las new ways of working

NewWays of WorkingTransforming Clinical Leadership

The objective is a simple one: to create on each ambulance station the perfectenvironment for clinical leadership to grow and flourish, improving not only thepatient’s experience, but also the job satisfaction of all the staff.

This document is also available in other languages, large print, andaudio format upon request.

020 7921 5258 Bill O’NeillLondon Ambulance Service NHS Trust220 Waterloo RoadLondonSE1 8SD

[email protected]


The objective is a simple one: to create on each ambulance station the perfectenvironment for clinical leadership to grow and flourish, improving not only thepatient’s experience, but also the job satisfaction of all the staff.

Produced by Bill O’NeillAssistant Director of Organisation Development

Contents

page

Foreword - Chief Executive Officer Peter Bradley CBE 1

1. New Ways of Working 3The Station Vision – New Ways of Working

2. Staff Engagement and Communication 13

3. Future Clinical Response 16

4. Modernising the Delivery of Training & Development 18

5. Clinical Leadership & Support 22

6. Clinical Leadership on Complexes: 28Role Modelling Excellence in Patient Care

7. Workforce Planning 31

8. Education & Development Restructure 34

9. Working Practice Modernisation 37

10. Organisation Development & Leadership 41

11. Access programme – Delivery for the New Ways of Working: 44Clinical Leadership on Complexes

12. New Ways of Working: 47Operational Support for Station Complexes

13. Partnerships in Health and Social Care Community Engagement 49

14. Community Engagement 51


Every once in a while, an opportunity arises to make a real and lastingchange. This is not the type of change that happens when you give yourhome a fresh lick of paint, or move the same old furniture round todifferent positions. Just every so often, the time is right for deep,fundamental change; the kind of lasting change that makes a realdifference to us and our working lives.

For me, the New Ways of Working is this kind of opportunity. The chance tocreate ‘new’ stations, where excellent patient care and staff developmentand support are the two top priorities. It is an opportunity to ask ourselveswhy we’re here, what our purpose is, and how best can we organiseourselves so that each one of us contributes to fulfilling that purpose.

Change can be exciting, and it can also be daunting. It involves movingaway from the familiar into sometimes unknown territory. But if we moveforward together to meet this challenge in a spirit of partnership, sharedresponsibility, mutual trust and support, we will be able to make a realdifference in improving not only the experience of our patients, but alsoeach of our working lives.

This is a very exciting development in the history of the Service and I amtotally committed to making it a success. This is our chance for that deepand lasting change, and I will be giving it my personal support every step ofthe way. I and the senior management team look forward to workingalongside you all in making this vision a reality.

Peter Bradley CBEChief Executive Officer

New Ways of Working:Transforming Clinical Leadership

The objective is a simple one: to create on eachstation the perfect environment for clinicalleadership to grow and flourish, improving not onlythe patient’s experience, but also the jobsatisfaction of all the staff.

With this visionary future firmly in mind, the Servicehas set about carrying out the work that will enablethis vision to be realised. Our Service ImprovementProgramme – SIP 2012 is about creating a Servicethat responds appropriately to all our patients” andNew Ways of Working (NWoW) is a crucial part ofthat. NWoW projects are the key elements of theOperational Model and Organisation Developmentand People programmes. There are also areas thatoverlap with the Corporate Processes and Accessprogrammes. However, there is a sense in whichthis work has a very clear identity of its own,focusing attention on life on our stations and howthat can be improved to the benefit of theorganisation, our staff, patients, partners and thewider community as a whole.

The following areas have been identified as of keyimportance in establishing this new way of workingon stations:

Staff Engagement

Staff engagement and communication are oftenspoken about separately but they are part of thesame thing – you cannot have one without theother. For simplicity, this work refers to these two

activities as staff engagement.

Healthy staff engagement is at the core of positiveculture change and is absolutely key to the Service’sfuture success.

In the organisation of the future, in the ‘new’station complexes, it is vital to create a culture ofengagement, where staff feel they are kept betterinformed and involved. It must become the way theService does business.

Future Clinical Response

This is about the way that the Service deploys itsvehicles and clinical resources in response tooperational requirements. The Operational Modelprojects – supported by other related projects - willcontribute to the delivery of better patient care by:

• Enabling us to get to patients sooner (twominutes sooner)

• Providing access to resources and pathways mostappropriate to the patient’s need

• Delivering a sustainable, consistent service acrossLondon, capable of absorbing variations indemand and giving equality of access.

The projects are about putting in place changes tothe way clinical response happens through:

New Ways of Working: Transforming Clinical Leadership 3

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• Sending to each call the staff most appropriatelytrained to deal with that call

• Increasing the use of cars to better enable themost appropriately trained staff to reach patientsmore quickly, more of the time

• Increasing access to alternative care routes forpatients, allowing them to be cared for in theway most appropriate to their needs, saving fullyequipped ambulances for those calls thatgenuinely need them

• Providing staff with the appropriate levels oftraining and development to deliver the above.

The Education & Training Plan

The Education & Training Plan recognises theaspirations and strategic direction of theorganisation to deliver more post-registrationcontinuing professional development and trainingat station level whilst maintaining a programme ofrecruitment and pre-registration courses at ourtraining centres and providing a workforce that isskilled appropriately to satisfy the aspirations of theworkforce plan.

(The full plan can be found on the pulse)

Modernising the Delivery ofTraining and Development

The Service, in common with much of the NHS, isnow beginning to move toward a model of deliveryfor education and training that not only relies onworking relationships with HE partners but thatplaces much greater emphasis on the provision ofworkplace-based, practice learning that allowsexperiential learning to sit alongside theory-basedlearning as equal partners, and uses the expertise ofpractitioners to assist staff in developing theirpractice. In addition, the provision of onlinelearning will further enhance the access todevelopment and training for all staff.

Clinical Leadership and Support

Continuing improvement in clinical leadershipwithin the Service will be achieved throughproviding not only higher level leadership andcommitment, but also through appropriate andreliable resources, development, information,guidance and performance appraisal and feedbackbeing made available to station-based clinical andtraining leads, who will actually deliver the clinicalleadership agenda.

The Service’s patient care agenda will be clearlystated and able to be easily understood by allclinical staff. It will be kept focused, involving asmall number of key objectives that are wellcommunicated, initially from the MedicalDirectorate and senior management team.

Although there is clear recognition that the clinicalleadership roles fall largely to the station complex’smanagement team, all operational staff will acceptthat clinical leadership is part of everyone’s role, andtake responsibility for their own clinical practice anddevelopment.

The Clinical Audit and Research Unit (CARU) is thepart of the Medical Directorate that undertakesrobust scientific research projects to explore newavenues for treatments and services aimed atdelivering the best possible care to our patients.Additionally, through its programme of systematicclinical audit, CARU monitors and reviews thequality of the care that is delivered to our patientsand recommends appropriate changes to practiceaimed at improving patient care both locally and ata national level.

In establishing enhanced clinical leadership onstations, the interface between frontline managersand staff and CARU will itself be enhanced, and willallow our clinical care to be better monitored andevaluated, and information and feedback mademore readily available to help inform individualpractitioners’ appraisal and development, andthereby their practice.

London Ambulance Service NHS Trust4

Complex-based Roles &Responsibilities

As part of this work, redefinition of the roles thatenable clinical leadership to exist on complexes willprovide clarity of purpose, identify interdepen -dencies and reliance between roles, and enablecritical success factors for each role to beestablished and monitored.

