd 35 29/11/06 11:01:46 Figure 11: Difference between English and Welsh categorisations of emergency calls, applied to a sample of Welsh emergency calls between April 2005 and September 2006

Welsh categorisation Welsh calls using English Difference of emergency calls categorisation of emergency calls Category ‘A’ (Red) 180,363 181,482 +1,119 Category ‘B’ (Amber) 216,280 219,184 +2,904 Category ‘C’ (Green) 74,641 70,618 -4,023

Source: Welsh Ambulances Services NHS Trust

Figure 12: Category ‘A’ emergency incidents: percentage of responses within 8 minutes in Wales (red) and English rural Ambulance Trusts (blue)

75 National Target

60 Percentage

40 2001-02 2002-03 2003-04 2004-05 2005-06

Source: data supplied by WAG Health Statistics, KA34; and English rural Ambulance Trusts: Department of Health, KA34

three were rural services. This poor performance 1.24 It is difficult to benchmark overall emergency compared with English rural services5 dates response performance including Category has been a consistent trend since 2001/2002. ‘B’ calls because slightly different response Analysis carried out by the Trust shows that time standards apply for Category ‘B’ calls Welsh performance looks little better relative to in England and Wales, with an 18 minute English rural services using performance for the standard in Welsh rural areas and 19 minutes twelve rural unitary authority areas in Wales. in English rural areas. However, we were able to compare Welsh performance for GP urgent

5 Department of Health, Ambulance Services, England: 2005-2006

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4340_WAO Amb ENG_v0_14.indd 36 29/11/06 11:01:46 Figure 13: Wales has the lowest response time performance for Category ‘A’ calls compared with England and Scotland

Year 2003/2004 2004/2005 2005/2006 Responses to Responses to Responses to Category ‘A’ calls Category ‘A’ calls Category ‘A’ calls within 8 minutes within 8 minutes within 8 minutes (per cent) (per cent) (per cent) Wales 52 57.7 572 Scotland1 56.5 57 58.52 England 75.7 76.2 742

1 Scottish performance data is for the mainland only and excludes the islands. 2 This figure has been adjusted to reflect concerns about data recording in six English Trusts.

Source: Wales Audit Office

calls with English rural services, and found that other emergency services have been forced Wales compared badly with England. Figure 5 to transport emergency patients to hospital shows that while GP urgent performance because of the failure of ambulances to attend, declined in Wales between 2000/2001 and or have faced harrowing waits for paramedics 2005/2006, it improved overall in England to arrive at the scene of serious incidents (Case during the same period, and all but one English Study B). We received detailed submissions rural service performed better than Wales. outlining the extent to which the emergency services had transported emergency patients 1.25 Although Category ‘A’ performance has been to hospital in 2006. This showed that the higher in England at national level, Figure 13 Welsh police forces, fire and rescue services shows that performance in Scotland has been transported a minimum of 90 patients to hospital similar to that in Wales in recent years. Figure 12 between January and August 2006. These also shows that English rural trusts have incidents took place predominantly in South East achieved higher response time performance Wales and were reported by the Gwent and than Wales. The Scottish Ambulance Service South Wales Police and the South Wales Fire has also measured average response times and Rescue Service, with particular problems for Category ‘A’ calls, which fell from 8.6 to 8.4 in Bridgend, Cardiff, Rhondda Cynon Taff and minutes between 2004/2005 and 2005/2006. Newport. Generally, officers involved in these incidents reported that they had waited for Poor response times have led between twenty and thirty minutes before taking to other emergency services the personal decision to transport the patient to transporting patients to hospital hospital. When speaking to Trust control rooms to find out the estimated time of arrival for the 1.26 During the course of the inquiry, we received ambulance, the Trust provided other emergency evidence that one of the negative consequences services with the following responses: of long emergency response times is that

Ambulance Services in Wales 37

4340_WAO Amb ENG_v0_14.indd 37 29/11/06 11:01:49 ■ no ambulances available; death at the hospital after transport by the police could be deemed a ‘death after ■ we are stacking calls; police contact’; deaths in police custody are a performance indicator for each ■ your call is eighth in the queue force which are reported annually, and (incident involved a female who which may affect forces’ reputations. had been stabbed); and 1.28 We found no formal systems of communication ■ an ambulance will be sent when one between the other emergency services is available – and then the police and the ambulance service to learn from controller was cut off (incident involved such incidents and jointly to take steps to a man collapsed in a roadway). minimise their occurrence or to identify ways to handle them more effectively in future. 1.27 The statistics do not do justice to the seriousness of such incidents which should There has been an increase in emergency be avoided at all costs because they activity in the Trust which is consistent with cause the following serious problems: rural trusts in England but which does not fully explain the failure to improve performance ■ carrying emergency patients to hospital in a police or fire vehicle carries clinical 1.29 The Trust has consistently cited unfunded risks as vehicles are not suitably equipped, increased demand as a root cause of its and fire and police officers have first consistent failure to achieve performance aid training not paramedic training; targets. Demand for emergency ambulance services can be measured in a number of ways: ■ it distracts the other emergency services from fulfilling their core responsibilities; and ■ the number of emergency calls received; ■ if the patient dies while technically in police ■ the number of responses; and custody in the vehicle, this automatically triggers an investigation by the Independent ■ the number of patients treated Police Complaints Commission, and a and transported.

Case Study B: Examples of incidents where police services have transported patients to hospital or faced long waits for an ambulance to arrive

1 Following a serious assault on a female in Bridgend, resulting in lacerations to the head, the ambulance service stated that the nearest available ambulance was in Rhondda, and that the estimated time of arrival “could take some time”. After 45 minutes, the police officers conveyed the injured woman to hospital. 2 The ambulance service asked for police assistance in Newport after a man had taken an overdose of painkillers, and had drunk half a bottle of whisky. It was reported that he was likely to be violent and police officers were redeployed from another incident. He was not violent but clearly needed emergency medical treatment and an ambulance was called. The ambulance arrived 38 minutes later, by which point the man was lapsing in and out of consciousness in the care of police officers.

Source: Submission to the Auditor General from the Joint Emergency Services Group

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4340_WAO Amb ENG_v0_14.indd 38 29/11/06 11:01:50 Figure 14: Between 2000/2001 and 2005/2006, the percentage increase in emergency incidents for the Trust (red) was in the middle of the range when compared with English rural ambulance services (blue and yellow)

10 Percentage change of emergency incidents Percentage 0 2001-02 2002-03 2003-04 2004-05 2005-06 2000-01 to 2005-06 -10

Note: Figures for individual years represent the percentage change in the number of incidents compared with the previous year.

Source: Welsh Ambulance Services NHS Trust: National Assembly for Wales, SDR 102-2006; English rural Ambulance Trusts: Department of Health, KA34

1.30 The number of calls the Trust receives has that the increase in emergency incidents in increased significantly, but is not necessarily Wales has been in the middle of the range the most appropriate measure of demand for when compared with rural ambulance services emergency ambulance services because of: in England. Whilst 43.3 per cent is a significant increase in demand, Figure 10 clearly shows ■ duplicate calls to report the same incident; that greater increases have been experienced in some of the English rural counterparts, ■ calls asking for an updated supporting the conclusion that increasing estimated time of arrival; and emergency activity does not fully explain the Trust’s failure to meet its performance targets. ■ the fact that not every call results in the activation of an emergency response. 1.32 Figure 15 shows that a 19 per cent increase in emergency patient journeys has been 1.31 The number of emergency incidents requiring accompanied by a 30 per cent decrease in the a response is a good measure of demand for urgent workload. Overall between 2001/2002 emergency medical despatch services. The and 2005/2006, there has been a 2.8 per cent numbers of emergency incidents (calls resulting increase in the total number of emergency in response arriving at the scene of the incident) and urgent patient journeys. This analysis have risen by 43.3 per cent in Wales between suggests that, while there has been a change 2000/2001 and 2005/2006. Figure 14 shows

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4340_WAO Amb ENG_v0_14.indd 39 29/11/06 11:01:53 Figure 15: Changes in the number of emergency and urgent patient journeys

Financial Year Emergency Urgent Total 2001/2002 178,000 90,000 268,000 2002/2003 195,000 80,000 276,000 2003/2004 203,000 74,000 277,000 2004/2005 208,000 66,000 275,000 2005/2006 212,000 63,000 275,000 Movement 2001/2002 – 2005/2006 19% -30% 2.8%

Note: Numbers of journeys have been rounded to the nearest thousand

Source: Welsh Ambulance Services NHS Trust

in the profile of demand which will have placed 1.34 Some English trusts have found new ways new pressures on the Trust, this is not as to respond to demand for unscheduled significant as suggested by the Trust in some care, particularly in minimising the number of statements from the Board and correspondence attendances at scene that lead to the patient with HCW, its main commissioner. The being taken to hospital when that is not change in patterns of demand may reflect GP clinically necessary. Not only does this make dissatisfaction with the deteriorating speed the best use of ambulance capacity, but it also of response to urgent calls (Figure 5), and a reduces the significant pressures on accident consequent trend to encourage patients, who and emergency services in acute trusts, and would previously have been GP urgents, to minimises the impact of long handover times call 999 themselves to secure a response. tying up ambulance crews because of pressures on accident and emergency departments. We 1.33 Our analysis of performance data for other Trusts found that rural English ambulance services have suggests that Wales has been less successful reduced the proportion of patients transferred than English trusts in accommodating increased for each emergency incident that required a demand by changing the way it responds to response. Figure 16 illustrates this declining trend incidents. Transporting patients to hospital takes and also highlights that the overall numbers of a significant amount of time, particularly in the patient journeys per emergency incident remains rural areas of Wales. The Department of Health high relative to English rural Ambulance Services. report, Taking Healthcare to the Patient (Box 4) identified that only ten per cent of emergency There is little information about Patient calls are truly life threatening, and that potentially Care Services performance and there at least one third of patients in England should be able to benefit from treatment at or closer have been serious adverse incidents to their home or the scene, rather than being 1.35 The Trust has not maintained a sharp focus unnecessarily transported to hospital. on its Patient Care Services, despite the fact that it provides some 1.41 million journeys each year and has individual contracts with

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4340_WAO Amb ENG_v0_14.indd 40 29/11/06 11:01:53 1.100 Figure 16: Emergency patient journeys (headcount) as a proportion of total emergency incidents

1.000

0.900

0.800

0.700

Patient journeys per Emergency incident 0.600

0.500 2001-02 2002-03 2003-04 2004-05 2005-06

Source: Wales Audit Office, based on Department of Health KA34 and Welsh Ambulance Services NHS Trust data

the 13 acute trusts in Wales, 6 English Trusts ■ a robust analysis of demand for PCS and Powys LHB. The Trust still operates five and whether the current shift pattern different regional systems to run PCS, based of working between 08:30 and 16:30, on its five legacy organisations, which are not Monday to Friday, is the best model compatible with each other and, in one case, to meet the needs of patients and the is still not computerised. Consequently, there acute trusts that commission PCS. is no useful management information on this important service and how it performs, such as: 1.36 This total absence of performance management for patient care services is of particular ■ the number of patients on a PCS vehicle; concern in the light of serious adverse incidents involving Patient Care Services, ■ the cost of taxis and escalating one of which involved a patient dying after voluntary car service bills; being delivered to the wrong address.

■ crucially, given that the acute trusts could seek patient transport services from the open market, the Trust does not know what it actually costs to provide the service nor does it know what it should cost;

■ the number of patients who do not attend; and

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4340_WAO Amb ENG_v0_14.indd 41 29/11/06 11:01:56 Figure 17: Reported thrombolysis rates in Wales in 2005/2006 were below those of England

Percentage of patients having thrombolytic Percentage of eligible patients treatment within 60 minutess of calling for that received pre-hospital help (ambulance services or acute trusts) thrombolysis (ambulance service) Wales target 60% – Wales 31% 10% England target 68% – England (average) 58% 18%

Source: How the NHS manages heart attacks, fifth report of the Myocardial Infarction Project (MINAP), June 2006

Clinical performance needs The Trust has explained that English ambulance to improve further services commenced their implementation plans and paramedic training at an earlier Rates of pre-hospital thrombolysis stage and that, when compared against the are rising but can increase further performance of English services at a similar stage of implementation, the Trust is performing 1.37 Although they are linked, it is essential well in terms of pre-hospital thrombolysis and to measure and focus on both clinical is increasing rates. The Trust has also raised performance and response times. The concerns about the accuracy of the figures Trust is currently training its paramedics in on pre-hospital thrombolysis, which it relies thrombolysis, a clot-busting technique which on other NHS trusts to record. The Trust is is a clinical response when patients have a working collaboratively with its partners to heart attack, administered either pre-hospital resolve these problems and improve the quality by ambulance paramedics or upon arrival and completeness of the MINAP data. at hospital. By the end of the 2006 calendar year, all paramedics in the Trust will have We are not able to report at this stage received training in this important technique. on the extent to which improved performance might save additional lives 1.38 Among other measures of the treatment of heart attacks, the MINAP (Myocardial Infarction 1.39 In May 2006, public statements by the then National Audit Project) project measures Interim Chief Executive, Mr Thayne, included progress in thrombolysing patients. The latest, reference to an estimate of 500 lives which and fifth, public report shows that, on two might be saved by the Trust as a result of separate measures, there is scope to increase improved performance. As part of its review rates of thrombolysis in Wales (Figure 17). The of the Trust, Healthare Inspectorate Wales percentage of patients having thrombolytic (HIW) has been reviewing that suggestion. We treatment within 60 minutes of calling for help is had hoped to be able to include a summary delivered jointly by the ambulance service and of their findings in this report but HIW has not other acute trusts, whereas the pre-hospital yet concluded this element of its investigations thrombolysis is delivered by the Trust alone. and will report separately in due course.

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4340_WAO Amb ENG_v0_14.indd 42 29/11/06 11:01:57 Part 2: The Trust’s strengths have been let down by a wide range of factors

2.1 In this Part we present a diagnosis of the The Trust has a number of key strengths Trust’s performance, namely the reasons underlying the disappointing performance 2.2 Despite its present problems, the Trust described in Part 1. We conclude that the Trust has strengths in the following areas: has a number of important strengths both absolutely and relative to other ambulance ■ a strategic framework that presents trusts in the United Kingdom. We find, opportunities for development; however, that in the past these strengths ■ examples of innovation and good practice; have been let down by important failures in all key aspects of business management. ■ significant goodwill towards the ambulance service in Wales;

Box 2: Delivering Emergency Care Services

The Welsh Assembly Government’s vision is to ‘provide a service that ensures patients – no matter how or when they contact any of the emergency or unscheduled care services – are assessed and then seen by the most appropriate health care professional at the most appropriate time’. DECS covers all unscheduled care services, emergency medical and surgical assessment,NHS Direct, all primary care services, including GP out-of-hours services, social services, mental health services, the ambulance service and A&E departments. It seeks to improve the planning of emergency and unscheduled care services, and take an integrated approach to all levels of emergency and unscheduled care as part of a single system. The key aims for the future ambulance service in Wales are to: 1 be the first point of contact for unscheduled care, with greater flexibility in the type of response provided; 2 increase joint working with others involved in call handling and triage to allow a more structured and flexible response; 3 develop new service models to see and treat, or treat by telephone (hear and treat) those who do not have a genuinely life-threatening emergency; 4 deploy ambulance staff in other settings, for example by developing paramedics’ roles so that they often work for other unscheduled care providers to support alternative care pathways; 5 improve dramatically response times by providing alternatives for those who do not require an emergency response; and 6 locating ambulance services in the context of a regional unscheduled care plan with appropriate changes to commissioning.

Source: Delivering Emergency Care – An integrated approach to unscheduled care in Wales, Welsh Assembly Government consultation document, July 2006.

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4340_WAO Amb ENG_v0_14.indd 43 29/11/06 11:02:02 ■ structural stability as a national service 2.4 The principles of DECS are consistent with with national commissioning; those of the Department of Health’s document on the future of ambulance services, Taking ■ enough human and financial resources to healthcare to the patient (the so-called ‘Bradley deliver performance in line with expectations report’). This document, which focuses only elsewhere in the United Kingdom; and on ambulance services, rather than the whole of the unscheduled care system like DECS, ■ its staff. advocates the further development of ambulance The strategic framework will provide services, so that they become clinically-driven significant opportunities mobile providers of healthcare services, rather than a patient transport or emergency

2.3 The Welsh policy framework for unscheduled service. Such service developments can help care – all unplanned clinical events – is to provide more appropriate responses to changing. The Welsh Assembly Government is people who call 999 but do not need a double- currently consulting on Delivering Emergency crewed ambulance, and which can significantly Care Services (DECS), which is described compromise emergency medical service in Box 2. Estimates suggest that only 10 per capacity. Concerns about the inappropriate use cent of 999 calls are genuinely life-threatening, of the service were the third most significant which means that ambulance services concern of staff participating in our focus should develop alternative models of care, groups (Appendix 4). Box 3 provides examples other than double-crewed ambulances, to of inappropriate use of ambulances, from a enable them to provide a more appropriate diary sent to the inquiry team by a serving response to meet patients’ needs. paramedic employed by the Trust. These reflect

Box 3: Reported examples of the inappropriate use of 999 ambulances

• A patient with abdominal pain for 36 hours, who had decided that she had suffered enough. She did not attempt to contact a GP service or A&E or NHS Direct, she just thought to dial 999. • A call to a male who had been assaulted three days ago and was complaining of rib pain. • A crew travelling 12 miles to a person who was cold. Let me make this clear, we are not talking about hypothermia, we are talking, ‘I am cold, could you put the fire on’. • A 999 call to a woman who had suffered with a headache for two weeks. • The patient was due for surgery in England and despite knowing about the operation arranged urgent transport through the GP out of hours service in the early hours of the day he was to go to hospital. I can only assume that this service did not know the patient, but they took on board this task and arranged transport for that day – with the surgery being scheduled for the next day. The patient failed to follow the hospital’s procedure to contact them before travelling and, on arrival, we were told that the operation had been cancelled. They kept him there on the unlikely chance that the operation going ahead on the next day may be brought forward and as such he stayed. This case took an emergency crew out of Wales for three hours, obviously removing a valuable resource from the system.

Source: Diary supplied anonymously by a serving paramedic with the Trust

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4340_WAO Amb ENG_v0_14.indd 44 29/11/06 11:02:03 problems with the overall unscheduled care vehicles and community responders), it has system and ambulance control, as well as the done so in a piecemeal way and is still a service way the public uses the ambulance service. that operates in a largely traditional manner. The broader development of new roles and 2.5 A Department of Health report champions more modern approaches to meeting changing the significant expansion of the roles and demand for services is not well developed in training of paramedics (see Box 4 below). Wales, which the data on the percentage of patients transported suggests. Case Study C 2.6 These examples provide opportunities for shows how East Anglia developed new the Trust, its employees, those who use its roles and service models that reduced the services and other providers of unscheduled percentage of patients transported to hospital. healthcare. The very serious problems providing adequate services in many rural 2.8 In addition, the DECS strategy provides a areas reflect the scope to support ambulance significant opportunity for the Trust to provide capacity with community-based paramedics a wider range of unscheduled care services, who could provide emergency services and using its existing capacity (see Box 2). whose advanced skills can enable them to see For example, the Trust could consider: and treat the patient without them needing to be transported to hospital. CPOs can ■ bidding for GP out-of-hours services, also work in primary care and minor injuries perhaps provided from A&E departments; units. In areas like Powys, where transporting patients to hospitals outside the county leads ■ providing paramedic services to to a significant drain on capacity to deal with support the management of long- genuine emergencies, the development of term conditions in the community; such roles provides opportunities to improve ■ the quality of services and response times. working with partners to develop new care pathways for patients accessing 2.7 Although the Trust has developed some new the unscheduled care system; models of response (paramedic practitioners, alternative care pathways, rapid response

Box 4: Taking healthcare to the patient: extending the role of paramedics in England

The vision espoused by the report includes ambulance services providing a wider range of services, such as diagnostics, primary care and chronic disease management in the community. To support such developments, new roles will be developed for paramedics and nurses, such as: Emergency Care Practitioner – an advanced practitioner capable of assessing, treating and discharging or referring patients at the scene. Specific higher training (and qualifications) are required for this role, which can take some time. Community Paramedic Officer – an advanced practitioner based in local communities, often in primary care, who provides emergency responses but also primary care services. CPOs are often used in rural communities, such as East Anglia Ambulance Service (Case Study C).

Source: Taking Healthcare to the Patient, Department of Health (June 2005)

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4340_WAO Amb ENG_v0_14.indd 45 29/11/06 11:02:05 Case Study C: Community Paramedics in East Anglia Ambulance Service have reduced the proportion of Category ‘B’ patients transported

After the publication of a public inquiry into the Trust, a series of changes led to improve performance and services, particularly in rural areas with poor road infrastructure. The Trust had provided a very traditional ambulance based around double-crewed ambulances and few single responders. The Trust expanded community responder schemes in rural areas. Also, in 2001, the Trust established the Community Paramedic Officer (CPO) role, based in GP surgeries but employed by the East Anglia Ambulance Trust. They respond to 999 calls and provide a range of community services, such as: • taking blood in people’s homes; • carrying out electrocardiograms (ECGs); • minor injuries work; • supporting specialist clinics, such as asthma and diabetes; and • conducting acute visits on behalf of the GP to carry out an initial assessment and recommend a course of action. CPOs were targeted at areas with poor response times, and tended to go into the market towns to provide a visible presence for the service. There have been a number of beneficial results, including improvements in Category ‘A’ and GP urgent performance, as well as dramatically reducing the proportion of Category ‘B’ calls that lead to the patient being transported to hospital, although the Trust had a relatively high proportion of Category ‘A’ calls transported to hospital. There are some risks in the CPO approach that the Trust has had to manage: • management accountability when the CPO is based in the GP surgery and may ‘go native’; • initial resistance from paramedics who may regard working on an ambulance as being the highest value work; • skills decay because the CPOs deal with fewer life-threatening incidents – rotation with ambulance crews can help offset this risk; • relief, as it is difficult to provide cover when CPOs are on leave; and • the impact of Agenda for Change anti-social hours payments which have tended to lead to CPOs being paid less than traditional paramedics, although East Anglia Ambulance Service has sought to provide out-of-hours work to CPOs to offset this risk.

Source: Wales Audit Office and benchmarking report conducted by ORH

■ providing mobile diagnostic services There are examples of innovation and in the community, particularly using good practice within the Trust telemedicine to send the results to the secondary care provider; or 2.9 There are some examples of innovation and good practice that have been developed on ■ developing a new high-dependency a piecemeal basis across Wales. Although service to meet the needs of those with these are not universal, they have the potential urgent but not emergency needs.

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4340_WAO Amb ENG_v0_14.indd 46 29/11/06 11:02:06 to support the development of new service 2.11 The Trust has also developed two Emergency models to better meet patients’ needs, improve Care Practitioners who have received in-depth clinical care and drive down response times. training and have been deployed in south east Wales. In addition, advanced paramedic 2.10 One particularly successful innovation has practitioners have been developed and been the development of partnerships to deployed in some parts of south Wales. Case deliver medical treatment centres in Cardiff Study E shows the impact of these advanced and Swansea city centres at peak times. paramedic practitioners in reducing the Although some of the demand for these number of patients transported to hospital. mobile services has been new demand, which probably would not have led to an ambulance 2.12 The Trust has also developed community being deployed, there is strong evidence, responders, lay people trained in life saving skills, both quantitative and qualitative, that these who can respond from within the community innovations have reduced the number of patients to complement the fully-equipped ambulance. needing to be transported to hospital and The Welsh Assembly Government has also improved the quality of care (Case Study D). purchased community defibrillators. Community responders are especially valuable in providing

Case Study D: Cardiff Medical Treatment Centre

This scheme is a partnership between the Trust, Cardiff Council, Cardiff and Vale NHS Trust, St John Cymru Wales, South Wales Constabulary and the Welsh Rugby Union. It involves providing night time medical care in Cardiff city centre at peak times, such as Christmas and New Year, and following major sporting events, using a Mobile Medical Response Unit (MMRU) and a medical treatment centre based at the Millennium Stadium. The MMRU is made up of a Trust triage vehicle, staffed by a driver and a paramedic, supported by transport vehicles provided by St John Cymru Wales and the Trust. Patients are either treated in the triage vehicle, taken to the treatment centre at the Millennium Stadium, or transported to hospital. Although this scheme will have met latent demand from patients who probably would not have ended up on an ambulance, an evaluation of the scheme found that 67 per cent of patients who required treatment from the MMRU were able to be treated without a hospital visit. A further 19 per cent went to hospital following treatment at the medical centre, taking with them their paperwork and x-ray requests, helping speed up treatment at the A&E department. The evaluation found that only 7 per cent of patients who needed treatment required an EMS ambulance to transport them to hospital. As a consequence, EMS vehicles were largely freed of city centre calls. The police also commented that the scheme helped free up their time because they did not have to wait with patients until an ambulance arrived.

Source: An independent evaluation of the Mobile Medical Response Unit and Cardiff Medical Treatment Centre arrangements in Cardiff City Centre, Tim John, July 2006

Case Study E: Advanced paramedic practitioners

In November 2005, the Trust introduced advanced paramedic practitioners into the Vale of Glamorgan, Swansea and Bridgend. These paramedics have received additional training and are able to provide an alternative range of treatments to those provided by existing paramedics. In November and December 2005, the three paramedic practitioners attended 246 patients, treating 68 per cent at home, referring 8 per cent to another source of healthcare without emergency ambulance transport, and transporting only 24 per cent to an A&E department by ambulance.

Source: Report by the Acting Director of Operations to the Trust Board, January 2006

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4340_WAO Amb ENG_v0_14.indd 47 29/11/06 11:02:08 rapid treatment for people having heart attacks 2.15 The two permanent air ambulance helicopters (paragraphs 2.169-2.171). In addition, the Trust are based at Caernarfon and Swansea and has participated in the development of some attended over 1,300 incidents and carried over alternative care pathways for unscheduled care 548 patients in 2005/2006. The air ambulance services. These have included alternative care is able to take off within two and a half minutes pathways to allow patients to access the most of receiving a call and has an average flying appropriate source of care without automatically time of 14.5 minutes. Aircraft are available on being transported in an ambulance (see Box 5). line for ten hours a day, seven days a week, which improves patient outcomes, mitigates There is significant goodwill towards difficulties in rural areas and frees other vehicles the ambulance service in Wales to respond to emergency incidents. The Trust’s annual report for 2005/2006 states that the 2.13 Our public hearings and submissions from cost of running the air ambulance is likely to members of the public and service users rise significantly – it says that new generation showed that, despite widespread concerns aircraft must be in place by 2009 but need about response time performance and to be ordered 18 months in advance. service cover in particular areas, there is clear evidence of the widespread public support 2.16 At our public hearings, many people expressed and goodwill towards the ambulance service the opinion that the air ambulance should be fully in Wales. This is a major strength for the Trust publicly funded and a more formal part of the as it seeks to modernise and improve. ambulance service in Wales. This is a matter of policy for the Welsh Assembly Government but 2.14 Another indicator of public goodwill is Wales’ Wales is no different to England in this regard. air ambulance service. In 2005/2006, the In Scotland, however, the air ambulance is an £1.6m cost of leasing and running the two absolute necessity to reach the islands and permanent helicopters was met mainly through areas of extreme rurality, and receives £9m public fundraising by the Air Ambulance annual funding from the Scottish Executive. Charity, with a £229,000 contribution from the Trust (a third helicopter was introduced temporarily to cover Powys in the summer months of 2006 and will cease to operate at the end of November). Paramedic salaries for the service are funded centrally via HCW, in line with similar services in England.

Box 5: Assess and Refer pilot scheme

The Trust set up an Assess and Refer pilot scheme in Flintshire, adapted from the Kent model. The Trust provided a five day training course. The scheme considers 6 presenting conditions for which there is an algorithm, clinical notes, and guidance. There are currently 3 alternative pathways of care. Between April and September 2005, the Assess & Refer scheme has saved a median of 17:32 minutes per job cycle compared with the standard operational job cycle, which is typically between 60 and 70 minutes.

Source: Wales Audit Office, based on Trust report on Phase 1 of the Welsh Emergency Care Access Collaborative sustainability project, September 2005.

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4340_WAO Amb ENG_v0_14.indd 48 29/11/06 11:02:09 The Trust has structural stability as a national can provide economies of scale, improved service, with national commissioning and career opportunities for staff and greater scope for further national developments capacity to learn and do things differently.

2.17 The Bradley report in England, (Box 4) led 2.20 The fact that emergency medical services to a programme of mergers to create twelve are commissioned by a single national large ambulance services from the previous commissioner, HCW, is a strength because 31 services from 1 July 2006. The Trust this increases the simplicity and speed of the benefits from having been through such commissioning structure. Although there are a merger and from being a single national practical difficulties in liaising with 22 Local service covering the whole of Wales. Health Boards, there is a need to improve the liaison between LHBs and HCW to ensure 2.18 Nevertheless, many people who provided that its national commissioning takes account evidence to the inquiry team expressed the of local needs; the development of regional view that the creation of a single Trust had unscheduled care plans under DECS represents produced an organisation that could not provide a further opportunity to link national and local appropriate services across an area the size of commissioning to improve ambulance services. Wales. Although we believe that there should be greater operational autonomy for, and 2.21 As part of its consultation on DECS, the Welsh managerial capacity within, the Trust’s regions Assembly Government included proposals to to develop local unscheduled care services bring NHS Direct Wales into the Trust from to meet patients’ needs, we disagree that the 1 April 2007. There are clear synergies at a single Trust should be split up because: national level between the telephone advice already provided by NHS Direct and the a the lack of management capacity we development of a broader range of ambulance found in the single Trust is unlikely to services and roles. The opportunities of this improve by creating more trusts; merger include the scope to develop:

b a demerger would cause huge a more hear and treat services; disruption after an extremely turbulent period for the Trust; b alternative care pathways to respond more appropriately to the very many c having a national Trust should not patients who do not require a fully- prevent the development of innovative equipped ambulance response; local schemes if the management structure is appropriate; and c new and enhanced roles for paramedics and nurses; d creating a number of new ambulance trusts in Wales would result in a significant d an increased range of primary care services; increase in administrative costs. e improved clinical triage and 2.19 Having a single Trust in Wales provides a call categorisation; and number of advantages that represent a genuine strength in delivering the principles of DECS. f increased managerial and clinical capacity. Subject to improvements in management, it

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4340_WAO Amb ENG_v0_14.indd 49 29/11/06 11:02:11 The Trust has enough human the 2005/2006 financial year. Sixty-five per cent and financial resources of EMS staff are paramedics and 35 per cent are technicians, a relatively highly trained workforce. 2.22 In common with many parts of the NHS, the Trust could doubtless find ways to spend 2.26 We compared the number of staff in Wales with any additional funding it received on further the number of people employed in English services. improvements to services. The service We found that the Trust has a high staffing performance demanded, and the funding proportion with one employee for every 1,184 to support it, is ultimately a matter for the residents: only two of the 31 English ambulance Welsh Assembly Government. In saying, as services had higher staffing than the Trust. we do, that the Trust has “enough” human and financial resources we mean that the 2.27 There are other indications that the total resources with which it has been provided number of staff employed by the Trust may should have been sufficient, if appropriately not be a constraint. Mr Thayne, while still applied, to provide a level of service that Chief Executive of Staffordshire, carried out a would have been comparable with ambulance benchmarking report that compared the Trust trusts elsewhere in the United Kingdom. with Staffordshire. His report suggested that the EMS establishment in Staffordshire was 2.23 In that sense, the Trust has: one quarter of that in Wales but that its EMS workload was 44 per cent of that in Wales. The ■ enough staff; new Chief Executive has stopped an exercise to recruit 102 technicians, initiated with a ■ enough revenue; view to addressing the impact on capacity of Agenda for Change, on the basis that they are ■ but needs further capital investment, partly not required. This mirrors comments made as a result of poor management of capital. to us by regional operational managers that Indicators suggest that the Trust has they did not need the additional staff. The enough staff to meet demand paramedic capacity already available within the Trust represents a significant opportunity 2.24 Many people have expressed the view that to address poor performance by changing the Trust has insufficient staff to meet the working practices, developing new roles and demands placed on it effectively, and that this providing additional unscheduled care services. perceived shortage of staff is a contributory factor in the Trust’s poor performance. 2.28 We also considered whether existing staff were Consequently, we examined whether the Trust effectively utilised. While there is no doubt that has sufficient staff and whether it uses them many staff within the Trust have extremely busy, as effectively as possible to meet demand. hectic and stressful jobs, the overall way in which they are organised does not match the 2.25 Although workforce information and planning supply of people to demand for services as was poor (paragraphs 2.120-2.121), staff well as it should. We found that many trained numbers (headcount) increased by 27 per cent paramedics are filling managerial roles and between the creation of the Trust in 1998 and represent an effective loss of capacity and skills for the service. We also heard concerns about relief – being on call to cover unexpected

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4340_WAO Amb ENG_v0_14.indd 50 29/11/06 11:02:12 shortfalls – which, though an important contract by other NHS Trusts. The Trust also element of providing an effective service, receives income directly from the National has been badly organised and disruptive. Assembly for Wales and other sources. In 2005/2006, the Trust received £115m total 2.29 We drew on an analysis of demand and the income: £81m from HCW, £16m from other rostered hours of cover in each region, carried NHS Trusts and £9m from the Welsh Assembly out by the new Chief Executive, Mr Murray. Mr Government. Figure 18 shows that the Trust’s Murray’s analysis suggested, as the Thayne income has risen by 73 per cent over the benchmarking report had previously, that the six year period between 2000 and 2006. Trust has not organised its staff in such a way to meet peaks of demand effectively. The 2.31 Our review identified that, compared with other demand analysis does not account for hours rural ambulance services, Wales has received a lost due to sickness, vehicle failure, meetings higher income per head of population. Figure 19, or secondments, which means that it is based shows that, the Trust has received the highest on planned hours rather than those actually total income per head of population, relative to delivered. The analysis suggested that the Trust’s a sample of other UK rural ambulance services rosters were planning to provide over 50 per which includes Scotland and Northern Ireland.7 cent more hours of cover than it needed to meet demand, but that it was providing too many 2.32 We also examined funding per square mile hours of cover when they were not needed and covered to assess whether this affected our too few at times of peak demand, (Figure 29). conclusions about the relative resources Accounting for ‘lost hours’6 which are estimated provided to the Welsh Ambulance Service. to be around 20 per cent in the south-east but Figure 20 shows that funding per square very much lower in the other two regions, this mile in Wales has, in 2004/2005 and means around a 30 per cent surplus of hours, 2005/2006, been lower than in the North which suggests that the Trust has enough East and East Anglia ambulance services, staff overall, but that the way it organises but that it has been significantly greater their time is inadequate to meet demand. than in Scotland and Northern Ireland.

The Trust appears to have enough revenue The relationship between regional funding and performance needs further exploration but needs further capital investment, partly as a result of poor management of capital 2.33 A District Audit report in 2001, Commissioning Emergency Ambulance Services, identified The Trust has been adequately revenue resourced substantial differences in the amount of funding 2.30 Emergency services (EMS) in Wales are and resources available regionally for the Trust’s commissioned by a single national strategic Emergency Medical Service in 2000/2001, commissioner – Health Commission Wales when the service was commissioned by the five (HCW), which is an executive arm of the former health authorities in Wales (Appendix 5). Welsh Assembly Government. Patient Care The North Wales region received the highest Services (PCS) are commissioned under funding per head of population, rota hour and journey and achieved the highest standards of

6 Lost hours are those planned but not produced, for example because of sickness, leave, unfilled secondments, meetings, vehicle failures and inefficient working practices. 7 We have compared audited financial information with a selected sample of comparable English ambulance trusts and with the Scottish and Northern Ireland ambulance services. We have not compared financial information for the same data set as the performance analysis due to the lack of complete and robust financial information readily available from a single source.

