Wellbeing and inclusion: How ambulance trusts are seeking improvements for staff

Addressing and improving staff wellbeing can be challenging in any organisation, within the NHS and other sectors, but the ambulance sector faces a unique set of challenges. Covering large regions, working with a broad range of partner organisations and having a workforce that is disparate, working variable shift patterns across a large geography, often isolated from colleagues. 

The unique pressures created for staff by the complexity of the working environment are only amplified by the sustained pressures the ambulance sector is facing:  

Demand has been rising relentlessly placing pressure on those in clinical and call-handling roles in ambulance trusts, exacerbated by record vacancy rates and ongoing industrial action, high rates of sickness absence and high turnover. These experiences are reflected in the NHS' annual staff survey, where ambulance trusts have seen some of the worst results on key measures around experiences of stress, burnout, anxiety and staff members' intention to leave their current role (NHS England 2022).  

Staff absences and vacancies risk undermining efforts to recover services and ensure performance meets the expectations of patients and the public. Staff absences and vacancies risk undermining trusts' efforts to recover services and ensure performance meets the expectations of patients and the public. As ambulance trust leaders work hard to restore core operational performance standards, workforce issues remain the major rate limiting factor in reducing waiting times and transforming services. At the same time, there is a large body of evidence showing that staff burnout and poor wellbeing can impact the safety and quality of healthcare services (Hall et al 2016; Janes et al 2021; Hodkinson et al 2022).  

The equality, diversity and inclusion improvement plan and Long Term Workforce Plan recently published by  NHS England highlight  staff wellbeing as a national priority,  and we know that trusts are at the same time embedding local initiatives to support the wellbeing of their workforce. 

To understand some of the challenges and approaches to embedding wellbeing and inclusion in ambulance trusts specifically we spoke to two ambulance trust chief executives, Tom Abell from the East of England Ambulance Service NHS Trust (EEAST) and Daniel Elkeles from the London Ambulance Service NHS Trust (LAS).

Research shows that staff need to have a sense of autonomy, belonging and contribution, to feel valued in their role. This is known as the ABC framework. We use this structure below to set out the interventions and learnings we heard about in our interviews (West et al 2020). We would like to thank both our contributors and hope this proves a helpful summary for colleagues in the sector.   

Autonomy

The concept of autonomy at work reflects people's need to have sufficient control over their work life and to be able to act consistently with their values. This could include having the influence within your organisation to change how care is structured and delivered, as well shaping your working conditions or working patterns.

London Ambulance Service NHS Trust

The role of paramedic or call-handler is responsive, requiring sound judgement in an environment which is highly reactive and in which the events of the working day cannot be planned.

Paramedics in particular, operate in small, mobile teams, with a risk of feeling isolated or disconnected from teams, and the role of managers or larger teams onsite whose daily focus may seem quite different from their roles.  It can be difficult to forge usual working relationships and connect with colleagues across the organisation making face to face team briefings, line management relationships, visibility from senior leadership and training and development critically important.

Despite the many unique challenges of their roles, paramedics and call handlers often operate with high levels of autonomy, empowered to make informed, clinical decisions within an agreed approach to risk management.

Daniel Elkeles explained to us how the LAS is working to ensure all staff have sufficient autonomy to shape how their roles are delivered. Taking learnings from the Buurtzorg Model of self-managing teams, LAS is implementing an approach which sees local operational teams come together to manage their own rotas and have team huddles ahead of a sequence of shifts.

So far just over a quarter of the LAS’ operational teams have adopted this model of self-management, with more teams working to implement the change.

The groups that are working on a self-managing basis develop their own rotas, which are only signed off when 50% of the team agrees. The core principles are that consecutive night shifts should be avoided, there should be proper downtime between shifts and managers are expected to work shift patterns as well.