Clinical Workforce Reconfiguration

Detailed work has been undertaken to identify thelikely front-line clinical workforce requirements,based on modelling and planning assumptionsmade for the plan period 2007-2013, to bestenable the delivery of the improvements toresponding to patients detailed previously.

Analysis has shown that we will need largernumbers of staff with enhanced patient assessmentskills working as single responders. Crew staffnumbers are planned to increase over the period byaround six per cent (eight per cent including theincrease in CTA staff). There will be a four-tierfrontline workforce: emergency care practitioners;registered paramedics, a reduced number ofemergency medical technicians; and emergencycare assistants (title under review). This will create afront-line clinical workforce with almost 80 per centof staff providing direct care to patients beingprofessionally trained, together with an increase inthose with basic training. The majority of existingemergency medical technicians will be up-skilledthrough professional, higher education accreditedtraining to paramedic status at diploma level,complemented by the recruitment of universitytrained paramedics.

The Restructure of Education &Development

The context within which ambulance servicesprovide education and training for their staff ischanging nationally. With greater emphasis on themerging of internally delivered training with higher

education (HE)-based development, the workforcereview and the emerging financial/fundingpressures for all training outside medicine andnursing, there is a need for a fundamental shift inthe way that ambulance services design, plan anddeliver staff training and development.

For the Service this will mean that over the next fiveyears:

• Greater emphasis will need to be placed onfront-line staff’s clinical development andcontinuing professional development than iscurrently the case

• There will need to be an enhanced internalcapacity for upskilling EMTs, and developingexisting EMTs to paramedic level (bearing inmind the anticipated increase in the academicstanding of the paramedic award fromcertificate to diploma), and in upskilling existingparamedics to the new standards of education.

It is within this context that the changes proposedin this document are made. The objective of thechanges is to meet the above stated challengesthrough:

• Increasing the number of training deliverypositions

• Putting more of those posts onto stations

• Modernising our use of managerial positions

• Making greater clinical support and adviceavailable to staff.

Working Practice Modernisation

There are a number of existing practices that willneed to be modernised to allow new ways ofworking, teamwork and leadership to emerge andbe developed, including:

• Review of working patterns (rosters) and


exploring concepts such as self-rostering,annualised hours and the creation of ‘watch’systems to meet the joint goals of establishinggenuinely flexible working arrangements, andthe provision of dedicated training anddevelopment within rosters

• The establishment of real teams, enabling good,reliable face-to-face communication to takeplace, consistent and reliable management andleadership, and the development of strongrelationships between team members

• Dynamic deployment of vehicles where staffaccept they will be mobile for most of their shift,returning to their base only for their rest break

• Revisiting the rest break agreement

• Reviewing annual leave arrangements in light ofwhichever team working pattern system ischosen.

Organisation Development &Leadership

As part of the Organisation Development strand ofthe New Ways of Working, three distinct areas willbe developed:

Performance Management

Within the Service’s New Ways of Working,performance management will be established as apositive, comprehensive system through whichgood individual performance and the achievementof personal, business and development objectivesare identified, recognised and rewarded, andthrough which below standard performance andnon-achievement of objectives is fairly appraisedand monitored, with appropriate support anddevelopment available, and clear and consistentperformance capability processes are applied wherenecessary.

Talent Management

The organisation will put in place a framework of

access to dedicated, targeted development for anymember of staff from across all departments whohas been recognised (or who recognise themselves)as having the raw talent for leadership. Through aprocess of initial selection and appraisal, thestrengths and potential of these individuals isexplored, and with their managers, a developmentplan is designed that enables them to work towardreaching that potential through promotion.

Leadership Development

Whilst a traditional ‘managerial’ or transactional‘command and control’ approach is sometimesnecessary, and is an important part of any leader’stoolkit, it will no longer be the default style for theService, where empowering, inclusivetransformational leadership will become theprevalent style.

We will approach the leadership of the organisationin the same way we approach patient care - that is,by engaging and communicating with individuals tobetter understand and meet their existing andemerging needs, and by motivating and inspiringthem to develop both themselves and theorganisation to enable continual growth,effectiveness and success. In addition, the seniormanagement team will clearly act as role models,providing example of transformational, values-based leadership in action.

Information & Technology SystemsSupport

As a vital enabler of the New Ways of Working,IM&T’s Access Programme will support clinicalleadership on stations through:

• Electronic PRFs being fully installed in allresponse vehicles

• Many training modules, both clinical and non-clinical, being delivered by web-based e-learningpackages

• Every crew member carrying a digital radio that


provides point to point communication for crewmembers, direct access to the control room anda panic button in case of emergencies

• ESR being the single repository for all staff data,including records of personal issue equipment.Application forms are all electronic and from themoment of initial enquiry, the entire employeeprocess is automated

• All staff booking on/off duty (ultimately usingswipe cards), so time recording will thereforeautomatically satisfy the requirements of theWorking Time Directive

• All managers who have a justified businessrequirements having a laptop computerequipped with full remote access, allowing 24/7access to all corporate services. All staff will haveaccess to basic e-mail (known as web mail) fromany internet terminal – essentially giving freeaccess to Service e-mail from home computersor internet cafés

• The concept of ‘IM&T Super User’ beingestablished. This role is a recognisedresponsibility undertaken by appropriate staff ateach main Service location. The person provideslocal user support and has a direct liaison withthe IM&T Customer Services Department, whoprovide ongoing support and training

• There being a 24/7 IM&T Support desk that actsas a single focal point for all IM&T support

• There being a new, fully integrated CAD systemsupporting two control rooms (each with 100per cent spare capacity for resilience). Reliabilityis 99.9 per cent plus with complete systemfailures now unheard of

• Access to information being provided by a suiteof reporting tools that reside on all desktop andremote access computers. There are differentlevels of tools, and staff are able to generatereports as and when they require them,according to their access rights

• Providing a new suite of services for people whodo not speak English, and/or who cannot usethe telephone as an able bodied person would.

Operational Support

Operational Support is being transformed by anumber of initiatives and corporate projects tosupport the New Ways of Working.

Fleet, Logistics, and Make Ready are gradually beingintegrated into a single command unit to improveco-ordination and achieve maximum synergy.

There is a comprehensive review of Fleet SupportServices being undertaken which is considering thefuture sizes and numbers of workshops, staff levels,hours of work, and additional services. Largerworkshops, increased hours of work, additionalmobile workshops, and a 24/7 call centre are beingplanned. Ensuring that vehicle resourcing ismanaged and maintained will be a key task.

Logistical support will be delivered centrally by anintegrated Tender/Equipment Support PersonnelService operating from the Logistics Support Unit.The merged operation will cover all services such asdrug pack exchange, equipment exchange, blanketexchange, and post collection/delivery.

Medical consumables will also be managedcentrally and local stores maintained tominimum/maximum levels by Logistics staff.

The Logistics Support Unit will operate a 24/7service. Electronic asset tracking and inventorycontrol projects will be implemented to improveoversight and make efficient use of resources.

The local Operational Support Centre will contain aFleet Workshop, Logistics Co-ordinator, and will behome to a Make Ready staff member. Vehicles willbe deep cleaned when they come in for servicing.Daily cleaning and equipping will be carried out bymobile services. Spare vehicles will be held at thesecentres.