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4340_WAO Amb ENG_v0_14.indd 51 29/11/06 11:02:15 Figure 18: The Trust’s income has risen in recent years

140

120

100

60 £ million

0 2000/2001 2001/2002 2002/2003 2003/2004 2004/2005 2005/2006

Source: Wales Audit Office, based on audited financial statements.

Figure 19: The Trust has received relatively more income per head of population compared to other benchmark rural ambulance services

10 Income per head of population £

0 2003/2004 2004/2005 2005/2006

N Wales N North East N Scotland N West Country N Northern Ireland N East Anglia

Source: Wales Audit Office, based on Audited Financial Statements

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4340_WAO Amb ENG_v0_14.indd 52 29/11/06 11:02:16 Figure 20: There are some substantial differences in funding per square mile between Wales and other benchmark rural ambulance services 20

6 Income per square mile £ Income per square

0 2003/2004 2004/2005 2005/2006

N North East N Wales N East Anglia N West Country N Northern Ireland N Scotland

Source: Wales Audit Office, based on Audited Financial Statements

performance as regards responses to Category journey are not consistent across the regions, ‘A’ or ‘B’ calls. However, the report noted that, which may reflect rurality, the road network and whilst differing standards of performance were the number of receiving hospitals as well as the evident, it was less clear whether this was due additional cost of providing cover across Wales. to the adequacy of funding or to the effective North Wales has median costs but achieves use of resources made available to the Trust. the highest response time performance for Category ‘A’ calls, while the South East costs 2.34 The information currently available from the the least but produces the lowest response time Trust suggests that, on two measures, such performance. Rural areas (with low population differential funding levels between the three densities) tend to have lower response rates and regions of Wales persist today (Figure 21), as longer round-trips to hospital, all of which tends do differences in performance as illustrated to increase the cost per response, which means previously in Part 1. However, the costs that these results need further detailed analysis presented in Figure 21 exclude fleet and estate to identify the scope for improved efficiency.8 related costs which, in 2005/2006, were met from a central budget and are not able to There are indicators that the Trust has be separated on a regional basis. Costs per not used its resources efficiently emergency incident, scene attended and EMS

8 Audit Commission, Technical Note, Statistical Comparison of Unit Costs and Response Times between Emergency Ambulance Services, 1998.

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4340_WAO Amb ENG_v0_14.indd 53 29/11/06 11:02:18 Figure 21: Comparison of regional EMS costs and performance in 2005/2006

Region North Wales Central and South East West Cost per EMS incident £162 £177 £127 Cost per EMS journey £218 £219 £161 Percentage of Category ‘A’ incidents attended 64% 58% 53% within 8 minutes

Source: Wales Audit Office

2.35 In 2005/2006 the Trust spent £115m, of which 2.38 Three external reviews have also found that £85m related to staff costs, £14m to transport, the Trust is relatively expensive and/or that £3m to premises, £4m to depreciation of there is scope for efficiencies to be made. their asset base, and £9m on other costs. ■ Operational Research in Health (ORH) 2.36 Expenditure is incurred maintaining the Trust’s identified in 2001 that at least a 5 percentage existing infrastructure and historical working point improvement in performance against practices but these are not based on a current the Category ‘A’ eight minute target could be review of demand and options for the most achieved through efficiency measures (Box 7); efficient means of service delivery. Historically, the Trust has not analysed the full costs of PCS ■ Prior to becoming the Trust’s Interim Chief and EMS as separate services. Consequently Executive in March 2006, Mr Thayne’s there is insufficient information to conclude benchmarking report of 2005 identified whether the services are independently efficient. significant potential improvements in efficiency Trust officers have told us that there is cross through service modernisation; and subsidisation between the services. In the ■ absence of costing information for each part of In 2006, external consultants identified the service, our review considered total revenue that the cost of the Welsh EMS was higher expenditure and found that, compared with a per head of population, incident attended sample of five other UK rural ambulance services and call received than many other UK (including Scotland and Northern Ireland), the ambulance services (Appendix 6). Trust had the highest total expenditure per head 2.39 The Trust has not routinely benchmarked of population over the last three financial years. its costs internally or with other ambulance services, beyond Mr Thayne’s benchmarking 2.37 Our analysis found that in 2005/2006 the Trust’s staff and transport costs (excluding lease report and a benchmarking exercise for control costs) were the highest type of cost per head of centres in 2005. Consequently the Trust has population when compared with our sample of not assured itself of the efficiency of its own five benchmark UK rural ambulance trusts. activities or services or learnt from best practice. Trust staff told us that they can see ways that the service can operate more efficiently

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4340_WAO Amb ENG_v0_14.indd 54 29/11/06 11:02:19 Figure 22: The Trust’s asset base and capital expenditure is comparable to other rural services

Ambulance Service 2005/2006 2005/2006 Average annual Average annual capital spend capital spend Asset base per Asset base per (2003-2006) per (2003-2006) per head of population square mile head of population square mile £ £ £ £ Wales 12.70 4.68 1.69 0.62 East Anglia 4.41 2.73 0.60 0.37 North East 12.62 8.53 1.81 1.22 Scotland 15.26 2.51 2.55 0.42 Northern Ireland 10.49 3.18 1.83 0.55 West Country 10.34 4.49 1.19 0.52 Average 11.42 3.39 1.71 0.51

Source: Wales Audit Office, based on audited financial statements

without reducing the service to the public Despite receiving comparable capital to (paragraphs 2.49-2.53). This was reaffirmed other rural services, the Trust remains in by interviews with financial and management need of further capital investment staff who stated that the Trust could operate 2.41 Figure 22 shows that in recent years the Trust more efficiently within their current levels of has had an asset base and capital expenditure resources. A costing and benchmarking exercise comparable to other rural ambulance services is needed to inform modernisation planning. in the UK. Trust officers have told us that they expect the impending valuation by the 2.40 The review by external consultants ORH District Valuer to significantly reduce the identified the significant additional funding value of its land and buildings, because of the required to meet the targets set by the lack of investment in estates since the last Welsh Assembly Government. The Assembly valuation in November 2002. The asset base Government introduced additional recurrent of English Trusts was revalued in April 2005. funding of £1m in 2002/2003 and a further £2.5m in 2003/2004 to improve response times. 2.42 Despite the comparable asset base and capital While the initial funding in the last quarter of expenditure in recent years, our review identified 2003/2004 corresponded to the achievement that the capital infrastructure at the Trust was of 60 per cent of Category ‘A’ responses weak, particularly in respect of estates, fleet, taking place within 8 minutes, this was not ICT and communication systems (paragraphs sustained in 2004/2005 or 2005/2006. 2.175-2.194). The current Chief Executive has proposed a ten-year capital investment plan of £132m as part of his modernisation review

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4340_WAO Amb ENG_v0_14.indd 55 29/11/06 11:02:22 Box 6: There is strong public support for front-line ambulance staff

‘They are overworked people and they really do an excellent job.’ ‘I think the people, the operational staff of the ambulance service, need to be far more valued than they are at the present moment.’ ‘I could not fault the treatment and attention I was given. I give my wholehearted support to the paramedics for the treatment I received.’ ‘They worked on my father trying to ‘bring him back’ for a long while – it seemed until we as a family were ready and able to accept his death. They were very professional and compassionate and made a horrific time a little bit easier to bear.’ ‘She is an 85 year old lady who has suffered two heart attacks and, on both occasions, the paramedics were with her within minutes and she feels their attention was superb – she couldn’t praise them highly enough.’ ‘The ambulance crew finally arrived at 7.50 p.m. They apologised profusely for the delay which they said was due to the changeover of shifts. They were really wonderful in dealing with my husband and the dreadful condition he and the bathroom were in. They were marvellous in reassuring us, cleaned him up a bit, carried out all sorts of emergency tests and transferred to him to the University Hospital of Wales where all the tests proved inconclusive. But if it had been a heart attack he would surely have died while waiting for help.’

Source: Written submissions to the Auditor General

(paragraphs 3.94 and Figure 44). Currently, these ■ staff generally recognise the plans are necessarily indicative, including broad need to modernise. estimates built on themes in the modernisation plan, rather than derived from operational plans The public have commended front-line staff based on a comprehensive analysis of demand and options for a more effective and efficient 2.44 A key theme which emerged from our service delivery. The plans have not yet been inquiry was the strong public support for and submitted to the Welsh Assembly Government. appreciation of the front-line ambulance staff. Although the public raised many concerns The Trust’s staff are a key strength about the way the ambulance service was run, they consistently praised front-line staff for their 2.43 The Trust is in a service business. Its staff professionalism and commitment (Box 6). The are therefore a crucial resource. We consider Board of CHCs in Wales told us that, generally that they are a key strength too, because: speaking, the anecdotal evidence that they receive makes it clear that people are satisfied ■ the public recognises the skill and with and grateful for the efforts of the field commitment of front-line staff; staff; and that the only problem is whether they respond within the desired timescale. ■ A&E consultants also view the staff positively; Finally, Dr van Dellen emphasised in a report ■ management relations with the to the Welsh Assembly Government upon his trade unions are positive; and departure, that the Trust’s front-line staff should be viewed as a key asset of the service, with a

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4340_WAO Amb ENG_v0_14.indd 56 29/11/06 11:02:22 high percentage of paramedics among the front- 2.47 However, others view the staff side as a potential line staff and a number of degree paramedics. barrier to progress, particularly in regard to key Mr Thayne told us that front-line crews in modernisation issues, such as meal breaks Wales were as good as those elsewhere. and roster reviews. The Trade Unions appear to be extremely well organised, communicate A&E consultants have positive effectively with their members and have views of ambulance staff talented people working for them. Several people expressed the view that the unions 2.45 We conducted a survey of consultants in have effectively filled part of the void created A&E departments. We asked consultants to by the Trust’s lack of managerial capacity. tell us about the comments patients make about crews from the Trust – they said that 2.48 Rather than a threat, we regard the good patients provide positive feedback and we relations with the unions as a potential received no examples of negative feedback. strength for the future. However, more effective In addition, A&E consultants had generally management and communication, directly positive views about the clinical care provided with staff as well as through the unions, will by front-line paramedics and technicians. Most be essential to delivering necessary change consultants responding to our survey believed on key issues, such as meal breaks and roster that ambulance staff make appropriate clinical reviews. An important element of that change decisions about the appropriate use of pain relief will be to work closely with the unions: it is agents, cannulation, using aspirin in chest pain encouraging that the unions will sit on the and the management of asthma and diabetes. Modernisation Committee of the Board that the new Chair has established. We were also Positive relations with the Trade Unions are encouraged by the stated commitment of the a strength but will need to be effectively union representatives we met to modernisation managed to deliver necessary change and change. They appeared to recognise the value to their members of developing new 2.46 There has been considerable discussion about roles, training, career paths and new service the role of the Trade Unions within the Trust models to better meet the needs of patients. and whether their influence is too strong. We met the principal trade union representatives on Most staff recognise the need to modernise a number of occasions and reviewed relevant documentation. We were struck by the fact that 2.49 A key strength of the Trust in moving forward the Trust enjoys a generally positive relationship is the fact that the majority of staff appear to with the staff side. Board members highlighted recognise the need to modernise. Figure 23 their view to us that the involvement of three shows that around 8 out of 10 staff responding staff side representatives at Board meetings was to our survey both believed that most staff are valuable. The Trust has a range of partnership prepared to work in different ways to improve structures and mechanisms for joint consultation services, and that they can see ways in which that have the potential to support accelerated the Trust can operate more efficiently without decision-making and finding solutions to the reducing the quality of service to the public. Trust’s problems outlined in this report. These findings were consistent across the three regions and between different groups of staff.

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4340_WAO Amb ENG_v0_14.indd 57 29/11/06 11:02:25 Figure 23: Most staff recognise the need to operate more efficiently and believe that most staff are prepared to work differently

I can see ways WAST can operate more efficiently 29 52 13 3 1 without reducing service to the public

I believe most staff are prepared to work in different 16 61 15 7 1 ways to improve service

N Strongly agree N Agree N Neither N Disagree N Strongly disagree N DK/NA

Source: Wales Audit Office survey of the Trust employees, analysed and reported by Beaufort Research Ltd

2.50 Staff stressed the need to modernise at the the past, focused on clinical training and has focus groups we held, raising the importance of successfully increased the clinical nature of developing local flexibilities and care pathways, the training provided; staff have learned new and recognising that the Trust needs to be able techniques such as thrombolysis, the use to deliver a response that is more appropriate of resuscitating devices, and all paramedics to the needs of the patient (Appendix 4). Staff should have received thrombolysis training also highlighted the importance of making by the end of the 2006 financial year. better use of the Trust’s resources, to get more from them and to stop doing what is not 2.52 The modernisation agenda will expand the needed. Most staff we interviewed understood training needs of staff, particularly to support the importance of changing the way the Trust paramedics in new ways of delivering care, for operated and the opportunities this presented example by becoming ECPs and CPOs (see for them and service users. Staff provided Box 4). One of the many potentially positive us with a wide range of good ideas about benefits of delivering the emerging DECS improving the Trust which we have shared with strategy should be a broadening of the range the new Chief Executive who has used this of training the Trust provides for its staff, to information to inform his own ongoing meetings facilitate more appropriate responses to the with staff about their ideas for improvement. majority of calls that are not genuinely life- threatening. Taking healthcare to the patient 2.51 Front-line staff are generally well-trained. In our (Box 4) estimates that up to 90 per cent of survey, 68 per cent of respondents said that patients calling 999 do not need advanced they had been adequately trained to do their life-saving skills, although they do need urgent job, with 16 per cent disagreeing. The level of primary care. Consequently, high quality agreement was highest for front-line operational training to enable staff to see and treat, or staff and lowest in the control room and non- assess and refer, patients in the community, operational management. The Trust has, in

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4340_WAO Amb ENG_v0_14.indd 58 29/11/06 11:02:25 without transporting them to hospital, has There has been no effective the potential to deliver significant benefits strategic direction for the Trust across the whole unscheduled care system. There has been an absence of a clear vision for the 2.53 The Trust accepts that it has management future of the organisation and strategy to deliver it capacity issues that need to be addressed. Training and development should encompass 2.55 Ambulance services generally face a number not only clinical staff, but also managerial and of clear opportunities and threats, as demand support staff, to ensure that they have the skills for services changes, new models of service to fulfil their roles as effectively as possible. The delivery emerge and the configuration of health Trust recognises that training and development services changes. This provides opportunities for middle managers has been a weakness but to develop new ways of working, provide this should be addressed through the knowledge new services, and take a leading role in the and skills framework within Agenda for Change, provision of mobile primary healthcare across and implementation of the draft modernisation the whole system of health and social care. plan. The Trust will also need to ensure adequate Consequently, the development of a clear specialist training for those working in functions strategic vision for the Trust, and of plans such as fleet, estates, ICT, HR and finance. to deliver the vision, has been an essential requirement for it to operate effectively. The Trust has been let down by failures in a number of key areas 2.56 The Trust’s new Chief Executive is currently developing and consulting on a detailed modernisation plan, Time to make a difference, 2.54 Having seen clear evidence of considerable strengths in the Trust, we examined which will form the Trust’s strategy for the why its performance has nevertheless future. The Trust has developed previous been disappointing for many years. strategies which the new modernisation We found failures in all the key areas of plan will supersede. The rapid changes in business management, namely: strategy are perhaps not surprising, given the changes in leadership since November ■ an absence of strategic direction; 2005, but the absence of a clear, agreed vision and strategy, supported by sound ■ a short-term approach to business planning processes, has been a financial management; major barrier to change and improvement.

■ ineffective governance; 2.57 The Trust has produced various strategy documents: ■ weak leadership; ■ a strategy 2005-2009; ■ poorly designed and managed processes; ■ a strategic action plan, agreed ■ poor systems and infrastructure; and in January 2006;

■ serious concerns about organisational culture. ■ a business plan 2006/2007, developed by Dr van Dellen; and

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4340_WAO Amb ENG_v0_14.indd 59 29/11/06 11:02:28 ■ Time to make a difference: transforming the Welsh Assembly Government Department for ambulance services in Wales, which Health and Social Services North Wales Regional is currently subject to consultation. Office identified the ongoing need for the Trust to develop and communicate a clear vision and 2.58 The strategy 2005-2009 was developed after modernisation plan for the next five years. the Trust came under pressure to develop a modernisation vision and strategy from the 2.60 The Trust’s strategic planning has also been Welsh Assembly Government Department compromised by a ‘one size fits all’ approach. for Health and Social Services North Wales We found that, although there are many Regional Office, central Welsh Assembly common factors, there are also differences in Government divisions and HCW, in the the main strategic challenges and opportunities middle of 2004. These organisations met in that face the different regions of the Trust, July 2004, and all parties expressed concern and particular challenges in some localities, about the performance and strategic direction such as Powys which covers a very large of the Trust and its ability to modernise and geographical area in which there is no district change. This meeting took place shortly after general hospital. Consequently, there needs to the then Commission for Health Improvement be more effective strategic planning at a regional (CHI) published in February 2004 a clinical and local level, within the framework of the governance review that criticised the strategic corporate strategy, to ensure the development management of clinical governance in the Trust. and delivery of appropriate changes that can meet specific local requirements. 2.59 It is unusual for external pressure to be necessary to encourage an organisation to 2.61 The significant weaknesses in the Trust’s produce a strategy: effective organisations strategic direction are reflected by the scan their environment continuously, have consistent confusion of stakeholders about strategic planning processes that are embedded the strategic direction of the Trust: within their day-to-day operations and strive continually to improve services through robust a only 12 per cent of staff agreed that corporate planning processes. Nevertheless, it the Trust kept them well-informed was external pressure in 2004 that impelled the of its future strategic direction; Trust to produce the strategy 2005-2009 and the strategic action plan, as well as to accept b the Joint Emergency Services Group external advice from Roger Thayne. However, expressed the view that the ‘strategic the Trust failed to support these high-level direction of the Welsh Ambulance Service documents with any clear business or action has been and remains unclear’, although plan that set out how the strategic objectives it recognised that the modernisation plan would be delivered. Senior managers in the should provide this clarity of remit; Trust told us that they lacked the leadership and c only one of the 13 A&E consultants who capacity to translate the strategic documents responded to our survey agreed that the into clear, deliverable action plans. The lack Trust had a clear plan for improvement of costed plans, clear priorities and individual that is well understood within the A&E responsibilities raises significant doubts about department – six were neutral, four whether the Trust knew how it would deliver disagreed on the whole and two disagreed modernisation. In its 2005/2006 annual report,

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4340_WAO Amb ENG_v0_14.indd 60 29/11/06 11:02:28 strongly. Eight out of 13 disagreed – two on the achievement of the annual financial strongly – that the Trust had consulted target to break even, rather than sustaining the A&E department about its plan; and the long-term financial position. In particular:

d one Trust Chief Executive wrote to us ■ revenue budgets have not been to highlight the importance of the Trust derived from any long-term financial developing a clear sense of strategic strategy but have been merely a roll direction which aligns with the Department over of the previous year’s out-turn; of Health report, Taking Healthcare to the Patient. Another highlighted the need to ■ financial balance has been achieved through develop new roles and to integrate the essentially short-term measures; and ambulance service much more closely with ■ the whole unscheduled care system, to capital funding has been only develop a single integrated unscheduled weakly managed. care team that meets local patients’ needs. 2.64 Revenue budgets have not been explicitly Financial targets have been achieved aligned to a long-term organisational strategy but not in a sustainable way because the or medium-term business plans to improve Trust has not been sufficiently focused services, identify efficiencies and manage on long-term financial considerations financial pressures. Revenue budgets are essentially a rollover of the previous 2.62 One of the achievements of the Trust has been year’s outturn, with adjustments for non- its achievement of statutory financial targets recurring items and an inflationary uplift. to break even and meet the external financing Budgets therefore reflect the Trust’s existing limits. In 1999/2000, the Trust predicted a infrastructure and working practices, rather £3m funding deficit to meet the costs of its than key strategic priorities and an analysis reconfiguration as a national Trust. The Welsh of demand and review of options to improve Assembly Government provided additional the efficiency and effectiveness of services. funds and agreed a financial recovery plan with the Trust. The Trust repaid the funds and 2.65 The Trust does not systematically produce, achieved financial balance by 2004/2005 in line monitor or benchmark adequate costing with its agreement with the Welsh Assembly information to identify inefficiencies and to Government. The Trust has, however, predicted learn from best practice. The Trust does not a significant revenue deficit in the current monitor, analyse or compare the full cost of and future financial years and is negotiating a its core EMS and PCS activity. Nor does it Strategic Change and Efficiency Plan (SCEP) adequately collect or compare the costs of with the Welsh Assembly Government to other services, such as fleet and estates. manage its financial recovery, and enable it to 2.66 Since 2001/2002 the Trust has carried an meet the statutory financial target to break even. income and expenditure reserve deficit due to an increase in long-term provisions 2.63 Our examination of the Trust’s underlying financial position and of its current financial not being funded by the Welsh Assembly difficulties indicates that it has been too focused Government. The reserve deficit began as £2.2m 2001/2002 and by 2005/2006 had

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4340_WAO Amb ENG_v0_14.indd 61 29/11/06 11:02:31 reduced to £1.4m. Trust officers told us that and unplanned capital funding (£1.5m) that the Welsh Assembly Government agreed that became available from the Welsh Assembly the deficit could be left to erode over time. Government at the end of the financial year to fund their capital expenditure needs. 2.67 Despite receiving adequate revenue funding (paragraphs 2.30-2.32), the Trust is facing 2.71 Trust officials told us that capital decisions significant financial pressures. In 2005/2006 were rushed at the year end when there was the Trust broke even as a result of £7.4m greater confidence about the availability of additional funding and unplanned non- resources for capital expenditure, but this recurring gains, composed of the following: made it very difficult to plan more than a few months in advance and may have contributed ■ £2.2m additional funding to meet to capital not being used in the most effective Agenda for Change costs; way. The Trust was insufficiently proactive in developing business cases in preparation ■ £3.2m transfer of capital resources to for the later availability of capital or with a revenue on special dispensation from view to securing additional capital from the the Welsh Assembly Government; Assembly Government. This was a factor in the procurement of the chest compression devices ■ £1.9m release of provisions; and (Case Study K). Our analysis of cumulative ■ £0.1m interest gained on the investment capital expenditure shows how the majority of Agenda for Change funding. of capital expenditure was incurred in the final months of the financial year (Figure 24). 2.68 Capital management has also been weak. Despite a comparable asset base and capital 2.72 Mrs Lloyd, the Head of Health and Social expenditure in recent years (paragraphs 2.41- Services in the Welsh Assembly Government, 2.42), we found evidence that the Trust’s told us that capital funding had been, and capital infrastructure was in need of significant continued to be, available but that the Trust investment, particularly in respect of estates, had not until recently submitted timely and fleet, ICT and communications equipment. robust business cases to access capital. The Trust’s Director of Finance disputed this claim. 2.69 Long-term capital planning has not been However, Mrs Lloyd told us that the Assembly explicitly linked to a Trust strategy or quantifiable Government was prepared to consider future revenue savings. There have been supporting a capital scheme to purchase rather serious deficiencies in capital procurement than lease vehicles as long as the business processes which have led to capital being case could demonstrate value for money in the wasted, (paragraphs 2.195-2.207). long-term. The Assembly Government had only recently received a business case to purchase 2.70 Each year the Trust has transferred a significant additional vehicles, which it had approved. amount of its discretionary capital funding to revenue to meet vehicle leasing costs. In 2005/2006, £3.2m of the Trust’s £3.9m recurring discretionary capital funds were transferred to revenue. The Trust was then reliant on additional

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4340_WAO Amb ENG_v0_14.indd 62 29/11/06 11:02:32 Figure 24: Capital expenditure is considerably higher at the end of the financial year

1 Cumulative capital expenditure £ millions Cumulative capital expenditure

0 April May June July Aug Sept Oct Nov Dec Jan Feb Mar

N 2004/2005 N 2005/2006

Source: Wales Audit Office, based on Welsh Ambulance Services NHS Trust Monitoring Returns to the Welsh Assembly Government

Governance has not been effective In this regard, the Board has been hampered in securing improvement by the poor quality of information it received. Non-executives explained that the poor quality Internal governance has been weak and availability of information from successive Chief Executives had hampered scrutiny. 2.73 The Trust Board has a key role to play in setting Performance monitoring reports were around the direction for the organisation, overseeing two hundred pages long and did not provide progress towards strategic goals and monitoring meaningful analysis of such a large quantity operational performance. There are a number of data. Similarly, the Board has not received of other committees that support the Board: accurate costing information, linking financial and performance information. Some Board members ■ HR Committee; told us that when they asked executives for ■ Audit Committee; more information to aid their understanding, they believed the executives’ response was to ■ Governance Committee; swamp them with a large amount of data rather than meaningful management information. ■ Remuneration Committee; and 2.75 There has been no benchmarking of the Trust ■ a new Modernisation Committee. against other ambulance services, which has compromised the Board’s understanding of 2.74 We found evidence that, historically, the Board the business. Some non-executives told us did not adequately set and monitor a strategic that they had asked the executives to produce direction for the executives and organisation. benchmarking information but that this was not

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4340_WAO Amb ENG_v0_14.indd 63 29/11/06 11:02:34 forthcoming, partly because the executives, Board discussed in closed session in wrongly, stated that Scotland was the only May 2006, and Dr van Dellen produced appropriate comparator. The impact of Mr a report for Mrs Lloyd of the Assembly Thayne’s benchmarking report reflects the Government upon his departure. Both significance of this omission – benchmarking raised their concerns about the lack of should be a routine part of running an effective Board’s understanding of the seriousness organisation. Even where organisations of the problems in the Trust, particularly in differ in important ways – as Staffordshire regarding the service as ‘average’. They and Wales do – the results of benchmarking repeated these concerns in interviews with exercises raise important questions that the Wales Audit Office. Board members felt can act as a driver of improvement. that they had not had sufficient opportunity to discuss and challenge these claims; 2.76 It is essential for executive and non-executive members of the Board to have a good d regarding improving performance against understanding of the business. Although our targets, the Trust consistently focused interviews suggested that the current non- on the additional funding requirements it executives now understand the key issues facing felt it needed to achieve certain response the Trust, historically there may not have been times but did not pursue the 5-6 per cent the depth of understanding of the business efficiency gains the ORH report said the required to move it forward, partly because of the Trust should be able to deliver by improving frequency of Board meetings and the fact that its processes, or the fact that the Welsh non-executives did not all feel that the previous Assembly Government had provided Chair had fully involved them in decision- one third of the identified funding but making. The following issues suggest this: the Trust had not delivered sustainable improvement in performance once it had a there has been a strong focus on perceived achieved 60 per cent in March 2004; and increases in demand, and the level of funding for the organisation, despite e there are significant problems with the fact that other similar services have Patient Care Services, yet this has experienced similar or greater increases not been a priority because of the in demand (paragraph 1.29-1.34) and the Board’s focus on EMS response time Trust has received additional funding as performance and the financial position. a result of the ORH report (see Box 7); 2.77 There is also historical evidence that the Board b before the Thayne benchmarking report was not effective in scrutinising performance. of April 2005, the Board appears to have One obvious weakness is that the Board met been unaware that the Trust was relatively only quarterly, plus an Annual General Meeting, generously funded or of the extent of the under the previous Chair, Mr Norris. The new problems with the way it was operating; Chair, Mr Fletcher, who took up office on 1 April 2006, has instituted monthly meetings. c both Mr Thayne and Dr van Dellen The previous Chair told us that the use of the highlighted concerns about the Board’s Trust’s other committees and ‘awaydays’ was understanding of the Trust’s position. Mr a more appropriate way to do business, and Thayne produced a report, which the expressed the view that monthly meetings

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4340_WAO Amb ENG_v0_14.indd 64 29/11/06 11:02:35 Box 7: Operational Research in Health Limited (ORH) Study

In early January 2001, the National Assembly commissioned Operational Research in Health Limited (ORH) to undertake a study of emergency ambulance cover in Wales. ORH reviewed emergency ambulance and ‘responder’ cover across Wales to identify optimum resource deployments to allow targets to be met efficiently. The study concluded that, based on a 3 per cent annual increase in demand, the Trust could improve the service-wide Category ‘A’ performance against the 8 minute standard by 5 percentage points based on existing resources with some modernisation in how the service was delivered. They also provided a series of different options of investment to hit minimum targets at a Unitary Authority level (see table below).

Options set out in the ORH report

Target at Unitary Authority Level Additional Annual Cost

Category ‘A’ 8 minute All emergency calls within 14, 18, 21 minutes GP urgent calls – arrival within 15 £ million minutes of the agreed time

60% 95% 95% 4.7

75% 95% 95% 6.7

85% 95% 95% 8.9

As a result of the ORH study, in 2002/2003 the Welsh Assembly Government provided £1m additional funding and in 2003/2004 HCW provided the Trust with an additional £2.5m recurrent funding to start to improve performance. While performance improved in the last quarter of 2003/2004, this was not sustained in 2004/2005 and 2005/2006.

Source: Wales Audit Office, adapted from ORH study.

‘gave an air of crisis’. However, other Board then implementing a clear strategic vision. members indicated that the regular ‘awaydays’ Nevertheless, Mr Norris told us that one of generated good discussion and ideas, but the reasons for moving to quarterly meetings that very little happened as a result. They also was to help executives provide the Board with told us that the ‘awaydays’ did not happen more strategic papers of a higher quality. as regularly as had originally been planned. 2.79 The Board has also lacked a forward 2.78 Given the poor performance of the Trust, and programme, both for the main Board and its the significant problems with service provision, other committees, to guide its work and to make leadership, management capacity and the the best use of the limited time and expertise overall health of the organisation, quarterly of non-executives. There has been no regional meetings were insufficient. Given the often responsibility of non-executives which could poor quality of information presented by contribute to non-executives’ understanding executives, quarterly meetings seem to be a of the business on an all-Wales basis and factor in the inability of the Trust to develop help to support managers in resolving some and maintain momentum in developing and of the regional variations in performance.

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4340_WAO Amb ENG_v0_14.indd 65 29/11/06 11:02:37 2.80 The absence of a clear vision and strategy for the documented between Mr Page and members organisation has compromised the effectiveness of his executive team. As a consequence, of the Board. Weaknesses in performance the Board was slow to identify and act upon management have exacerbated this. As well weaknesses in management capacity. as weaknesses and gaps in the information provided to non-executives, the previous Chair 2.81 The circumstances surrounding Mr Page failed to agree written performance objectives departing the Trust are an example of a failure with the then Chief Executive, Mr Page, although to involve non-executives appropriately and to some discussions about his performance manage the performance of the organisation and took place sporadically. In turn, individual its leaders (Case Study F). Mr Page had been objectives were not regularly agreed and successful in bringing together the predecessor

Case study F: Mr Page’s departure reflects weaknesses in internal governance

In July 2004, the various external governance organisations met to discuss serious concerns about the Trust. Subsequently, during 2005 the previous Chairman agreed that Mr Page’s voluntary premature retirement would be ‘in the interests of the efficiency’ of the service. The former Chairman wrote to Mrs Lloyd explaining that “Mr Page has recently realised that he would wish to pass the challenging leadership mantle to a new Chief Executive who would have the renewed vision, enthusiasm, skills and leadership style to take this organisation to a different level of development.” Both the former Chair and former Chief Executive believed that Mr Page had reached an agreement with the Welsh Assembly Government on this, which would take effect from the end of November 2005. This case reveals serious governance issues: • the Chair sought to initiate a meeting of the Remuneration Committee to discuss significant issues about the terms of Mr Page’s proposed departure via e-mail, rather than a meeting, in late November; some of the non-executives expressed the view that there had been little or no prior consultation from the Chair or time to consider this decision and a decision was not made until March 2006; • the former Chief Executive’s performance does not appear to have been managed effectively, and there is no record of any performance management on the former Chief Executive’s file; Mr Norris had written to Mrs Lloyd in April 2004 indicating that Mr Page had met all of his objectives, yet by the following year had entered into discussions with Mr Page about his future; Mr Page told us that Mr Norris had not provided him with written performance objectives although they discussed priorities more generally; • the concerns about the Trust appear to have emerged very rapidly, possibly as a result of external pressures; non- executives told us that they had raised concerns individually with the Chair about Trust leadership, but that they had not been aware that others had done the same; the Board should have discussed and addressed these issues earlier in the interests of the organisation and the individuals concerned; and • the issues of the terms of Mr Page’s departure should have been discussed earlier by the Board rather than the previous Chair seeking to rush the decision through in November after discussions with Assembly Government officials, which placed non-executives in an invidious position.