This form of self-management helps remove a sense of a central “head office” imposing working patterns, providing staff a greater sense of ownership and autonomy in their work. Daniel told us that the approval rate for the change is very high, at around 90% and the sickness rate has dropped to around 3%, compared to a national average of 7% for ambulance trusts.

East of England Ambulance Service NHS Trust (EEAST)

EEAST are in an earlier phase of implementing more autonomous models of working. Tom Abell has already led a process of reorganising the trust’s leadership structure, with a view to creating local teams with more autonomy. EEAST took the view that embedding a leadership culture of respect and compassion is key to developing a sense of autonomy across the workforce, however this leadership approach was not consistently applied across the trust.

Investing in training and upskilling managers is a priority for EEAST, but so too is taking a firm and clear approach to setting out the behaviours and values that are expected in leadership roles.

As well as putting in place a positive support scheme and training offer, the trust also launched a voluntary severance scheme (Mutually Agreed Resignation Scheme) to support some leaders to move on from the organisation at the appropriate time for them. In taking this direct approach, being clear about the kind of leadership that is needed to support autonomy, the trust has taken early steps in developing self-managing autonomous teams.   

Belonging

Belonging describes the need for people to feel connected to, cared for and caring of others around them at work. This should mean people feel valued, respected and supported at work.

East of England Ambulance Service NHS Trust (EEAST) 

When Tom arrived in his role at EEAST, there had been a recent history of unacceptable behaviours within the staff team, including experiences of racism, ableism, homophobia, sexism and bullying. He explained how coming into the role, he knew that rebuilding trust with staff, so they knew that experiences like this would not be tolerated, would be the first step to ensure people felt a sense of belonging at work.

Tom took the view that "if you don't admit the problem, you won't solve the problem" and set about addressing the issues around racism, bullying and unacceptable behaviours head on.  

One of the first actions was to commission an independent review into the working lives of ethnic minority staff at EEAST. While, at the same time, staff engagement exercises highlighted the extent and level of bullying and discrimination some staff had faced.

Once the problem was better understood, publicly acknowledged and apologised for, the trust was able to take action.

Firstly, EEAST ran an internal campaign to encourage more staff to speak up when they had experienced or observed unprofessional behaviours. At the same time, the trust took action to improve their internal HR processes. Too often in the past, complaints or concerns had gone unaddressed, leaving staff feeling like the organisation was unresponsive and that nothing would happen to tackle issues if they were raised.

Secondly, every two weeks, someone from EEAST's senior executive team holds an open forum "Q&A" session with staff, so that they can be questioned openly, making them more accountable and helping embed a culture of transparency. Separately, Tom reserves every Friday for visiting staff in different parts of his trust's region.

While these initial actions have delivered positive returns and improvements - for example, staff turnover within emergency operations at the trust has decreased from 14% to 8%, notably below the national average of 11.8% - Tom and his team are clear that there is still a long way to go to.

Alongside efforts to improve inclusion and address experiences of prejudice, EEAST has developed a broad universal wellbeing support offer as well as more specialist mental health support services like counselling and psychotherapy.

London Ambulance Service NHS Trust 

Daniel Elkeles made similar points around the importance of inclusion, culture and modelling values.

LAS' newly developed core values are care, respect and teamwork.

Daniel and the leadership team co-produced these with staff. This was vital as it made staff feel that they co-owned them and really understood why they were important.

2,000 staff across LAS took part in the co-production exercise to develop the values. Staff were challenged to articulate what makes a day at work either good or bad. The results were that a good day involved feeling appreciated and part of a team, a bad day was the reverse. Care, respect and teamwork were identified as the core things you need to have a "good day".

The values are now very prominent in the trust's communications and the leadership team are mindful to model the values. The trust has also developed their five staff networks, focused on race equality, disabled staff, LGBTQ+ staff, women, and an emergent multi-faith network for all staff.