Partnerships within Health andSocial Care

As a result of the New Ways of Working,ambulance staff will have a much bigger range ofoptions for their patients and much more trainingto support good decisions about which to choose.They will be able to arrive at their patients knowingthat they are better able to provide what theyactually need.

If a patient does need to travel, staff will be able totake them to minor injuries units and walk-in-centres, urgent care centres and polyclinics insteadof the emergency department. They will also beable to refer them to district nurses, psychiatriccrisis teams, falls teams and intermediate care –schemes designed to support patients in remainingindependent in their own homes.

Ambulance staff will be much more familiar withhow these services work, often because theprofessionals running these services have providedtraining and familiarisation.

As clinical leaders, team leaders, trainers and ECPswill be able to provide support and advice in thedecision-making required. The ambulanceoperations manager will be a regular member ofthe PCT’s urgent care network and it is part ofhis/her role to seek out new opportunities for co-operation with other parts of the health and socialcare system.

Community Engagement

On each ambulance station complex there will be aCommunity Involvement Officer designated to leadon Patient and Public Involvement (PPI), publiceducation and building relationships with partnersin their area.

PPI and public education will be regarded as ‘corebusiness’. There will be a budget, held on thestation complex, allocated specifically to meet thecosts of community engagement work. The

community involvement officer will report to theAOM and his or her performance is monitoredagainst clear objectives and a PersonalDevelopment Plan.

The community involvement officer will identifyother people on their stations who (a) already enjoydoing PPI and public education work, and have theskills to do it well and (b) those who would like toget involved, or for whom it would be a gooddevelopment, but whose skills and knowledge needto be improved. In this way, no-one who isinterested in this work is excluded. All of the peopleso identified can then have PPI and publiceducation work in their Personal Development Plansand personal objectives, and will be supported todevelop and to participate in this work.

Benefits

In summary, the point of the New Ways of Workingis to realise the following benefits:

• To resolve patients’ needs without them havingto leave home

• To take fewer patients to hospital

• To achieve better survival rates for patients whoare seriously ill and injured, especially thosesuffering from:

- Myocardial infarction

- Cardiac arrest

- Stroke

- Serious trauma

- Respiratory arrest

• To achieve even better patient satisfaction

• To achieve high levels of staff satisfaction

• To achieve organisational improvement.


The Station Vision – New Ways of Working

“My name is Johnny O’Keefe, and I’m a Team Leader. I’ve been in the Service about 12 years.

Two years ago, in 2008, the Service began tointroduce the, New Ways of Working’ at ambulancestations (or ‘Extreme Makeover – LAS Edition’ as Icall it!). As part of the process for deciding whichstations to start with, complexes were asked topresent their bid for being the first. My station wasone of the first three stations chosen. From then onour complex, and the community it serves, wasgiven all the help it needed to make the new waysactually work!

So, what’s it like to work here now? Probably thebest way to show you is by describing a typicalworking day – here’s how yesterday went!

I arrived on station and swiped my I.D card to bookmyself on duty. It seems a long time since I used tohave to ‘sign on and off’ duty! As I swipe my card,EOC recognise that the vehicle is going to bestaffed and know my level of training.

There was an e-mail from my AOM in my inboxabout my application to join the TalentManagement Programme. Great news! I have aninterview next Tuesday!

I took a ‘handover’ from the team leader of thewatch going off duty at 7am; they had a busy nightagain. At 6.30 the rest of our watch arrived and‘swipe in’. Once they had a cup of tea in hand Istarted the daily briefing. Yesterday we werecovering all the early vehicles: two 12-hourambulances, one 10-hour ambulance, two 12-hourcars and two 12-hour UOC/Central servicesvehicles. The cars and A&E ambulances almost allhave a paramedic on board now, supported by

some emergency medical technicians andemergency care assistants.

First on the agenda was the rota for next month.This used to be sorted out by the Resource Centres,but we found we could get better cover, reducesickness and keep people happier (and healthier!) if we did our own resourcing. Now the team have a free hand to cover the shifts however theychoose, so long as they’re covered! We’ve seeneverything from split shifts to permanent Fridaynights in our ever-changing rota! The team love theflexibility and there always seems to be someonewho will cover your duty if you have a DIY job tofinish off, or the child minder goes sick! Thisflexibility has created a real ‘team’ feel whereeveryone looks after each other. Sickness hasplummeted, or as one team member put it, “We don’t do sick in this team!”

The team was one person ‘over strength’ yesterday;Jon, one of the team’s reliefs, hasn’t been neededmuch this month and so needs to use some hoursto meet his quota. This gave us the capacity to usethe day to develop one of the team. Erina, one ofthe team’s paramedics, is hoping to apply for teamleader soon, so this was a good opportunity for herto meet one of her PDP objectives by refreshing hermaternity skills, in advance of the exam paper. Aquick call to my contact, Jill, in the maternitydepartment and Erina was soon on her way for aday of screaming babies!

I briefed the team on the main points from thelatest RIB and CARU bulletin – they can catch up onthe detail at their leisure. As usual they asked some


sensible questions which I fed ‘up the line’ to thetrainers. Should have some answers for them today.

Finally, we discussed team performance and ourposition in relation to the other teams. As usual weare top on Cat A, but what the team really want toimprove is our cardiac arrest survival figures (we’rebehind Tom and Liz’s watch who have a brilliant37% survival!), so that will be the focus for the next month.

At the end of the meeting we agreed who wouldbe covering each of the deployment points. Theseare prioritised from one to four depending on howbusy they are. Whatever happens, we always try tokeep number one and two covered with anambulance and a car. Everyone moves up a point when the other vehicles are sent on a call.This means that we are normally in the best place for the next call coming in. We also all moveround at lunch time to share out the workloadacross the day.

Our first call of the day was to a patient with COPD.On the way, (whilst Jo drove) I brought up theclinical guideline for COPD on the MDT and had aquick read. I noticed there was a recent CARUbulletin attached and I opened that too. Thisreminded me of the need to score the patient’spain. No problem!

After thoroughly assessing and treating the patient,I arranged for him to be taken to the hospitalwhere he is known, and called for my Urgent Careambulance to get him there within an hours. Backin the ambulance I quickly completed the electronicPRF and sent it off.

I was then asked to go and help out one of ourcrews who were attending a terminal cancerpatient who had taken a turn for the worst – thecrew weren’t sure what to do for the best interestsof the patient whilst taking into account the distressof the relatives. I went along and together we cameup with a plan that helped address the concerns ofall involved and arranged for the palliative care

nurse to attend, allowing the patient to stay athome in relative comfort.

After a busy morning we went back to station for abreak, at a time that had been agreed with the restof the team that morning to maintain cover.

It was a bit quieter after our break and the final callof the day was to an RTA. It was quite serious andwe decide to bypass the A&E, to go to the traumaunit. It all went smoothly and we were able to turnround quickly now that we don’t have to bookpatients in.

Back on station I had the usual ‘wash up’ meetingwith the team. It was a good day. I thanked theteam and they all went home for a well-earnedevening. I held a performance review meeting withone of the team though, as I wanted to recognisehis extraordinary ability to get more letters ofthanks, over the past six months, than anyone else.Must be something there that the rest of the teamcan learn!

It’s also probably worth describing what differencethe new logistics arrangement for equipment andvehicles (apparently it’s now called ‘operationalsupport’!) has made to us on station.