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 66 29/11/06 11:02:38 trusts to form a single Trust for Wales after a e annual performance reports from the Welsh long career in the ambulance service. The case Assembly Government Department for study relates to the adequacy of governance Health and Social Services North Wales rather than Mr Page’s performance. Regional Office have raised similar issues;

2.82 The weaknesses in strategy, performance f the issue of transferring capital to revenue management and governance have led to an to cover car leasing costs has been overall lack of accountability for the performance a known problem for some years but of the organisation and of the senior executives the Trust did not until recently submit a responsible. There have been a series of business case on which it and the Welsh very damaging mistakes in procurement, yet Assembly Government might find a we found no evidence of this being picked sustainable solution. This has significantly up in the appraisals of senior executives. reduced the level of planned discretionary capital available to the Trust; and 2.83 A series of known problems has not been addressed effectively: g executives did not bring the new system purchased for PCS to the a differential performance levels and Audit Committee to identify what had processes have not been addressed, caused the problems and to learn and good practice has not been lessons for future procurements. disseminated effectively within the Trust or from services outside Wales; 2.84 Despite these weaknesses, there is some recent evidence of progress in strengthening b in 2001, the ORH report (Box 7) highlighted the Board and management structures the fact that the Trust could better and improving internal governance: match supply and demand through improved dynamic cover practices a since April 2006, the Board has and roster changes, yet rosters still moved to monthly meetings; remain to be reviewed and changed; b a governance development c. there have been very serious problems programme is ongoing with support with the Trust’s estate over a number of from the Trust’s internal auditors; years, with an ongoing Health and Safety Executive notice, but there has been no c all non-executives told us that they are clear decision about future estates strategy much more closely involved in decision- despite a number of external reviews; making under the new Chair than they were under the previous Chair; d audit reports have highlighted weaknesses in performance management d the new Chief Executive, Alan arrangements, particularly in supporting Murray, has agreed, documented the Board to oversee strategic priorities, personal objectives which have been yet there has been little progress in shared with all Board members; improving the performance management framework in line with the auditors’ e a new company secretary has recommendations of October 2004; recently been appointed;

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4340_WAO Amb ENG_v0_14.indd 67 29/11/06 11:02:41 f the events of the last 18 months appear to for Health and Social Services North Wales have served to inform non-executives of the Regional Office clearly sought to push the Trust scale of the problems facing the Trust; and to improve its performance against Ministerial targets and to encourage the organisation g the Chair has established a Modernisation to develop a clear modernisation strategy. In Committee, which will oversee the delivery addition, Ann Lloyd, Head of the Department for of the Trust’s modernisation plan and the Health and Social Services, and Derek Griffin, Service Change and Efficiency Plan (SCEP). North Wales Regional Director, of the Welsh Assembly Government, met the Chair and External governance has not been Chief Executive on a number of occasions and sufficiently co-ordinated met some of the non-executives in February 2006 and April 2006, to raise their concerns 2.85 HCW has commissioned ambulance services about the organisation and how to address in Wales since 1 April 2003. The 13 acute trusts the lack of management capacity within the in Wales, 6 trusts in England and Powys LHB Trust. Both the regional office and HCW commission patient care services. The Welsh individually visited Staffordshire Ambulance Assembly Government Department for Health Service in January and April 2005 respectively. and Social Services North Wales Regional Office has been responsible for the performance 2.87 Nevertheless, we also found evidence management of the Trust since April 2003, with of difficulties between the parties input from the Welsh Assembly Government involved in external governance: Department for Health and Social Services Directorate of Performance and Operations on a there were problems agreeing the policy, and quality directorate on clinical matters. minutes of the meeting between the external governance bodies of July 2004 2.86 The external governance organisations correctly (and following action); consequently, diagnosed many of the issues facing the Trust the agreed minutes state that since the and have sought to take various actions to meeting it has become clear that there address them. There was a meeting on 16 is ‘no overall agreement as to the way June 2004 between HCW, CHI reviewers and forward’; Mrs Lloyd told us that she over- the Welsh Assembly Government Director of ruled this and ensured agreement about Performance and Operations. There was a how the decision to engage external further meeting on 7 July 2004 between HCW, support should be taken forward; and the Welsh Assembly Government Department for Health and Social Services Regional Office b when the Trust argued vigorously against and the Welsh Assembly Government policy HCW’s attempts to introduce rewards and operations and quality directorates to and penalties into the 2004/2005 Heads discuss concerns about the organisation. of Agreement for achieving 60 per cent These concerns reflected many of the issues performance, the regional office expressed highlighted in our report, and led to the concerns about the impact and potential decision to seek external assistance for the for the Trust’s performance to fall as a Trust, which eventually resulted in Mr Thayne consequence of the method proposed producing his original benchmarking report in – as a result, HCW agreed to drop its April 2005. In particular, both HCW and the plans to introduce rewards and penalties. Welsh Assembly Government Department

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4340_WAO Amb ENG_v0_14.indd 68 29/11/06 11:02:41 2.88 We also found that there was some wider 2.90 Recognising the risk of overlap between risk of overlap about the external governance performance management and commissioning arrangements and the respective roles of the for this unique organisation within NHS various organisations. Both HCW and the Wales, Mrs Lloyd has asked the Director regional office have a role in performance of Performance and Operations to draft a management. HCW is responsible for memorandum on roles and responsibilities , ensuring the achievement of the service which she will issue in March 2007, after the specification it commissions, which covers Trust has given its views on these proposals. quality, targets, funding and activity. The regional office is responsible for ensuring 2.91 There have been consistent problems between that the Ministerial targets are achieved and the Trust and HCW in agreeing Heads of monitors the organisation against a balanced Agreement to support the delivery of SaFF scorecard that measures four perspectives of targets, both under Mr Page and Mr Thayne. performance (stakeholders, resource utilisation, The Welsh Assembly Government Department management process and innovation and for Health and Social Services Regional learning). However, HCW’s role focuses on Office’s annual report in 2004/2005 referred one part of the Trust’s business, whereas the to relationship issues between the Trust and Welsh Assembly Government Department for HCW, while documents from HCW claim that Health and Social Services Regional Office the Trust adopted a confrontational approach has a focus on the whole organisation. to their EMS commissioner, with disagreements appearing to centre on the financial resources 2.89 In addition, some interventions by the bodies necessary to achieve targets. Historically, responsible for external governance have the Trust argued that increased demand not been sufficiently co-ordinated. There necessitated additional resources. Problems were particular problems around the original agreeing the 2004/2005 Heads of Agreement benchmarking report produced by Mr Thayne. led to an unacceptably late arbitration meeting, The Welsh Assembly Government Department facilitated by the Welsh Assembly Government’s for Health and Social Services Regional Regional Office, in January 2005, less than Office told us that it had discussed the need three months before the end of the financial for assistance with the Chief Executive and year in question. Subsequently, in 2006, Mr Chair of the Trust, who then invited Mr Thayne Thayne argued against the imposition of an to carry out the benchmarking report. HCW improvement plan and SCEP, which would officials told us that they had not been involved show over time how the Trust would return to in establishing the terms of reference of the balance, at a time when he believed investment benchmarking review. In addition, HCW officials was necessary to deliver changes in service experienced difficulties obtaining a copy of Mr models. There are ongoing discussions about Thayne’s original benchmarking report from the the SCEP for the current financial year, which Trust and that the Trust did not provide HCW covers the whole organisation and not just with a copy of the report, produced in April the elements of it commissioned by HCW. 2005, until the December of the same year. 2.92 Further indicators of the problems with external governance are manifested in a number of other ways:

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4340_WAO Amb ENG_v0_14.indd 69 29/11/06 11:02:44 a commissioning has not yet, in common c In a report to the Board, one of the reasons with most services in England, sufficiently cited by Mr Thayne for his resignation focused on clinical outcomes and a as interim Chief Executive was that ‘the broader range of indicators of performance. seriousness of the Trust problems and the Expert commissioning is important need for action were not fully understood for ambulance services so that the by the Trust Board, the North Wales Region commissioner understands the specific or the Welsh Assembly Government’; both issues involved in providing ambulance Board members and the Welsh Assembly services. Case Study G demonstrates two Government dispute this assertion. Mrs different commissioning systems, used in Lloyd has also told us that Mr Thayne gave Scotland and East Anglia, both of which her different reasons for his resignation; and benefit from expert commissioning; d additional resources have been provided b the strength of focus on delivering a 60 but have not delivered sustainable per cent response rate for Category ‘A’ improvements; in response to the ORH calls has tackled the symptoms rather report, the Welsh Assembly Government than the causes of poor performance, introduced additional recurrent funding and may have constrained the delivery of £3.5m in two tranches in 2002/2003 of broader improvements in services and and 2003/2004; this led to the delivery of the way the organisation operates; 60 per cent performance in March 2004,

Case Study G: Commissioning emergency ambulance services in Scotland and East Anglia

The Scottish Ambulance Service (SAS) aims to balance the local focus of a national service through a ‘commissioner and provider’ relationship between the Board and its divisions. The Board and the executive team align themselves with the Scottish Executive and consider themselves responsible for setting and maintaining the strategic direction of the service by ‘commissioning’ ambulance services from the six ‘providing’ regional teams. Regional managers align themselves with local NHS Boards and Regional Health Boards to maintain a local focus for the services they provide. There are central support services for the regions but the centre aims to empower regional teams by ensuring they are responsible and accountable to the centre for their own performance (it has to be noted that the accountability between the Welsh Assembly Government and the NHS in Wales is different to the accountability between the Scottish Executive and the NHS in Scotland). SAS holds local and national Annual General Meetings to affirm regional autonomy. SAS is funded centrally from the Scottish Executive. They believe that local commissioning by each health board would be inefficient and would potentially produce a divergent service with different local levels of care dependent on the financial health of local health boards. As a national service they can control resources and funding efficiently, which fits well with the service’s perception of the executive being a ‘commissioner’ of local service delivery. In the former East Anglia Ambulance Trust, a consortium, with representation from all of its constituent Primary Care Trusts (PCTs), commissioned emergency ambulance services. The consortium employed a lead commissioner who liaised between the ambulance service and PCTs. Clear and agreed ‘rules of engagement’ for decision-making were central to the effective operation of this system, for example to ensure that all members of the consortium contributed to investments if a majority vote carried the decision. There were occasional tensions when the financial position was difficult, but the Trust told us that the system worked well and contributed to service development in East Anglia.

Source: Wales Audit Office and interviews with the Scottish Ambulance Service and East of England Ambulance Trust

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4340_WAO Amb ENG_v0_14.indd 70 29/11/06 11:02:44 Figure 25: In the last 18 months, there has been considerable instability at the top of the Welsh Ambulance Services NHS Trust

2004 2005 2006 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 11 12 01 02 03 04 05 06 07 08 09 10 Chair of Trust Roy Norris began April 2002 end of tenure Stuart Fletcher continuing Chief Executive Don Page began November 1998 leave retired Mik Webb * Roger Thayne * Anton van Dellen * Derek Griffin * Alan Murray ** continuing Director of Finance Mik Webb began April 1998 leave continuing Director of Operations John Bottell leave retired Anton van Dellen * Michael Collins * shared resp. David Lyden * shared resp. Director of Personnel and Development Lyn Meadows began January 2000 continuing Medical Director Dr Michael Colquhoun part time appointment began January 2002 continuing

Notations: * Acting or Interim; ** Chief Executive Designate until 1 October 2006

Source: Wales Audit Office.

in line with the SaFF target to achieve 60 to maintain 60 per cent performance per cent by the end of the financial year; suggests. The Welsh Assembly Government subsequently, the Trust has not been able intended for the Trust then to maintain to maintain this performance, achieving and improve on that target but the Trust 60 per cent in only two months since April did not make the fundamental changes 2004, (paragraph 1.10). The decision to necessary to deliver sustainable change, frame the 2003/2004 response time target and performance fell after March 2004. as a target to be achieved by the end of the financial year, rather than across There has been weak leadership in the Trust the whole of the year, was intended to encourage the Trust to deliver the target in 2.93 There are many dimensions to leadership. a sustainable way, but the Trust appears In our view the Trust’s leadership has to have focused on the single month of been weak in a number of respects: March 2004, as its subsequent failure

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4340_WAO Amb ENG_v0_14.indd 71 29/11/06 11:02:47 ■ rapid changes of leadership during appeared advantageous to the Board given the last year have been damaging; the knowledge of Wales he obtained by producing the benchmarking report; his record ■ clinical leadership has not been of achievement in Staffordshire; and the fact well resourced; and that he was immediately available as a result of his resignation from Staffordshire. He had ■ there has been a lack of brought with him from Staffordshire, Dr van management capacity. Dellen as interim director of operations. The North Wales regional director informed us that Rapid changes in leadership have their brief was to stabilise the organisation and to been extremely damaging and reflect improve performance wherever they could, while the wider problems in the Trust the Board advertised for a substantive Chief

2.94 In the last 18 months, the Trust has undergone Executive. Board members and Welsh Assembly a period of intense instability in the leadership Government officials told us that they believed of the organisation. Figure 25 shows the Mr Thayne had given an undertaking to stay changes of people in key positions over that at the Trust until a substantive Chief Executive period, which followed a seven year period had been appointed. However, Mr Thayne of relative stability in which there was a single told us that he gave no such undertaking. He Chief Executive, Mr Page, and two chairs, resigned in May 2006 after two months in Eifion Pritchard (1998-2001) and Roy Norris post. Essentially, the reasons for Mr Thayne’s (2002-2006). Nevertheless, the Trust has not resignation appear to have centred on his belief had a substantive director of operations in post that there was insufficient understanding of since June 2004, when the previous director the scale of the problems facing the Trust and began a period of long-term absence, and his support for the required solutions. Dr van Dellen departure from the Trust in January 2006. then took over as interim Chief Executive. He resigned in July 2006: he stated publicly that his 2.95 Mr Page became absent from work in November resignation was because he could not commit 2005. His contract subsequently ended on 30 long-term to working in Wales, and cited similar September 2006. Between November 2005 issues about the Trust on his departure that Mr and the appointment of Alan Murray as Chief Thayne had raised. These issues were set out Executive designate in August 2006, four people by Dr van Dellen in a private report to Mrs Lloyd, were either acting Chief Executive or interim Head of the Department for Health and Social Chief Executive. During this period, a new Chair, Services in the Welsh Assembly Government: Stuart Fletcher, was appointed from 1 April 2006, at the end of Roy Norris’s term of office. ■ the lack of Board-level understanding of the seriousness of the problem; 2.96 The overall period of instability in leadership over the past 18 months has, inevitably, caused ■ lack of support within the Trust for the problems within the ambulance service. Mr changes he wished to introduce; and Thayne became interim Chief Executive in ■ problems he perceived working with the Trade March 2006, initially on a part-time secondment Unions and in bringing in people whom he and subsequently on a full-time basis after his believed could turn the organisation around. resignation from Staffordshire. The opportunity to appoint Mr Thayne as interim Chief Executive

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4340_WAO Amb ENG_v0_14.indd 72 29/11/06 11:02:48 2.97 We found that Mr Thayne and Dr van Dellen strove ■ a heightened awareness of the scope to modernise the organisation very rapidly because to improve efficiency and that available of their serious concerns about the way the resources needed to be matched more organisation operated and its poor performance. closely with demand for services. Many staff, including senior executives, informed us that there were differing views of Mr Thayne’s 2.99 There is evidence that historically the Trust strong management style: some said that the lacked strong leadership at Board level. We rapid decision-making was welcome while others heard evidence that the previous Chair, Mr felt intimidated. There were also confrontations Norris and former Chief Executive, Mr Page, with HCW and the Welsh Assembly Government had a poor relationship and that this relationship Government Department for Health and Social deteriorated over time, compromising the Services North Wales Regional Office, and effective working of the Board. Mr Page did not evidence that Mr Thayne threatened to resign engage as fully with the Board as its members on a number of occasions before his eventual would have wished. The previous Chair, Roy resignation. Many people we spoke to, within the Norris, became less involved once it became Trust or outside, supported Mr Thayne’s vision clear that he did not intend to reapply for the of the organisation and its modernisation, but position of Chair towards the end of 2005. questioned his method of introducing change. Non-executives told us that they were much It appears that Mr Thayne and Dr van Dellen more involved in decision-making under the new attempted, because of a genuine desire to Chair, with the issues surrounding the departure improve the service, to move an organisation of Mr Page a good example of non-executives previously in a ‘steady state’ forward too quickly being insufficiently involved in decision-making, towards a vision which few if any people disputed, (paragraphs 2.81 and Case Study F). with resulting disruption and distress for many staff. There had been a long period of stability Clinical leadership has not been well resourced and a somewhat insular culture prior to this. 2.100 Clinical leadership has been provided by a part-time medical director, Dr Colquhoun, who 2.98 Despite some of the negative consequences of this turbulent period, we found that there spends half of his week working for Cardiff were some clear benefits that represent University. He told HIW reviewers that his role opportunities for the organisation to build upon: was one of a clinical advisor, rather than a conventional medical director. He has produced ■ this period significantly raised awareness documentation on clinical governance, but of the need for the Trust to modernise and HIW informed us that the clinical governance an improved understanding of the direction framework would have been enhanced if it in which the Trust needed to travel; had been personally led by a clinical director employed full-time within the Trust. There is little ■ there was a stronger focus on improving clinical support in the regions, and HIW told us performance to save patients’ lives; that they believed there was a need to bolster regional clinical leadership. Full details on clinical ■ there was a strong focus on developing leadership will be available in HIW’s forthcoming performance information, key performance clinical governance review of the Trust. indicators and on using information to improve performance, in stark contrast to the previous use of performance information; and

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4340_WAO Amb ENG_v0_14.indd 73 29/11/06 11:02:50 There has been a lack of management capacity interviews and focus groups with Trust staff supported these findings – 12 out of 15 locality 2.101 We have found a number of important areas ambulance officers, key operational managers, in which there appears to have been a lack of indicated that they had not had a performance management capacity in the Trust. These were: appraisal this year. The introduction of the knowledge and skills framework under Agenda ■ project management, especially in for Change will introduce performance appraisal relation to some major procurements; and personal development planning for staff. ■ performance management, both 2.104 Within the Trust there has also been little corporate and of individuals; effective performance management at corporate or regional level. Very long performance reports ■ poor change management; and have been provided to non-executives, but ■ many aspects of people management. there had been little effort to pull together key performance indicators until Mr Thayne There has been a shortage of project and Dr van Dellen produced the 2006/2007 management capacity business plan. The Trust did complete its 2.102 There have been examples of the Trust lacking Balanced Scorecard reports for the Welsh project management capacity. In particular, the Assembly Government Department for project management arrangements for a number Health and Social Services Regional Office, of failed procurements – particularly the recent but this tool was not used internally to drive ambulance procurement and North Gate PCS the service forward. The development of a computer system – fell down largely as a result small but balanced set of key performance of failures of project management, (paragraphs measures, which identify the extent to which an 2.195-2.197). In addition, executives did not have organisation is delivering its strategic objectives, the capacity to translate the strategic plans they cascaded to regional and individual level, is a had developed into operational action plans. fundamental pillar of sound management.

Performance management has been under-developed 2.105 The Trust’s performance management appears to have been fixated on the target for 2.103 The Trust has suffered from significant Category ‘A’ response times, and on achieving weaknesses in performance management, both financial balance. There has been very little corporately and at the level of individuals. There focus on measuring important components of has been no established or robust performance delivering these and other important targets management framework for individual staff, for an ambulance service, such as indicators from Board level (paragraph 2.80) downwards. of clinical performance, measures of the This relates to the lack of strategy and overall efficiency with which the Trust produced, direction. Responding to our survey, only 30 distributed and utilised ambulance unit hours per cent of staff agreed that they were given the percentage of patients transported to clear personal performance objectives, while hospital, and measures of PCS performance. 10 per cent agreed that they received regular feedback on their performance. Only 6 per 2.106 Performance information has also been weak, cent of those responding to our survey who largely because there was not a strong culture provide patient care said that they received of performance management or prioritisation regular feedback on their performance. Our of performance management information,

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4340_WAO Amb ENG_v0_14.indd 74 29/11/06 11:02:51 Case Study H: Performance management systems in other ambulance services

Staffordshire Ambulance Service has developed a real-time performance management system that enables its management to track its resources in real time and to measure efficiency very tightly. The service bases its overall budget on the efficiency with which it plans, distributes and utilises its ambulance unit hours. Sophisticated analysis of demand allows the service to predict where ambulances need to be deployed and stationed and to be able respond to small changes in external circumstances, for example roadworks.

Source: Wales Audit Office

(paragraphs 2.74-2.75). A recent consultant’s by the views of staff – only 13 per cent of staff report, commissioned by the Trust, found responding to our survey had confidence in the that ‘management have little visibility of the ability of managers to lead change successfully. performance of the service in a way that will Several staff observed that there needed to be enable the outcomes of patient care events to much better communication and information be improved’. Operational managers have had about changes that were happening. inconsistent access to performance information and have had variable levels of understanding. 2.109 Change management capacity has been a Performance information has been historical, concern of several other stakeholders and led often produced at the end of the month and Mr Thayne to bring in outside consultants to has not been in real time to enable managers to work in the Trust. Because of his concerns about manage resources proactively according to the the willingness and ability of many senior and prevailing circumstances of any particular day. middle managers to lead and deliver change, Dr van Dellen believed that he needed over a 2.107 Some ambulance services have developed dozen ‘change agents’ to join him to deliver more sophisticated performance management the extent of change required. Trust staff systems that enable close and proactive who submitted evidence to the inquiry team, management of resources (Case Study H). through interviews, public hearings, surveys, Consequently, the historical absence of focus groups and the Internet, often told us robust demand analysis, costing information about a perceived unwillingness of managers and benchmarking data has compromised and some staff to change, listen and learn. the ability of the Board to make the best use of the resources available to it and There are problems with people management to develop a culture of accountability 2.110 Effective management of people is fundamental for performance and improvement. to the delivery of an effective service business. We found problems with a number of aspects There has been poor change management of people management in the Trust, as follows: 2.108 The Trust has lacked change management skills. Before Mr Thayne’s arrival, change ■ managers generally had not been management was too slow and lacked direction. adequately trained to do their job; While Mr Thayne and Dr van Dellen were at ■ the Trust, they tried to move the organisation unclear roles and responsibilities; forward more quickly than was possible with the ■ a high and increasing incidence of disciplinary available management capacity. This is reflected cases, grievances and suspensions;

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4340_WAO Amb ENG_v0_14.indd 75 29/11/06 11:02:53 ■ weak workforce planning; and application but there is not yet a process in place to identify individuals who would most ■ high rates of staff sickness absence. benefit from this type of programme.

General management has been poor Roles, responsibilities and accountabilities are not clear

2.111 We found little evidence that local managers 2.114 We found evidence of confused roles, had been adequately developed to undertake responsibilities and accountabilities. Although their roles. The structure of the service does secondments are a legitimate tool, we not identify teams of staff with clear lines of found evidence of their widespread use, accountability, and there are various titles with unfilled substantive posts common. in use which serve to confuse even some Secondments often reduce the capacity of the long standing staff about who does what in organisation to provide front-line services. the management line. Staff development is patchy and for many non existent; there has 2.115 In addition, there are confused accountabilities. been no personal development system and Managerial and financial responsibilities are managers have not had personal objectives often different. For example, PCS staff are set for them, let alone staff more widely. managed by Locality Ambulance Officers, but financial responsibility for PCS services rests 2.112 Staff we spoke to, or who participated in our with the national and regional PCS managers. focus groups, cited a culture in which they Control staff are managed by the national are rarely praised and often blamed, with a and regional control managers, but Locality management style where managers do not often Ambulance Officers are accountable for seem to listen. Staff told us that there were no response time performance, which is heavily forums where they could discuss problems and influenced by the Trust’s four control centres. share good practice. Some staff expressed the view that if you raised issues with managers 2.116 At very senior levels, we were told that nothing ever got resolved, so they had stopped key staff had not agreed clear direction or raising issues. Among staff participating in measurable objectives for their roles, or our focus groups, ‘managing people and the been told to whom they were accountable. organisation’ was the second highest of their We also heard from a number of staff that ten priorities for improvement (Appendix 4). the lack of clear roles, responsibilities and In particular, they cited the need to improve accountabilities and reporting lines meant that management capacity and capability at all levels. they often reported to more than one person.

2.113 To address management capacity issues, the There has been an overall increase in disciplinaries, Trust established a management development grievances and suspensions over the past six years, although the Trust is unable to fully quantify them over time programme two and half years ago called ‘Leadership begins with me’. The first cohort 2.117 Many of the staff that we spoke to of 16 managers have access to the Public expressed concerns about the apparently Service Management Wales (PSMW) People high levels of grievances, disciplinaries and Exchange Programme, and a second suspensions across the Trust. These issues programme has commenced with 17 managers. are clearly related, as a grievance case could Access to the programme is by competitive subsequently result in a member of staff being disciplined and then suspended.

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4340_WAO Amb ENG_v0_14.indd 76 29/11/06 11:02:54 2.118 The Trust has been unable to provide effective and comprehensive workforce planning comprehensive data on the numbers of to identify current and future staffing levels and grievances, disciplinaries and suspensions skills needed to deliver the Trust’s strategic over time and we found evidence of regional direction/plan. Workforce planning tends to take differences in the monitoring and recording place at a corporate level, based on historical of these cases. The figures available show a patterns and has not been based around reduction in the number of suspensions to just creating new roles and anticipated future staffing three in 2005/2006. The Director of Personnel levels and skill mix requirements. The current explained that this was because she now workforce plan (2005/2006 – 2009/2010) does approved all suspensions herself. However, not include an assessment of the effects of there has been a significant increase in the modernisation, and has not yet been accepted number of grievances, from seven in 2001/2002 by the Welsh Assembly Government. to 35 in 2005/2006. The Director of Personnel told us that this illustrates a positive culture of 2.121 Agenda for Change (paragraphs 3.56-3.66), staff feeling able to raise issues. While this may has only been incorporated within the workforce be true, it has also been suggested to us that plan in relation to the impact of the reduced the high levels of grievances reflect a lack of working week and increased annual leave. For confidence in management. This could lead example, recruitment of 102 technicians was to staff taking formal action under grievance underway to meet the capacity gap likely to be and dignity at work policies to try to resolve caused by the reduction in the working week situations and ‘get their voice heard’. Use of the under Agenda for Change. We found no clear formal procedures in this way has a significant evidence to support the decision to recruit 102 resource impact, in terms of the time taken to technicians, and Alan Murray has suspended investigate and resolve issues that could have the recruitment since taking up post, although been dealt with through a more appropriate 40 technicians had already been recruited. and less resource intensive mechanism. Some managers in the regions expressed their belief that they had enough staff in their region 2.119 Information on suspensions, disciplinaries without the additional technician recruitment. and grievances has not historically been reported to the Trust Board. However, Despite some recent progress, staff sickness absence is continuing to have a significant financial impact figures for disciplinaries and grievances now form part of the Trust’s key performance Levels of staff sickness absence increased sharply indicators for 2006/2007, and there is some in 2005/2006 evidence that the Trust is now tackling this issue, as the Board’s Modernisation Plan 2.122 In The Management of Sickness Absence has an objective to reduce by 25 per cent by NHS Trusts in Wales (January 2004), the the number of formal grievances lodged. previous Auditor General reported that the Trust lost 6.8 per cent of contracted hours to Workforce planning has been weak sickness absence in 2002/2003. The Welsh Assembly Government Department for Health 2.120 The primary purpose of the workforce plans that the Trust submit annually to the Welsh Assembly and Social Services has since set a Service Government is to identify and seek funding for and Financial Framework (SaFF) target for the Trust’s education and training needs for EMS, all NHS trusts in Wales to reduce sickness PCS and control staff. We found little evidence of

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4340_WAO Amb ENG_v0_14.indd 77 29/11/06 11:02:56 absence to 4.2 per cent of contracted hours an attempt to mitigate these risks. The Trust (matching the target set by the Department has also contracted with an independent of Health for the NHS in England). counselling service which, during 2005/2006 provided direct support to 124 members of staff, 2.123 By the end of 2004/2005, the Trust had delivered training to Trust staff on bereavement succeeded in reducing its reported sickness and breaking bad news, and undertook a well absence to 5.45 per cent of contracted hours, being survey in the North Wales region. but the Trust reported a sharp increase, to 6.32 per cent of contracted hours, in 2005/2006, 2.125 There are, however, substantial differences with a particular peak in absence between in the rates of sickness absence reported January and March 2006 (Figure 26). across the three regions of the Trust, as well as between different groups of staff and localities 2.124 However, sickness absence is by no means a (Appendix 7). For the two groups of staff with problem unique to the ambulance service in the highest levels of sickness absence – control Wales, and although English ambulance trusts room staff (8.72 per cent) and those working reported an average sickness absence rate of in the Monmouthshire locality (11.05 per cent) 6.0 per cent in 2005, almost half of these trusts – sickness absence is clearly contributing reported rates higher than in Wales (Figure 27). to problems with operational performance, Higher levels of sickness absence are sometimes although it may also be symptomatic of associated with occupations that expose the pressures on staff in these areas. employees to known health risks including manual handling, violence and aggression, The Trust’s annual figures for 2005/2006 and shift-working. These issues are particularly understate the true extent of sickness absence, relevant to front-line ambulance personnel, while the suggestion that sickness absence although the Trust has invested heavily in manual rates have halved since 1999 is misinformed handling and conflict awareness training in

Figure 26: Sickness absence trend by month (any period between April 2004 and June 2006)

1 Percentage of contracted hours lost Percentage 0

Jul 04 Jul 05 Apr 04 May 04 Jun 04 Aug 04 Sep 04 Oct 04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05 May 05 Jun 05 Aug 05 Sep 05 Oct 05 Nov 05 Dec 05 Jan 06 Feb 06 Mar 06 Apr 06 May 06 Jun 06

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 78 29/11/06 11:02:57 Figure 27: Sickness total for 2005/2006 compared with other English ambulance trusts

7 WAST 6

Percentage of contracted hours Percentage 1

Note: The English figures relate to the 2005 calendar year, while the the Trust figures relate to the 2005/2006 financial year.

Source: Wales Audit Office

2.126 As in many organisations, managers and HR 2.128 Trust-wide trends in sickness absence were staff acknowledged that there was likely to be presented in a report to the Trust’s HR some under-recording of sickness absence, Committee in May 2006. Despite the increase despite efforts to consolidate common in sickness absence during 2005/2006, this reporting systems across the three regions report stated that sickness levels had halved of the Trust. In time, the new NHS Electronic since 1999/2000. We found no evidence to Staff Record should eliminate the current support this claim which was based on a reliance on a paper based reporting system comparison with the rate of 13.2 days per which, given the geographical spread of staff, person identified in a District Audit report from is likely to contribute to recording errors. October 2001. This figure is not comparable with the percentage of contracted hours lost 2.127 We did not examine the accuracy of individuals’ definition which is now used by the ambulance sickness absence records but we did identify service, in common with the other NHS trusts an anomaly in the way in which the Trust’s in Wales to measure sickness absence rates. annual sickness absence rate for 2005/2006 was calculated, which excluded staff who had The costs of staff sickness absence are likely left the Trust’s payroll during the period. This to increase as a result of Agenda for Change included several staff who had been on long- term sickness absence for much of the year. 2.129 The Trust has valued the direct cost of Taking those cases into account and, based salaries paid to staff while off sick as £3.9m on the average sickness absence rate reported in 2005/2006. However, the true cost to the for each month in 2005/2006, it is likely that Trust is much greater because of the need to the Trust’s overall sickness absence rate was replace staff to provide adequate levels of cover, nearer to 6.7 per cent of contracted hours. particularly in front-line services, as well as the

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4340_WAO Amb ENG_v0_14.indd 79 29/11/06 11:03:00 management and administrative time required report three or more separate absences, or to deal with sickness absence and manage its 12 working days of absence in any 12-month impact. These replacement staff costs are likely period. In respect of the first of these two to increase as a result of Agenda for Change, with triggers, this applied to a total of 653 staff in the Trust now required to pay overtime at a rate the 12-month period from 1 April 2005 to 31 of time and a half, rather than at the normal daily March 2006, although an almost equal number rate. And change can be stressful for some staff, of staff (658) reported no sickness absence. and may increase the risk of sickness absence. 2.132 However, the sickness absence report There is a particular problem with long-term presented to the HR Committee in May 2006 sickness absence acknowledged that there were ongoing problems with the application of these procedures, with 2.130 In the sickness absence figures presented managers concerned about the apparent to the HR Committee in May 2006, the Trust complexity of the policy, while a report to the reported that 11 per cent of sickness absence Trust Board in January 2006 reported that cases were attributed to long term absence managers were finding it difficult to make the in 2005/2006 (defined as absences of 28 time to carry out these procedures. In addition, calendar days or more). However, this statistic some of the HR managers that we spoke to does not reflect the true impact of long term recognised that the HR team had perhaps lost sickness absence, which accounted for 39,520 some of its own focus on this issue because (68 per cent) of the 57,810 calendar days lost of other competing pressures on their time, to sickness absence over the same period. notably the delivery of Agenda for Change and Overall, 451 staff reported at least one period the NHS Electronic Staff Record System. of long term sickness absence in 2005/2006 which, even accounting for staff turnover, 2.133 There are also ongoing problems in obtaining equates to around one in six staff. Some long appointments for occupational health referrals, term sickness absence is, of course, inevitable. which are contracted out to other NHS trust For example, 12 per cent of the long term providers across Wales. These problems with sickness absence reported in 2005/2006 occupational health provision are, again, not was attributed to post operation recovery. necessarily unique to the Trust and may reflect the problems reported by the previous Auditor Core policies and procedures for General in 2004 in relation to all NHS Trusts in managing sickness absence are broadly Wales. We also received correspondence from in line with good practice, but there the Welsh branch of the Association of NHS are problems with implementation Occupational Physicians (ANHOPS), which includes representatives from eight of the Welsh 2.131 The Trust has, over the past three years, NHS trusts that provide occupational health reviewed its sickness absence policies and services to the Trust. This correspondence procedures and these contain many of the raised concerns from the perspective of the basic features of good practice. This includes service providers about: the apparent lack a requirement for return to work interviews of up to date and consistent service level after all periods of absence, and trigger points agreements between the Trust and the other for management intervention in response to NHS Trust providers; variations in the financial frequent short-term absence. These trigger arrangements for providing these services; points are intended to pick up on staff who inconsistencies in pre-employment screening,

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4340_WAO Amb ENG_v0_14.indd 80 29/11/06 11:03:01 particularly for existing staff who change roles; Processes are badly designed and managed and problems in communication between ANHOPS members and Trust managers. 2.134 We have examined the Trust’s operational There is also anecdotal evidence to suggest processes and have found evidence of that return to work recommendations made by bad design and management in each occupational health providers were not always of the four key areas, namely: followed. The Welsh Assembly Government will shortly be issuing updated advice on ■ emergency services – services are not health clearance for NHS staff, as well as new systematically matched to demand; standards for occupational health provision. ■ control rooms – inconsistent processes These developments provide an opportunity leading to poor performance; for the Trust to revisit the way in which occupational health services are provided. ■ Patient Care Service – weak or non-existent processes; and

Figure 28: Supply and demand influences the provision of ambulance services

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 81 29/11/06 11:03:20 ■ clinical governance – not integrated 2.137 We examined a demand analysis conducted into managerial processes. by Alan Murray since his arrival in Wales. Although the Trust is unable to count by hour Ambulance services are regularly supplied at times of the week the number of ‘lost hours’ through and in places where they are not needed and meetings, sickness, vehicle failures and other regularly not supplied when and where they are reasons, the analysis compared the number of rostered hours (planned hours rather than the The deployment of available resources does not optimally match demand number of hours actually delivered) with peaks of average demand for ambulances every hour 2.135 There is significant public concern about whether of the week, based on an analysis of historical there are sufficient ambulances – vehicles and patterns of demand. Figure 29 shows that Mr crews – to meet demand, both across Wales Murray’s analysis suggests that Wales has a and in particular localities. Long response times much higher weekly supply of rostered hours for emergency calls compound such concerns. than it needs to meet average peaks of demand. Figure 28 explains the factors that influence demand for ambulance services and their supply. 2.138 The position shown in Figure 29 is complicated by the inability of the Trust to measure accurately 2.136 The efficient use of ambulance resources the planned hours that it ‘loses’. Alan Murray requires sophisticated analysis of demand, has done some initial work which has led to temporally and geographically, to enable an estimate that the Trust produces around services to predict how many ambulances 80 per cent of its planned hours. Removing and other forms of response they need at 20 per cent of the rostered hours from the different times of the day and in different places. figures shown in Figure 29 still leaves a healthy Historically, the Trust has not conducted such surplus of hours supplied. The Trust’s inability analysis. Mr Thayne’s original benchmarking to meet response time targets suggests that the report first raised awareness of some of the available hours are not distributed to the right techniques that could be used to examine places, scheduled at times of peak demand demand and supply of ambulance services to or that hours are lost at peak times. The optimise their use to improve services. His initial Trust also loses time due to long turnaround benchmarking report suggested inefficiency times at hospitals, (paragraphs 3.15-3.20). in the way the Trust deployed and used its ambulances in comparison with Staffordshire.

