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Waiting times focus ‘overshadows misconduct’, finds NHSE review

Published on: 15 Feb 2024

Ambulance trusts have often prioritised capacity and response times over dealing with cases of misconduct, a review of culture in the sector for NHS England has found.

The review, due to be published today, says ambulance trusts need to “establish clear standards and procedures to address misconduct”.

The work was carried out by Siobhan Melia, who is Sussex Community Healthcare Trust CEO, and was seconded to be South East Coast Ambulance Service Foundation Trust interim chief from summer 2022 to spring last year.

Her report, seen by HSJ,  says bullying and harassment – including sexual harassment – are “deeply rooted” in ambulance trusts, and made worse by organisational and psychological barriers, with inconsistencies in holding offenders to account and a failure to tackle repeat offenders.

She says “cultural assessments” of three trusts by NHSE had found “competing pressures often lead to poor behaviours, with capacity prioritisation overshadowing misconduct management”, adding: “Staff shortages and limited opportunities for development mean that any work beyond direct clinical care is seen as a luxury or is rushed.

“Despite this, there is a clear link between positive organisational culture and improved patient outcomes. However, trusts often focus on meeting response time standards for urgent calls, whilst sidelining training, professional development, and research.”

Ms Melia says: “My experience has highlighted to me that the ambulance sector is different to other parts of the wider NHS… This review was an opportunity to shine a light on that fact and to consider how the local, regional, and national NHS architecture can work differently with ambulance trusts and in a way that is more enabling of cultural improvement.

“A focus on operational performance often overshadows a focus on people and culture, creating a disconnect between the two, and this is an opportunity for change.”

The review follows HSJ’s  reporting of cases of serious sexual harassment  in ambulance trusts, and the National Guardian highlighting widespread problems a year ago. These problems have also been increasingly recognised by ambulance leaders.

The review says trusts are now reporting an improving relationship with NHSE and more acknowledgement of their operational pressures, but calls for NHSE to “embed culture improvement alongside operational targets in planning and delivery oversight”.

Ms Melia acknowledges a traditional “command and control” leadership style in ambulance services, but says there is recognition this only works effectively for short periods. There was a need for change and support for a more “compassionate and inclusive approach”, Ms Melia adds.

She made several recommendations for ambulance leaders, NHSE and integrated care boards including:

  • A review of ICB lead commissioning of the services, with ambulance leaders having called for greater delineation of roles and responsibilities between ICBs and regions;
  • NHSE should monitor delivery of the national sexual safety charter and ICBs should monitor bullying and harassment in ambulance services, and take action where needed;
  • NHSE and ambulance trusts to work together on an equality, diversity and inclusion improvement plan;
  • A “bespoke” leadership and management development service, and a review of career frameworks;
  • All ambulance trusts should have a paramedic on the board;
  • NHSE and trade unions working on a joint statement supporting cultural change, including a focus on more effective “speak up cultures”, and recognition of the particular problems in the sector;
  • “Portfolio working” opportunities so paramedics can work in different organisations, and a review of paramedics’ operating environment and management model; and
  • NHSE to work with the Association of Ambulance Chief Executives to “review the role they play in embedding culture improvement in the ambulance sector”.

AACE managing director Anna Parry said: “This timely review focuses on many areas that are already a priority for the sector. We know that there is much still to be done to ensure that NHS ambulance services offer a safe, inclusive, well-led working environment for all their people where inappropriate behaviour will not be tolerated and concerns will be responded to appropriately and compassionately.”

AACE chair Daren Mochrie added: “Today’s review provides us with a further impetus to continue to build upon this vital work and create meaningful and lasting change – for the benefit of our people and our patients.”

Dr Navina Evans, chief workforce, training and education officer, NHSE said:  “This is an incredibly important report, and we welcome its recommendations, which will help build on the work we have already been doing through the NHS People Plan, and equality, diversity and inclusion improvement plan.

“We are committed to supporting ambulance trusts and all NHS organisations to continuously improve staff experience and services for patients – everyone working in the NHS must feel safe from any form of bullying, harassment, discrimination or abuse, and feel confident that they can raise concerns and that they will be taken seriously and acted on.

Trust sacks staff for sexual misconduct

London Ambulance Service Trust’s chief executive has described today’s report as a “wake-up call” to the ambulance sector and revealed his trust sacked nine staff members for sexual misconduct in the last year.

Daniel Elkeles said: “The NHS is built on the dedication and teamwork of our staff, and so the working culture we operate in, the values we live by and the behaviour we experience from colleagues is of critical importance. It is vital that the whole ambulance sector takes this report as a wake-up call and commits to making the necessary changes.

“As a trust, we have made progress in some key areas, including a zero-tolerance approach to sexual misconduct leading to nine dismissals in the last year, our focus on Freedom to Speak Up, and pioneering a new approach to teams-based working which enables operational teams to work more closely together.

“But there is much more to do. There are still too many members of staff who may not feel safe at work all the time and where our values of teamwork, caring and respect are not lived up to.”

LAS is not alone in sacking staff due to sexual behaviour. South Central Ambulance Service FT sacked at least seven  people after it encouraged staff to speak up.