Since the introduction of the New Ways ofWorking, the delivery of operational support hasbeen transformed. The Fleet Engineering, Logistics,and Make Ready services are now fully co-ordinatedunder one command.

Let me give some examples of this. This morningthe equipment support personnel (ESP) will call.There used to be two operatives who would call atdifferent times to deliver logistical support. Nowone person calls within an agreed time slot. Theyexchange drug packs, equipment and blankets,collect PRFs and deliver the post. They useelectronic held devices to keep track of equipmentand drug packs. A database is available to checkwhere equipment is being held and when drugpacks go out of date. There is no need to do timeconsuming paper audits any more!


The Logistics Support Unit is now open 24 hours a day. If any additional help is required in theevenings and at weekends, you can ring onenumber and someone will deal promptly with yourrequest. This really helps if we are short of blanketsas more can be delivered by the Unit.

Medical consumables are now managed byOperational Support. The ESPs maintain theconsumable stores using a minimum/maximumstock management system. There are no longer anyshortages or items that go out of date and wedon’t have to spend time chasing up orders anymore. We have a small running store that we useduring the day to top up vehicles.

Fleet engineering services are now provided fromlarge workshops working longer hours. There aremobile workshops that operate in the evenings andat weekends. The Fleet Resource Centre managesall issues around vehicle availability, servicing andrepair. You just call one number at any time and thecall centre will arrange for a mobile repair to becarried out, a tyre to be replaced, or a newwindscreen to be fitted. Some broken downvehicles are also now towed into workshops ratherthan having to wait for the RAC!

When we start work each day a fully equipped,clean vehicle is waiting for us. We don’t have toworry any more about finding spare or replacementvehicles. Spare resources have been pooled and areheld centrally which means they are now availableto anyone who needs one. The Fleet ResourceCentre will send a replacement within one hour if alocal repair cannot be carried out. Vehicles thatneed servicing are taken out each night and thereare no longer any backlogs. “Ferry drivers” areemployed to move vehicles between the stationand workshops. We no longer have to wastevaluable time waiting for and collecting vehicles.

Make Ready now operates from the largeworkshops. These workshops are now part ofOperational Support Centres where a logistics co-ordinator manages equipment and vehicle cleaningservices. Our vehicles are now deep cleaned when

they are serviced at workshops. Vehicles are cleanedand equipped on stations by mobile resources. This helps Make Ready as they can clean vehicles at satellites or at hospitals.

The best thing I can say about operational supportis that our concerns about vehicles, equipment, andconsumables have gone away – they are no longerissues. All our time can be spent on providing goodquality clinical care. Operational Support isproactively delivered and customer focussed.

That just about sums up what a ‘normal’ day onstation looks like these days. But there’s loads morestuff going on now outside the station than thereused to be too!

Our team have adopted one of the local communitycentres for the year and have raised severalthousand pounds from sponsored bike rides,marathons and other charity fund raising activities.This one is used mainly by Bangladeshi and Somaliwomen. Some of the locals from another part ofour borough have joined together with Service staffto form a cricket team that has entered a localleague – they’re doing OK too!!

Our local College of Further Education has beguntwo new and interesting courses. One is designedto improve community engagement, and is aimedat public sector staff, teaching them about the localcommunity, its history, traditions and problems.Students meet key players in the borough, andwork on a project with one of the communitycentres. Five staff from our complex attend this andsay it’s been really interesting and useful. Thesecond course is aimed at local people, and wasdeveloped as an access programme for theParamedic Science Foundation Degree course, nowbeing run at a number of universities. At the lastrecruitment event the Service held in the boroughwe recruited 15 people, mostly from Bangladeshibackground, and five were women.

The Service’s Decontamination Team carried out ademonstration of their work at a local park.Judging from the photographs everyone had a


great time and loads of fun. The Decon Team got aton of useful feedback on how to improve theirprocedures, particularly regarding those difficultlanguage, cultural and religious obstacles.

Our station’s Community Involvement guy Samhosted a delegation of local residents and arrangedfor them to have a tour of EOC and a briefing fromthe Service’s Olympics project team on how we arepreparing for the 2012 Games. Sam is alwaysgetting local press coverage about the station andwhat we’re doing; it’s made a real difference.

Seeing as, at the end of the day, we’re here to treatpatients, the most brilliant change of all is that thehealth of the people of our borough has improvedsignificantly over the past two years. Cardiacsurvival rates have come up to just short of theaverage for London, with significant gains forBangladeshi men, who were previously well behindother groups. Infant mortality rates in the Boroughhave improved following implementation of therecommendations from the Service’s ObstetricsAudit. The self-reported health assessment ofresidents has also risen to just below the averagefor London. Following our successful rollout of thediabetes management awareness sessions thenumber of diabetic-related calls to EOC hasdeclined significantly. To show off these successes,our borough is now the destination of choice forVIP visitors and international delegations who allwant to see how we’ve improved the health ofsignificant numbers of people in one of the poorestand most deprived parts of the Capital.

We’ve often talked about becoming a “world classambulance service”, we can now see just what thismeans for patients as well as for staff.”


Staff Engagement and Communication


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Effective, open and honest communication throughan active programme of meaningful staffengagement will be at the heart of a successfulambulance complex.

Through this engagement, a growing loyalty andcommitment will be nurtured, resulting in a positiveimpact on patient care and performance.

A strong commitment to good communication anda determination to engage with staff, recognisingthat everyone on complex can and should be ableon an equal basis to contribute to improving theService, will be key qualities of local managementteams.

For the complex management teams to successfullydevelop this vital culture of communication andengagement, they will be supported by their senioroperational managers and the senior managementgroup (SMG).

Each management team will have a clearcommunication and engagement plan. This willcover both how they are communicated with andhow they will communicate and engage with allstaff on complex.

Managers will have clear information from the“top” to share and discuss with their staff. Thecommunication lines between senior and frontlinemanagement will be clear and effective.

Current tools which include conferences, bulletins,e-mail will be examined carefully to ensure they areused to the greatest effect. We will develop newtools, some of which will involve expanding ourintranet and harnessing the power of the newmedia. Others may include the development ofsimple briefing sheets or building more extensiveconference call and video conferencing facilities.

Face to face communication (accepted as the mosteffective form of communication anywhere andeverywhere) will be developed further. Toencourage engagement, we must ensure that localmanagers have an efficient two-way process

through which they can feed back the views oftheir staff and their own views.

As well as providing information to local managers– and listening carefully to them – senior leaderswill be aware of the need to build their visibility. TheCEO staff consultation meetings will continue butfurther communications activities will be developedthroughout the year for the Director of Operations,the senior operational team and other SMGmembers.

On complex, existing communication tools will beused to best effect. For example:

• Develop the local pages on the intranet

• Manage the noticeboard(s) carefully andconstantly

• Make sure every member of staff has their owncopy of bulletins.

These are small things but all play a role in the localmanager’s communications toolkit to be used todevelop good staff engagement.

What else will be in this toolkit ?

• Regular complex management team meetings

• Regular management meetings with trade unionrepresentatives

• Regular complex/station meetings with frontlinestaff, involving staff in creating agendas anddeveloping a resilient process of feedback andaction

• Training events to support staff in developingclinical knowledge and skills

• Working groups – involving staff in localinitiatives both internal and external

• Well conducted personal development reviews(PDRs). Results will be collated to identifythemes.