Figure 29: Weekly rostered hours are significantly higher than predicted demand

Central South-east and west North TOTAL Rostered hours 9,647 5,054 5,354 20,055 Required hours 4,261 2,474 2,321 9,056 Difference 5,386 2,580 3,033 10,999 Percentage of rostered hours required 56% 51% 57% 55%

Source: Wales Audit Office, based on the Trust’s demand analysis

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4340_WAO Amb ENG_v0_14.indd 82 29/11/06 11:03:20 2.139 Mr Murray’s recent analysis suggests that dietary needs that require them to return to the configuration of shift patterns does not base; the Trust is currently negotiating the optimise the supply of resources at times of status of meal breaks within the Agenda for peak average demand. Although there are Change agreement, as the current policy of enough hours of supply in total, these are not including meal breaks within the 37.5 hour configured to meet peaks of demand. At times working week is non-compliant with the of low demand, there tends to be too much national agreement (paragraph 3.66); and supply, and at times of peak demand, there is often insufficient supply, which leads to chronic c long travelling times at the end of shifts, pressure on crews and control rooms, as well especially in rural areas or where crews as other emergency services, (paragraphs have been significantly displaced from their 1.26-1.28), and unacceptably long response base, can lead to it being impractical to times. The Trust generally operates traditional 12 deploy certain crews very late in their shifts. hour shifts which, under the 37.5 hour working week under Agenda for Change, can mean 2.141 There are also problems matching supply and that staff work only three shifts each week. If demand in PCS, although the extremely poor shifts generally start at similar times, the Trust management information makes it difficult to can over-resource the quieter times of the day quantify. In most parts of Wales, PCS operates (usually the early morning) before the peak generally between the hours of 8:30 and 16:30 demand kicks in (usually during the afternoon on weekdays, whereas hospitals are providing and early evening, rising again towards midnight. services at a wider range of times, particularly as day surgery becomes increasingly prevalent. 2.140 Other factors also compromise the Consequently, patient transport services may supply of ambulances at key times: not optimally meet the needs of patients and their hospitals, and could lead to other Trusts a crews are responsible for checking their incurring unnecessary expenditure on taxis, or vehicles at the start of a shift; this can the Trust providing an expensive emergency often take forty minutes or more; other vehicle, during the hours when PCS services Trusts operate ‘Make Ready’ systems are not available. In North Wales, PCS staff where vehicles are fully prepared by work until midnight in Wrexham, with the specialist teams, with associated infection longer hours of service helping to accelerate control benefits, so that crews are discharge, save bed costs and providing available from the start of their shifts; much cheaper routine transport than EMS.

b meal breaks can reduce cover – crews The significant use of overtime suggests that the receive an undisturbed meal break after six Trust has not matched supply and demand hours of a shift; in some areas of Wales, 2.142 Overtime is an important part of providing controls do not disturb crews during meal adequate cover but is also an indicator of breaks, even if there is a 999 call; we heard whether the Trust has adequately matched that some crews return to their base station supply and demand. We analysed the use for the meal break, often involving a long of overtime and its management at the drive, on the basis that they cannot carry Trust during the 2005/2006 and found food on the ambulance, have no money that overtime at the Trust is significant. In on them while on duty, or have special 2005/2006 Trust staff worked 384,300 hours

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4340_WAO Amb ENG_v0_14.indd 83 29/11/06 11:03:23 overtime. This is equivalent to 3 hours a There are weaknesses in the week for every member of staff. However, management of control 25 per cent of Trust staff received no overtime payment during 2005/2006. The controls do not operate consistent processes 2.147 Ambulance controls play a pivotal role in the 2.143 A small number of staff worked very significant effective deployment of ambulances and amounts of overtime. Fourteen members ensuring appropriate responses to calls. They of staff worked over 1,000 hours overtime also deal with people in the stressful position of in 2005/2006. After annual leave, this is making a 999 call. Their main functions are to: equivalent to these staff working, on average, more than 21 hours’ overtime each week. One a take details of the caller’s name, the member of staff worked almost 1,400 hours’ location and the nature of the problem; overtime, an average of almost 30 hours per week. Such levels of overtime raise significant b decide on the category of call; health and safety issues as well as issues of compliance with the European Working c despatch the most appropriate Time Directive. It also supports the anecdotal vehicle or person to send to evidence that processes for allocating available respond to the incident; and overtime have been poorly managed. d monitor progress in responding to the call.

2.144 There are also geographical differentials in the 2.148 Since 1998, the Trust has reduced the distribution of overtime. Many of the highest number of controls from nine to four, with overtime earners are clustered in South East the fourth – Church Village – scheduled to Wales, particularly the Gwent area. This close but without a firm date. We found is an area of high demand and problems that there were inconsistent processes meeting performance standards. There are between the four controls. There are also smaller clusters around other geographical complications when crews and vehicles locations, such as Carmarthenshire. There move between the boundaries of areas is an inconsistent spread of overtime covered by the various controls. between geographical areas.

2.149 We found no evidence of regular contact 2.145 We were told in interviews that overtime working between the controls to share ideas and is the key driver of travel expenses but this was good practice, which is compounded by not supported by the evidence. Of the top 20 a lack of performance information about expense claimants, 10 worked no overtime. call cycles and the time taken to answer the call once the telephone rang. 2.146 Further, our analysis does not support the theory that overtime was used at the 2.150 We also found that the use of standby and year-end to improve performance against preferred response points (locating vehicles targets in 2005/2006. The March overtime where demand is most likely to occur) was not payments were less than one twelfth of in consistent use. Revised deployment plans that for the annual total overtime. based around locating vehicles at locations that maximise the prospects of meeting predicted demand, rather than in ambulance stations,

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4340_WAO Amb ENG_v0_14.indd 84 29/11/06 11:03:23 were introduced by Dr van Dellen but do not c data systems to send details of calls appear to have been implemented consistently, directly to ambulance vehicles are not particularly in the South-East region where the consistently available, which means that plan was amended because of concerns about details have to be passed via speech its effectiveness and some resistance to change. radio or personal mobile phones; once the details have been communicated, The performance of controls is hampered by the the lack of satellite navigation on vehicles lack of ICT can compromise the efficiency of control 2.151 The performance of controls is hampered because staff sometimes have to assist by the lack of modern information and crews to locate the incident; and communications technology. The following weaknesses are particularly significant: d four gazetteers are in use to identify locations; the fact that there are four a Automatic Vehicle Locating systems (AVLS) different gazetteers causes problems with are not available in all parts of Wales, the data in control because hospitals have which means that control staff, who are different names on the various gazetteers often responsible for 20 or more vehicles, and do not recognise all postcodes, which do not have visual confirmation of the requires retrospective sanitisation of data exact location of vehicles, (paragraph to ensure that calls are allocated to the 2.194), and are unable to locate Rapid correct hospital and LHB area; the systems Response Vehicles on the same screen in use are inconsistent, incompatible with as ambulances; Case Study I shows the each other and together do not comply problems that the lack of AVLS can cause; with the British Standard BS7666 that specifies a standard format for holding b radio communication with ambulances is details on every property and street. of variable quality with some staff using their own personal mobile telephones as a means of communication with control;

Case study I: Problems caused by poor technology in controls

During a visit to a Welsh control room, we observed an incident where an ambulance crew appeared to have been dealing with an emergency call for an unusually long time. Following further enquiries, we found that the crew was clear at the A&E department and, without reference to the control room, had returned to their base station with a journey time of between 20 and 30 minutes, instead of notifying control that they were clear. Radio cover is poor in this area – where crews cannot contact control by radio, the procedure is to call from a telephone in A&E. During the hour or so that had passed since the crew left the hospital without the control’s permission, control had difficulty in sending resources to a serious road traffic accident on the M4, as well as two further 999 calls. Staff in the various controls told us that some crews “regularly” return to base stations without permission, which causes significant problems. On returning to stations crews who are due a meal break should start that break after 15 minutes. In this case the crew did not do so, which further compromised capacity as a result of poor information systems to locate and track resources.

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 85 29/11/06 11:03:26 There is poor morale and management in controls 2.154 The physical environment in control rooms is very poor. This is especially 2.152 Sickness levels in control are high, and staff have expressed concern about stress arising the case in Mamhilad where working from shortages of operational and control room conditions are dark, cluttered and dirty. resources, and a perception of bullying. In the 2.155 Control room staff have also expressed case of the control rooms, these staff accounted concerns about the adequacy of their training. for 22 per cent of all stress/psychological The highest proportion of any group responding related absence reported across the Trust to our survey – 31 per cent – disagreed that during 2005/2006, and yet they account for less they had been adequately trained to do their job. than 10 per cent of the total Trust workforce. All EMS call takers are accredited emergency We heard concerns about morale from staff call takers using the Trust’s Advanced Medical working both on EMS and PCS control. Priority Dispatch System (AMPDS) but we found examples of accreditation having lapsed 2.153 In our survey, job satisfaction was lowest among control room staff, where dissatisfaction with because of disciplinary incidents and a lapsed their job ran at 44 per cent. We also found that qualification requiring reaccreditation. only 31 per cent of control room staff responding There are indicators that control could to our survey felt that they would be supported operate more effectively by their manager if they had a problem. 2.156 We found that the components of the call cycle indicators (Figure 30) do not comply with known best practice of completing

Figure 30: Components of ambulance incident service times

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 86 29/11/06 11:03:38 the call cycle within 30 seconds in 95 per PCS processes are weak and inconsistent cent of cases. The call cycle times in Welsh controls are significantly lower at the 95th 2.159 There are weaknesses in PCS services across percentile than benchmark figures. Wales, that stem largely from weak and inconsistent systems. Five different systems There is a lack of clarity about the future of sharing exist in the predecessor ambulance trust joint controls with other emergency services areas, none of which is fit for purpose. This is 2.157 One Trust control is co-located with the police exacerbated by the lack of a control system, and fire control in Carmarthen. Although located which compromises planning, the efficient on the same site, it is not a genuinely shared use of resources and ultimately performance control operating joint systems with co-located monitoring and service development. There control staff because the three services operate is no costing information about the individual separate controls on the same site. There was contracts let with the 13 acute trusts and Powys a proposal to co-locate controls in North Wales LHB. This means that the Trust does not know but this proposal did not proceed because which contracts are profitable and which make the Trust Board was not convinced of the a loss, individually or collectively, and there are benefits of the initiative and its fit with DECS. currently no common standards or contracts.

2.158 The new Chief Executive has stated publicly 2.160 HIW reviewers informed us that PCS service his agreement with the concept of shared quality is extremely variable across Wales. controls. The Joint Emergency Services This results from poor planning, vehicles and Group’s submission to the Auditor General staff availability. HIW told us that PCS vehicles also strongly advocates the development were old and uncomfortable. Crews receive of genuinely shared controls. They see lists of patients at the start of the day but significant economies of scale and spreading there is significant duplication, for example of good practice in the spirit of Making the different crews being sent to the same street Connections. They also see opportunities or engaging in ‘double runs’. HIW told us that to build on existing close and productive the service runs well in the morning but plans working relationships between the ambulance fall into abeyance after midday because of service and other emergency services, and the unpredictability of outpatient clinics. This the scope to improve significantly responses may not be uncommon among ambulance to major incidents. Joint control rooms are services, but the poor planning means that the norm in the USA, but the Welsh Assembly there is little scope to adapt to inherent Government, which is currently evaluating the uncertainties, and crews can end up thinly scope for shared controls, and ambulance stretched and struggling to get a lunch break. service may wish to pursue a different policy direction by aligning the ambulance service 2.161 There is little evidence that the Trust has more closely with other clinical, rather than prioritised PCS because of its focus on EMS emergency, services, particularly through the performance targets. General management proposed merger with NHS Direct and closer capacity problems within the Trust have working with GP out-of-hours services. exacerbated this lack of focus and PCS is seen very much as the ‘Cinderella’ service. Usually managed by EMS staff, PCS staff feel very much the poor relation and many believe that

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4340_WAO Amb ENG_v0_14.indd 87 29/11/06 11:03:40 there is no longer a route from PCS to EMS. Trust checks only 6 per cent of invoices from This has resulted in a poor service, with eligibility volunteers and taxis before payment despite criteria inconsistently applied and acute Trusts past audit evidence of abuse of the system. The telling us about patients often arriving late for new scheduling system will make payments to appointments or the failure of PCS ambulances taxis and volunteers on the basis of bookings to arrive delaying patients’ discharge. and standard mileages, thereby providing a much more robust check on payments 2.162 There have also been a small number of adverse after the system is introduced in April 2007. incidents involving patients being transported Black cabs are used exclusively in the Cardiff to the wrong address and, in one tragic case, area. Two companies provide these services. a patient dying after being left at the wrong Unlike taxis used in other parts of Wales, they address. The Trust was fined £20,000 in respect are paid at their normal hire rates. The two of that incident. The Trust has introduced new companies used were selected some years procedures but HIW have told us that they are ago on the basis of being able to cope with the unable to give an unqualified assurance that anticipated volume of work and no competitive such an incident could not happen again. This is tenders were invited. The use of black cabs because their reviewers did not find a common is reducing, and it is intended to replace them understanding of the new procedures, and largely with in-house provision. However, had differing willingness to use the tags now if their use remains significant, competitive introduced to track individual patients. There tenders should be obtained for the service. is also inconsistency in how crews record their day which means that there are weaknesses Clinical governance has developed but is not in the audit trail, which could affect the Trust’s an integral part of managerial processes ability to avoid a further adverse incident. 2.165 Full details on clinical governance will be 2.163 In addition to services provided by Trust available in HIW’s forthcoming clinical employees, PCS also provides services through governance review of the Trust. some 350 volunteer drivers and taxi firms. They are generally paid at a rate of 34p per mile 2.166 The Commission for Health Improvement (CHI) (although there remain some local variances). published a report in 2003 that criticised clinical Total expenditure on PCS in 2005/2006 was governance in the Trust. In responding to that £4.2m. The Trust has very little management report, the Trust developed clinical governance and costing information on the service. For systems and structures, but HIW reviewers example, no information is available on whether told us that these had been suspended during the costs of service level agreements with Mr Thayne’s period as interim Chief Executive. specific trusts are being recovered from the Mr Thayne informed us that he had sought to respective contracts. However, a specification refocus clinical governance on collecting better is currently being compiled for a computerised clinical data. Recent changes have seen non- scheduling system, which will also provide executives join the Clinical Governance and effective management and costing information. Risk committees. Following the CHI review, clinical operations managers were established 2.164 It is particularly important to have robust in each of the three regions to champion controls of expenditure on the voluntary car clinical audit and Public Patient Involvement. service and taxi suppliers of PCS services. The However, the HIW review found evidence that:

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4340_WAO Amb ENG_v0_14.indd 88 29/11/06 11:03:41 ■ clinical governance structures were not in some of the situations the Trust faces. integral aspects of management processes, It has developed some alternative models partly because staff lacked training and of service but on a small scale so far; awareness in clinical governance and line managers did not take responsibility ■ the Trust’s physical and ICT infrastructure for clinical governance matters; and is a constraint on its ability to deliver an acceptable standard of service; and ■ patient and public involvement is not well-developed although there are CHC ■ procurement of new systems and representatives on the Trust Board, and infrastructure has been beset by problems. on the Patient and Public Involvement and Clinical Governance Committees. There has been some development of alternative models of service 2.167 Clinical audit has developed because of Community responders have been developed the efforts of the clinical audit manager but could be utilised more effectively with and individual enthusiasts but there are few greater clarity of roles and responsibilities supporting structures. Data is input manually, 2.169 The use of community responders to provide with insufficient resource and several different an initial response to emergency incidents has systems. HIW told us that the overall culture delivered a number of benefits to patients. of the Trust is not conducive to clinical audit Where there is appropriate training, supervision but there is some good practice on which the and clinical governance, there can be particular Trust can build further progress as follows: benefits in rural areas, where community ■ the Trust carried out an audit in Cardiff and responders can often reach those in their Vale NHS Trust to examine the consequences communities much more quickly than an of changes in women’s services; and ambulance to administer defibrillators or other lifesaving techniques. Community responders are ■ the clinical audit department provided people, based in local communities, who have a training course for clinical operations been trained in basic lifesaving techniques who managers which involved them carrying can provide an initial response to an incident out a practical clinical audit. while awaiting a fully equipped ambulance. First responders are often employees of other The Trust has poor systems and infrastructure emergency and public services, others with clinical training or members of the public. 2.168 The Trust delivers its services by managing staff who work within a context of systems 2.170 Figure 31 shows the number of community and infrastructure. In addition to the responder schemes, trained community weaknesses described above in strategic responders and the number of incidents they direction and operational management, we attended in 2005/2006 and the percentage of found that the systems and infrastructure the total emergencies that these represented. themselves present problems, as follows: 2.171 While some members of the public attending our ■ the Trust has generally operated a single hearings expressed concern about the use of model of service when there is evidence community responders, community responders that alternative models bring advantages are recognised as a valuable source of lifesaving

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4340_WAO Amb ENG_v0_14.indd 89 29/11/06 11:03:43 Figure 31: The Trust has developed community first responder schemes

Region Number of Number of Number of Percentage of schemes responders incidents all emergency attended in calls 2005/2006 South east 51 558 543 0.21% Central and west 38 769 1,897 0.55% North 17 187 348 0.22% WALES 106 1,514 2,788 0.37%

Source: Wales Audit Office

capacity working in tandem with fully crewed to those suffering heart attacks and provide ambulances. We also heard concerns from cover from volunteers at major events. St trained community responders that their capacity John Cymru Wales volunteers have also had not been utilised as effectively as they could provided occasional ambulance cover at times have been by the ambulance service in Wales. of significant pressure in parts of Wales. In particular, they believed that there was scope to improve advanced training and understanding Rapid response vehicles have been developed in some areas of community responder schemes within ambulance controls, by improving significantly 2.173 The Trust has developed new models of service, the clarity about the roles and responsibilities including rapid response vehicles. There are of community responders within the overall now 1,280 hours each week of cover from rapid clinical service provided to patients. One clear response or other intermediate tier vehicles in challenge with the community responder Wales, provided by 39 rapid response vehicles. scheme is to ensure robust clinical governance, Rapid response vehicles represent 11 per ongoing training and supervision. The draft cent of the Trust’s fleet, but their effectiveness modernisation plan includes an objective is compromised by the fact that controls to develop a strategic approach to the cannot locate them in the same way as they development and deployment of community can traditional double-crewed ambulances. responders, supported by a series of targets for community responders in respect of Category Infrastructure and equipment are a major constraint ‘A’ responses within 8 minutes. This reflects the Stakeholders believed that poor infrastructure importance of the targeted use of community and equipment were a significant problem responders in East Anglia (see Case Study C). 2.174 Our analysis of the results of staff focus groups St John Cymru Wales volunteers contribute to capacity showed that their main priority for improvement was ‘being properly equipped to do the job’ 2.172 Volunteers from St John Cymru Wales provide (Appendix 4). This included having sufficient support for the Trust at very busy times of vehicles that are fit for purpose, equipment the year or at times of peak demand. They and the effective management of assets act as first responders providing defibrillation

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4340_WAO Amb ENG_v0_14.indd 90 29/11/06 11:03:44 to get the most out of what is available. It 2.176 In 2004, the Trust commissioned an estates also includes issues around ICT. The quality condition survey which indicated that over of infrastructure and equipment was also one third of the estate was in a sub-standard a consistent theme at our public hearings physical condition – status C and D (Figure 32). and in the written submissions we received. This is not a new problem – in 2001, the Trust’s There was real concern about vehicles that original estates strategy noted that a substantial were not fit for purpose, the condition of proportion of the estate inherited upon creation the Trust’s estate and ICT facilities. Such of the Trust was of poor quality. To a large concerns about infrastructure and equipment extent, the condition of the estate reflects the clearly affect the confidence of staff and the age of buildings and, at the end of 2004/2005, public in the ambulance service in Wales. information supplied by the Trust to Welsh Health Estates showed that 50 per cent of the estate The Trust is trying to address its dated from before 1965, with 14 per cent dating longstanding problem with estates from before 1948. The one-off cost of bringing Problems caused by the age and condition of the estate up to an acceptable standard, i.e. the estate have not been fully resolved, resulting condition A or B, was estimated by the Trust to in action by the Health and Safety Executive be almost £1.9 m, although estates staff have 2.175 As at September 2006, the Trust occupied suggested that this may not fully reflect the true 99 buildings, 64 owned and 35 leased across cost to deliver the required improvement in the Wales. This overall number of properties estate, which they estimate will be as much as, if is largely unchanged since the creation of not more than, the cost of backlog maintenance. the Trust in 1998, although there has been a reduction in the number of control centre 2.177 The sub-standard condition of the estate resulted locations, from nine to four, investment in a in the Health and Safety Executive (HSE) issuing new National Training College for Wales and an Improvement Notice on the Trust’s estate, in provision of a number of new or significantly 2003. Although some progress has been made refurbished ambulance stations, such as those to address the initial concerns raised by the at Barmouth, Chepstow and Milford Haven. In HSE in respect of 40 properties, there are still addition, the Trust has occupation or use of 19 properties that are the subject of this notice 77 radio mast sites, both leased and owned. and the Trust has until March 2007 to address

Figure 32: Condition of the Trust estate

Category Description Percentage of estate Condition A The asset is as new and can be expected to perform adequately to its full 42 per cent normal life Condition B The asset is sound, operationally safe and exhibits only minor deterioration 23 per cent Condition C The asset is operational but major repair or replacement is currently needed to 7 per cent bring up to condition B Condition D The asset is operationally unsound and in imminent danger of breakdown. 28 per cent

Source: Tribal Secta, Review of the Welsh Ambulance Services Trust Operational Estate, Interim Report, March 2006

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4340_WAO Amb ENG_v0_14.indd 91 29/11/06 11:03:46 these issues. After this time it is likely that the Notice. Tenders for the works to be carried out HSE will take further action, having already using the Major Risk Framework funding were extended the Improvement Notice on three issued in early October 2006. Although the Trust occasions. This action could include the serving has a clear responsibility to address the issues of prohibition notices, prosecution or fines. raised by the HSE, it is possible that some of this money will be spent improving properties The Trust has secured £1 million external funding to that are subsequently deemed surplus to the address major risks in its property portfolio, although Trust’s requirements, as it finalises the details of there is the possibility that some of this money will be spent at sites that do not have a long-term future its modernisation plan and new estates strategy.

2.178 In December 2005, Welsh Health Estates The Trust has lacked capacity in its confirmed that the Trust had been successful estates management function

in three bids submitted under the terms of the 2.180 Historically, the Trust’s estates department Welsh Assembly Government Department has consisted of an estates manager and for Health and Social Services Major Risk assistant estates manager, reporting to the Framework. These bids represented a total then Director of Operations. Both the estates funding package of £977,077 and provide for manager and his assistant left the Trust in improvements at 14 ambulance station sites 2005/2006, to be replaced by a new estates relating to the physical condition of the buildings, manager and a member of staff who is engineering services (such as electrical and supporting him on a temporary basis. The Trust mechanical installations) and improvements does not directly employ any maintenance to accommodation to comply with statutory staff, with these services provided by external legislation (such as the lack of inclusive facilities contractors, including other NHS trusts, for female and male staff and provision of although the new estates manager told us adequate infection control). The Trust is that this presented logistical problems in contributing a further £51,424 to the project. arranging for any works to be undertaken. The Trust has also committed an additional £300,000 from its own discretionary capital 2.181 As part of the fieldwork for our examination of to carry out peripheral works at these and a NHS Energy Management in Wales (published further five properties which are the subject of December 2005), the previous estates staff the HSE’s Improvement Notice. In addition to raised concerns about their ability to provide the works planned for these 19 properties, the sufficient coverage of estates issues across Trust is putting in place alternative operational the whole of the estate, complicated by the arrangements through collaborative working sheer numbers of buildings and their spread with other emergency service providers which across Wales. This lack of capacity meant will enable nine obsolete (in terms of age and that broader aspects of estates management, fitness for purpose, and being beyond economic such as the monitoring and management repair) ambulance station buildings to be closed. of energy consumption (the Trust spent approximately £450,000 on energy for its 2.179 The Trust’s estates manager explained to us buildings in 2005/2006) and the development that his current priority is to ensure that these and implementation of an environmental works are undertaken as swiftly as possible, management system in line with the requirement and at least before March 2007, to address the of Welsh Health Circular (2002) 116, had not timetable required by the HSE’s Improvement been addressed in any meaningful way.

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4340_WAO Amb ENG_v0_14.indd 92 29/11/06 11:03:47 2.182 The new Head of Estates recognised ■ improve the overall condition of the estate these pressures and, in the case of energy by addressing the current facility constraints management, was confident that he could and provide a working environment deliver significant savings in expenditure if he for staff that is fit for purpose; and had the time to commit to this issue, but that the immediate priority was the development of ■ improve the cost effectiveness of the the future estates strategy and addressing the estate allowing revenue to be released. HSE Improvement Notice. Nevertheless, the Carbon Trust is in the process of undertaking 2.185 This work, originally commissioned in 2005 energy surveys at a number of Trust sites concluded that, “there is little doubt that a with a view to bidding for resources from the programme of estate rationalisation is required £3.5 m energy efficiency fund established by to support the delivery of a modern fit for the Welsh Assembly Government Department purpose service”. However, this message for Health and Social Services. However, is not particularly new, as in April 2001 the decisions on the viability of any significant ORH report identified 90 optimum locations energy saving measures will have to take from which to improve response times, account of the development of the new of which only 12 coincided with existing estates strategy, and the extent to which any ambulance station sites. Although the Trust’s measures will provide significant benefits within original estates strategy in 2001 put forward the useful life of the buildings concerned. 28 stations for relocation, drawing on the recommendations of the ORH report, it is The make-up of the Trust’s estate has clear that limited progress was subsequently not been driven by business need made to convert these proposals into firm action. For example, the ambulance station 2.183 It is difficult to compare the Trust’s estates revenue and capital costs with those of and workshops in Dolgellau were recognised other ambulance trusts on a reliable basis. in 2001 to be in dire need of replacement for However, based on the current condition of reasons of building conditions and health and many of the Trust’s properties, and the very safety. Yet it has since taken some five years existence of the HSE notice, it is clear that for the future of this station to be resolved there has been insufficient expenditure to (the station being closed with staff moving to bring buildings up to the required standard. share facilities locally with the fire service). There are serious fleet problems 2.184 More importantly, there has been insufficient ‘strategic’ investment in the estate, aligned 2.186 The Trust’s fleet is composed of 656 vehicles, to wider modernisation of the service. In including 231 emergency ambulances, 42 rapid March 2006, the Trust received an interim response vehicles, 239 PCS ambulances, report from external consultants (Tribal Secta) 64 non ambulance transport service vehicles following their review of the Trust’s operational and 80 other vehicles. The Trust owns 289, estate. The rationale for this review was 44 per cent, of its vehicles, and leases the described as being based on the need to: other 56 per cent. The Trust spent £6.5m on fleet services in 2005/2006. It operates four ■ deliver service modernisation in a manner in-house workshops, two in North Wales and that ensures sustainable improvement in the delivery of operational performance targets;

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4340_WAO Amb ENG_v0_14.indd 93 29/11/06 11:03:50 Figure 33: Critical vehicle failure rate, April 2006

South East Central and North Wales West Wales Wales Total EMS 8% 8% 7% 8% PCS 6% 12% 7% 8% Total 7% 10% 7% 8%

Source: Welsh Ambulance Services NHS Trust data

two in the South East. Vehicle maintenance 2.189 There has been a problem with management in the central and west region takes place capacity for fleet due to the long-term absence through a number of third party workshops. of the fleet manager. Temporary support from Mersey Regional Ambulance Service 2.187 The average age of the fleet is 7 years, but helped to fill this gap but the Trust appointed the condition of vehicles remains a concern. a full-time fleet manager in September 2006, Figure 33 shows that in April 2006 the Trust who will develop a fleet strategy to support lost around 8 per cent of available fleet the overall modernisation plan for the Trust. hours through critical vehicle failures. A key issue will be to provide sufficient fleet cover to enable vehicles, services 2.188 One of the key issues with the Trust’s fleet is and cover to be properly maintained. that the recent procurement of 46 ambulances that were not fully fit for purpose and the JAKAB 2.190 The Trust has a computerised fleet management procurement which also failed to deliver fully system with the capability to provide a control useable ambulances, (Case Study J). The system for vehicle workshops. Although Trust is operating a seven year depreciation there are plans to upgrade the system and cycle, yet 43 per cent of its EMS ambulances roll out its usage across the Trust, currently are older than their replacement age of five the system only works in one of the North years. In total, 30 per cent of the entire fleet is Wales workshops due to networking and older than its replacement age (Figure 34). This training limitations. Without access to the is compounded by the procurement failures system and trained users, compounded by around the fleet, and short-term maintenance the long-term absence of the fleet manager, – in the course of our fieldwork we observed the Trust has been unable to produce useful the use of ‘gaffer tape’ to make temporary fleet information to benchmark costs internally repairs to enable vehicles to stay on the road. and externally to ensure that the current HIW reviewers also identified problems with arrangements are delivering value for money. the PCS fleet, which they told us was old and uncomfortable. In October 2006, the 2.191 There are a number of different arrangements Welsh Assembly Government announced in place for maintenance. Owned and leased funding of £16m to purchase an additional 119 vehicles are maintained in house or by third emergency ambulances and 67 PCS vehicles. party garages, some costs are met by the Trust and some are the responsibility of the

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4340_WAO Amb ENG_v0_14.indd 94 29/11/06 11:03:50 Figure 34: Summary of fleet age

Vehicle Type Total vehicles Number of % of vehicles currently in vehicles in use use older than older than replacement replacement life life EMS 231 100 43 PCS 239 39 16 Specialist 55 18 33 Non-ambulance transport services and Health Courier Services 64 14 22 Rapid Response Vehicles 42 8 19 Paediatric 1 0 0 Grade 3 intermediate tier 24 19 79 Total 656 198 30

Source: Wales Audit Office

lease company. Trust officers stated that during their shifts, rather than them spending there was significant scope for a review of time preparing vehicles. This system, which the value for money achieved by the range is already in use in some other ambulance of arrangements in place. Front-line crews services, merits consideration by the Trust provided anecdotal evidence of significant within the context of its new fleet and estates lost time driving to workshops or waiting for strategy, and the wider modernisation plan. travelling mechanics to repair or service vehicles, There are also other developments elsewhere contributing to the loss of planned unit hours. which the Trust should consider – the Scottish Ambulance Service is developing proposals 2.192 Management control of maintenance work to operate joint fleet services with other undertaken in third party workshops has public services, particularly by rationalising been poor. As an example, records to transport arrangements with local authorities. confirm that vehicle maintenance has been undertaken have not been provided or The Trust needs to make better use of ICT

monitored by the Fleet office. The annual 2.194 The Trust suffers from the paucity of ICT cost of this work is approximately £0.2m. systems available to it. There is a lack of satellite navigation in ambulances and mobile data 2.193 The Trust does not operate a ‘Make Ready’ terminals, which the Chief Executive of the (paragraph 2.140) system whereby a specialist London Ambulance Service told us has the team prepares vehicles before shifts to potential to improve significantly response time maximise their cleanliness and ensure the performance. Some staff confirmed to us as availability of paramedics to attend incidents had been reported in the press that they have

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4340_WAO Amb ENG_v0_14.indd 95 29/11/06 11:03:53 provided their own satellite navigation systems There have been procurement weaknesses for to help them reach incidents and to reduce some time stress at work. Control rooms sometimes lack 2.195 The efficiency and effectiveness of the AVLS and GPS systems (paragraph 2.151), and ambulance service is dependent to a large there is a major ongoing £54m procurement to degree on having the right equipment and provide a new radio network as key wavelengths technology in place. With only limited capital are being withdrawn. In addition, clinical resources available it is critical that the information is collected on paper, and there Trust invests wisely, prioritises effectively are risks of losing important clinical data or and procures the assets it needs to information about adverse incidents. The Trust deliver its business objectives. The Trust’s has not yet started to use telemetry to improve record in this area has been very poor. clinical services by providing information in advance to A&E departments or to reduce 2.196 The Trust has not had a coherent capital strategy the need to transport patients to hospital. in place (paragraphs 2.68-2.71). As a result there has been a tendency for procurements to There have been serious deficiencies in capital be ad hoc, driven more by the desire to spend procurement processes which have led to available monies by the financial year-end significant wasted money and opportunities, than to meet demonstrable business needs. although systems have now been developed

Case Study J: Poor procurement has led to significant failed procurements

PCS scheduling system A new IT based scheduling system for the Patient Care Service had, by March 2006, cost the Trust £0.44m in capital and a further £0.4m in revenue. After testing and piloting, the system has not been rolled out across the whole Trust because of concerns about its fitness for purpose which have led to the Audit Committee commissioning a review. There is a risk that the costs incurred will have to be written off. Ambulance procurements In 2002, the Trust entered into an agreement with a company to purchase, and have fitted out, 30 emergency ambulances. The company was declared insolvent prior to fitting out three of these vehicles. These three vehicles have never been used and are still in storage; they cost £83,000. Following an engineer’s report it was found that the remaining vehicles did not meet safety standards as emergency vehicles and therefore have had to be deployed within the Patient Care Service. In 2005, the Trust arranged to purchase and convert into emergency ambulances 46 Renault Master Vans at a cost of £2.4m. After these vehicles had been converted it was found that the new ambulances had a weight overload on their front axles, which rendered the vehicles potentially unsafe. As a result the Trust has had to spend £120,000 to make the vehicles operational and to extend existing leases while modifications were made. The Trust is able to use the vehicles but in a restricted way, for example being unable to carry relatives with the patients. Full details of the Renault procurement can be found in the auditor’s report on the procurement, which we have published on the Wales Audit Office website, www.wao.gov.uk.

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 96 29/11/06 11:03:53 2.197 Significant procurements have been progressed However, there were further procurement in isolation by individual parts of the Trust without weaknesses during 2006 the input of professional procurement advice 2.199 In April 2006, soon after his appointment, Mr and expertise. As a result there have been Thayne wrote a memorandum to the Trust Board several examples of poor and potentially unlawful seeking approval to appoint a firm of consultants procurements (Case Study J) which have to “establish as quickly as possible the current compromised value for the money. Each of these status of the Trust and to be able to inform the procurements was characterised by the following action plan to develop the organisation into a high factors: performance ambulance service”. Mr Thayne also believed that time was of the essence because ■ poor or no project management; Mrs Lloyd, Head of the Assembly Government’s Department for Health and Social Services, had ■ limited professional procurement input; asked for an initial report on the Trust by mid ■ poorly designed specifications; May 2006. Mrs Lloyd told us that she would not endorse any action that might breach Standing ■ an inadequate audit trail of Financial Instructions or Standing Orders. The procurement documentation; proposal was to focus particularly on fleet, estates and ICT infrastructure. The value of the contract ■ a lack of internal co-ordination; was £58,700, although this was not paid for some time because of concerns that the original brief ■ failure to manage relationships had not been fully delivered. We understand that with suppliers effectively; and a settlement has now been agreed between the Trust and the firm of consultants. In proposing ■ in the case of both ambulance procurements, the firm of consultants to undertake this work, Mr the Trust also failed to adequately test Thayne stated that “other consultancies would the market, failed to procure ambulances not fully comprehend the management processes that were fully fit for purpose and, in so required and culture needed to develop System doing, failed to demonstrate adequately Status Management (SSM)”. On the basis of the that it had achieved value for money. Chief Executive’s recommendation that a decision The Trust sought to develop new systems for needed to be taken urgently to expedite the work procurement in the light of these cases because, as he asserted, ‘failure to take notice of the situation as reported could lead to the 2.198 Following these high profile failures, in 2005, continued loss of life and risk of a total collapse the Trust appointed a new procurement of the Service manager to bring professional discipline ’, the consultants were forthwith to future procurement exercises through a appointed. We have found no evidence that the more consistent and corporate approach to Chief Executive’s memorandum was considered procurement. There is some evidence that formally by the Board prior to the appointment of these systems had begun to address the the consultants and no formal waiver of Standing weaknesses in procurement processes. Financial Instructions appears to have been actioned. We saw no evidence that this company was the only company capable of delivering this exercise and believe it likely that there would have been significant competition for a contract

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4340_WAO Amb ENG_v0_14.indd 97 29/11/06 11:03:56 of this nature. Indeed the company appointed 2.202 We have discussed this matter with the Trust’s was newly formed and therefore without a track auditors. They have confirmed that they were record of its own. The Trust exposed itself to approached by the Director of Finance but significant risk, is unable to demonstrate it has they did not provide any assurances that the obtained value for money and has opened proposed contract award was in accordance itself to allegation of unethical practices. Even with Standing Financial Instructions. Rather, if this company was the only one capable of they stressed the importance of the Trust delivering this assignment, we also found that: taking action to ensure that the arrangements complied with Standing Financial Instructions, ■ no purchase order was raised and no other and wrote to the Director of Finance in response quotes were obtained or market testing to Mr Thayne’s memorandum of April 2006 undertaken to check value for money; setting out a number of key issues which they believed the Trust should address before ■ no financial checks of the appointing the consultants. The Director company were undertaken; of Finance forwarded these e-mails to Mr Thayne, which raised the following issues: ■ no contract was drawn up; and ■ Have [the Trust] separately been able ■ there was no specification to justify that this work needs to be agreed by the Trust. undertaken in the first place?