Daniel also chairs the Association of Ambulance Chief Executive's (AACE) national ambulance diversity and inclusion forum (NADIF). This group brings together equality diversity and inclusion leads from across the NHS ambulance sector and chairs of national peer support groups (BME, LGBT+, disability and women), to share peer learning and insight on their experience of promoting diversity and inclusion in their trusts.

LAS have also developed a range of measures to support staff wellbeing, which contribute to a sense of belonging. These range from low-level or general support, like healthy eating and physical activity advice to a psychotherapy service that can support staff experiencing post-traumatic stress disorder or other mental health crises. Alongside this the trust has a universal wellbeing offer and a peer support network.

Not only are wellbeing and mental health support offers like those offered by both LAS and EEAST good in and of themselves, but we also know that improving staff wellbeing and tackling burnout can have a positive impact on quality and safety.

Contribution

Contribution is about people's need to experience being effective in their role and delivering outcomes that align with their values.

London Ambulance Service NHS Trust

The ambulance sector is working hard to deliver improvements in call response times, including working with hospital-based colleagues to reduce delays in transferring patients into a hospital setting. We know that delays are bad for patients, and contribute to a sense of frustration and ineffectiveness for ambulance staff who are prevented from responding to new calls while waiting to transfer patients to emergency departments.

Early progress has been made here, including improved call response times, reduced handover delays and improved partnership working with other providers – this will all help develop a sense of contribution to a team that is delivering an effective service.

There are additional steps trusts can take to embed that sense of contribution and provide staff with clear career development opportunities.

For example, LAS has invested substantially in management training. Working with their lead integrated care system for the region, the trust is putting 163 managers through NVQ level 6 training in healthcare management and provided every manager with a one day "masterclass" in leading with respect.

The self-managing teams that the trust is developing are also supporting a sense of contribution, as staff feel more embedded in a team working toward wider objectives. Self-managing teams are provided five days of team training per year.

East of England Ambulance Service NHS Trust

Similarly, Tom's approach has seen the trust invest more in training and coaching.

The senior executive team at EEAST take part in a team coaching session every two months to help them reflect on how the team is working together and what is expected of them in terms of behaviours, values and approach to work. More widely, the trust is taking an assessment centre approach to developing new leadership roles, where they look at people's development needs and what they need to get to the next level.

This has helped the process of career progression in the trust become more transparent and equitable, as before it had been perceived as being a "boys' club".

Reflecting on the impact that coaching and the new approach to leadership had already had, Tom noted that one of the early benefits was improved relationships with partner organisations. This included other providers like local acute trusts, integrated care systems and local politicians. That in turn should translate to better performance, improved outcomes for patients and improved public perception of the trust.

Conclusion

Nationally, the NHS has set out clear priorities for developing and growing the workforce as well as for restoring core performance standards across urgent and emergency care. In addition, to key the enablers and funding required from government and national NHS bodies, to train and recruit skilled staff in the right numbers, in EEAST and LAS we can see two examples where leaders have prioritised wellbeing and inclusion to deliver real improvements.

These two examples from EEAST and LAS, clearly illustrate how important support for the workforce is, in its own right, as well as how central it is to improving performance and quality of services.

Focusing on wellbeing and inclusion is clearly key to retaining and developing the NHS workforce as well as creating attractive working environments for new recruits. What is more, being able to thrive in the workplace influences performance, patient care and job satisfaction.  We hope these case studies prove helpful to other trusts on similar journeys and look forward to continuing to track the improvements in the two ambulance trusts featured.

Alongside its member trusts, the Association of Ambulance Chief Executives has, in conjunction with partners, such as NHS England, Samaritans and the College of Paramedics, produced national resources for ambulance services, such as a mental health continuum for everyone who works in the ambulance service, a family handbook, to guide and support employees’ family members or friends in supporting their loved ones in their role, and suicide postvention guidance, to ensure that in the devastating event of an employee suicide, managers are as well-equipped as possible to respond in a compassionate, appropriate and timely way. These resources can be found here: Suicide Prevention in Ambulance Services - aace.org.uk.