Other activities should/could include:

• Local staff suggestion schemes

• Rewarding staff for jobs well done rather thanjust mentioning long delays or lengthy turn-round times

• Honestly feeding back to staff when theirindividual performance could be better

• Congratulating staff over letters of thanks

• Recognising service milestones – both throughthe formal corporate process and locally

• Developing social events.

Some of these are small things but they will all addup. They put credits in the credibility bank for whentougher decisions have to be made anduncomfortable actions taken.

The glue that will bind these more formal activitiestogether to create a healthy communicationsculture is the day-to-day informal communications,with all staff feeling that there is equity of access togenuine two-way communication. This will involvethe demonstration of excellent interpersonal skillsthrough which all staff will feel noticed and thattheir contribution is recognised and valued.

The management team will consistentlydemonstrate the right attitudes and behaviours - a very powerful piece of communication in itself.


Future Clinical Response


33

The programme that relates to the new design andstructure of clinical response and delivery –supported by other related projects - will contributeto the delivery of better patient care by:

• Enabling us to get to patients sooner (twominutes sooner by April 2008)

• providing access to resources and pathwaysmost appropriate to the patient’s need

• delivering a sustainable, consistent service acrossLondon better able to absorb variations indemand and giving equality of access.

The most serious (Category A) calls will be attendedby a paramedic or an emergency care practitioner(ECP), within eight minutes of connecting the 999call to the Emergency Operations Centre (EOC) in atleast 75 per cent of cases, consistently acrossLondon. This will be achieved by sending anambulance and a solo responder in a car as aninitial response to the 20 per cent of emergencypatients whose conditions are life-threateningand/or whose condition may rapidly deteriorate.We will also send a dual response to those callsinvolving a staff safety issue.

We will send a solo response to the remaining calls(about 70 per cent) which have not receivedtelephone advice in the first instance. We will sendan ambulance subsequently, only when a need isidentified by the initial responder. To this end wewill deploy either an Advanced Life Support (ALS)ambulance crewed by a paramedic and (in time) arevised EMT role, or a Basic Life Support (BLS)ambulance crewed by two emergency support staff(this is an end point and may need to be revisited inthe future).

Cars and ambulances will be dynamically deployedoff-station, there will be a raft of IM&Tenhancements, and staffing will be 97 per centagainst plan. There will be operational changes inControl Services, and a significant expansion in thenumber and use of local alternative care pathways.

Urgent calls will be dealt with predominantlythrough the Urgent Operations Centre. We willmaximise the use of clinical telephone advice toensure that patients receive the correct level of carefor their condition, including home care advice andappropriate referral to other providers wherenecessary. The highest level of clinical supervisionand assessment, including from team leaders, ECPsand in some cases GPs, will be available to ensurepatient safety and satisfaction, both as an initialresponse to calls, as well as in response to referralsfrom other members of the Service’s frontline staff.

Greater reliance will be placed on PTS and A&ESupport staff in providing BLS ambulanceresponses. Where patients do require ambulancetransport, we will ensure that the response theyreceive is appropriate to their condition.

By 2012 we will progressively reduce the number ofpatients taken to A&E. This reduction will amountto 200,000 patients per annum.


Modernising the Delivery ofTraining & Development

New Education & Training DeliveryModel

The Service, in common with much of the NHS, isnow beginning to move toward a model of deliveryfor education and training that not only relies onworking relationships with HE partners but thatplaces much greater emphasis on the provision ofworkplace-based, practice learning that allowsexperiential learning to sit alongside theory based

learning as equal partners, and uses the expertise ofpractitioners to assist staff in developing theirpractice. In addition, the provision of onlinelearning will further enhance the access todevelopment and training for all staff.

Recruitment Courses

Recruitment training courses for roles other thanparamedic will continue to be delivered at a ServiceEducation Centre. The courses will be delivered by


44

appropriately qualified staff (for details of this seesection 8 - Education & Development Restructure).Accredited by one or more of the Service’s HEpartners, each course delivered will be continuouslyreviewed and updated to ensure the higheststandards are maintained, and quality assurance willbe built into that process.

Continuing Professional Development

The Department of Clinical Education &Development will develop a schedule of availablein-house courses/modules, accredited by one ormore of the Service’s HE partners, from which staffcan choose and plan a development portfolio. Inparallel the department will publish a list ofapproved externally-provided courses that staff canaccess. Whilst some modules will be compulsory(such as resuscitation training), there will besufficient diversity within the schedule for staff tobe able to choose modules that reflect theirinterests and/or development needs. Thesemodules/courses will allow the Service to give staffaccess to only the highest standard of educationand training.

CPD training and development will be deliveredusing this modular framework, delivered through acombination of:

• One/two-day classroom-based modules deliveredby appropriately-qualified staff at either anEducation Centre or on station (for details of thissee Section 8 - Education & DevelopmentRestructure).

• Web-based e-learning packages

• Self-directed learning and reflectivepractice/mentoring

• Clinical placements to allow consolidation oftheory and practical skills, facilitated by practiceplacement educators (see beow).

Some modules, such as manual handling, wouldclearly be suitable for all levels of staff to attend.However, where appropriate, modules will be

designed to allow staff in particular grades, andwith similar specific needs to attend together (e.g.all team leaders/paramedics would be required toaccess the advanced resuscitation module whereasall EMTs would access the basic resuscitationmodule).

Each classroom-based module will be one or twodays in length (being either eight, 10 or 12 hourdays), with some being half a day in length,properly utilising this time with both theoretical andpractical content. In the first 18 months eachperson will be provided with three days’ CPD. Infuture this will be replaced by the provision ofprotected training and development time withinstaff rotas.

Each member of staff will be required to agree withtheir line manager through the PDR process aminimum number of modules they would accessover a given period of time i.e. 12 or 18 months. Itwill be the joint responsibility of both the complexmanagement team and the individual to ensure thisis completed. Monitoring of completion will beachieved through both regular one to one appraisalmeetings between staff and supervisors, and themaintenance of a centrally administrated trainingdatabase. Support will be offered to staff who areunable to meet the agreed objectives of their PDP,either through inability to reach the requiredstandard, or through non-attendance or absencefrom work, as part of the Service’s performancemanagement framework.

Where the content of the module is web-based,each member of staff will be responsible forachieving the objectives for that module bymanaging their own study time in agreement withtheir line manager/supervisor. The local trainer willprovide mentoring and guidance to enable thestudent to manage their own progress.

Each student will receive certification for eachmodule successfully completed. This will allow acomprehensive training record to be establishedand provide evidence of development when staffare applying for promotion. Dedicated modules will


be developed for EMTs who are planning toundertake the paramedic course to ensure they areadequately prepared and thus maximising levels ofsuccessful completion.

All course/module content will be regularlyreviewed by both Clinical Education and theMedical Directorate to ensure that subjects taughtare up to date and still appropriate for the Service’sneeds. In particular, emphasis will be placed on thepatient assessment aspect of all relevant courses toensure it enables us to provide staff with therequisite skills to deliver the level of care thatunderpins the future operational response model.

Having the modular system will allow more accessto development, more regularly, for more staffacross the Service. For example a number of 12 leadECG modules may run concurrently; one being forteam leaders, one for EMTs, and one forparamedics.