2.200 Mr Thayne has told us that details of the ■ Mention is made of the various work consultancy proposals were circulated to undertaken by [the consultants] members of the executive team prior to the in England and Scotland but has appointment and that senior officers could have anyone approached these trusts for a raised any concerns they had. We accept this reference, even an informal one? was the case. However, an informal mechanism such as this is no substitute for following the ■ It seems that other consultancies formal procurement and approval processes set are discarded a bit too easily… out in the Trust’s Standing Financial Instructions. other firms may be interested

2.201 On 16 May 2006 Mr Thayne submitted a ■ [The price per day] seems reasonable but [the further memorandum to the Board asking Chief Executive refers] to it being the lowest that it “formally approves the appointment of level for consultancy – have [the Trust] actually the management consultants”. However by checked this. What about travel expenses this time the consultants had already been – depending on where [the consultants] are appointed and had commenced work. The based this could add significantly to the bill. memorandum records that, at the request of the Chair, “in order to safeguard the position ■ Is [the number of days] too much or too of both individuals and the Board discussions little? Seems a lot of days for a consultancy [had taken place] with the Trust auditors project (particularly if there is an expectation to ensure that the proposals conformed to of substantial Trust resource being required Trust Standing Financial Instructions”. as well). You could argue that it might be

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4340_WAO Amb ENG_v0_14.indd 98 29/11/06 11:03:56 better to pay £1,000 a day for 50 days and get award but took assurance from Mr Thayne’s real specialist input, rather than pay a lower report that he had confirmed with the Trust’s rate for a longer term. Quality is the issue! auditors that the arrangements complied with the Trust’s Standing Financial Instructions. 2.203 We are unclear what action, if any was taken to address the concerns raised by the auditors. 2.205 Mr Thayne also initiated a series of procurement It is evident however that the assurances processes for IT systems and clinical provided by Mr Thayne at the Trust Board of equipment after his arrival in March 2006. 16 May 2006 that the auditors had confirmed These procurements appear to have been that the proposal complied with Standing progressed without the direct involvement Financial Instructions was not accurate. or professional input of the procurement department, although we have been told that 2.204 In our view the Board was placed in an invidious they were discussed, at least in summary detail, position, being asked to approve the award of by the Trust’s executive management team. a contract which had already been awarded without competition and in contravention of 2.206 Within weeks of Mr Thayne’s appointment as the Trust’s Standing Financial Instructions. interim Chief Executive, the Trust spent £0.76m Members of the Board have told us that they on purchasing 155 automatic chest compression were uneasy about approving the contract devices. Mr Thayne has described the urgency which existed to spend this money by the end

Case Study K: Procurement of chest compression devices

The interim Chief Executive Mr Thayne recommended the purchase of 155 automatic chest compression devices at a cost of £0.76m. The Trust completed the purchase of these devices from a single supplier without competition and complying with the legal requirements to advertise in OJEU and for the successful supplier to complete a pre-purchase questionnaire. The Chief Executive completed a standard form requesting that the Board waive its Standing Financial Instructions for the purchase of equipment with a value of £0.764m despite the waiver form stating that the Standing Financial Instructions may only be waived for purchases of between £15,000 and £99,695 and that “Above £93,738 EU Regulations apply and cannot be waived by the Trust”. The form states that the reason for the request to waive Standing Financial Instructions was because only one supplier had a product able to meet guidelines set out by the UK Resuscitation Committee. The waiver form was dated 24 March 2006 and an e-mail was sent to the company on the same date ordering the equipment, albeit the e-mail does state that the purchase was “subject to Trust Board approval on 28 March 2006’. An official order was raised on 27 March 2006 and the equipment was delivered to the Trust in two batches on 30 and 31 March 2006. The request to waive the Standing Financial Instructions was not formally presented to Members until July 2006, by which time Mr Thayne had left the Trust and the equipment was already in use. The Interim Chief Executive did report the proposed purchase to a closed meeting of the Board on 28 March 2006. The Board was told in this meeting that the device was the “only automated device suitable for use by the ambulance service and a monopoly supplier for an automated CPR device”. We have found no evidence to support this claim and indeed the interim Chief Executive acknowledged in his report to the Board that there was a “potential alternative supplier” but that this supplier ‘would not contest the decision’. continued...

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4340_WAO Amb ENG_v0_14.indd 99 29/11/06 11:03:59 The Interim Chief Executive advised the Board that the purchase would be subject to the waiver of Standing Financial Instructions and that there was no need to advertise the contract in the Official Journal of the European Union as the supplier was a monopoly supplier. Board minutes do not record that there was any discussion of the legality of the proposed procurement arrangements; of the need to demonstrate value for money; or indeed that the equipment had already been ordered. The minutes record that an e-mail from the Trust’s Medical Director was shared with the Board, which highlighted research questioning whether these devices improve clinical outcomes. However, the Interim Chief Executive told the Board that the “Director of NHS Wales (Mrs Lloyd), and Health Commission Wales (HCW) were ‘generally supportive of the intention to purchase this equipment, subject to Board approval”, (although this is disputed by Mrs Lloyd). On this basis the Board approved the purchase. It is a matter of serious concern that such a significant purchase was undertaken without any proper business case, option appraisal or procurement specification, particularly given the strongly divergent views about the clinical effectiveness of these devices. Moreover, the Trust had a duty under European law to test the market to see whether other suitable products and suppliers existed and to provide potential suppliers to modify existing products to comply with a required specification. We have found no evidence to suggest that waiving the SFIs was justifiable. Mr Thayne has told us that he believes the action taken to procure these devices was appropriate and justifiable on the basis that it would save more patients’ lives. He does not accept that a competitive process was necessary as he spoke directly with an alternative supplier and this supplier was unable to match the price of the supplier he selected. We do not accept this argument. The fact remains that the Trust had a duty to comply with European law and Standing Financial Instructions. Furthermore, in conducting informal discussions with potential suppliers in respect of such a major contract, the Trust has been laid open to allegations of impropriety, particularly as the alternative supplier was subsequently selected without competition as the preferred supplier for another major contract, the purchase of defibrillators (Case Study L). Following the purchase of the equipment, the Trust took steps to legitimise retrospectively the procurement. The supplier was asked to complete a pre-purchase questionnaire and the Trust placed an award notice in the Official Journal of the European Union. This notice justified the decision not to seek competition on the grounds of “extreme urgency brought about by events unforeseeable by the contracting authority and in accordance with the strict conditions stated in the Directive”. There is no evidence that any such urgency existed, other than a desire on the part of the Trust and the interim Chief Executive to spend its available budget by the financial year-end. This is not an appropriate consideration in deciding whether to seek competition.

Source: Wales Audit Office

of the financial year. He told us that his first are questions about the basis of this proposal. priority would have been to purchase satellite Case Study K describes the deficiencies in the navigation devices but that this would not procurement of 155 chest compression devices. have been possible in the time available before the end of March. However, at the time of Mr 2.207 There were also weaknesses in a number of Thayne’s appointment, the Trust had already other procurements for which business cases developed other plans to spend the money on were in development (Case Study L), which buying out existing vehicle leases, although there sought to address weaknesses in the Trust’s infrastructure. These procurements were due to go before the Board for approval but this did

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4340_WAO Amb ENG_v0_14.indd 100 29/11/06 11:03:59 Case Study L: Weaknesses in procurement processes that are now being reviewed

Proposed purchase of 103 defibrillators at a cost of £1.8m In April to July 2006 a procurement process was progressed to replace 103 defibrillators. The business case is deficient in all material respects. Specifically it fails to: • identify a business need; • specify the Trust’s requirement; and • identify procurement options. Moreover, the business case recommends the purchase of the equipment from a single supplier. Mr Thayne told us that he approached this company and obtained quotations from it as it was an existing supplier of the Trust. It appears that there was no intention to use the existing All Wales framework agreement for the purchase of the equipment. Failure to use this framework or to seek competition through advertisement in the Official Journal of the European Union was anti-competitive and if a contract had been let would have been unlawful. Furthermore, Mr Thayne’s approach to a single possible supplier without the involvement of the Trust’s procurement department was in our view very unwise and has laid the Trust open to allegations of impropriety. Whilst the procurement process was being progressed, a member of staff who had been appointed by Mr Thayne on a temporary contract and was involved in the procurement process was offered, and accepted, a job with the proposed supplier. The Trust continued to use him in a limited capacity in the procurement process, prior to his leaving its employment, although the member of staff concerned has stressed that his continued involvement was with the full knowledge of the Trust’s executive management team. In July 2006, the Procurement Department carried out a review of the business case for the procurement and expressed grave concerns regarding the integrity of the procurement process. The procurement proposal has been withdrawn. Computer Aided Dispatch (CAD) System Between March and June 2006, the Trust’s IT Manager was tasked with reviewing options for a new Computer Aided Dispatch (CAD) system to track and plan vehicle movement, prior to a procurement process commencing. The estimated cost of this procurement is in excess of £1m. Subsequently, a temporary project manager was appointed to the Trust to progress both this and two other procurement processes: Emergency Call Location System (EMCLP), and Automatic Vehicle Location Navigation and Mobile Data System (AVLS). In June 2006, the project manager invited a firm of consultants to present to the Trust on CAD Systems and to provide indicative prices. During this presentation the consultants identified a specific product as a solution to the Trust’s needs and also identified specific EMCLP and AVLS systems this product could interface with. The consultants are the UK distributors of the product identified. This activity was likely to have given the supplier a commercial advantage and was therefore anti-competitive. In July 2006, the Procurement Department carried out a review of the business case and expressed grave concerns regarding the procurement process. On 27 July 2006 the contract was advertised in the Official Journal of the European Union and the Trust has received 14 expressions of interest. This procurement process is ongoing. continued...

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4340_WAO Amb ENG_v0_14.indd 101 29/11/06 11:04:02 Emergency Call Location Package (EMCLP) The Trust also commenced a process to procure an Emergency Call Location system. Such a product would enable the ambulance service to pinpoint the precise location of emergency calls. The procurement process was not pursued via the Procurement Department. A business case for this procurement was produced but is deficient in a number of key respects: • it referred throughout to one product; • it concluded that only one supplier can provide the necessary technology; and • it recommended the purchase of a product without a call to competition. After an internal review of the procurement process, the Trust has now advertised the contract in the Official Journal of the European Union and has received 11 expressions of interest, indicating that there are other suppliers capable of meeting the Trust’s requirement. Automatic Vehicle Location Navigation and Mobile Data (AVLS) The Trust also sought to procure an AVLS. This equipment would enable the Trust to identify the precise location of every ambulance. This procurement is likely to have a value of several million pounds. In March 2006, the proposed procurement was advertised in the Official Journal of the European Union and 54 expressions of interest were received from prospective suppliers. Following this exercise, a Trust official visited the premises of one potential supplier in order to draw up a specification for the procurement. This provided a commercial advantage to this supplier. A business case was produced but was deficient. The business case stated that ‘preferred supplier stage has been reached’. This was before any tenders were received or evaluated. The actions of the Trust have been anti-competitive and have compromised the integrity of the procurement process. This procurement is ongoing.

Source: Wales Audit Office

not happen as the procurement department There are serious concerns about decided, appropriately, to suspend them after the organisational culture the resignation of Dr van Dellen, because of concerns about the basis of the business cases: 2.208 A number of current and former employees of the Trust told us that they perceived a culture of ■ 103 defibrillators; bullying and harassment within the organisation. Inevitably, there is a fine line between robust ■ computer-aided despatch system; management and a perception of bullying. Nevertheless, despite the Trust’s dignity at ■ emergency call location package; and work policy and policies to tackle bullying and harassment, the perception of bullying is an ■ automatic vehicle location navigation and mobile data (AVLS). important issue for the Trust to address.

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4340_WAO Amb ENG_v0_14.indd 102 29/11/06 11:04:02 2.209 Linked to this, we found that there was a have many ideas about improving the Trust culture in which suspensions and grievances yet even at relatively senior levels they told appear to be common (paragraphs 2.117‑2.119). us that they have not been listened to or There appears to be a lack of confidence encouraged to provide ideas for improvement. in management, which leads to staff taking formal action under grievance and 2.213 Another consistent theme was the need to dignity at work policies to try to resolve provide information to staff, particularly at situations, rather than trying to work with a time of rapid change. Only one in every managers to improve their situation. ten people responding to our staff survey agreed that the Trust kept them informed 2.210 We also found that job satisfaction is low of its future strategic direction. This reflects among some of the Trust’s employees and potential weaknesses in communicating with is a crucial issue for the Trust to address. external stakeholders about the future strategic Of those responding to our survey, 47 per direction of the Trust (paragraph 2.61). cent were satisfied with their job, but 34 per cent were dissatisfied. Job satisfaction There has not been a culture of learning was lowest in control rooms, where 44 per cent of staff expressed dissatisfaction. 2.214 We found little evidence that the Trust has established effective systems to encourage the The Trust has not fully developed identification and dissemination of good practice. a clear corporate identity There appears to be little communication between regions on how they are tackling common 2.211 One of the major achievements of the early problems and how some areas – for example years of the Trust is that the previous services Conwy and Denbighshire – have achieved have been merged, and the existence of a high levels of performance yet others have not. single national service is a strength rather There appears to be a piecemeal approach to than a weakness for the future of the Trust. spreading good practice and, in some quarters, Nevertheless, staff still believe that the Trust a reluctance to adopt good practice if the idea lacks a strong corporate identity. Seventy per was not generated in a particular locality. cent of staff responding to our survey do not believe that the Trust headquarters and its three 2.215 The widespread perception of a blame culture regions operate on a consistent basis. During in the Trust militates against developing a our fieldwork in the three regions, we also culture of learning and sharing. Learning found evidence of regional variations in terms from adverse incidents and complaints is and conditions and operating processes, such especially important as the service develops as controls, meal breaks and shift patterns. an increasingly clinical focus. Yet, we found that the Trust’s approach to dealing with Communication has been weak complaints was somewhat defensive. However in its discussion with complaints staff at 2.212 Trust staff consistently expressed concerns the Trust HIW noted that there had been a about communication. Communication is change in approach commencing when Mr inherently difficult in an organisation in which Thayne had become Interim Chief Executive. staff are spread across over 100 sites and This marked a greater determination to learn in which most do not have ready access from complaints and to be prepared to make to a computer and the Trust Intranet. Staff appropriate apologies when they were justified.

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4340_WAO Amb ENG_v0_14.indd 103 29/11/06 11:04:05 Part 3: The problems can be resolved over time provided key challenges are dealt with

3.1 In this Part we consider the prognosis for the this judgement on our discussions with other Trust, under its new Chair and Chief Executive ambulance services, particularly the Chief and in the light of the findings of this report. Executives of the London and East Anglia Despite the record of poor performance and of Ambulance Services, both of which went through failures in key areas of business management, significant service development programmes. we find that there are grounds for optimism. We reviewed the service improvement Other ambulance trusts in the United Kingdom programme in London Ambulance Service, have faced somewhat similar situations in the which delivered significant change over the six past and have been able to turn themselves years between 2000 and 2005. Case Study M round, given time. The Chief Executive’s shows the key achievements of the programme modernisation plan, which was being developed and the lessons learned for the future. This in parallel with our work, addresses all the major shows not only that ambulance services can issues that we have identified. It remains for the deliver fundamental change through sound Trust to deliver that plan, not all the details of planning, change management and budgeting, which have yet been developed. In doing so, the but also that there are important lessons for Trust will face a number of internal and external other services around strong programme challenges requiring action by others as well as management, the need to refresh plans, and within the Trust. Given effective collaboration, the need to consider the management capacity however, the challenges appear to be resolvable. required to support and maintain change.

The problems can be resolved over time 3.4 The Chief Executive of the East of England Ambulance Trust told us that the period Other trusts have turned themselves around following the regional inquiry in the former East Anglia Trust had been very difficult, but 3.2 Although we identified significant and that the focus should be on ‘quick wins’, longstanding problems with the ambulance including investing in technology and improving service in Wales in Part 1, we also highlighted performance to ‘put the umbrella up’ and free the strengths of the Trust and some of the the organisation to pursue the fundamental positive opportunities it faces. We found that long-term changes that can transform the the longstanding problems can be fixed over service. In addition, there are specific challenges time provided key challenges are dealt with. that the Trust and its stakeholders will need to address if its current problems are to be 3.3 Addressing the problems and improving the fixed over time, both internal and external. situation will require strong leadership, some investment, and a long-term plan of change, as we believe it will take between three and five years to turn the service around. We base

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4340_WAO Amb ENG_v0_14.indd 104 29/11/06 11:04:08 Case Study M: London’s Service Improvement Programme delivered benefits and lessons for the future from which Wales can learn

Main achievements of the Service Improvement Programme 2000-2005 • The SIP delivered measurable improvements, for example staff satisfaction increased from 42% in November 2000 to 60% in 2005 Category ‘A’ response times improving from 40% in eight minutes to 75.1% and cardiac arrest survival rate increasing from 4% to 8.6%. The organisation needed a coherent programme of work supported by dedicated resource. • London Ambulance Service was the first NHS organisation to do anything like a costed SIP, as the culture of developing SIPs was not a feature of the NHS when it was launched. This gave the London Ambulance Service credibility within the wider NHS which was recently verified by OGC feedback that the SIP was the most comprehensive improvement programme of its type in the NHS. • The SIP provided good direction and an approach to getting things done quickly, and caused the organisation to move significantly further forward: it gave overall focus to the organisation starting from a low base when it needed to get on with making change happen and there were significant project successes. • The SIP allowed for a wide margin of innovation and flexibility and people broadly felt empowered to deliver their projects rather than following an overly bureaucratic documentation process. Improvement opportunities identified for future change programmes • A strong programme management approach is required in the future, as in some departments, there was a lack of project control and structure which has partly been addressed. • The SIP lost steam in the last 18 months, it hit a plateau and lost its freshness after three years so a way needs to be found to refresh the new programme and keep it meaningful and energised. • The SIP did not deliver some of the changes to working practices envisaged and the need to do this was avoided by the level of investment obtained in the early years of the programme. Opportunities to modernise working practices arising during the course of the next programme need to be capitalised upon. • Projects, generally, were uni-disciplinary and progressed in functional silos; the new programme needs a cross-functional approach. • There was insufficient capacity and capability to deliver the change required, the work was done by managers on top of their day jobs which caused slippage and probably impacted on day to day performance as well. Not enough training was given to people who managed projects. These issues need to be considered in the design of the new programme. • It is difficult to define the clinical aspects of the SIP (eg, patients diverted to alternative care like walk-in-centres where management could check the extent to which they were used but did not have the resource to check if patients were sent there appropriately). This illustrates the need for patient outcome measurement to be incorporated into the new plan. • Some of the things that need to be done going forward may not be amenable to the SIP/project management approach (such as managers dealing with performance and individual behaviour on a more informal basis in an ongoing manner, rather than waiting either until annual appraisal time or until something becomes a disciplinary matter). Such intangibles need to be made tangible through an over-arching programme strand relating to organisational development and people, identifying action plans with milestones and measures (eg, use of staff surveys).

Source: Service Improvement Programme: Review of lessons learned, London Ambulance Service, Service Development Committee, 27 June 2006

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4340_WAO Amb ENG_v0_14.indd 105 29/11/06 11:04:11 The draft modernisation plan sets External challenges need out a direction to address the to be addressed weaknesses we identified 3.8 The ambulance service is not a self-contained 3.5 The Trust’s new Chief Executive, Alan Murray, is operation. Its activities are profoundly affected in the process of finalising a new modernisation by the demands and constraints placed upon plan with the Board. We have reviewed the it by external factors. To achieve success as latest plan. Although the detailed plans for an integral part of the NHS, the Trust needs to implementation are, understandably at this engage actively with stakeholders to address stage, not yet complete, the plan sets out a the following important external challenges: direction to address the key weaknesses we have identified, including some of the ‘softer’ a changing demand for ambulance services organisational, cultural and managerial issues, arising from reconfiguration of NHS facilities; and so provides a blueprint with the potential to move the service forward over the coming b ineffective interfaces with other years. The plan has two key areas of focus: NHS systems;

■ building confidence in the service’s ability to c loss of PCS contracts through competition; deliver as a traditional ambulance service in the short-term, ‘getting the basics right’; and d stakeholder expectations on how ambulance services are delivered and ■ undergoing, simultaneously, a more on the timescale for improvement; fundamental process of change over a longer period, ‘delivering patient care differently’. e dissatisfaction with the service among GPs; and 3.6 It is also encouraging that most staff we met after his appointment were positive about f developing effective partnerships. Mr Murray’s ideas and approach to change. NHS reconfiguration changing There has also been some external support demand for ambulance services for the emerging plan, for example the Chief Constable of North Wales informed me that 3.9 The Welsh Assembly Government’s 10 year the Joint Emergency Services Group had strategy for health 2005-2015, Designed been ‘unanimous in expressing their strong for Life, has led to local health communities support for the draft plan which seems to producing plans to reconfigure acute health us to offer a very sound foundation upon services in each of the three NHS regions which to base the future of the Welsh in Wales. The thrust of the reconfiguration Ambulance Service. Such a plan has been plans is to address the following major sorely needed, and we all have confidence challenges facing NHS Wales: that the proposals if adopted will address the concerns that we have previously raised’. ■ ensure a safe service, by dealing with the fragmentation of specialist services 3.7 Appendix 8 provides the Trust’s views on among too many trusts/hospitals; how its draft modernisation plan addresses each of the recommendations in this report.

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4340_WAO Amb ENG_v0_14.indd 106 29/11/06 11:04:11 ■ attract and retain top quality professionals; 3.13 We also heard concerns about the impact of other reconfiguration plans on the ambulance ■ respond to an increasing demand on service. For example, the Gwent health services which threatens to overwhelm the community is developing proposals known as current highly congested services; and Clinical Futures, which will establish a single major specialist and critical care centre and ■ avoid spreading resources too thinly. six local general hospitals. This will involve changes in A&E services, with accidents and 3.10 Any change to the number and location of A&E major emergencies being directed to the single departments, or to the configuration of other specialist and critical care centre, rather than specialist services, would obviously affect the the existing two A&E departments in Newport ambulance service as it would change the and Abergavenny. This will affect travelling nature of demand and distances to be travelled. times for ambulance services. Given that this As an example, the former Chief Executive, accident and emergency department is likely Mr Page, described the Trust as having to to service patients from one of the areas of meet the costs of additional overtime in the Wales with the worst Category ‘A’ response evenings to cover the additional travelling times time performance – Monmouthshire – it is in the Llanelli area after the A&E department in essential that the ambulance service is fully Prince Phillip Hospital closed in the evenings. involved in service reconfiguration so that new

3.11 Many of the people who submitted information to services genuinely reflect and improve the the Inquiry team expressed significant concerns whole system of care. This will require changes about whether the impact on the ambulance in service provision, commissioning and much services of changes in the configuration of stronger links with LHB’s and acute trusts. services are properly considered. We heard Ineffective interfaces with other NHS systems a number of concerns about the impact of longer travelling times if the Neurosurgery 3.14 A very common source of unsatisfactory Service moves from Swansea to Cardiff. performance in complex systems is the tendency of interfaces between component 3.12 Other submissions expressed concern that parts of the system to operate ineffectively. such policy changes are dependent on a The ambulance service has two highly important well‑resourced ambulance service that is able to interfaces with the rest of the NHS namely deliver excellent response times. For example, with hospital A&E departments and with GPs. residents of Powys described their concerns Both of these interfaces present challenges. about the impact of moving patients with acute coronary heart disease from Brecon to Hospital turnaround times seriously Abergavenny because of the longer travelling compromise ambulance capacity times and poor response times in Powys. The ‘Keep the Heart in the Hospital’ group 3.15 Accident and Emergency departments in Wales from Brecon expressed concern that this are under significant pressure, because of bed decision, taken in 2003, did not take account pressures and also because of demand, some of the quality of ambulance services. of which might best be met elsewhere. Many of

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4340_WAO Amb ENG_v0_14.indd 107 29/11/06 11:04:14 the people attending A&E arrive in an emergency turnarounds during 2005/2006 took place within ambulance (over 250,000 turnarounds at 20 minutes. This represents a deterioration A&E departments in 2005/2006). The Welsh of three per cent against performance in Assembly Government has recognised the 2004/2005. In addition, the monthly average potential impact of long turnaround times at turnaround time became consistently worse A&E departments and has set a target in the as the 2005/2006 financial year went on. ambulance balanced scorecard that there This problem relates to capacity in A&E should be no waits of more than 20 minutes in departments but also to the quality of operational handing patients over to A&E departments. management by the Trust in terms of ensuring that crews clear hospitals as quickly as possible. 3.16 Compliance with the Trust’s 20 minute target, which consists of the 15 minutes set for 3.17 To assess the impact that slow hospital patient handover and a further five minutes to turnaround times have on the operational return to and mobilise the ambulance, varies, capacity of the Trust, we analysed average with very long turnarounds at some hospitals turnaround times for each month of a two compromising capacity. Only 52 per cent of and a half year period. To quantify the lost

Figure 35: Significant lost operational time because of slow hospital turnaround at some hospitals

500

450

400

350

300

250

200

150

100

0 Operational crew hours over target per month deemed lost Operational crew

Prince Charles Hereford County Nevill Hall Hosp. Morriston Hosp. Singleton Hosp. Wrexham Maelor Royal ShrewsburyRoyal Glamorgan Bronglais General Princess of Wales W.Wales GeneralWithybush Hosp. Glan ClwydLlandudno Hosp. Hosp. Ysbyty Gwynedd Royal Gwent Hosp. Prince Philip Hosp. Llandough, Penarth Uni. Hosp. of Wales Neath & Port Talbot Countess of Chester Caerphilly Dist Miners

N 2004/2005 N 2005/2006 N 2006/2007

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 108 29/11/06 11:04:14 operational resources attributable to slow 3.19 Steps taken already to improve hospital turnarounds, we calculated the number turnaround times include: of hours lost above the Assembly Government’s 20 minute turnaround time target. Figure 35 ■ touch screens being installed at a number of shows that a significant proportion of the A&E departments which help communicate to lost crew operational hours are incurred in control when ambulance crews are available; a few hospitals, with particular problems at ■ University of Wales Hospital, Cardiff, and the in some A&E departments, additional Royal Gwent Hospital, Newport, contrasting stretchers are provided, or shared with the with Glan Clwyd which receives a large department so that, when it is clinically safe number of patients from ambulances yet to do so, one crew or crew member can there is compliance with the 20 minute target. look after a number of patients to enable The Chair of Conwy and Denbighshire Trust another crew to take another call; and wrote to us to highlight the robust partnership ■ the introduction of ambulance liaison arrangements between the Trust and the officers, operating at A&E departments. ambulance service. Appendix 9 shows average

turnaround times per hospital per month. 3.20 Another way to reduce turnaround times at A&E departments would be to reduce the number 3.18 Some people contributing to this inquiry of patients who are taken there who do not expressed the opinion that the four hour waiting need to be. Minor Injuries Units (MIUs) exist time target in A&E departments contributed to in various parts of Wales but are not always the unacceptably long turnaround times. On the fully integrated into care pathways used by face of it, there could be a perverse incentive for ambulance crews. A good example is the Powys the A&E department to avoid taking a patient area, where there have been efforts to develop from an ambulance and thus delay the start of clinically safe protocols to transport appropriate the four hour period. That, however, does not patients to MIUs. However, ambulance staff in seem to be true because: Powys report that there has been reluctance on the part of some MIUs to accept patients ■ the four hour target time starts in A&E as soon as the patient arrives in the ambulance from ambulances, due to a lack of training and and not when they are handed over; and experience on the part of MIU staff. Making more effective use of MIUs in rural areas, linked ■ although 10 out of 13 A&E consultants to the development of new paramedic roles, responding to our survey believed that has significant potential to improve patient pressures in their departments compromised care and ambulance service capacity. turnaround times for ambulance crews at their departments, 10 out of 13 disagreed that the The new GP out-of-hours arrangements appear four hour target provided perverse incentive to have changed patterns of demand for the department to take patients from 3.21 There is a common perception that the new ambulance crews at times of heavy pressure. GMS contract, which allowed GPs to opt out of providing out-of-hours cover from October 2004, has significantly increased demand for ambulance services. We examined this claim and found that there is no evidence

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4340_WAO Amb ENG_v0_14.indd 109 29/11/06 11:04:17 of a substantial increase in total demand for their impact on ambulance services may well ambulance services. Figure 36 shows that there have varied in different parts of Wales. We did has not been a sharp increase in total demand not examine this question fully; however, it is for emergency ambulance services since clearly essential to ensure that all unscheduled October 2004, but that the longer-term trend of care services in particular localities – emergency increased total demand has slightly decreased ambulance, GP out-of-hours, A&E departments since the new contract was introduced. and minor injuries units – work together in an integrated way to ensure that patients access 3.22 Nevertheless, ambulance staff clearly believe the most appropriate level of treatment in the that the way the ambulance service is used right place and at the appropriate time. has changed since the introduction of the new out-of-hours arrangements. One indicator is PCS contracts are at risk from competition the fact that while the amount of Category ‘A’ and internal system weaknesses and Category ‘B’ has increased in recent years, GP urgent activity has decreased (Figure 15). 3.23 The Trust provides routine patient transport Consequently, lack of confidence in unscheduled services (known as Patient Care Services), care services, both ambulance and out-of‑hours, operated under individual contracts with on the part of GPs and their patients, may have 13 Trusts in Wales and six in England. led to people accessing the ambulance service Contracts are based on a payment of in different ways, thereby increasing demand by £7.39 per patient transported, regardless using 999 to access services. The new out-of- of distance travelled or complexity. hours arrangements differ across Wales and so

Figure 36: The trend of increasing activity has not changed significantly since the new GP out-of-hours arrangements began

300 Out of hours 280 Medical Services

260

240

220

200

180 Number of emergency incidents in year (000’s) 160 2000-01 2001-02 2002-03 2003-04 2004-05 2005-06

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 110 29/11/06 11:04:18 3.24 We have noted in Parts 1 and 2 of this report ■ reducing the need to take patients in to that there are a number of concerns about hospital by PCS staff taking bloods in the PCS performance, and that the Trust seriously community and taking the bloods into lacks performance information about PCS. hospital, carrying out basic tests in the community, like telemetry retrieval, monitoring 3.25 The problem for the Trust is that this lack of blood pressure and even mobile x-rays; and information makes it impossible to determine whether PCS is self-sufficient and, for individual ■ training staff in using defibrillators contracts, whether it is breaking even, making and put them back onto vehicles, a profit or making a loss. Agenda for Change is especially in rural areas. leading to increases in PCS staff and ultimately a more expensive cost base for PCS. Trusts 3.27 We also heard from St John Cymru Wales can tender for PCS, and two of the four who who provide some patient transport services responded to our survey indicated that they are and believe there is considerable scope for considering contracting with a provider other better integration and co-ordination of patient than the Trust for PCS. The increasing cost transport services with broader community base for PCS, arising from Agenda for Change, transport schemes, and that St John could increase the likelihood of losing contracts, Cymru Wales would like the opportunity to and therefore financial stability arising from the compete for PCS contracts. There are also contribution of PCS to the Trust’s overheads. private sector providers, who have already secured some contracts in England. 3.26 The Trust has lost one contract for transporting patients to England. Any further loss of contracts 3.28 Nevertheless, the Trust is in the process would be financially damaging to the Trust. It of making some improvements to could also limit the contribution PCS might be PCS in the following areas: able to make, given appropriate training and ■ equipment, to the emergency medical service in a medical call centre has been established the following important ways: in North Wales to book in patients and confirm appointment times, with benefits ■ managing some GP urgent calls and in reducing rates of missed appointments inter-hospital transfers, especially and improving the consistency with neo‑natal transfers as these are always which eligibility criteria are applied; transported with a medical team; ■ developing a standard model contract ■ taking home ‘do not resuscitates’ and service specification; who are being taken home to die; ■ developing policy guidance for taxi drivers ■ through appropriate triage in control, and voluntary car service operators dealing with some Category ‘C’ calls; which sets out the Trust’s expectations of car service operators; and ■ subject to placing mobile data technology on the PCS vehicles so that control knows their ■ developing a standard specification location, PCS staff can respond to 999 calls; for PCS vehicles.

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4340_WAO Amb ENG_v0_14.indd 111 29/11/06 11:04:20 3.29 Patient Care Service is one of the seven costs. Case Study N also shows the potential strategic themes in the draft modernisation to develop new service models to meet plan, Time to make a difference. The draft plan the needs of patients more effectively. contains a number of objectives for PCS to improve flexibility, reliability, competitiveness Managing stakeholder expectations and punctuality. Among the objectives for PCS, there are plans to develop: 3.31 The changes and developments in ambulance services will fundamentally change the ■ a standard IT system that captures service to increase its clinical focus and role and relays performance information to as the ‘glue’ in the unscheduled care system. resolve current system deficiencies; Double-crewed ambulances will become less common and ambulance stations less ■ consistent application of agreed prevalent as ambulances use standby points eligibility criteria through call centres and more highly trained paramedics in new in collaboration with LHBs; roles provide a wider range of services.

■ introducing national standards for PCS, 3.32 Nevertheless, many members of the public, with lead commissioners, by March 2008; very reasonably, view the service very strongly as one based around ambulance stations and ■ a reprofiled PCS fleet; and traditional ambulances. Changing the public understanding of what a modernised ambulance ■ a new management structure. service looks like, does and its benefits for them, will be a significant challenge for the leaders 3.30 As well as the risk of losing contracts, PCS of ambulance services and the wider NHS in is an area of business opportunity for the Wales. There is a need to explain clearly to the Trust: by collaborating with Social Services public that changing the way the ambulance and mental health departments, a more service works, including the location and integrated patient transport system could be number of ambulance stations in some areas, developed to improve services and reduce is about providing a greater level of service.

Case Study N: The Grampian Bus

The Scottish Ambulance Service (SAS) pursues a strategic objective to improve the punctuality of pick up and attendance at appointments for its Patient Transport Services (PTS). In order to achieve this objective the SAS has looked at ways to increase capacity within current PTS resources. To this end, the service undertook a review of why patient transport was required. The review identified that some patients were requesting transport because of their concerns about driving to hospitals in big urban cities rather than because of a clinical need. These patients were happy to drive themselves locally. To cater for this type of patient more economically, SAS developed the idea of the ‘Grampian Bus’. Patients were asked to drive themselves to local health care centres for a given time. The Grampian bus then travels a planned route collecting patients from the health centres, avoiding the extra mileage and time that would have been required for home collection and thus freeing PTS capacity for use elsewhere.

Source: Wales Audit Office visit to Scottish Ambulance Service

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4340_WAO Amb ENG_v0_14.indd 112 29/11/06 11:04:21 3.33 The Trust has also been subject to intense Developing effective partnerships public scrutiny in recent times. There is strong public demand for an improvement in 3.37 As DECS evolves, the Trust will need to work the service, but addressing the breadth and closely with partners across the system of significance of the issues identified in this unscheduled care, to develop alternative report will take some years. Other services care pathways for patients that enable them that have turned themselves around have to receive the most appropriate treatment stressed the importance of recognising that and to help the various NHS organisations to lasting and sustainable change takes years optimise the use of their resources and services. not months. Consequently, there will be a In particular, the Trust will need to work very need to manage stakeholder expectations closely with LHBs and consortia of LHBs to about the timescale for improvement. examine how ambulance services can support the provision of unscheduled care services in 3.34 The new Chief Executive has already particular localities, by developing clinically safe begun the process of seeking to discuss protocols and pathways, and considering how the new modernisation plan with key paramedics can contribute to the unscheduled stakeholders. He has met a number of care system. This consideration will need to LHB and Trust Chief Executives and has cover primary care, both in and out of hours, presented his strategy to some members and the interface with secondary care, in of the National Assembly for Wales. A&E departments and minor injuries units.