Not all modules will require face to face teaching.The department will continue to move forward withe-learning which could allow the member of staffto access their development from both stationand/or home, so long as evidence of completioncan be demonstrated.

There are a number of technical subjects that willbe included as modules. For example modules suchas ‘Road traffic collision scene management’ and‘Introduction to complaint investigation’ can be runto develop duty station officers. Likewise, a numberof modules will cover or include subjects such asequality and diversity.

For this modular system of CPD delivery to besuccessful it is vital that each complex has clearlyidentifiable clinical leads, who will be the twodedicated trainers. It also requires a “buy in” from the AOM who must, as the clinical leader for each complex, and with the support of senior management, establish and support thedevelopment of staff as a priority issue for achieving excellence in patient care.

Paramedic Courses

Paramedic training and development will beconsolidated at the Service’s main education centre,currently at Fulham, which will become a ‘satellitecampus’ for one of the Service’s HE partners. Thiswill allow the creation and maintenance of a coreteam of specialist training delivery staff (possiblylecturer practitioners jointly appointed by theService and HE partner) who will deliver HEaccredited education and development to diplomalevel. Additionally, the paramedic course will becontinuously updated to reflect current clinicalneeds of the Service, and to maintain the minimum standards of the BPA national curriculumand HPC requirements.

The course will include a mix of residential and non-residential elements. However, in the short termand to support the initial introduction of the NewWays of Working and Future Clinical ResponseModels, the potential will exist for delivering thecourse at one of the other Service education centresshould the need arise to provide for large numbersin a single geographical location.

Priority will be given to delivering paramedictraining to convert existing EMTs from within theService (see the Training Plan - on the pulse). As far as possible, this will be achieved throughaccumulation of modules to prepare EMTs for ashorter final paramedic element to allow them to qualify.

All existing paramedics will be provided with updatetraining to enhance their skills, particularly withregard to patient assessment, to provide them withthe requisite skills to deliver the level of care thatsupports the future operational response model(see the Training Plan - on the pulse).

Practice Placement Education

The Service will develop a comprehensive PracticePlacement Education framework that will allowstaff undertaking any form of clinical education andtraining to consolidate theoretical concepts in apractice-based environment. The role of practice


based educator (PPE) will continue to beestablished, and will be open to EMTs at Associatelevel, and HPC registered paramedics at practiceplacement educator level (see Section 8), who havean interest in supervising and supporting thedevelopment of students. PPEs will work as part ofthe management team on complexes, takingresponsibility for a named student for the period oftheir development, complementing the role of teamleader, station training lead and practice learningteam to identify and enhance learningopportunities of their students.

Emergency Care Practitioner Courses

The programme of development for ECPs will, asfar as possible and as at least a minimum standard,reflect the national curriculum (yet to be agreed)and will be delivered in partnership with, andaccredited by, one or more of the Service’s HEpartners.

Promotion Courses

Courses associated with promotion and careerprogression (team leader, DSO, AOM, ExploringLeadership & Self Awareness, etc.) will continue tobe run and delivered in their current format, whichis already designed on a modular basis.


Clinical Leadership & Support


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Clinical Leadership, as its name suggests, is abouttwo things.

The first is clinical expertise. The clinical expert issomeone at the forefront of their field. Theirknowledge, both broad and specialist, is of thehighest standard. They accept responsibility for theirown learning, and not only keep themselves up todate, but are forward thinking in the likely directionof future developments in their field. The clinicalexpert understands the importance of translatingtheir knowledge into skills and practical application,and the importance of maintaining those skills,developing and honing them to be the best they can.

The second is leadership. The clinical leader is notonly at the forefront of their field, but is seen asbeing so, and provides a visible example for othersof how excellence in both knowledge and theapplication of skills should look. The clinical leaderis forward looking, and is actively involved inshaping the future of their specialist role. Clinicalleaders set the pace for change within their field.They are mentors and role models for both thosenew to the field, and for more experiencedpractitioners, providing support and challenge topoor practice through development, appraisal andfeedback.

The clinical leader puts the patient and their wellbeing, in all respects, at the centre of everythingthey do clinically and professionally, and motivatesothers to do the same.

High level Clinical Leadership &Support

The patient care/clinical leadership agenda for theService will be led by the Medical Director whowill provide the lead in establishing a clear directionof travel for patient care that takes into account thenational, London-wide and international patientcare picture. Working with the Assistant MedicalDirector in Primary Care, the Clinical PracticeManager and Senior Clinical Advisor, focus and

clarity will be given to allow the Service tounderstand its organisational commitments as wellas allowing clinical staff within the Service tounderstand their own individual commitments tothe provision of excellent patient care.

The assistant directors of operations (ADOs) willhave the overall responsibility for ensuring thatclinical excellence and patient care are at theforefront of both strategic and tacticalmanagement within their Area. Working with theperformance improvement managers (PIMs),practice learning managers (PLMs) andambulance operations managers (AOMs), theADOs will maintain not only an ultimate respon -sibility for maintaining a clinical focus in all thebusiness of their Area, but will act as a champion ofclinical excellence, recognising and rewardingdemonstrable clinical leadership, challenging poorachievement of clinical targets, and providing equalsupport for clinical as for operational performance.

At station complex level the AOM will provide theclinical focus and will drive forward the concept ofclinical excellence. It is through the AOM that theorganisation will channel information both from thestaff and from the senior management team. Theclinical support provided to the AOM will comefrom the PLM, the station-based trainers and theteam leaders.

Within Control Services a clinical support functionwill be introduced that will have overallresponsibility for clinical leadership and governancewithin EOC and UOC, overseeing 24-hour clinicaladvice for frontline staff, agreeing and monitoringclinical performance indicators, and partnershipwork with the Clinical Audit and Research Unit(CARU) to oversee the Service’s contribution toresearch and audit involving UOC and EOCincluding AMPDS and the DART study.

Front-line Clinical Leadership &Support

Continuing improvement in clinical leadership


within the Service will be achieved throughproviding not only higher level leadership andcommitment, but also through appropriate andreliable resources, development, information,guidance and performance appraisal and feedbackbeing made available to complex-based clinical andtraining leads, who will actually deliver the clinicalleadership agenda.

Station-based trainers (title to yet be finalised)will provide the clinical expertise on each complex,being responsible for the local delivery of clinicaleducation and training, and providing support anddevelopment to ensure the clinical anddevelopmental performance of team leaders.

Team leaders will be provided with the means todeliver meaningful feedback to their staff not onlyon CPIs, but on individual clinical performance,enabling them to be a first-hand source of advicefor operational staff. This will require reliable andup to date information to be available to teamleaders and trainers on the clinical performance ofindividuals from sources such as PRF, MDT,performance information gained throughappraisals, ride-outs, feedback from service usersand undertaking clinical case reviews, etc. Inaddition, information will be made available fromvarious sources, including specific patient outcomedata (particularly around cardiac arrest and STEMI),results of clinical audit, internal and external clinicalresearch outcomes, etc, to allow frontline staff tounderstand the outcomes of their own clinicalperformance and to inform their own perception oftheir strengths and their development needs.

A 24-hour telephone advice line will continue to beprovided for frontline staff. This gives staff themeans of speaking directly with a senior clinician atany time, and is of particular value for staff who areon scene with a patient.

The role of emergency care practitioners inproviding clinical leadership will need a greaterfocus, seeing them potentially being targeted tomore complex patient cases etc. This group of staffhave benefited from significant clinical development

and have the opportunity to act as role models andadvisors to their front line colleagues in day to daypatient encounters. The current small numbers andspread of the ECP cohort has minimised theirimpact.

Although there is clear recognition that the clinicalleadership roles fall largely to the complexmanagement team, all operational staff accept thatclinical leadership is part of everyone’s role, andthey take responsibility for their own clinicalpractice and development. There are manyparamedics and EMTs who, though not working asteam leaders, have a real passion and interest inparticular, specialist areas of their work, and havetherefore developed specialist expertise that islargely untapped. The concept of Patient CareChampion could be a means of expanding the roleof clinical leader to include paramedics and EMTswho are exemplary in their patient care, clinicalknowledge, interpersonal and leadership skills etc,or who have a specific expertise in a given area (e.g.sickle cell, mental health, older people etc.), withlinkages into the sponsorship for study and bursaryschemes currently available.

A number of UK ambulance services are training acohort of critical care paramedics (CCPs), usuallyin conjunction with their HE provider, and with theintention that they will work on the air ambulanceor be involved in inter-hospital transfer. In view ofthe likely changes in the provision of specialisedcare in London, there is an increasing need todevelop such a cohort of staff to support thedecisions made to transfer patients who may wellbe critically ill or injured to the specialised centresreferred to in the Healthcare For London ‘AFramework For Action’ report.

The Service will consider building on the principle ofthe existing cohort of HEMS paramedics, includingthe emeritus group. Many of these paramedicshave extensive experience of advanced airway andtrauma management. They are more likely to haveseen injured children and been involved in multiplecasualty situations.


Courses have already been developed for ourexisting HE providers which could support theextensive practical knowledge and skills this grouphas acquired.

Such a cohort would complement the knowledgeand skills acquired by ECPs, who are experiencedparamedics who are targeted to the lower priority,but more complex, primary care cases, giving ourstaff increased opportunity to develop in either, orpossibly both, directions.

Clinical Audit & Research

The Clinical Audit and Research Unit (CARU) is thepart of the Medical Directorate that undertakesrobust scientific research projects to explore newavenues for treatments and services aimed atdelivering the best possible care to our patients.Additionally, through its programme of systematicclinical audit, CARU monitors and reviews thequality of the care that is delivered to our patientsand recommends appropriate changes to practiceaimed at improving patient care both locally and ata national level.

In establishing enhanced clinical leadership onstations the interface between frontline managersand staff and CARU will itself be enhanced, and willallow our clinical care to be better monitored andevaluated, and information and feedback mademore readily available to help inform individualpractitioners’ appraisal and development andthereby their practice.

Clinical Audit

The aim of the clinical audit programme is to ensurethat the Service delivers high quality care to all itspatients in line with best practice. Quality of care ismeasured in a number of ways, including:

• Adherence to clinical practice guidelines

• Delivery of patients to appropriate care providers

• Speed of response; health outcomes, andpatient satisfaction

The results of all our clinical audits are used todevelop recommendations for enhancing patientcare. The programme is overseen by the ClinicalAudit and Research Steering Group who ensurethat the areas of care audited are of relevance tothe strategic objectives of the Service and currentpriorities in pre-hospital care and the wider NHS.The findings of all audits are disseminated widelyacross the Service and externally to other UKambulance services, local hospitals and otherinterested parties.

There are four types of clinical audit activitiesundertaken by CARU:

1. Central audits – large-scale multi-disciplinaryaudits which aim to look at the process ofpatient care as a whole. Some examples ofprevious central audits are the asthma auditand re-audit which looked at diagnosis ofasthma and administration of salbutamol.Forthcoming audits will look at ET tubeplacement and obstetric care. These auditswill be primarily undertaken by CARU, underthe day to day management of the ClinicalAudit Co-ordinator.

2. Snapshot audits – smaller audits focusing ona specific aspect of care or area. These areundertaken largely by the Clinical Audit Co-ordinator. However, all staff members in theService, who express an interest in clinicalaudit, are encouraged to undertake asnapshot audit or become involved in clinicalreviews for audits.

3. Clinical Performance Indicators (CPIs) – acontinual clinical audit of the care given topatients as recorded on the Patient ReportForm (PRF). This type of audit is carried out byteam leaders as part of their role and ismanaged day to day by the Clinical AuditFacilitator. It looks at increasing the quality ofdocumentation on the PRF and improvingspecific aspects of patient care which have astrong evidence base and are of clinical risk.We are currently in the process of rolling-outa set of ECP-specific CPIs.


4. We also carry out regional and nationalcollaborative audits with other NHS Trusts tolook at patient outcomes and the impact ofpre-hospital care and allow benchmarking.

As part of the clinical audit programme, CARU alsoundertakes continuous audit of cardiac arrest andmyocardial infarction cases. Through these auditswe produce station complex-specific information(via the monthly Cardiac Care Pack) to enable localmonitoring of cardiac care. We also produce theService’s Cardiac Arrest Annual Report thatpresents, along with other important information,the Service’s cardiac arrest survival rate.

Within the New Ways of Working it is envisagedthat CPIs will play an important role in furtherdeveloping clinical care:

• A CPI champion on each station complex toliaise with CARU and to assist with thedevelopment of CPIs and give feedback to CARU

• CPI completion will regularly exceed 95 per cent

• Compliance rates will regularly achieve 100 percent

• An enhanced system for monitoringperformance against the above targets will beput in place

• Team leaders will be given the time both toundertake CPI audits and to provide quarterlyCPI feedback sessions with staff

• Trainers will be given the time to producequarterly CPI Quality Assurance checks and givefeedback to team leaders as a group

• Staff will have access to computers such thatthey can access their own CPI data

• Robust systems of staff movement will be inplace so that the CPI database can remain up todate

• PRF training and refreshers will be undertakenregularly to ensure that operational staffunderstand the importance of a comprehensive PRF.

Research

The Service’s comprehensive research programmefocuses on remodelling the way the ambulanceservice responds to patients and is aimed atdeveloping new knowledge that is of benefit topre-hospital care and the wider NHS. Findings fromresearch are used to contribute to the evidencebase for pre-hospital care and to improve patientcare.

We are currently running a number of cardiacresearch trials in collaboration with internationalpartners including Seattle Emergency MedicalService, University of Washington and New YorkCity Emergency Medical Service, examining variousaspects of care, from telephone CPR instructions tothe use of defibrillators in the field. We are alsocurrently developing two cardiac drug trials incollaboration with some London hospitals and drugmanufacturers. Other research projects in theprogramme encompass areas of care such asstroke, older people who fall, and the role ofemergency care practitioners.

CARU is also responsible for approving all researchthat takes place in the Service or using our staff ordata, and ensures that the Service’s researchactivities comply with relevant guidelines andlegislation.

In order to support and encourage awareness ofevidence-based practice throughout the Service,CARU runs Evidence for Practice Seminars everyother month where research, audit and evaluationfindings are presented. We also run a Journal Clubevery second month, where staff with no or limitedresearch backgrounds have the opportunity to readand critically appraise published research papersand discuss the implications of the findings on day-to-day practices. We also hold ‘Advice Surgeries’ inwhich we answer questions and advise staff aboutresearch and audit methodologies. The seminars,


Journal Club and ‘Advice Surgeries’ are open to allmembers of staff.