GP dissatisfaction with the service 3.38 In accordance with the principles of Making the Connections, the Assembly Government strategy 3.35 There is evidence that GPs have lost to improve public services, there is also potential confidence in the ambulance service. The to develop partnerships with other public sector shift of activity from GP urgent calls to 999 organisations. The Scottish Ambulance Service calls may have a number of causes, one of is reviewing shared facilities in two areas, which is very likely to be a loss of confidence which the Trust could use to inform its own in the service by GPs and their patients. As a partnership working in Wales (Case Study O). result, GPs may be suggesting that patients, who would previously have been urgents, call Internal challenges need 999 themselves to access the ambulance to be addressed service, rather than facing unacceptably

long waiting times for an agreed GP urgent 3.39 Whatever the Trust’s relationships with its response (paragraph 1.15 and Figure 5). external stakeholders, its internal arrangements clearly need to be very considerably 3.36 The draft modernisation plan highlights the improved. The internal challenges are: importance of providing a responsive and safe admission service for patients identified as a developing sound operational processes; urgent by their GP or other clinical professional. It also plans to establish a high dependency b developing a new culture; service to deal more effectively with GP patients and other high dependency patients who require c addressing a difficult financial position; and transport but who do not need a fully equipped double-crewed ambulance to transport them. d improving the estate.

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4340_WAO Amb ENG_v0_14.indd 113 29/11/06 11:04:23 Case Study O: Shared facilities with other emergency services and public sector bodies

The Scottish Ambulance Service is keen to develop itself as the emergency wing of the NHS, rather than the healthcare wing of the emergency services. The service is not keen to pursue shared control centres with other emergency services on the basis that their control equipment and processes are too specialised. The Scottish Ambulance Service is however looking at the potential to share facilities with other emergency services and public bodies to deliver efficiencies. Scottish Ambulance Service has recently had business cases approved to undertake two reviews in this area: • a review of shared fleet workshops with other emergency services; and • a review of the use of other ‘public transport’ e.g. social service to establish other potential shared resources.

Source: Wales Audit Office visit to the Scottish Ambulance Service

Developing sound operational processes Study P). This can have particular benefits out-of-hours and in dealing with patients with Control operations long-term conditions. An increased clinical presence in control is an important element 3.40 There are significant problems in the Trust’s in delivering this vision, although the basic control operations (paragraphs 2.147-2.158), competencies required in the control room do in terms of process, morale and performance. not require a clinical background: the ability Other Trusts we have visited consistently to make good decisions under pressure; to cited the importance of addressing issues in deal well with colleagues and the public; and ambulance controls to achieve ‘quick wins’ in to have good spatial awareness. Another key respect of performance, by improving activation element in making control centres the hub of times and call handling, and through the the unscheduled care system is a directory introduction of basic control technologies. The of services, updated daily, so that referral ability of the service to achieve performance to other parts of the unscheduled system is targets can be significantly improved through seamless, accurate and good for patients. better technology, process and morale in control. 3.42 Given the importance of the control function, the 3.41 A key issue for the Trust to address in respect current working environment, morale, sickness of control is to improve call classification, to and turnover, is a major risk for the service. reduce the relatively conservative categorisations The Trust needs to recognise, value and support (paragraph 1.22), which add to the pressure on its control staff to ensure that this function is crews and difficulties achieving performance accorded the importance it deserves. There are standards. The triage of calls can be improved many models of modern control rooms, by reintroducing Category ‘C’ and, in particular, involving well-designed and modern working by developing a focus on control as an urgent environments, and a strong emphasis on team and emergency care call centre after NHS working and staff welfare, are available in other Direct merges with the Trust. This can help the services. The East of England Ambulance Trust’s Trust to provide more telephone assessment, control room in Norwich is a good example advice and, where appropriate, referral, and a of a control centre that includes out-of-hours more integrated service for patients currently operators, good information systems and a transported to hospital by the Trust (Case

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4340_WAO Amb ENG_v0_14.indd 114 29/11/06 11:04:24 Case Study P: Developing the control room function in Scotland

The Scottish Ambulance Service reduced its control centres from 8 to 3 between 2001 and 2003. It has considered reducing to a single control centre. This would address the known inefficiencies in allocating resources at ‘control borders’. Managing resources – fleet and personnel – on a national level would potentially allow for more efficient deployment processes. Advances in control technology, such as satellite navigation and GPRS (General Packet Radio Service – a non-voice value service which allows you to send and receive data across a mobile phone network) would assist in this. The Scottish Ambulance Service found that when there was a clinical presence in the control room the rate of call referral to NHS24 (the Scottish equivalent of NHS direct) increased. Scottish Ambulance Service told us that this was the result of the clinical presence affording more confidence to control staff to refer relevant calls rather than send an unnecessary ambulance response.

Source: Wales Audit Office visit to Scottish Ambulance Service

pleasant, light working environment whose match between resources and demand that layout reflects the geography of incoming calls delivers time-critical performance standards but also seeks to minimise noise levels. and clinically effective interventions.

3.43 The draft modernisation plan includes targets to Unit hours need to be produced more efficiently

introduce status plan management to deploy and 3.46 The Trust currently lacks accurate information manage resources, and to train all control staff in about lost unit hours, which makes it difficult vehicle movement tactics, dynamic deployment to assess the effectiveness of unit hour policies and contingency management. production. The Trust is currently undertaking an exercise to identify lost hours. Matching resources and demand

3.47 The Trust urgently needs to develop systems to 3.44 A more fundamental challenge than improving measure lost unit hours, so that it can implement control rooms is to develop systems to improvements in the fleet, scheduling and improve significantly the Trust’s use of supplies functions. This will also be necessary resources by matching supply and demand to enable the Trust to measure the objectives more effectively. The production (ensuring in the draft modernisation strategy, to produce that hours of ambulance cover are available at least 95 per cent of planned unit hours for use), distribution (making sure they are each week. A central component of ensuring optimally placed to meet patients’ needs) better production will be the establishment of and utilisation (making sure they are used central resource and scheduling centres in each efficiently) of ambulance ‘unit hours’ is a region to ensure that shift patterns produce crucial discipline in modern ambulance unit hours when they are needed according provision. Figure 37 describes the factors to the Trust’s demand analysis. An important that influence ambulance unit hours. challenge will be not only to produce unit hours of double-crewed ambulances more 3.45 The Trust’s draft modernisation plan includes as one of its strategic objectives a restructuring effectively, but also to produce unit hours of of how services are delivered to ensure a new models of supply, through rapid response vehicles and extended scope paramedic roles.

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4340_WAO Amb ENG_v0_14.indd 115 29/11/06 11:04:26 Figure 37: Ambulance unit hours One unit hour is one hour of a crewed, fully equipped ambulance. Utilisation is an index based on the number of patients taken to hospital divided by the total number of unit hours, i.e, the percentage of the unit hour taken to transport a single patient

Produced Distributed Utilised

Produce units when you need Getting unit hours to where they • efficiency, preventing loss of units; them, according to the demand are most likely to be needed, • call taking time; analysis carried out by distribution. according to a rigorous demand Around 70 per cent of system analysis using historical data • allocation and activation of costs lie in unit hour production. about peaks of average demand, ambulances; Production involves: to ensure: • A&E turnaround times; • people; • the efficient use of available • percentage patients transported; resources; and • fleet; • clinical skills of paramedics: • equitable coverage so that all • equipment; and areas have adequate cover. – assess and refer; • scheduling. – see and treat; and Planned unit hours are lost – hear and treat (not produced) because: • They are not produced at all because of: – sickness; – leave; and – unfilled secondments. • They are lost after shifts start because of: – meetings; – vehicle failures or other fleet problems; – inefficient working practices, such as returning many miles to stations for meal breaks; and – vehicles not being ready for shifts.

Source: Wales Audit Office

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4340_WAO Amb ENG_v0_14.indd 116 29/11/06 11:04:27 Distributing unit hours more efficiently plan remains partially implemented but has already been revised by the South-East Wales 3.48 Distribution involves predicting where resources should be placed to meet likely demand, based regional ambulance officer after Dr van Dellen on rigorous analysis of historical demand by left the Trust. The new Chief Executive is locations at each hour and day of the week. currently developing a demand analysis, and is This enables the production of deployment introducing central scheduling departments in plans that predict where resources should each region, which will lead to a new patient- be positioned to have the best chance of centred deployment plan in each region. This responding sufficiently quickly to likely demand. is likely to involve changes in shift patterns, both in terms of shift length and shift start time. 3.49 The importance of effective distribution is Staggered start times enable cover to build graphically illustrated by the current problems up in proportion to increasing demand as the with response times in certain parts of Wales. day progresses, and a mix of shift lengths can Bridgend has the worst response times in help to add cover at times of peak demand. Wales, yet covers a relatively compact area with reasonable roads, close to a number of 3.51 However, changing shift patterns is extremely A&E departments. The problem is that there controversial and difficult: understandably, are distribution problems in neighbouring areas staff like 12 hour shifts, while shorter shifts which means that Bridgend crews are ‘sucked tend to increase the number of weekends that in’ to neighbouring areas, such as Cardiff and they work. Consequently, the Trust will need Swansea, leaving Bridgend with insufficient to work closely with the staff side to develop cover to meet demand. Case Study Q shows more appropriate shift patterns. The draft that Swansea is another example of such modernisation plan includes a proposal to hold a ‘whirlpool’, redistributing resources and monthly staff-led reviews of the new deployment affecting cover elsewhere, highlighting the plans that will be introduced in each region. absolute importance of the Trust analysing Unit hour utilisation supply and demand to ensure that resources are optimally scheduled, deployed and utilised 3.52 The Trust utilises its unit hours with variable to meet patients’ needs. Similar problems affect efficiency. Unit hour utilisation is a common performance and cover in other response time measure of the efficiency with which ‘deserts’ such as Powys and Monmouthshire. ambulance services used their resources. The transport UHU measures the number 3.50 A new deployment plan was introduced of patients transported, divided by the by Dr van Dellen before his departure in total number of planned ambulance hours. August 2006. The introduction of the new Figure 38, which is based on an analysis deployment plan proved problematic with conducted by Dr van Dellen using data from staff-side resistance. The new deployment the last two years, shows that the transport

Case Study Q: Drawing resources towards Swansea

Category ‘A’ response time performance for calls originating within the county boundaries of Swansea is relatively good, and is one of the best in Wales. However, unit hour utilisation in Swansea is poor and there is likely to under-resourcing in Swansea, which ‘sucks in’ resources from neighbouring areas, such as Carmarthenshire. Unit hour utilisation in Carmarthenshire is much higher than Swansea, but performance is lower because of the problems with distribution and utilisation.

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4340_WAO Amb ENG_v0_14.indd 117 29/11/06 11:04:30 Figure 38: Unit hour utilisation varied between planning to meet current and future needs regions in 2005/2006 is critical. Workforce planning will be a key component of delivering modernisation by Region Transport UHU making the best use of new paramedic roles, North 0.25 by developing new career paths for staff and increasing the clinical focus and range of Central and West 0.28 services delivered by the Trust. In particular, South East 0.29 the proposed merger with NHS Direct will broaden the skill mix available to the Trust and Source: Welsh Ambulance Services NHS Trust report will necessitate clear and effective workforce of Dr van Dellen’s analysis planning to make the best use of the wider mix of skill available to the Trust. The Department unit hour utilisation is lowest in North Wales of Health continues to work on the definitions, and highest in South East Wales. Zero point training needs and skill mix of new roles such five is considered a good UHU, but the Trust’s as Community Paramedic and Emergency Care UHU was some way below this level. Practitioner. The Trust will need to monitor this Developing a new culture developing agenda and determine the optimum mix of new roles, develop specific solutions to 3.53 Organisational culture (‘the way we do meet the particular needs of individual localities things round here’) has a very great effect on and develop existing skills and experience. organisational performance. There are concerns about the culture of the Trust. To remedy 3.55 The Trust will also need to review its these requires changes in culture, yet in any management structure, assess the capability organisation that is not something that can be of those in existing management positions and done quickly or by direct means. Some particular simplify structure, roles and accountabilities issues where action is needed are as follows: within the Trust. The draft modernisation plan recognises these issues and refers to a workforce planning; designing organisational structures with clear responsibilities which will be measured to b realising the intended benefits meet demanding patient-focused and financial from Agenda for Change; measures. It also refers to providing training for line managers and team leaders in basic c establishing appropriate roles management techniques and leadership. for HQ and the Regions; Realising the intended benefits d communication and engagement from Agenda for Change with staff; and 3.56 Agenda for Change is the new UK NHS e change management capability. pay agreement which aims to simplify pay scales and structures, ensure employees Workforce planning are rewarded for good work and are given

3.54 Ambulance services are delivered by people, opportunities to develop and progress. It and wages represent 74 per cent of ambulance seeks to modernise ways of working by service costs. Consequently, robust workforce offering staff more opportunities to take on

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4340_WAO Amb ENG_v0_14.indd 118 29/11/06 11:04:30 Figure 39: The annual cost of Agenda for Change at the Welsh Ambulance Services Trust is higher per whole time equivalent than at other Welsh trusts 10

9 8,788 8

3 £ 000 Cost of A4C per WTE 2

1 1,408 1,181 1,181 1,179 1,145 1,127 1,089 1,044 1,014 1,011 1,002 994 854 0 835

Trusts WAST Gwent Velindre Swansea Powys LHB Cardiff & Vale Carmarthenshire Bro Morgannwg Ceredigion & MW North Glamorgan North East Wales North West WalesPembs & Derwen

Pontypridd & Rhondda Conwy & Denbighshire Source: Wales Audit Office

greater responsibility and reward them for funding provided by the Assembly Government it. The contract was negotiated nationally to meet the costs of Agenda for Change. for the UK with the Department of Health However, as assimilation has progressed, cost and applied locally. The contract applied estimates are becoming increasingly accurate from 1 October 2004 for staff on national and a more recent estimate suggests that contracts, with application to staff on local the funding shortfall for Agenda for Change is contracts dependent on whether and when around £5.4 million. This significant funding gap they chose to take up the new contract. highlights the need for service modernisation.

3.57 Figure 39 shows that the cost of Agenda for Change The Trust has not yet realised any has been much higher for the Ambulance Trust benefits from Agenda for Change than for other Welsh trusts. This is consistent 3.59 In order to deliver realisable benefits from with other UK ambulance services. Agenda for Change, NHS bodies were expected to establish new ways to deliver services 3.58 The high cost of Agenda for Change has which the Agenda for Change contract was increased expenditure on salaries and wages supposed to facilitate. In the Trust, however: in the Trust by 29 per cent. This high figure is attributable to the enhancement – up to ■ consistent with other NHS trusts, the Trust 25 per cent – payable to staff for their unsocial did not compile a Benefits Realisation hours. Figure 40 shows that the Trust’s estimates Plan until July 2005, 10 months after of the cost of Agenda for Change, shown the contract came into effect; and in its 2004/2005 and 2005/2006 financial statements, suggests a funding shortfall of just below £4 million compared with additional

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4340_WAO Amb ENG_v0_14.indd 119 29/11/06 11:04:33 Figure 40: Estimated costs of Agenda for Change

2004/2005 2005/2006 Total (£m) (£m) (£m) Cost 6.34 14.8 21.2 Funding 4.78 12.5 17.3 Variance 1.56 2.3 3.9

Source: Wales Audit Office

■ there were no detailed plans or significant implementation have seriously compromised the actions taken to date to address key areas already limited capacity of the HR department where modernisation was required. to deliver other elements of its functions.

3.60 Currently, there is very little progress 3.64 Although many of these issues were not on addressing the changes needed in wholly in the hands of the Trust, they provide working practice and culture to deliver examples of the impact that the variable the potential benefits of modernisation procedures and working practices the Trust under Agenda for Change. has had. One key example is the failure to put in place updated job descriptions for each The Trust has been slow to implement role throughout the Trust since the formation Agenda for Change of the Trust from its three predecessors. 3.61 The new contract was effective from 1 October 2004, with a target to have all staff assimilated 3.65 One key condition of the contract is the by 30 September 2005 and all staff to have a payment of enhancements for those working review under the Agenda for Change knowledge unsocial hours as part of their normal working and skills framework by 30 October 2006. week. Unsocial hours and shift overruns were previously bought out and included in basic 3.62 The Trust has not met this timetable for a number pay in the late 1980s. However, the national of reasons, many of which are outside its control, agreement did not take sufficiently into account, and at 19 October 2006, some two years after the specific circumstances of ambulance the effective date of the contract, 31 per cent services. Because the Trust did not argue that of staff remain unassimilated and are still being unsocial hours were already part of existing paid under the old contract. It should be noted basic pay arrangements, staff have been paid that trusts across Wales have experienced for unsocial hours and shift overruns again. implementation delays – at the end of September 2006, the Trust had the fifth highest proportion 3.66 In addition, the current inclusive meal of staff assimilated within Wales and has caught break policy comprises capacity and does up substantially during the current financial year. not conform with the national agreement on Agenda for Change which requires 3.63 Figure 41 shows the key assimilation tasks meal breaks to be exclusive. The inclusive under Agenda for Change, the current position meal break policy further compromises at the Trust and some of the factors which have capacity and makes it more difficult for the contributed to the delays. The difficulties in Trust to match supply and demand.

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4340_WAO Amb ENG_v0_14.indd 120 29/11/06 11:04:34 Figure 41: Delays in implementing Agenda for Change at various stages of assimilation

Assimilation Task Position at Trust Other complications

Update and agree job description for A large number of out of date job NHS Staff Council arbitration was each post where required descriptions led to additional work required to resolve the failure to and delays right at the start of agree paramedic job descriptions the project Using national profiles evaluate each Relatively few national profiles post and weight to calculate its could be used for Trust posts points score so many had to be individually evaluated, weighted Where there is no national profile for and scored. post, evaluate locally Local job evaluation took significantly longer than at other trusts. Using the points score match each Job matching was less successful Additional consultation with PMU post to the appropriate pay band and and lengthier than other trusts. was required after failure to agree consistency check each matched post On Pay Modernisation Unit (PMU) paramedic and EMT job matching. advice, a second matching panel was established. Pay on new rate and calculate and Payroll resource at North The Trust is tied into the payroll pay arrears East Wales Trust (NEWT) was contract at NEWT due to new inadequate: Electronic Staff Record. • NEWT over estimated processing capacity by over 200 per cent (650 versus 200 per month); and • arrears payments had to be made in house by Human Resources as a consequence

Source: Wales Audit Office

Ensuring that Trust headquarters and East Wales. The location of headquarters is a the regions have appropriate roles matter for the Trust Board and the Assembly Government. Nevertheless, the location 3.67 A significant number of people who provided of headquarters is clearly a widespread evidence to the Inquiry team expressed concern. However, we did not find that the the view that the Trust’s headquarters was location of headquarters in St Asaph was inappropriately located in St Asaph as this a primary driver of the Trust’s problems. was too far from the majority of the Trust’s activity and political decision-making in South-

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4340_WAO Amb ENG_v0_14.indd 121 29/11/06 11:04:36 3.68 However, we found problems in the relationship each other’s trust. He also highlighted the between headquarters and the regions. There importance of high quality information on was excessive involvement from headquarters which to base partnership working with the in operational matters of detail and too little staff side – if there is good quality information, empowerment and accountability in the for example, about matching demand and regions. This may well reflect wider issues of supply, the staff side is much more likely to management capacity both at the centre and in support and commit to change than if the the regions, as well as an excessively complex case for change is less clear. It is encouraging and muddled organisational structure. There is that the staff side of the Trust will sit on the a need to review the Trust structure to develop newly constituted Modernisation Committee. a more strategic Trust headquarters providing direction, leadership and policy, with empowered 3.72 One of the key challenges is to ensure that regions delivering against these priorities, with staff clearly understand the new modernisation strong accountability to the corporate centre. plan and commit to its delivery, both across the organisation and on an individual basis. 3.69 If such a structure could be developed it would The modernisation plan will use a CD‑ROM provide the advantages sought by those who education package to explain the new consider that the ambulance service in Wales modernisation plan, the reasons for it and should be delivered by three separate trusts its intended benefits. There will also be staff without the disadvantages that would flow workshops to discuss the draft plan. The plan from breaking up the existing single trust. contains a section about communications, which states the communications vision, Communication and engagement ‘to create an environment in which people feel informed, support our values and understand 3.70 Poor communication is frequently cited the part they play in or with the organisation’. as a problem in organisations. In the Trust that problem is compounded by inherent 3.73 In addition, to develop ownership and difficulties of communicating with a dispersed accountability for delivering the new strategy, the workforce many of whose work takes them Trust will need to develop effective performance away from a base for long periods of time. management arrangements that clearly link As we were often told that the Trade Unions the modernisation plan with individual staff communicated much more effectively with objectives and personal development. This has staff than the Trust, there must be scope for been a serious weakness of the Trust and is a the Trust’s management to overcome the difficult area to address. The draft modernisation inherent communication difficulties that exist. plan recognises this weakness and includes as one of its strategic objectives, ‘to develop 3.71 Our visit to East of England Ambulance Trust an improvement culture that underpins and showed that effective partnership working with drives continuous service improvement through the staff side had been a core component the timely delivery of appropriate and effective of turning around the former East Anglia performance management information’. service after its own public inquiry in the late 1990s. The Chief Executive informed 3.74 One of the main concerns of staff responding us that the development of very mature to our survey, participating in our focus partnership working took time and required groups or who spoke to our team, was both management and the staff side to earn that management did not listen to them or

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4340_WAO Amb ENG_v0_14.indd 122 29/11/06 11:04:37 take action when they raised suggestions, committee will play a key role in ensuring that concerns or ideas about improving the Trust. the modernisation plans, delivery of efficiencies They also expressed concern about slow through the SCEP and capital investment plans decision-making and difficulties obtaining are properly co-ordinated and managed. decisions at all. Part of the communications section of the draft modernisation plan 3.77 Recognising the fundamental importance of states that the Trust will encourage feedback project and programme management, the from staff and will guarantee a response. Trust’s draft modernisation plan includes a In addition, the modernisation plan includes strong emphasis on project management. mechanisms to accelerate decision making. The plan focuses on training key staff in project management and developing business Change management capability cases. The modernisation plan also addresses the key issue of managing performance 3.75 Implementing the modernisation plan will involve in delivering the plan. A performance significant change to the Trust, and the system dashboard will be developed to measure key within which it operates. The draft modernisation strategic aspects of delivering the strategy plan rightly recognises the importance of at corporate, regional and locality levels. effective change management, which has been an historical weakness of the Trust. In particular, Addressing a difficult financial position it is encouraging that the plan recognises the importance of delivering the plan through The Trust is forecasting an in-year deficit programme management techniques and and is in the process of agreeing a Strategic proposes to use an established methodology, Change and Efficiency Plan (SCEP) Managing Successful Programmes, developed by the Office of Government Commerce. It will 3.78 There have been ongoing discussions between be essential to define the intended benefits of the Trust and Assembly Government about the the change programme, to co-ordinate individual Trust’s forecast deficit. A draft SCEP of July projects, and to schedule the various activities in 2006 was built on some significant assumptions an appropriate and deliverable order of priority. which did not consider all financial pressures. In October 2006, following discussions with HCW 3.76 The Trust has created a programme manager and the Welsh Assembly Government, and a role to oversee the delivery of the draft more detailed analysis of the Trust’s financial modernisation plan and will establish plans position in the context of the modernisation with dated milestones and clear executive, plan, the Trust produced a revised draft SCEP. senior management and staff accountabilities. The Trust has further addressed governance 3.79 The revised October 2006 draft SCEP arrangements by creating a new Modernisation appropriately excludes the unconfirmed Committee of the Board to support the process funding for the £3.2m vehicle leasing costs and communicate internally and externally. and includes the efficiency savings that are The Modernisation Committee will also be required by HCW. Trust officers also told us responsible for overseeing the Strategic that they had agreement in principle from the Change and Efficiency Plan (SCEP) process, Welsh Assembly Government that capital so that modernisation activities align with charges arising from their significant capital downstream savings and efficiencies. The investment in the modernisation plan would be fully funded and so have excluded these

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4340_WAO Amb ENG_v0_14.indd 123 29/11/06 11:04:39 Figure 42: Financial position as proposed in the Trust’s October 2006 draft Strategic Change and Efficiency Plan

2006/2007 2007/2008 2008/2009 2009/2010 2010/2011 2011/2012 Opening deficit before savings £12.0m £14.4m £17.0m £20.1m £20.2m £20.2m Total Savings £5.4m £12.4m £17.0m £23.0m £23.1m £23.1m Financial positon –£6.6m –£2.0m £0.0m £2.9m £2.9m £2.9m

Source: Wales Audit Office, based on WAST draft SCEP October 26th 2006

costs from the plan. Through more detailed The SCEP needs to be delivered financial analysis the Trust has also concluded over a reasonable timescale that some of the cost pressures included in the original SCEP were lower than previously 3.81 To date, the Trust has still been unable to thought and that significant efficiency savings agree the revised SCEP with the Welsh could be achieved from modernisation, in Assembly Government. Given that eight particular from demand analysis work that months of the financial year have passed, should match resources more closely to the Trust is unlikely to meet its statutory demand. In consideration of all of these factors, financial target to break even in 2006/2007. the Trust is proposing a financial recovery plan to break even by 2008/2009. Figure 42 sets out 3.82 Although there is clear scope for the Trust to the Trust’s financial position as documented operate more efficiently, further investment in the revised October 2006 draft SCEP. of capital and time will be needed to secure the additional income and release the 3.80 The Trust’s financial analysis and the draft SCEP significant efficiencies, as set out in the Trust’s are still evolving and, as a result, we have been modernisation plan and assumed in the revised unable to conclude whether all the values, in October draft SCEP. The Trust has identified particular the significant efficiency savings, in the that primary efficiencies and income generation current draft plan are robust. We identified that will result from roster reviews and improving the revised October draft SCEP still excludes the alignment of supply and demand, reviewing the projected funding gaps associated with the the skill mix of front-line staff to offer more ARRP project (paragraph 3.89), although Trust efficient service delivery options and selling officers have stated that negotiations are ongoing paramedic skills in rural areas to LHBs as with the Welsh Assembly Government and the part of DECS. Consequently, it is important contract providers to eliminate these deficits, in that the SCEP eventually agreed between the conjunction with the projected savings in later Trust and Welsh Assembly Government sets years. The October draft SCEP also continues to out a realistic timeframe in which to deliver exclude the resolution of the Trust’s underlying financial efficiencies and generate additional £1.4m income and expenditure reserve deficit. income, and that this timeframe is consistent with the Trust’s modernisation plan. One

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4340_WAO Amb ENG_v0_14.indd 124 29/11/06 11:04:40 positive step in this respect is the establishment 3.86 The Trust’s recent modernisation plan by the Trust of a Modernisation Committee has recognised the need for a robust responsible for managing the SCEP process. communications infrastructure and identifies the implementation of ARRP as one of the The Ambulance Radio Re-Procurement strategic objectives. Consequently the Trust is Project is a financial risk in discussion with the Assembly Government and is in the process of submitting an updated 3.83 The Ambulance Radio Re-procurement Project business case to seek approval to proceed (ARRP) was set up to replace the Trust’s to contract signature. The update states that existing analogue radio network with a digital contractual issues have been resolved and communications system. The Trust’s current provides updated financial information to reflect system uses radio and microwave frequencies recent changes in the service infrastructure, such that will no longer be available for use from as the additional 40 rapid response vehicles, April 2009. This is an issue for all ambulance changes to implementation plans (caused by services across the UK. Following a tender the delay of contract agreement) and changes exercise on behalf of England and Wales in to the contract as a result of the contractor’s 2004/2005, Airwave Mm02 was selected as experience in England. The revised plan the preferred supplier of the digital system. continues to refer to concerns about affordability.

3.84 In April 2006, the Trust submitted a financial 3.87 The delay in signing the contract has resulted business case to the Welsh Assembly in the re-profiling of the implementation plans Government for the ARRP in Wales. The for the Trust’s three regions. The impact Assembly Government approved the business of this new plan is that completion will be case in principle in May, subject to the delayed by six months. However, assuming resolution of outstanding contractual issues contract signature in December 2006, and a solution to concerns about affordability. this will result in the new network being in place in time to meet the 2009 deadline for 3.85 Progress in finalising the business case release of microwave link frequencies. was then delayed by changes to the Trust’s management arrangements. Mr Thayne called 3.88 The original business case recommended for a review of control room locations and the lease option as the most cost effective, of front line operational procedures, both of with a total cost over 13 years of £56 million which affected the design of the ARRP solution which subsequently reduced to £54 million. and the contract costs. Both proposals have The revised business case confirmed the lease since been abandoned. Delays have also been option as the most favourable but reduced the attributed to the merger of English ambulance projected costs to £54 million to incorporate services and the contactor’s reluctance the changes since the original submission to provide final prices to the Trust until the (Figure 43). These changes include: impact of these changes on Wales are better understood. The contractor has indicated that ■ re-profiling of project costs and this will not be resolved until November 2006. revenue savings to meet new implementation timescales;

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4340_WAO Amb ENG_v0_14.indd 125 29/11/06 11:04:42 Figure 43: Costs of the Ambulance Radio Reprocurement

£ Lease Option total cost from 2006/2007 – 2018/2019 54,262,382 Committed Welsh Assembly Government Funding 45,421,325 Proposed revenue release from the Trust 9,333,953 Additional Funding Requirement 492,896

Source: Wales Audit Office

■ re-assessment of contingency budgets intended and were in fact revenue costs to be (the contingency set aside to cover the met out of revenue funding. This caused the additional cost to the Trust should England Trust significant financial pressure to manage terminate has been removed); and this unplanned revenue cost at year end.

■ development of a third repayment option 3.91 The Trust states that it is on target for by Airwave MmO2 which allows for a 2006/2007 to incur the £1.5 million project flat repayment profile in an attempt to costs in accordance with the revised project overcome the affordability issues in plans. In the absence of formal approval of Years two and three of the contract. the revised business case the Assembly Government has confirmed in discussions with 3.89 While the total additional funding requirement the Trust that it will fully fund these costs. is reported as £493,000, this is the net position over the life of the project and includes 3.92 There are a number of key risks that significant funding surpluses and deficits year the Trust will need to manage over the on year. Consequently, there are significant coming years in respect of ARRP: affordability issues arising for the Trust, notably in 2008/2009 where the Trust has projected a The new network being in place in time a £7.5 million funding gap. The Assembly to meet the 2009 deadline for release of Government has stated that it would be unlikely microwave link frequencies is dependent to be able provide the additional funding on contract signature in December 2006. from its existing resources. The Trust and b The contractor has indicated that as Assembly Government are considering this a result of the changes to the English issue in the context of the Trust’s SCEP. ambulance organisational structure and

3.90 By the end of 2005/2006 the Trust had already the uncertain impact on Wales, final costs incurred £1.4 million of set up costs. These will not be resolved until November 2006. are not included in the above project costs. c The projected funding needs for ARRP The Trust had originally intended to capitalise are dependent on the Trust generating these costs on the presumption that the project significant savings from 2009/2010. would be capital expenditure. The Trust’s external auditors advised that these costs could not be capitalised as the Trust had

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4340_WAO Amb ENG_v0_14.indd 126 29/11/06 11:04:43 d The project predicts significant funding e The contingency previously set aside deficits in some years. Of most concern is to cover the additional cost to the Trust a funding gap of £7.5 million in 2008/2009. should England terminate (£1.5 million) has The Welsh Assembly Government has been removed from the contract costs. stated it would be unlikely to be able to provide the additional funding from Accessing and making good use within its existing resources. The Trust of the available capital and Welsh Assembly Government are considering the issue in the context 3.93 While capital expenditure over recent years of the Trust’s impending SCEP. has been comparable with other ambulance trusts, it has not been explicitly aligned to

Figure 44: The latest projected 10 year capital investment plan

Capital spend over 10 years Discretionary Capital £m Vehicles 82.8 Estates 9.1 ICT 8.4 Medical Equipment 20.0 Total 120.2 Less discretionary capital due from Welsh Assembly Government –48.0 Discretionary Capital Shortfall 72.2 Modernisation Requirements Vehicles 4.9 Estates 39.0 ICT 14.5 Project Support 1.0 Total Modernisation Requirements 59.4 Total Capital Requirement 131.6 Capital Receipts 0.0 Net Capital Requirement 131.6 Capital Charges 105.3

Source: Welsh Ambulance Services NHS Trust, Strategic Outline Plan

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4340_WAO Amb ENG_v0_14.indd 127 29/11/06 11:04:45 any long-term strategy, revenue efficiencies Improving the estate or plans to modernise the service. Annual transfers of capital funding to revenue and poor 3.97 The Tribal Secta report proposed a new service/ capital investment decisions have resulted estates model for the Trust based around a in a weak capital infrastructure. Estates, structure of main ambulance stations, ambulance vehicles, IT and communications require capital stations, shared facilities and deployment investment to provide a modernised service. points (Figure 45). Reflecting the Tribal Secta model, the Trust’s draft modernisation plan 3.94 The Welsh Assembly Government has indicated and new estates strategy centre on three that capital funds could be made available types of operational location, namely: and the Trust Chief Executive has produced a capital investment plan, linked to the draft ■ Super stations: current plans are for modernisation plan, for £132m over the next 17 super station depots to be established ten years. This bid has yet to be submitted to, on new or existing sites around Wales, or accepted by, the Assembly Government. to include vehicle maintenance facilities. Figure 44 shows the total capital requirement For example, proposals for a super station set out in the strategic outline case supporting in Wrexham are likely to lead to a new the draft modernisation plan. It is imperative shared facility with the police and fire service that, in contrast to the Trust’s previous capital on the existing ambulance station site. management, there are clear and explicit links between the use of capital and the overall ■ Standby points: these are likely to be a strategy, and that individual capital investments combination of some existing ambulance are supported by robust business cases. stations and shared facilities. In some cases these points may consist of little more 3.95 These capital requirements are currently than portacabin style accommodation; broad estimates to support the themes in the Trust’s draft modernisation plan. They are not ■ Response points: equivalent to yet supported by business cases or explicitly the deployment points described aligned to detailed operational plans to support in the Tribal Secta model. the modernisation plan. The requirements are 3.98 The final number and location of standby and therefore potentially subject to considerable response points will need to be determined change. As a result, while this inquiry has on the basis of wider demand analysis but identified that the Trust is in need of capital rationalisation of the existing estate, whether investment, it is too soon to conclude through the total closure or scaling down whether these indicative plans are robust. of certain sites, is inevitable. Nevertheless, based on the experience of the Scottish 3.96 In light of the Trust’s problematic history with the management of capital, it will need Ambulance Service, it is likely that the use to ensure that the necessary management of response points in preference to standby arrangements and procedures are in place points will be more practical in urban and are followed, to ensure that these capital areas of high demand (Case Study R). investment decisions are based on sound business cases and derived from the Trust’s overall strategy and detailed operational plans.

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4340_WAO Amb ENG_v0_14.indd 128 29/11/06 11:04:46 Figure 45: Service/estate model proposed by Tribal Secta

Main Ambulance Station

• a large station housing emergency ambulances, patient transport vehicles and rapid response vehicles, however, the sizing will be dependent on catchment area and projected demand; • provide a base for up to 100 + staff, who will start and finish their shift at the main ambulance station; • provide overnight parking for vehicles; • provide staff and training facilities; and • some of the main stations will also provide a minor vehicle maintenance service. Ambulance Station • house some emergency ambulances, patient transport vehicles and rapid response vehicles; • provide a base for staff who do not live within a reasonable distance from a main ambulance station; staff based here will start and finish their shift at the ambulance station; • provide overnight parking for a limited number of vehicles; and • provide staff rest facilities and storage space. Shared Facility • a shared premises with either the Fire service, Police service or other healthcare partner; • each day vehicles would travel from either a main ambulance station or an ambulance station at the start and end of a shift; • provide a temporary base for emergency vehicles between calls; • provide staff rest facilities and a small amount of storage space; and • a shared facility will not act as a staff base Deployment Point • an identified location for WAS vehicles to be parked; • located in strategic positions to enable ease of access to areas of high/known; • demand; and • a deployment point, therefore, has no infrastructure or associated cost.

Source: Tribal Secta report, Review of the Welsh Ambulance Services Trust Operational Estate, March 2006

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4340_WAO Amb ENG_v0_14.indd 129 29/11/06 11:04:48 3.99 Development of this new service/estate way as to ensure value for money. The model is long overdue and broadly reflects the Trust has recently appointed a capital approach to modernising ambulance services. project planning manager on a temporary Nevertheless, there is still a considerable secondment to oversee this process but amount of work to be done to turn these plans procurement and project management into reality, and the Trust will face a number of are both areas where the Trust has been significant challenges along the way, notably: found wanting in the past (paragraph 2.102 and paragraphs 2.195-2.207). ■ Securing the necessary capital investment to implement the strategy – the Trust’s ■ Managing the impact on staff – the current estimates suggest a total cash new service model will introduce new requirement of £9 million over 10 years ways of working and, for some staff, from April 2006 in discretionary capital to imply longer travel distances between deal with general maintenance, and almost their homes and bases of work. £39 million over five years from April 2007 to modernise the estate (Figure 44). ■ Managing public expectations – in rural areas in particular, the presence of local ■ Effective project management of ambulance stations is often regarded as the estates modernisation process an integral part of the community and, – including the disposal of buildings and as with wider reorganisation of the NHS procurement of new buildings in such a estate, moves to close existing buildings are likely to attract public concern.

Case Study R: The Scottish Ambulance Service – stations and meal breaks

The Scottish Ambulance Service has more ambulance stations in rural areas to reflect the lower levels of activity and the need for crews to have a place to spend their time when not on calls. In urban areas where activity is higher, there are fewer stations because crews spend the majority of their time on calls or at deployment points. Stations in urban areas are predominantly a place for crews to change and collect their vehicle and equipment. In order to afford the service greater flexibility and to avoid the difficulty with crews having to return to stations for meal breaks, all new employment contracts state employees ‘place of work’ as a designated area rather than a particular station.

Source: Wales Audit Office visit to Scottish Ambulance Service.

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4340_WAO Amb ENG_v0_14.indd 130 29/11/06 11:04:49 Appendix 1: Methodology

1 The Terms of Reference set by the National Nia Davies Assembly appeared to the Auditor General to Mari Wyn Roberts be consistent with the use by him of his powers Mark Jeffs under Section 145A of the Government of Wales Martin Peters Act 1998 (as inserted by the Public Audit (Wales) Paul Cunningham Act 2004) Studies for improving economy, Rachel Harries efficiency and effectiveness in the discharge of Stephen Lisle the functions of any relevant body or bodies’. Sue Henry

2 The study was carried out by the Auditor 3 We followed a broad methodology during the General supported by a large multidisciplinary inquiry. This fell into the following broad areas: team of Wales Audit Office staff as follows: a document review; Core team: Gill Lewis b data analysis; Jackie Joyce Lucy Evans c public hearings, written Martin Gibson submissions and public views; Matthew Mortlock Rob Powell d semi-structured interviews within the Trust;

With additional contibutions from: e semi-structured interviews outside the Trust; Ann Mansell Anthony Logan f focus groups; Christine Henry Catrin Sion g surveys; Chris Bolton Clare Stevens h comparative visits; Deirdre Brennan i visits and observation to the Dave Rees Trust’s three regions; and Ena Lloyd Gareth Lewis j clinical governance work of Heledd Daniel Healthcare Inspectorate Wales. Helen Thom Iolo Llewellyn 4 We also established a panel of experts to Kate Powell advise the Inquiry team at key stages. Details Laura Towler of the panel can be found in Appendix 2. Linda James Lisa Smyth

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4340_WAO Amb ENG_v0_14.indd 131 29/11/06 11:04:51 Document review Public hearings, written submissions and public views 5 We reviewed a wide range of documentation about the ambulance service in Wales. 9 Because of the public nature of this assignment, We looked at a number of trust documents, we also ran eight public hearings at which which included strategies, business planning any member of the public could give oral documentation, external reviews of the Trust, evidence about ambulance services in policies and procedures, minutes of meetings Wales. The hearings took place in: of the Board and its related committees, of meetings between management and the ■ Swansea; staff side, documents relating to operational processes and a range of other documents. ■ Newport;

6 We also reviewed a number of external ■ Llandrindod Wells; documents that included the benchmarking report produced by Mr Thayne, the Commission ■ Carmarthen; for Healthcare Improvement (CHI) clinical ■ Bangor; governance review, the reports to Mrs Lloyd provided by Mr Thayne and Dr van Dellen upon ■ Cardiff; their resignations as interim Chief Executive, reports by the external auditors, CHC reports on ■ Wrexham; and the ambulance service in Wales, performance management reports produced by the Welsh ■ Aberystwyth. Assembly Government’s Department for Health and Social Services North Wales 10 The hearings served two primary objectives: Regional Office, and a series of documents a to inform and consult the public about relating to commissioning on ambulance our approach to the Inquiry; and services by Health Commission Wales. b to provide an opportunity for the Data review public to present evidence to the Auditor General in a public forum. 7 We requested a wide range of data from

the Trust and Assembly Government, 11 The hearings followed this broad agenda: focusing particularly on financial and performance information. This involved a a an introductory presentation by the Inquiry review of published data on response times, team about the questions the Inquiry was performance, utilisation of resources, costings, to address and the methodology to be financial performance and productivity. followed; this included the opportunity for those attending the hearings to ask 8 We carried out a detailed analysis of questions about the Inquiry; and overtime payments, sickness absence data, expense claims, hospitality and HR files.

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4340_WAO Amb ENG_v0_14.indd 132 29/11/06 11:04:52 b an opportunity for those attending Semi-structured interviews the hearings to speak publicly about outside the Trust their experiences of, and views about, ambulance services in Wales. 17 We interviewed many stakeholders of the ambulance service in Wales. In particular, we 12 The public hearings had mixed levels of interviewed all of those who have been Chief attendance but provided useful feedback Executive of the Trust since November 1998. for the inquiry team. The Wales Audit We interviewed key employees of HCW, the Office website (www.wao.gov.uk) contains Assembly Government (separate interviews a verbatim transcript of each hearing. with the Head of the Department for Health and Social Services and Chief Executive of the NHS, 13 We set up a number of other channels of Directorate of Performance and Operations communication, so that members of the public and the North Wales Regional Office), and the could contribute to the Inquiry. These included: Project Manager for the ORH review. We also a a web-based form which 46 members spoke to, or corresponded with a number of of the public completed; trusts, LHBs and Community Health Councils.

b a freepost address for the inquiry; and Focus groups

c a facility for the public to telephone the 18 We conducted a focus group attended by Inquiry team. four members of the All-Wales Ambulance Group of Community Health Councils. 14 During the course of the inquiry, we received over 30 written or telephone submissions from 19 We conducted a number of focus groups members of the public or groups representing within the Trust, using focus group software stakeholders of the Welsh ambulance service. that enables participants to submit anonymous views, to see the views of other participants 15 We are extremely grateful to all of those and to assign priority to them. Our focus groups contributing to the inquiry, whether by sought to identify problems within the Trust, attending the public hearings, writing and to propose and prioritise solutions to those to us or making telephone contact. problems. We held one focus group, attended by 15 of the local ambulance officers. We also Semi-structured interviews held two focus groups in each of the three within the Trust regions of the Trust, attended by a regional cross-section of around 20 staff. We have 16 We conducted a wide range of semi-structured provided the new Chief Executive of the Trust interviews with employees of the Trust covering with a summary of the results of this exercise, a wide range of issues pertinent to ambulance particularly the ideas for improvement. services in Wales. We also interviewed the current and previous Chairs of the Trust and each member of the current Board. We also interviewed trade union representatives as well as individual members of staff.

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4340_WAO Amb ENG_v0_14.indd 133 29/11/06 11:04:54 Surveys (which includes the former East Anglia service), and members of their teams, for their very 20 We carried out three surveys positive and helpful attitude towards this inquiry. as part of our fieldwork: We also visited Staffordshire Ambulance Service to interview Dr van Dellen, and are ■ a survey sent to the home address grateful to him and Geoff Catling, acting Chief of all employees of the Trust – we Executive, for taking the time to demonstrate received 860 responses, a response their information systems to our team. rate of 34 per cent, spread evenly across the three regions of the Trust; Visits and observation in the

■ a survey sent to A&E consultants in the three regions of the Trust Welsh acute trusts and the three main 22 We sent teams into each of the Trust’s three English trusts which take Welsh patients regions for one week. They visited a number in their A&E department – we received of ambulance stations, spent time in the 13 responses out of 18 consultants; and regional headquarters examining records and interviewing key staff, held three drop‑in sessions ■ a survey sent to outpatient managers at the Welsh acute trusts and the three at different locations in each region, interviewed main English trusts which take Welsh staff in all of the control centres, visited local A&E outpatients – we received four responses. departments and, in some cases, travelled on ambulances with crews to observe their work. Comparative visits Clinical governance work of 21 We were keen to learn from the experience of Healthcare Inspectorate Wales other ambulance services to inform our findings and, in particular, our recommendations. 23 In the spirit of the Healthcare Concordat, we We conducted visits to two other ambulance worked very closely with our colleagues from services – Scotland and East Anglia. HIW, who were simultaneously conducting We selected Scotland because it is a a clinical governance review of the Trust, national service operating under a devolved also focusing on patient care services administration, facing many similar challenges and Mr Thayne’s claim that 500 lives were in terms of rurality as Wales, and where the avoidably lost each year as a result of the National Audit Office published a review of way the Trust operates. We drew on their the service in 1998. We selected East Anglia findings to inform this review in respect of because it is a highly rural service, was the clinical results, clinical processes, clinical subject of an official inquiry in 1998, and leadership, clinical governance and patient it has been at the forefront of developing care services, although it will be for their report new service models in rural areas and new to conclude on the extent to which improved approaches to commissioning ambulance performance could have saved lives. services. We are extremely grateful to Adrian Lucas and Chris Carney, Chief Executives of the Scottish Ambulance Service and the East of England Ambulance Service respectively

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4340_WAO Amb ENG_v0_14.indd 134 29/11/06 11:04:55 Appendix 2: Expert panel

1 As is customary for examinations of this type, ■ provide guidance and expertise we established a panel of experts to advise on specific issues relevant to their the Inquiry team. Although the panel had experience as we required it. no executive powers over the inquiry, they provided advice and guidance at key stages. 2 The inquiry team is extremely grateful to all In particular, we invited panel members to: members of the expert panel for their extremely helpful advice and guidance. Our expert ■ comment on the scope of the review panel was made up of the following people. and proposed methodology;

■ attend a meeting to discuss in detail our emerging findings, key issues on which we required expert advice and recommendations; and

Peter Bradley CBE Peter emigrated from England to New Zealand in the 1970s where he worked for the Commercial Bank of Australia prior to joining the Ambulance Service in Auckland. Chief Executive Officer, London Having spent a number of years as a Paramedic, Peter worked his way up through Ambulance Service NHS Trust management and in 1992 was appointed Chief Ambulance Officer of the Auckland and National Ambulance Advisor, Ambulance Service. In 1997 he was appointed Director of Operations of the London Department of Health Ambulance Service and in 2000 was appointed Chief Executive. In 2004 he was also appointed National Ambulance Advisor with the Department of Health. Peter holds a MBA from the University of Otago, is a Fellow of the New Zealand Institute of Management, was President of the Ambulance Service Association in 2003/2004 and in 2005 was awarded a CBE for his services to the NHS. Professor Tim Coats Tim Coats is Professor of Emergency Medicine in Leicester, UK. He trained in Emergency Medicine in Leeds and London and was appointed Senior Lecturer Leicester University in Accident, Emergency and Pre-Hospital Care at the Royal London Hospital in Whitechapel in 1996. He moved to his present post in December 2003. His research interests are the coagulation system following injury and the conduct of randomised trials in Emergency Care. He chairs the College of Emergency Medicine Research Committee, and is a member of the Executive of the Trauma Audit and Research network, a member of the Council of the College of Emergency Medicine and a trustee of BRAKE (a road safety charity).

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4340_WAO Amb ENG_v0_14.indd 135 29/11/06 11:04:57 Mandy Collins Following a career in audit, specialising in special exercises and investigations, Mandy joined the then NHS Directorate of the Welsh Assembly Government in 1998 Director of Investigations and to help establish a new performance management division. As Head of Performance Development at Healthcare Management Policy Development she took a lead role in the development of the Inspectorate Wales performance management framework for NHS Wales including the NHS Wales Balanced Scorecard and annual Service and Financial Framework (SaFF) targets. Mandy is a Fellow of the Institute of Internal Auditors and Vanderputt and Peter Hook prizewinner. Richard Diment Richard Diment has been Chief Executive of the Ambulance Service Association, the national representative body for NHS ambulance trusts, since 2000. Richard was Chief Executive, Ambulance brought up on Anglesey and took a degree in economics at the University of Liverpool. Services Association Following graduation in 1977, he has spent nearly 30 years working in public affairs across a range of sectors including education, transport, construction and now health. His current role gives him wide knowledge of the current state and developing role of ambulance services across the UK. Richard is a member of the NHS Ambulance Radio Project Implementation Board, the NHS employers’ national assembly and a number of other cross-government committees and working groups. Professor Neil Goodwin Neil Goodwin operated at Chief Executive level in the NHS for over 20 years including six years at St Mary’s Hospital, London. His last job before leaving the NHS in MBA PhD September 2006 was Chief Executive of the Greater Manchester strategic health authority. During Neil’s time as Chief Executive the Greater Manchester NHS delivered all national access and financial targets as well as successful local strategic change, innovation and major capital investments. Neil has also been active nationally. He was the sole NHS representative in a government review of public services leadership; a member of ministerial advisory groups for pathology services and patient choice; and led production of the Department of Health report, Recognising, Understanding and Addressing Performance Problems in Healthcare Organisations Providing Care to NHS Patients. He has just been commissioned by the Department of Health to develop a new national leadership development framework for the NHS. Neil is visiting professor of leadership studies at Manchester Business School and honorary fellow of the University of Durham. His book, Leadership in Healthcare, is the first publication on leadership in a European context. In 2005 Neil announced that he would leave the NHS during the 2006 NHS restructuring to pursue a portfolio career.

Ambulance Services in Wales 136

4340_WAO Amb ENG_v0_14.indd 136 29/11/06 11:04:57 David Griffiths David Griffiths is the Ambulance and Emergency Care Advisor with the Healthcare Commission in England. Prior to joining the Commission David spent 30 years in the Ambulance and Emergency Care ambulance service starting in an operational role on accident and emergency duties. Advisor, Healthcare Commission During that time he worked in Devon, Yorkshire, Avon and Sussex. David spent six years as a Chief Ambulance Officer and a further nine years as the Chief Executive of Sussex Ambulance Service NHS Trust. Throughout his career David worked extensively with the Department of Health and the Ambulance Service Association of which he is an ex President. In 1999 David was the NHS executive professional advisor during an Inquiry into the East Anglia Ambulance Service. Councillor John McLennan Born and brought up in North Wales, Councillor McLennon started work at Abergele Hospital gaining a qualification in Thoracic and Tuberculosis diseases. He left to Chair of Conwy East CHC and become a Police Officer serving in Wrexham, Glynceiriog, and Holyhead port as Chair of the Board of CHC’s a Special Branch Officer. After 10 years he left to join the Ambulance service and in Wales qualified as Paramedic. He finally retired after 14 years’ service due to multiple lesions in his spine. Councillor McLennon is now an elected County Councillor for Conwy County Borough Council and a Town Councillor in Abergele. Peter Richmond Peter Richmond has been a Consultant in Emergency Medicine in Cardiff for over 17 years and was Clinical Director for over 14 years in one of the busiest Emergency Accident and emergency Units in the UK. He was National Clinical Lead of the Wales Emergency Care Access consultant, Cardiff and Vale Collaborative and is the BAEM Representative for Wales. NHS Trust

Ambulance Services in Wales 137

4340_WAO Amb ENG_v0_14.indd 137 29/11/06 11:05:00 Appendix 3: Response time performance by Local Health Board area

This appendix provides detailed response time performance by LHB area. It draws on quarterly data from April 2001 to June 2006, and provides for each of the 22 LHBs:

1 Category ‘A’ responses within eight minutes;

2 Responses within 14, 18 or 21 minutes for all Category ‘A’ and ‘B’ calls, depending on whether the LHB area is urban, rural or sparsely populated; and

3 GP urgent calls arriving no later than 15 minutes after the agreed time.

Each graph also shows the highest and lowest performing LHB area in each quarter.

Figure 3.1: The Trust’s target (shown in blue) and actual percentage (red if below target; green if above target) of Category ‘A’ calls responded to within 8 minutes: April 2005 – March 2006

80 Central and West Wales North Wales South East Wales

75 National target

60 WAG Milestone target

55 Percentage

Powys Conwy Cardiff Torfaen Swansea Bridgend Wrexham Flintshire Newport Ceredigion Gwynedd Caerphilly Denbighshire Methyr Tydfil CarnarthenshirePembrokeshire Isle of Anglesey Monmouthshire Blaenau Gwent Neath Port Talbot Vale of Glamorgan Rhondda Cynon Taff Source: Welsh Ambulance Services NHS Trust, Performance Review - March 2006

Ambulance Services in Wales 138

4340_WAO Amb ENG_v0_14.indd 138 29/11/06 11:05:01 Figure C1: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in the Isle of Anglesey

50 Percentage 40

Isle of Anglesey Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C2: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within the Isle of Anglesey

100 95 90 85 80 75

Percentage 70 65 60

Isle of Anglesey Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C3: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within the Isle of Anglesey 100

60 Percentage

Isle of Anglesey Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 139

4340_WAO Amb ENG_v0_14.indd 139 29/11/06 11:05:04 Figure C4: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Gwynedd

50 Percentage 40

Gwynedd Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C5: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Gwynedd

100 95 90 85 80 75

Percentage 70 65 60

Gwynedd Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C6: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Gwynedd 100

60 Percentage

Gwynedd Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 140

4340_WAO Amb ENG_v0_14.indd 140 29/11/06 11:05:05 Figure C7: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Conwy

50 Percentage 40

Conwy Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C8: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Conwy

100 95 90 85 80 75

Percentage 70 65 60

Conwy Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C9: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Conwy 100

60 Percentage

Conwy Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 141

4340_WAO Amb ENG_v0_14.indd 141 29/11/06 11:05:08 Figure C10: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Denbighshire

50 Percentage 40

Denbighshire Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C11: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Denbighshire

100 95 90 85 80 75

Percentage 70 65 60

Denbighshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C12: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Denbighshire 100

60 Percentage

Denbighshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 142

4340_WAO Amb ENG_v0_14.indd 142 29/11/06 11:05:10 Figure C13: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Flintshire

50 Percentage 40

Flintshire Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C14: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Flintshire

100 95 90 85 80 75

Percentage 70 65 60

Flintshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C15: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Flintshire 100

60 Percentage

Flintshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 143

4340_WAO Amb ENG_v0_14.indd 143 29/11/06 11:05:13 Figure C16: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Wrexham

50 Percentage 40

Wrexham Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C17: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Wrexham

100 95 90 85 80 75

Percentage 70 65 60

Wrexham Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C18: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Wrexham 100

60 Percentage

Wrexham Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 144

4340_WAO Amb ENG_v0_14.indd 144 29/11/06 11:05:15 Figure C19: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Powys

50 Percentage 40

Powys Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C20: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Powys

100 95 90 85 80 75

Percentage 70 65 60

Powys Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C21: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Powys 100

60 Percentage

Powys Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 145

4340_WAO Amb ENG_v0_14.indd 145 29/11/06 11:05:18 Figure C22: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Ceredigion

50 Percentage 40

Ceredigion Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C23: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Ceredigion

100 95 90 85 80 75

Percentage 70 65 60

Ceredigion Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C24: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Ceredigion 100

60 Percentage

Ceredigion Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 146

4340_WAO Amb ENG_v0_14.indd 146 29/11/06 11:05:19 Figure C25: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Pembrokeshire

50 Percentage 40

Pembrokeshire Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C26: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Pembrokeshire

100 95 90 85 80 75

Percentage 70 65 60

Pembrokeshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C27: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Pembrokeshire 100

60 Percentage

Pembrokeshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 147

4340_WAO Amb ENG_v0_14.indd 147 29/11/06 11:05:23 Figure C28: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Carmarthenshire

50 Percentage 40

Carmarthenshire Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C29: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Camarthenshire

100 95 90 85 80 75

Percentage 70 65 60

Carmarthenshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C30: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Carmarthenshire

100

60 Percentage

Carmarthenshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 148

4340_WAO Amb ENG_v0_14.indd 148 29/11/06 11:05:24 Figure C31: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Swansea

50 Percentage 40

Swansea Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C32: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Swansea

100 95 90 85 80 75

Percentage 70 65 60

Swansea Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C33: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Swansea 100

60 Percentage

Swansea Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 149

4340_WAO Amb ENG_v0_14.indd 149 29/11/06 11:05:27 Figure C34: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Neath Port Talbot

50 Percentage 40

Neath Port Talbot Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C35: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Neath Port Talbot

100 95 90 85 80 75

Percentage 70 65 60

Neath Port Talbot Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C36: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Neath Port Talbot 100

60 Percentage

Neath Port Talbot Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 150

4340_WAO Amb ENG_v0_14.indd 150 29/11/06 11:05:29 Figure C37: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Bridgend

50 Percentage 40

Bridgend Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C38: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Bridgend

100 95 90 85 80 75

Percentage 70 65 60

Bridgend Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C39: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Bridgend 100

60 Percentage

Bridgend Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 151

4340_WAO Amb ENG_v0_14.indd 151 29/11/06 11:05:32 Figure C40: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in the Vale of Glamorgan

50 Percentage 40

Vale of Glamorgan Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C41: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within the Vale of Glamorgan

100 95 90 85 80 75

Percentage 70 65 60

Vale of Glamorgan Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C42: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within the Vale of Glamorgan 100

60 Percentage

Vale of Glamorgan Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 152

4340_WAO Amb ENG_v0_14.indd 152 29/11/06 11:05:34 Figure C43: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Rhondda,Cynon Taf

50 Percentage 40

Rhondda Cynon Taf Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C44: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Rhondda Cynon Taf

100 95 90 85 80 75

Percentage 70 65 60

Rhondda Cynon Taf Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C45: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Rhondda Cynon Taf 100

60 Percentage

Rhondda Cynon Taf Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 153

4340_WAO Amb ENG_v0_14.indd 153 29/11/06 11:05:37 Figure C46: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Merthyr Tydfil

50 Percentage 40

Merthyr Tydfil Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C47: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Merthyr Tydfil

100 95 90 85 80 75

Percentage 70 65 60

Merthyr Tydfil Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C48: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Merthyr Tydfil 100

60 Percentage

Merthyr Tydfil Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 154

4340_WAO Amb ENG_v0_14.indd 154 29/11/06 11:05:38 Figure C49: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Caerphilly

50 Percentage 40

Caerphilly Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C50: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Caerphilly

100 95 90 85 80 75

Percentage 70 65 60

Caerphilly Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C51: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Caerphilly 100

60 Percentage

Caerphilly Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 155

4340_WAO Amb ENG_v0_14.indd 155 29/11/06 11:05:42 Figure C52: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Blaenau Gwent

50 Percentage 40

Blaenau Gwent Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C53: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Blaenau Gwent

100 95 90 85 80 75

Percentage 70 65 60

Blaenau Gwent Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C54: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Blaenau Gwent 100

60 Percentage

Blaenau Gwent Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 156

4340_WAO Amb ENG_v0_14.indd 156 29/11/06 11:05:43 Figure C55: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Torfaen

50 Percentage 40

Torfaen Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C56: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Torfaen

100 95 90 85 80 75

Percentage 70 65 60

Torfaen Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C57: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Torfaen 100

60 Percentage

Torfaen Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 157

4340_WAO Amb ENG_v0_14.indd 157 29/11/06 11:05:46 Figure C58: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Monmouthshire

50 Percentage 40

Monmouthshire Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C59: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Monmouthshire

100 95 90 85 80 75

Percentage 70 65 60

Monmouthshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C60: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Monmouthshire 100

60 Percentage

Monmouthshire Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 158

4340_WAO Amb ENG_v0_14.indd 158 29/11/06 11:05:48 Figure C61: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Newport

50 Percentage 40

Newport Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C62: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Newport

100 95 90 85 80 75

Percentage 70 65 60

Newport Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C63: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Newport 100

60 Percentage

Newport Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 159

4340_WAO Amb ENG_v0_14.indd 159 29/11/06 11:05:51 Figure C64: Quarterly performance of WAST in responding to Category ’A’ emergency incidents within eight minutes in Cardiff

50 Percentage 40

Cardiff Highest LHB area Lowest LHB area SaFF milestone target SaFF target

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C65: Percentage of Category ‘A’ and ‘B’ emergency calls within 14, 18 or 21 minutes within Cardiff

100 95 90 85 80 75

Percentage 70 65 60

Cardiff Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Figure C66: Percentage of urgent journeys arriving not more than 15 minutes later than the agreed time within Cardiff 100

60 Percentage

Cardiff Highest LHB area Lowest LHB area

Source: Welsh Assembly Government, Health Statistics and Analysis Unit, KA34

Ambulance Services in Wales 160

4340_WAO Amb ENG_v0_14.indd 160 29/11/06 11:05:53 Appendix 4: Priorities for improvement identified by Trust staff participating in our focus groups

No Priority for Explanation Component parts improvement 1 Being properly Having the right equipment to do • Appropriately designed and equipped vehicles – fit for equipped to do the job required. Includes sufficient purpose the job vehicles, contents and the people • Sufficient vehicles and equipment to operate them. Equipment needs to be of the ‘fit for purpose’ with • Effective management of assets to get the most out better management of the assets. of what is available 2 Managing people and Having organisational structures • Organisational structure to match the needs of the the organisation that allow for better management business and reflect the needs of the service • Competent managers at all levels user. Having capable and effective managers at all levels. • Senior managers leading by example • HR policies that work – sickness, leave etc 3 Appropriate use of Making sure that service users • GPs – biggest issues the service understand what it is there for and • Other NHS bodies don’t misuse it. Has a significant impact upon already stretched – A&E backlogs resources. Education a major – NHS Direct component. • General public – ambulances are not a taxi service/ NHS safety net • The option to say ‘no’ 4 Communication Specifically concerns the • Range and effectiveness of communications equipment communications equipment used equipment between vehicles and control. Also • Develop communication links with other services with other services. 5 Staff training Need to improve the availability, • Location of training access, quality and location of • Availability of and access to training training to equip staff to do their jobs. • Match skill sets and service – what is needed today?

Ambulance Services in Wales 161

4340_WAO Amb ENG_v0_14.indd 161 29/11/06 11:05:55 inNo ourPriority focus for groupsExplanation Component parts improvement 6 Local flexibilities/ Being able to deliver a response • Local decision making care pathways that is more appropriate to the • Involving the public and patients in decisions and needs of the patient and their planning circumstances rather than following defined procedures and • Requires a change of approach from staff protocols. • Different methods of delivery, paramedics at locations, not in ambulances • Meets the needs of the patients and circumstances 7 Internal Improving the methods and nature • Appropriate methods communications of communication within the • What people need to know organisation. This includes the message, the method of delivery • Listening and giving feedback and arrangements for receiving and acting upon feedback. 8 Supporting staff/ Key element improving morale. • Rota arrangements people issues Recognising issues staff face and • Rest and recuperation responding to them. • Working environment • Praise and reward for a job well done • Dealing with under performance • Internal hierarchies 9 Call handling Specific to how calls are handled • Educating service users procedures and prioritised at control. • Links between control and the front line Responses need to be appropriate to the issue. • Having the option to say “no” • Local flexibility/decision making 10 Better use of The resources currently available • Stop doing what is not needed resources could be better used to get ‘more • Divert resources to priority areas from the same’. Stop doing things that don’t need to be done.

Ambulance Services in Wales 162

4340_WAO Amb ENG_v0_14.indd 162 29/11/06 11:05:56 Appendix 5: Extract from Appendix 6: Comparison of District Audit report, funding for the Trust and other Commissioning Emergency UK ambulance services Properly equipped to do the job Ambulance Services (2001)

Managing the organisation and people

Appropriate use of service

Communiucation Equipment

Staff Training

Care pathways / local flexibility

Internal communications

Supporting staff / People Issues

Call handling procedures

Better use of resources

Ambulance Services in Wales 163

4340_WAO Amb ENG_v0_14.indd 163 29/11/06 11:05:58 Appendix 5: Extract from District Audit report, Commissioning Emergency Ambulance Services (2001)

Table 1 Funding Significant differences across Wales in the amount of funding and populations served by the Trust

Locality Funding Locality Population Locality Funding per 000s head £ million £ All Wales 44.5 All Wales 2,931 All Wales 15 Region Region Region South East 15.7 South East 1,296 North 21 Central & West 15.1 Central & West 978 Central & West 15 North 13.7 North 657 South East 12

Table 2 Performance

Significant differences in performance across Wales with the poorer performances evident in the Gwent area

Locality % of category Locality % of category Locality % of urgent A calls met B calls met calls met

All Wales 52 All Wales 93 All Wales 86 Region Region Region North 56 North 97 South East 89 South East 55 South East 96 North 88 Central & West 51 Central & West 92 Central & West 86

Ambulance Services in Wales 164

4340_WAO Amb ENG_v0_14.indd 164 29/11/06 11:05:59 Table 3 Resources Significant differences in the amount of resources available to the Trust for the provision of services across Wales

Locality Rota hours per Locality Rota hours per Locality Funding per annum 000 population rota hour

£ All Wales 1,811,566 All Wales 618 All Wales 25 Region Region Region Central & West 660,960 North 796 North 26 South East 627,640 Central & West 676 South East 25 North 522,966 South East 484 Central & West 23

Table 4 Workload Significant differences across Wales in the workload of those areas served by the Trust

Locality Journeys pa Locality Journeys per Locality Funding per head journey £ All Wales 261,926 All Wales 11.2 All Wales 170 Region Region Region South East 114,123 South East 12.1 North 207 North 66,333 Central & West 12.0 Central & West 185 Central & West 81,470 North 9.9 South East 138

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4340_WAO Amb ENG_v0_14.indd 165 29/11/06 11:06:02 Appendix 76: – Comparison Sickness absence of funding for the Trust and other UK ambulance services

Funding comparisons

Funding per call received

Trust Square miles Funding Funding per Funding per Funding per per single per head of incident call received hectare incident population attended (sq miles) £ £ £ £ Trust 1 7.98 12.85 132.94 115.38 64.35 Trust 2 12.45 14.15 155.60 123.36 48.26 Trust 3 0.73 20.71 175.33 125.65 933.08 Trust 4 16.30 13.15 154.35 126.79 36.55 Trust 5 17.05 16.47 159.09 126.98 36.04 Trust 6 17.29 12.56 184.21 142.86 41.13 Trust 7 9.52 14.89 177.25 145.65 71.86 Trust 8 19.50 14.29 188.68 149.25 37.36 Trust 9 16.38 13.23 179.04 150.74 42.21 Trust 10 59.76 17.38 172.74 151.60 11.16 Trust 11 13.51 17.60 198.20 161.17 56.63 Trust 12 25.82 20.00 213.11 200.77 31.87 Wales 31.25 21.37 242.05 206.55 29.91

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4340_WAO Amb ENG_v0_14.indd 166 29/11/06 11:06:02 Funding per head of population

Trust Square miles Funding Funding per Funding per Funding per per single per head of incident call received hectare incident population attended (sq miles) £ £ £ £ Trust 1 7.98 12.85 132.94 115.38 64.35 Trust 2 16.30 13.15 154.35 126.79 36.55 Trust 3 16.38 13.23 179.04 150.74 42.21 Trust 4 12.45 14.15 155.60 123.36 48.26 Trust 5 19.50 14.29 188.68 149.25 37.36 Trust 6 9.52 14.89 177.25 145.65 71.86 Trust 7 17.05 16.47 159.09 126.98 36.04 Trust 8 59.76 17.38 172.74 151.60 11.16 Trust 9 13.51 17.60 198.20 161.17 56.63 Trust 10 25.82 20.00 213.11 200.77 31.87 Trust 11 0.73 20.71 175.33 125.65 933.08 Wales 31.25 21.37 242.05 206.55 29.91

Source: Performance Audit Report prepared for the Welsh Ambulance Services NHS Trust

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4340_WAO Amb ENG_v0_14.indd 167 29/11/06 11:06:05 Appendix 7: Sickness absence

Sickness total by region for 2005/2006

% South & East Region 7.19% Central & West 6.93% North Region 4.51% Grand total 6.32%

Sickness total by locality/group for 2005/2006

% Monmouth 11.05 Control 8.72 Neath & port talbot 8.49 Merthyr 8.29 Torfaen 8.21 Pembrokeshire 8.12 Vale of glamorgan 8.01 DTS 7.69 South Powys 7.52 Swansea 7.37 Cardiff 7.35 Newport 6.80 Rhondda Cynon Taff 6.52 Carmarthenshire 6.43 Caerphilly 6.33 Wrexham 6.05

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4340_WAO Amb ENG_v0_14.indd 168 29/11/06 11:06:06 % Blaenau 6.02 Bridgend 5.87 North Powys 5.78 Workshops 5.35 Gwynedd south 4.85 Denbighshire 4.67 Conwy 4.27 Flintshire 4.12 All other sections 4.07 North Gwynedd 3.80 Ceredigion 3.01 Weekly 2.87 Trainees 2.37

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4340_WAO Amb ENG_v0_14.indd 169 29/11/06 11:06:08 Appendix 8: The Trust’s response to our recommendations in respect of links to the draft modernisation plan

Rec Relevant extracts from the Trust’s Modernisation Plan 1a 2.1.2: To ensure that clinical audit and effectiveness is an integral part of the overall organisation-wide approach to managing and improving the quality of patient care. 1b 2.2.1: Recognising that, while most patients who dial 999 need urgent assistance but, not all need a full emergency response, the Trust will develop a system that will assess the needs of (with) the patient, and broker their access to appropriate urgent clinical care. 1c 3.2: The involvement of our patients and more widely, the public will underpin the development and delivery of all our key strategic themes. We will aim to ensure that we involve all our key stakeholders in the design and delivery of our services. This is to ensure that everything we deliver is appropriate to individual need and is integrated with all parts of the health and social care environment in which we operate. We will measure our success using a performance assessment framework, which identifies progress in improving the patient experience and engaging patients and the public. 1d 1a: Improving the effectiveness and responsiveness of staff consultation, resulting in a 25% reduction in formal grievances lodged, collective disputes and improved responses in biennial Staff Attitude Survey. This will be achieved using issue-based, time-limited working practice teams, which will be operational by December 2006. 2.5.1: Establish and maintain a culture where employees in all Departments and disciplines feel involved and empowered to deliver better patient care solutions and improve service delivery. 1e 2.3.1.7: Develop, jointly with our commissioners and users, a set of standard reports which measure our activity, quality, efficiency and economy and feed the enterprise-wide, SPC-based performance improvement system 1f 2.3.1: To develop reliable, punctual and cost effective Patient Care Services that will provide access to planned healthcare based on nationally agreed eligibility criteria. 2 1.2: The policy context for the modernisation of health services has been set out in Designed for Life: Creating World Class Health & Social Care for Wales in the 21st Century. It sets out a ten year modernisation programme for health and social care. The Trust is also working with the other emergency services within the framework of “Making Connections”, in order to ensure that there is effective co-ordination of activities where this can result in benefits for all three services. 2.1.4: Restructure the delivery of our services, in consideration of work life balance, flexibility & equality issues, to ensure a match between demand and resources that delivers time-critical performance standards and clinically effective interventions.

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4340_WAO Amb ENG_v0_14.indd 170 29/11/06 11:06:08 Rec Relevant extracts from the Trust’s Modernisation Plan 2.1.5: To ensure the optimal deployment and utilisation of alternative emergency responders. 2.2.2: In partnership with Local Health Boards, plan and implement an integrated unscheduled care strategy, with particular emphasis on rural and sparsely populated areas, taking cognisance of the recommendations of the Welsh Assembly Government report ‘Delivering Emergency Care’. 3 Page 2: Hospital handover times have to be managed so the responders become available for the next call. This is also vital if the service is to give front-line staff their rest breaks. 2.1.4 Utilisation 3. Implement a call cycle process review, working towards compliance with call cycle best practice standards at the 80th percentile and 95th percentile in an incremental approach. 2.2.2: As per response to Recommendation 2. 4 2.0: The Trust’s seven strategic themes are described in the following sections; these will form the basis for the detailed project plans which will underpin the Modernisation Programme. 2.5.4: To develop an improvement culture that underpins and drives continuous service improvement through the timely delivery of appropriate and effective performance management information. 2.6.6: Ensure our infrastructure and environment modernisation activities are identified, resourced and effectively implemented. 3.1: This plan is a working document; a blueprint for the improvement and modernisation of the Welsh Ambulance Services NHS Trust. It will be implemented using a formal programme management process based on Managing Successful Programmes (MSP), an Office of Government Commerce product. The Trust Board will of course, provide oversight of and measure the progress of the programme. A Modernisation Sub-Committee has been set up to provide additional assurance. It will be chaired by a non-executive director and have membership including staff-side, managers, staff and volunteers. The Chief Executive will run the Trust as a change programme, constituting the Executive Team as a Programme Sponsoring Group. Each director will be responsible for delivery of defined projects and will delegate delivery to senior managers in a formally documented way. Personal objectives will be programme based and each Executive Team member will have a fortnightly one-to-one with the Chief Executive to review their progress against these objectives, identify and resolve any issues and agree next steps. This process will be supported by the Programmes and Planning Manager, who will oversee the development and track the delivery of the individual projects within the modernisation programme. 3.3.3: The challenge for the Welsh Ambulance Services NHS Trust is to raise awareness and help create a climate of support among staff and the public to take forward the necessary changes that will ensure the organisation is fit for the future. Our strategy will be to create a dialogue with staff as they go through the modernisation plan so they feel engaged in the process. It will build understanding about where the Trust wants to be, how each person fits in and the role they can play to ensure they are able, and want, to make the Trust better (making a difference) for patients.

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4340_WAO Amb ENG_v0_14.indd 171 29/11/06 11:06:11 Rec Relevant extracts from the Trust’s Modernisation Plan 6a 1.5. It does not make sense, either economically or professionally, to have highly motivated healthcare professionals sitting idle for long periods between emergency incidents when, with carefully targeted additional development, they could be contributing to the delivery of home assessment and care, primary care, minor injuries services and diagnostics, among other things. The Trust could support this by separating assessment and treatment of emergency patients from transportation, allowing practitioners to stay in their localities when patients do not require advanced life support en route to the hospital. 1.9 Our strategic direction is determined and influenced by a range of key national and local policy frameworks, outlining core and developmental standards for today as well as the future. In this way we aim to ensure continuous improvement so that our patients receive the most effective and appropriate level of care according to their individual needs. 6b 2.1.3. Introducing a system for continuous professional development (CPD), including a formal personal development plan (PDP) ensuring it is compliant with the requirements of the Health Professions Council. 6c 2.2.1 As per response to Recommendation 1b, including: • Reintroduce Category C for measurement purposes only. • Review the training needed by call takers to ensure consistency of approach and improve the safety and specificity of call categorisation. • Complete an audit of the specificity and safety of call categorisation in each control centre with consideration given to the DoH data set. Subject to the results of the audit, measure the specificity and safety of call categorisation C, following implementation of lessons learned from the audit. • Reintroduce the 60 minute, 95th percentile response time standard for category C calls by 1st April 2007. • Integrate with NHS Direct to provide direct and timely access to urgent care. This will be done through the provision of a telephone-based assessment and signposting service for callers categorised as Category C, with further triage support and with clinical advice for EMS crews. To begin in July 2007, with completion. 6d 2.5.4 As per response to Recommendation 4. 6e 2.2.1.6. Integrate with NHS Direct to provide direct and timely access to urgent care. This will be done through the provision of a telephone-based assessment and signposting service for callers categorised as Category C, with further triage support and with clinical advice for EMS crews. To begin in July 2007. 6f 1.5 As per response to Recommendation 6a. 6g 2.2.1.5. Reintroduce the 60 minute, 95th percentile response time standard for category C calls by 1st April 2007. 2.2.2 As per response to Recommendation 2. 7 2.1.6 Although directed at the Assembly Government, the Modernisation Plan includes a commitment to: ‘review the role and provision of air ambulance services jointly with patients and partners, (including Commissioners)’

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4340_WAO Amb ENG_v0_14.indd 172 29/11/06 11:06:11 Rec Relevant extracts from the Trust’s Modernisation Plan 8 2.5 Organisational and Staff Development. The Trust Board development will be put into a specific goal within this section in version 8.0 of the modernisation plan. 9 Page 10: A significant proportion of ambulance service workload is also related to social, rather than health care. We will therefore ensure we contribute to the development of the recently published consultation document A Strategy for Social Services in Wales over the Next Decade and thereafter collaborate closely with colleagues in social services to ensure that the modernisation of the ambulance service integrates effectively wherever possible. 2.3.1.12 Identify and engage with key partners in local health economies to plan and deliver effective responses to the relevant aspects of the National Service Frameworks for renal, cancer, mental health and older people. 11a 3.1 As per response to Recommendation 4. 11b 2.5.1 As per response to Recommendation 1d. 11c 2.1.1.3 Design and implement a team leader-based clinical management structure in each region, with associated governance and management processes, between February 2007 and August 2007 2.5.2.3. Ensure Team Leaders are able to display the six core competencies and ensure that all receive one-to-one feedback. 2.5.3.12 Identify new roles, carry out job evaluation for grade and pay allocation, recruit and provide relevant training for jobholders in new skills required. 11d 3.1 As per response to Recommendation 4. 12 2.1.1 To establish a clinical governance framework that safeguards high standards of clinical care for patients and creates an environment in which clinical excellence will flourish. 2.1.2.4 Develop a clinical audit/effectiveness programme which: • considers the whole “patient care pathway” across organisational boundaries which include the inclusion of “patient outcome” information; • includes all operational care providers (PCS, community first responders and emergency service co-responders); • develops a comprehensive set of clinical performance indicators (CPIs) to facilitate performance management; • includes development of national, regional, and clinical team “snap shot” clinical audits; • when appropriate is multidisciplinary and includes all stakeholders; • utilises the existing research & development (R&D) capability of staff within the Trust, and further encourages all staff to develop their R&D awareness and skills; • uses national initiatives such as National Service Frameworks (NSF) and National Institute for Clinical Excellence (NICE) guidance as drivers for establishing areas for ongoing clinical audit/effectiveness projects; • identifies the need for benchmarking of performance. 2.1.2.5 Develop and implement a system to support the communication of audit/effectiveness results which integrates with the enterprise-wide Statistical Process Control based performance analysis system. 2.5.4.4. Maximise the use of relevant management information from[WAU7] the CAD, the ESR system, the clinical governance system and other sources.

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4340_WAO Amb ENG_v0_14.indd 173 29/11/06 11:06:14 Rec Relevant extracts from the Trust’s Modernisation Plan 13a 2.4.2 Achieve all financial obligations without the need for external support, by 2008/2009; 3.1 As per response to Recommendation 4. 13b 2.5.2 Organisational structures will be designed with clear responsibilities and measured to meet demanding patient service delivery targets within financial constraints. 2.5.4.3 Develop an organisational performance reporting framework that delivers effective and timely internal and mandatory reporting to managers to drive appropriate decision-making and improve performance. 13c 2.5.3.8. Identify Personal Development Review processes for operational staff in line with the new management structures and unit hour objectives by 30th November 2006. 2.5.4.7. Link the performance management system to the Knowledge and Skills Framework performance development review (PDR) meetings, incremental progression and staff development at team and individual PDR levels. 13d 3.1 Programme management arrangements, as per response to recommendation 4. 13e 3.1 Programme management arrangements, as per response to recommendation 4. 13f 3.1 Programme management arrangements, as per response to recommendation 4. 14 2.1.4.1 Resources and Production. Establish a single point of management accountability for Unit Hour Production (people, fleet and logistics) in each region, with national strategic leadership: • establishing a resource centre in each region, comprising a single number access point for staff booking sick, return from sick leave, casual leave and other leave requests and which also acts as a co-ordination point for training schedules; • supporting the work of these centres by implementing well managed UHP processes that are widely understood • procuring and implementing a rostering system to support these centres • implementing relevant procedures for managing short notice resource issues and deficiencies during out of hour periods, identifying key posts for managing such eventualities 2.1.4.2 Establish key responsibilities and functions within each control centre for managing resource issues in the out of hours periods (including sickness reporting, fleet and logistics) to ensure unit hour production targets are not compromised 2.5.3.1 Providing managers with relevant information from ESR system to help identify future staff and skill needs by December 2006. 2.5.3.2 Reduce absence to 5 per cent, by improved local management processes supported by tailored management information, which includes web-enabled services, with effect from September 2007.

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4340_WAO Amb ENG_v0_14.indd 174 29/11/06 11:06:14 Rec Relevant extracts from the Trust’s Modernisation Plan 15 2.1.3 To create an environment for the Operational workforce with the knowledge and skills required to perform their role to the appropriate clinical standards, as determined by evidence based practice (e.g. Joint Royal Colleges Ambulance Liaison Committee (JRCALC), NICE, NSFs etc). This is to be undertaken in conjunction with a system of clinical support and leadership. 2.5.3 Build the Trust’s capacity to deliver improved patient care 16 2.5.2.7 Realise and report to the HR Committee and Trust Board meetings all benefits associated with Agenda for Change and performance improvement during implementation of Modernisation Plan, and monitor progress against success criteria in Agenda for Change Handbook. 17a 2.1.4. Utilisation. Procure and implement modern information and communications technology systems, including upgraded CAD systems, automatic vehicle location, satellite navigation and caller line identification 2.1.4. Distribution. Procure and implement Status Plan Management on all CAD systems 2.1.4. Distribution. Train all relevant Control staff in the use of Status Plan Management, vehicle movement tactics, dynamic deployment policies and contingency management. 2.6.2.4 Undertake a review of the immediate issues arising from Control Centres, make recommendations for alternative arrangements and implement solutions 17b 2.2.1.6 As per response to Recommendation 6e. 17c 2.6.2.4 As per response to Recommendation 17a 18 3.3 It will be vital for people who work at the Trust and for those who work with us or receive our services to understand exactly what we are seeking to achieve and the role which they must play. Therefore, we will develop a robust communications programme that supports the delivery of this strategic framework. 4.1.2 The commitment of staff and the trade unions is critical to the success of the Improvement Programme and managers will have a key role in gaining this commitment. 19a 2.3.1.6 Review all of our PCS service level agreements with improved management arrangements to support this process. Thus enabling a review with commissioners and users, to reflect actual service provision and incorporate realistic activity and quality standards, pricing and monitoring/reporting arrangements; 2.3.2 To further develop, improve and deliver a range of responsive and cost effective non patient transport through partnership working 19b 2.3.1.3 Develop a standard IT platform for PCS, with robust business continuity arrangements. 19c 2.3.1.8 Design and implement a customer service centre based leadership model for day control, homeward planning and the line management of PCS crews.

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4340_WAO Amb ENG_v0_14.indd 175 29/11/06 11:06:16 Rec Relevant extracts from the Trust’s Modernisation Plan 19d 2.3.1.1 Develop the Ambulance Car Service as the service of choice for all suitable patients: • nominating lead managers for ACS in each region • developing an ACS marketing and delivery strategy that reflects the value and importance WAST place on this service • developing and implementing an ACS recruitment strategy, with clear targets, linked to objective 1 • reviewing ACS remuneration and setting mileage rates which reflect local markets and support the Trust’s service delivery strategy 20 2.3.1.8 As per response to Recommendation 19c. 2.1.4.1. Procuring and implementing a rostering system to support these centres. 21 2.4.1.4 Ensure an effective transfer of the relevant elements of finance and Procurement work to the North Wales Business Services Partnership (BSP) by January 2007, including the transfer of staff and resources as appropriate and the agreement of suitably robust Service Level Agreements with the BSP to safeguard the maintenance of high performance standards. 2.6.3 Ensure our logistics arrangements are fit for purpose, and able to support our service delivery objectives and provide value for money. 2.6.5 To ensure systems and infrastructure are in place to create and maintain a modern and reliable ambulance fleet, which is fit for purpose and well supported by a dependable and relevant supplies function. 2.6.6 As per response to Recommendation 4. 22 2.6.2. Ensure our estates infrastructure is fit for purpose, able to support our service delivery objectives and provides value for money. Includes development and implementation of a new estates strategy. 23a 2.5.4 As per response to Recommendation 4. 23b 2.5.4 As per response to Recommendation 4. 23c 2.5.4 As per response to Recommendation 4. 23d 2.5.4.2 Statistical Process Control performance analysis system. 23e 2.5.4.6. Develop and implement a training programme for all employees to raise awareness of performance management system. 23f 2.5.4.3 As per response to Recommendation 13b. 24 2.1.5 It is implicit in this section with regards to alternative emergency responders. The Trust will include a specific objective in Version 8.0 of the plan to cover this section with regard to working with other emergency services. 25 2.1.2.4 As per response to Recommendation 12. 26 2.1.4.3 Establish unit hour requirements by activity centre to match and manage average peak demand, by end September 2006. 2.1.4 As per response to Recommendation 14.

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4340_WAO Amb ENG_v0_14.indd 176 29/11/06 11:06:17 Rec Relevant extracts from the Trust’s Modernisation Plan 27 2.6.6 As per response to Recommendation 4. The Trust is working with the Welsh Assembly Government and Health Commission Wales to produce robust business cases in the context of its draft Strategic Outline Programme. 28 2.1.4.9 Implement service level agreements with fleet and supplies managers to provide an agreed number of roadworthy and equipped ambulances on a shift by shift basis, with a target standard of more than 97 per cent of planned fleet unit hours, measured weekly. 2.6.4.3 Undertake a review of fleet maintenance and make recommendations and ensure recommendations are implemented in full. 2.6.5 As per response to Recommendation 21.

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4340_WAO Amb ENG_v0_14.indd 177 29/11/06 11:06:19 Appendix 9: Hospital turnaround times

Number of emergency patient journeys and average turnaround times at each hospital by the Trust in 2004/2005

Average Average Average Average Average Average Average Average Average Average Average Average Total for Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround 2004/05

Unit hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss

April May June July August September October November December January February March

Caerphilly & District Miners 00:18:32 00:17:48 00:19:21 00:19:38 00:19:39 00:20:06 00:19:46 00:19:57 00:19:36 00:22:08 00:20:07 00:23:13

Caerphilly District Miners Hospital 172 152 181 199 199 181 197 218 193 202 186 195 2,275

Hereford County 00:25:03 00:25:08 00:23:27 00:27:17 00:27:10 00:29:24 00:28:45 00:29:42 00:27:22 00:29:48 00:28:55 00:30:09

Hereford County Hospital 120 148 106 133 141 120 124 139 149 131 125 120 1,556

Llandough, Penarth Data not collected for this hospital at the time

Llandough, Penarth Data not collected for this hospital at the time 0

Nevill Hall, Abergavenny 00:26:46 00:28:13 00:25:55 00:27:55 00:25:40 00:25:58 00:25:23 00:25:50 00:27:31 00:27:46 00:30:13 00:32:00

Nevill Hall Hosp, Abergavenny 1099 1204 1072 1104 1159 1083 1158 1062 1167 1228 1051 1174 13,561

Prince Charles, Merthyr 00:22:31 00:26:36 00:25:03 00:25:11 00:25:49 00:25:44 00:27:17 00:25:59 00:29:09 00:32:02 00:33:00 00:28:09

Prince Charles Hosp, Merthyr 1309 1361 1307 1322 1263 1354 1335 1286 1479 1478 1280 1425 16,199

Royal Gwent, Newport 00:30:20 00:27:38 00:27:05 00:27:38 00:31:01 00:31:42 00:30:11 00:31:36 00:32:57 00:34:01 00:37:27 00:35:44

Royal Gwent Hospital, Newport 2238 2299 2238 2331 2306 2226 2285 2235 2428 2392 2096 2316 27,390

Royal Shrewsbury 00:23:37 00:25:21 00:26:08 00:24:06 00:25:04 00:26:09 00:24:17 00:23:22 00:25:05 00:22:27 00:23:22 00:22:41

Royal Shrewsbury Hospital 280 313 283 272 283 234 265 266 315 261 267 275 3,314

Royal Glamorgan, Llantrisant, RCT 00:21:44 00:20:40 00:20:53 00:22:05 00:23:24 00:22:18 00:24:00 00:23:02 00:22:12 00:25:02 00:25:38 00:25:18

The Royal Glamorgan Hospital 1222 1325 1274 1363 1329 1202 1372 1370 1420 1455 1291 1370 15,993

University Hospital of Wales, Cardiff 00:22:04 00:22:02 00:23:10 00:23:58 00:23:09 00:24:41 00:26:21 00:25:26 00:24:10 00:28:28 00:30:02 00:32:42

University Hospital of Wales 2905 3026 2884 2869 2900 2699 3038 2921 3272 2861 2579 2935 34,889

Bronglais General, Aberystwyth 00:16:28 00:15:49 00:15:30 00:17:00 00:17:53 00:17:46 00:16:03 00:16:18 00:16:37 00:18:26 00:17:23 00:17:17

Bronglais Gen Hosp, Aberystwyth 425 467 446 442 497 445 428 413 480 494 415 466 5,418

Morriston, Swansea 00:22:40 00:21:33 00:23:06 00:22:57 00:22:48 00:23:13 00:23:38 00:22:28 00:24:34 00:27:30 00:23:26 00:26:59

Morriston Hospital, Swansea 1745 1981 1769 1834 1805 1757 1796 1810 1865 1823 1593 1779 21,557

Neath Port Talbot 00:16:45 00:17:12 00:16:53 00:18:06 00:17:15 00:18:21 00:18:11 00:18:45 00:19:05 00:21:05 00:26:40 00:26:41

Neath & Port Talbot Hospital 411 405 418 412 406 419 411 396 435 448 456 470 5,087

Prince Philip, Llanelli 00:19:45 00:19:47 00:18:47 00:19:05 00:18:32 00:19:01 00:18:30 00:18:53 00:19:17 00:20:26 00:20:56 00:24:47

Prince Philip Hospital, Llanelli 417 432 481 431 459 486 466 404 516 508 443 520 5,563

Princess of Wales, Bridgend 00:19:51 00:20:16 00:22:36 00:21:39 00:22:07 00:23:05 00:22:24 00:22:47 00:22:58 00:23:15 00:24:31 00:26:57

Princess of Wales, Bridgend 1097 1148 1096 1111 1093 1094 1195 1160 1216 1183 1129 1229 13,751

Singleton, Swansea 00:17:11 00:16:09 00:16:33 00:16:35 00:16:29 00:16:27 00:16:23 00:16:24 00:17:08 00:18:27 00:17:01 00:18:50

Singleton Hospital Swansea 818 812 810 755 779 779 891 1018 1038 1028 1009 1168 10,905

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4340_WAO Amb ENG_v0_14.indd 178 29/11/06 11:06:21 Average Average Average Average Average Average Average Average Average Average Average Average Total for Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround 2004/05

Unit hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss

April May June July August September October November December January February March

West Wales General, Carmarthen 00:16:50 00:17:53 00:17:00 00:17:34 00:17:52 00:19:09 00:18:15 00:17:42 00:18:48 00:17:50 00:18:45 00:23:47

West Wales General Hospital 741 801 820 767 831 747 755 780 862 802 762 892 9,560

Withybush, Haverford West 00:15:58 00:15:52 00:15:02 00:16:30 00:15:57 00:15:57 00:15:36 00:15:09 00:15:05 00:15:57 00:16:26 00:17:59

Withybush Hospital 727 767 748 735 831 736 735 765 743 814 672 853 9,126

Countess of Chester 00:17:39 00:16:47 00:17:32 00:16:57 00:18:15 00:18:19 00:17:40 00:17:00 00:17:36 00:17:08 00:17:05 00:19:03

Countess of Chester Hospital 362 369 347 330 341 340 348 389 408 391 348 367 4,340

Glan Clwyd, Bodelwyddan 00:18:45 00:18:41 00:18:31 00:18:07 00:18:02 00:17:51 00:17:40 00:16:54 00:17:54 00:19:14 00:18:08 00:21:16

Glan Clwyd Hosp, Bodelwyddan 1608 1703 1564 1673 1780 1595 1604 1616 1780 1760 1530 1773 19,986

Llandudno General 00:13:53 00:13:07 00:14:25 00:13:33 00:13:50 00:13:53 00:13:37 00:14:49 00:14:28 00:14:01 00:15:00 00:14:31

Llandudno Hosp, Llandudno 282 332 312 331 308 280 327 296 322 284 259 321 3,654

Wrexham Maelor 00:16:21 00:15:50 00:15:42 00:15:35 00:15:17 00:15:40 00:18:24 00:15:19 00:16:06 00:15:42 00:15:47 00:15:42

Maelor General Hosp, Wrecsam 1251 1310 1201 1267 1306 1182 1399 1240 1375 1333 1166 1344 15,374

Ysbyty Gwynedd, Bangor 00:18:26 00:18:39 00:18:33 00:18:40 00:18:50 00:18:52 00:15:30 00:18:31 00:18:48 00:18:35 00:18:43 00:19:49

Ysbyty Gwynedd, Bangor 1327 1483 1416 1426 1539 1263 1326 1322 1417 1331 1190 1372 16,412

Total All Wales 00:21:16 00:21:07 00:21:10 00:21:35 00:21:46 00:21:58 00:22:19 00:22:01 00:22:42 00:24:13 00:24:45 00:25:46

Total All Wales number 20,556 21,838 20,773 21,107 21,555 20,222 21,455 21,106 22,880 22,207 19,847 22,364 255,910

Source: Welsh Ambulance Services NHS Trust

Ambulance Services in Wales 179

4340_WAO Amb ENG_v0_14.indd 179 29/11/06 11:06:25 Number of emergency patient journeys and average turnaround times at each hospital by the Trust in 2005/2006

Unit hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss

April May June July August September October November December January February March

Caerphilly & District Miners 00:19:43 00:21:57 00:22:29 00:20:56 00:20:46 00:21:31 00:20:42 00:20:49 00:19:28 00:20:09 00:20:24 00:23:22

Caerphilly District Miners Hospital 177 131 197 192 190 215 237 230 182 228 133 127 2,239

Hereford County 00:26:58 00:25:50 00:27:32 00:31:23 00:26:41 00:28:16 00:29:50 00:31:42 00:29:35 00:36:57 00:33:54 00:31:35

Hereford County Hospital 120 126 109 127 136 116 96 100 126 128 116 129 1,429

Llandough, Penarth 00:17:42 00:16:38 00:17:54 00:18:18 00:18:09 00:17:48 00:18:20 00:18:47 00:16:48 00:20:50 00:21:03 00:22:08

Llandough, Penarth 636 662 543 570 657 596 641 551 590 579 558 607 7,190

Nevill Hall, Abergavenny 00:28:23 00:28:22 00:27:22 00:27:45 00:27:25 00:27:59 00:29:31 00:28:49 00:27:09 00:28:28 00:31:08 00:33:22

Nevill Hall Hosp, Abergavenny 1059 1168 1076 1166 1048 1083 1214 1142 1183 1238 1168 1205 13,750

Prince Charles, Merthyr 00:24:07 00:22:40 00:24:21 00:23:58 00:25:20 00:26:00 00:24:14 00:24:02 00:23:59 00:27:44 00:24:32 00:28:20

Prince Charles Hosp, Merthyr 1302 1307 1222 1256 1263 1247 1316 1282 1315 1400 1030 1112 15,052

Royal Gwent, Newport 00:29:35 00:30:40 00:25:28 00:25:38 00:24:50 00:25:49 00:25:18 00:28:49 00:28:21 00:29:37 00:33:59 00:34:40

Royal Gwent Hospital, Newport 2276 2297 2328 2385 2339 2284 2272 2327 2577 2424 2205 2341 28,055

Royal Shrewsbury 00:22:09 00:24:53 00:22:54 00:24:08 00:22:35 00:23:17 00:23:40 00:22:10 00:22:42 00:23:14 00:24:23 00:27:06

Royal Shrewsbury Hospital 264 288 253 242 248 245 257 242 267 224 241 255 3,026

Royal Glamorgan, Llantrisant, RCT 00:23:24 00:24:30 00:24:05 00:24:40 00:23:03 00:24:01 00:24:59 00:23:45 00:23:20 00:34:26 00:26:25 00:23:27

The Royal Glamorgan Hospital 1339 1339 1211 1231 1268 1160 1323 1287 1340 1389 978 1095 14,960

University Hospital of Wales, Cardiff 00:29:39 00:29:53 00:28:52 00:26:13 00:25:04 00:26:47 00:28:54 00:29:19 00:26:07 00:32:26 00:32:13 00:30:51

University Hospital of Wales 2674 2852 2605 2735 2669 2671 2853 2779 2965 2758 2510 2923 32,994

Bronglais General, Aberystwyth 00:16:31 00:16:24 00:16:06 00:16:45 00:18:04 00:17:19 00:16:34 00:17:47 00:17:08 00:17:40 00:17:14 00:17:29

Bronglais Gen Hosp, Aberystwyth 421 480 370 392 432 353 411 374 390 339 313 351 4,626

Morriston, Swansea 00:25:47 00:25:22 00:24:10 00:22:35 00:23:39 00:22:53 00:23:12 00:23:02 00:22:40 00:21:39 00:25:07 00:23:17

Morriston Hospital, Swansea 1765 1856 1592 1624 1661 1631 1753 1762 1897 1828 1502 1505 20,376

Neath Port Talbot 00:23:03 00:20:11 00:22:32 00:19:45 00:20:28 00:21:35 00:20:00 00:21:07 00:21:39 00:21:26 00:19:27 00:21:39

Neath & Port Talbot Hospital 411 418 360 389 395 398 397 414 516 407 409 413 4,927

Prince Philip, Llanelli 00:21:09 00:18:41 00:19:51 00:19:16 00:20:48 00:22:47 00:21:39 00:22:57 00:20:30 00:21:36 00:27:28 00:29:54

Prince Philip Hospital, Llanelli 444 464 397 379 384 419 440 445 475 476 365 456 5,144

Princess of Wales, Bridgend 00:25:54 00:24:37 00:24:26 00:24:20 00:23:11 00:25:32 00:25:07 00:24:18 00:23:49 00:24:32 00:25:46 00:25:24

Princess of Wales, Bridgend 1113 1180 1117 1146 1171 1127 1119 1110 1186 1145 953 1094 13,461

Singleton, Swansea 00:18:06 00:19:09 00:19:05 00:19:54 00:19:13 00:19:22 00:20:09 00:19:34 00:19:03 00:18:19 00:17:36 00:17:48

Singleton Hospital Swansea 951 930 795 714 844 741 916 913 1019 986 771 862 10,442

West Wales General, Carmarthen 00:18:52 00:18:43 00:20:59 00:19:11 00:20:56 00:23:27 00:21:32 00:24:23 00:19:05 00:23:07 00:27:20 00:26:10

West Wales General Hospital 763 804 745 742 790 743 780 760 800 847 728 754 9,256

Withybush, Haverford West 00:16:06 00:17:23 00:18:09 00:19:56 00:20:05 00:17:23 00:17:35 00:18:29 00:19:16 00:18:38 00:19:28 00:24:35

Withybush Hospital 774 793 747 812 822 743 684 755 815 744 642 688 9,019

Countess of Chester 00:18:31 00:19:02 00:17:31 00:18:17 00:19:35 00:18:54 00:19:11 00:17:57 00:18:36 00:18:51 00:18:29 00:19:48

Countess of Chester Hospital 334 391 319 366 347 346 405 320 399 374 346 431 4,378

Glan Clwyd, Bodelwyddan 00:18:01 00:18:39 00:18:32 00:18:29 00:19:06 00:17:21 00:18:12 00:17:36 00:19:20 00:20:25 00:19:29 00:17:06

Ambulance Services in Wales 180

4340_WAO Amb ENG_v0_14.indd 180 29/11/06 11:06:28 Average Average Average Average Average Average Average Average Average Average Average Average Total for Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround 2005/06

Unit hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss

April May June July August September October November December January February March

Glan Clwyd Hosp, Bodelwyddan 1612 1782 1540 1755 1817 1571 1622 1560 1756 1728 1528 1743 20,014

Llandudno General 00:14:34 00:14:16 00:14:12 00:15:25 00:16:32 00:14:42 00:14:42 00:15:15 00:15:19 00:16:50 00:15:39 00:20:24

Llandudno Hosp, Llandudno 310 328 284 305 287 281 277 252 278 257 219 276 3,354

Wrexham Maelor 00:16:20 00:16:05 00:15:36 00:16:14 00:17:05 00:17:02 00:15:59 00:16:28 00:16:44 00:17:08 00:21:16 00:15:51

Maelor General Hosp, Wrecsam 1221 1354 1234 1266 1231 1213 1316 1211 1272 1251 1153 1266 14,988

Ysbyty Gwynedd, Bangor 00:19:32 00:20:31 00:20:14 00:20:40 00:21:16 00:21:12 00:20:40 00:20:35 00:20:34 00:20:40 00:16:30 00:21:32

Ysbyty Gwynedd, Bangor 1329 1436 1263 1396 1436 1276 1327 1217 1380 1323 1164 1448 15,995

Total All Wales

Total All Wales number 21,295 22,386 20,307 21,190 21,435 20,459 21,656 21,033 22,728 22,073 19,032 21,081 254,675

Source: Welsh Ambulance Services NHS Trust

Ambulance Services in Wales 181

4340_WAO Amb ENG_v0_14.indd 181 29/11/06 11:06:31 Number of emergency patient journeys average turnaround times at each hospital by the Trust in April to August 2006

Unit hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss

April May June July August September October November December January February March

Caerphilly & District Miners 00:20:26 00:20:48 00:20:47 00:20:18 00:23:16

Caerphilly District Miners Hospital 173 163 168 162 183 849

Hereford County 00:33:05 00:29:48 00:25:32 00:30:17 00:29:13

Hereford County Hospital 121 122 112 145 119 619

Llandough, Penarth 00:18:23 00:16:57 00:20:02 00:21:33 00:20:21

Llandough, Penarth 636 662 586 617 601 3,102

Nevill Hall, Abergavenny 00:29:41 00:29:57 00:29:05 00:29:26 00:32:26

Nevill Hall Hosp, Abergavenny 1219 1214 1083 1197 1129 5,842

Prince Charles, Merthyr 00:23:28 00:25:57 00:25:30 00:26:36 00:25:35

Prince Charles Hosp, Merthyr 1280 1293 1206 1277 1180 6,236

Royal Gwent, Newport 00:28:15 00:29:50 00:28:20 00:28:04 00:28:31

Royal Gwent Hospital, Newport 2285 2374 2247 2328 2250 11,484

Royal Shrewsbury 00:23:03 00:24:43 00:24:18 00:27:57 00:24:22

Royal Shrewsbury Hospital 246 267 245 278 238 1,274

Royal Glamorgan, Llantrisant, RCT 00:24:08 00:25:27 00:25:12 00:26:35 00:26:07

The Royal Glamorgan Hospital 1357 1298 1255 1318 1225 6,453

University Hospital of Wales, Cardiff 00:28:01 00:25:09 00:25:26 00:28:57 00:28:24

University Hospital of Wales 2710 2760 2810 2884 2745 13,909

Bronglais General, Aberystwyth 00:18:08 00:16:42 00:17:25 00:17:51 00:17:39

Bronglais Gen Hosp, Aberystwyth 413 414 375 437 381 2,020

Morriston, Swansea 00:22:11 00:22:47 00:23:40 00:22:42 00:21:55

Morriston Hospital, Swansea 1792 1786 1856 2029 1863 9,326

Neath Port Talbot 00:20:51 00:21:10 00:18:33 00:19:19 00:20:26

Neath & Port Talbot Hospital 420 416 354 392 333 1,915

Prince Philip, Llanelli 00:20:08 00:20:03 00:19:12 00:20:48 00:20:52

Prince Philip Hospital, Llanelli 469 449 430 443 429 2,220

Princess of Wales, Bridgend 00:23:05 00:22:48 00:22:47 00:23:15 00:23:46

Princess of Wales, Bridgend 1110 1163 1169 1189 1146 5,777

Singleton, Swansea 00:18:23 00:17:27 00:17:58 00:17:22 00:18:53

Singleton Hospital Swansea 942 974 839 876 945 4,576

West Wales General, Carmarthen 00:21:33 00:20:20 00:21:54 00:21:22 00:21:47

West Wales General Hospital 807 797 767 802 810 3,983

Withybush, Haverford West 00:21:12 00:19:50 00:18:34 00:18:20 00:18:58

Withybush Hospital 706 734 738 861 802 3,841

Countess of Chester 00:17:56 00:18:30 00:17:14 00:18:12 00:18:04

Countess of Chester Hospital 368 333 312 378 329 1,720

Glan Clwyd, Bodelwyddan 00:19:35 00:18:56 00:18:31 00:19:23 00:18:35

Ambulance Services in Wales 182

4340_WAO Amb ENG_v0_14.indd 182 29/11/06 11:06:33 Average Average Average Average Average Average Average Average Average Average Average Average Total for Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround Turnround 2006/07

Unit hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss hh:mm:ss

April May June July August September October November December January February March

Glan Clwyd Hosp, Bodelwyddan 1759 1734 1669 1839 1648 8,649

Llandudno General 00:14:44 00:15:07 00:14:18 00:13:46 00:14:00

Llandudno Hosp, Llandudno 220 298 282 321 241 1,362

Wrexham Maelor 00:16:35 00:16:42 00:15:44 00:15:54 00:16:40

Maelor General Hosp, Wrecsam 1313 1247 1126 1230 1189 6,105

Ysbyty Gwynedd, Bangor 00:21:38 00:20:19 00:19:02 00:19:39 00:20:20

Ysbyty Gwynedd, Bangor 1384 1305 1276 1460 1383 6,808

Total All Wales 00:23:04 00:22:52 00:22:37 00:23:18 00:23:25

Total All Wales number 21,730 21,803 20,905 22,463 21,169 0 0 0 0 0 0 0 108,070

Source: Welsh Ambulance Services NHS Trust

Ambulance Services in Wales 183

4340_WAO Amb ENG_v0_14.indd 183 29/11/06 11:06:36 Appendix 10: Category ‘A’ response time performance by LHB area at the sixtieth, seventy fifth and ninety fifth percentiles

5 Minutes taken for first response to arrive Minutes taken for first response

Conwy Cardiff Powys Flintshire Torfaen Wrexham Swansea Newport Bridgend Caerphilly Gwynedd Ceredigion Denbighshire Methyr Tydfil Pembrokeshire Isle of Anglesey Carnarthenshire Blaenau Gwent Monmouthshire Neath Port Talbot Vale of Glamorgan Rhondda Cynon Taff N >= 60% of response N >= 75% of response N >= 95% of response

Source: Wales Audit Office Date source: Welsh Ambulance Services NHS Trust

Ambulance Services in Wales 184

4340_WAO Amb ENG_v0_14.indd 184 29/11/06 11:06:37