It is anticipated that the New Ways of Working willlead to:

• An audit and research champion at each stationcomplex

• The active involvement of stations in theproposal and design of research protocols,including providing logistical expertise of what ispossible

• Attendance at the Evidence for Practice Seminarsand Journal Clubs

• A commitment to release staff to attend theabove wherever possible

• More robust systems for data collection

• Proactive administration and dissemination ofaudit and research projects

• Each complex will have and audit and researchnoticeboard demonstrating the clinicaleffectiveness of that particular station complexesand the Service as a whole.

• CARU will be invited to and attend stationcomplex and Area meetings

• Management teams will actively champion theimportance of audit and research projectsthrough both actions and words.

Protected Training Time

Whilst there is always a place for both feedbackand development to be given ‘on the hoof,’ to relyon it being fully, or nearly fully, achieved in this wayis unreliable and unpredictable, and underlines anysense of it not really being valued by theorganisation. To enable a structured, planned,strategic approach, providing clear, achievable

objectives and measurable outcomes, a modulartraining and development delivery programme willbe introduced, alongside protected training timebuilt into staff rotas.

Patient Care Agenda

The Service’s ‘Patient Care Agenda’ will be clearlystated and able to be easily understood by allclinical staff. It will be kept focused, involving asmall number of key objectives that are wellcommunicated, initially from the MedicalDirectorate and senior management team.

Both team leaders and trainers will be providedwith clear objectives from AOMs and PLMsregarding the expectations placed upon them forachieving the agreed patient care agenda, bothservice-wide and complex-based. Appraisals forteam leaders and trainers will focus on these keyobjectives, as will appraisals for EMTs andparamedics, and will be clearly linked with PDR.


Clinical Leadership on Complexes:

Role Modelling Excellence in Patient Care


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Within the Service the aim is for there to be noseparation between clinical leadership andleadership per se, but rather we will develop theleadership skills of those in roles requiring them tobe clinical experts alongside doing the same forthose in non-clinical managerial roles. The aim is:

• To genuinely establish and embed clinicalexcellence through leadership as the first andmost important of the organisation’s values

• To build the same degree of support andprotection around it as is afforded to operationalperformance.

As part of this work, redefinition of the roles thatenable clinical leadership to exist on stations willprovide clarity of purpose, identifyinterdependencies and reliance between roles, andenable critical success factors for each role to beestablished and monitored.

Station Complex Roles

The station complex and its team are considered tobe the face of the Service locally. The ambulanceoperations manager is the local lead for allinitiatives, both clinical and non-clinical, for theircomplex. This does not require them to be the mostclinically expert, but instead is about the emphasisand importance placed on patient care by theAOM, the tone they set on the complex in thisrespect being paramount in enabling the clinicalexperts and role models within their team to havereal impact.

Working alongside the Area AOMs as a group (andin partnership with the Area ADO), the practicelearning manager plays a key role in supportingthe local patient care/clinical care developmentagenda, tying it in with the wider centralisedframework of patient care development, driventhrough the Medical Directorate, to ensure bothlocal applicability and governance needs are met aswell as service-wide consistency.

Both the AOM and PLM are responsible for tyingthe local, complex-based patient care agenda intothat of local partners, such as PCTs, PPI fora, acutetrusts, social services, etc to ensure that the needsof the local community are both understood andincluded in providing an inclusive and completepicture of local patient care.

The role of the station administrator is to supportthe management team and staff on a station orgroup of stations. They manage all theadministration which includes completing all pay,leave and absence returns, providing basic HRinformation for staff and managers, providing anadministrative service to the management team anda point of contact for other Service departmentsand external customers. They facilitate the smoothrunning of a station and its satellites.

The team of duty station officers provide themanagerial direction and support that enables thecomplex to function as a unit, both operationallyand developmentally. The DSO role is crucial inensuring operational performance iscomplementing clinical performance, and inensuring that frontline staff have all they need todeliver optimum patient care.

The clinical expert for each station complex is thetrainer who, as an integral part of themanagement team, is empowered and enabledthrough partnership with the AOM and PLM to set,deliver and monitor the local clinicalleadership/patient care agenda. Working directlywith a team of team leaders, the trainer isresponsible for supporting frontline staff in gainingand maintaining the skills and knowledge theyneed to deliver optimum patient care.

The purpose of the team leader role is, first andforemost, to provide mentoring, support and visibleclinical leadership to operational frontline staff. Theteam leader is the clinical role model for their team,which is not just about doing CPIs or formalrideouts/appraisals, but includes the example set byteam leaders in all their own interactions withpatients, their evident confidence in their own


clinical knowledge and expertise, as well as the waythey support others to achieve the same.

Emergency care practitioners work as part of thecomplex team to provide not only clinical rolemodelling, but also clinical support and expertise totheir paramedic and EMT colleagues. In addition,they play an important role in ensuring that existinglocal and service-wide care pathways are promotedand used, and that new pathways are developed toreflect the emerging care needs of the localcommunity.

On each ambulance complex there is a member ofstaff, the community involvement officer, who isdesignated to lead on patient and publicinvolvement (PPI), public education and buildingrelationships with partners in their area. Thecommunity involvement officer has good links bothwithin the Service and externally. Key relationshipswithin the Service are with the Events & SchoolsTeam, the Events, Schools and Media ResourcesManager, the Community Resuscitation TrainingTeam, the Diversity Team, the CommunicationsTeam, the Patient Advice & Liaison Service and thePPI Manager.

Although there is clear recognition that the clinicalleadership roles fall largely to the complexmanagement team, all operational staff accept thatclinical leadership is part of everyone’s role, andthey take responsibility for their own clinicalpractice and development. There are manyparamedics, EMTs and urgent care staff who,though not working as team leaders, have a realpassion and interest in particular, specialist areas oftheir work, and have therefore developed specialistexpertise that is largely untapped.

The concept of patient care champion could be ameans of expanding the role of the clinical leader toinclude paramedics, EMTs and urgent care staffwho are exemplary in their patient care, clinicalknowledge, interpersonal and leadership skills, etc,or who have a specific expertise in a given area (e.g.sickle cell, mental health, older people etc.), withlinkages into the sponsorship for study and bursary

schemes currently available. This would also enablepractitioners to be directly involved in work that isfocused on the specific health needs of thecomplex’s local community, where particularconditions, for example diabetes or sickle cell, maybe more prevalent than in other areas.


Workforce Planning


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Overview

Having a skilled, professional workforce shaped tomeet future needs and committed to both patientcare and the Values of the Service is a pre-requisiteto achieving our objectives. Detailed work has beenundertaken to identify the likely front-line clinicalworkforce requirements based on modelling andplanning assumptions made for the plan period2007-2013.

Analysis has been undertaken as to the skill mixrequirements for each type of potential responsewe provide to patients now and in the future. Thishas highlighted the need for a larger number ofsingle first responders who will be given anenhanced level of assessment skills and form agreater proportion of the workforce. We will alsomove progressively towards a two tier system ofambulance transport with Advanced Life Support(ALS) ambulances and Basic Life Support (BLS)ambulances with an appropriate workforce skillmix. Category C patients who cannot be managedappropriately through Clinical Telephone Advice(CTA) will receive an assessment visit from anemergency care practitioner or paramedic and soan increased number of staff trained to this levelwill also be required.

Crew staff numbers are planned to increase overthe period by around six per cent (eight per centincluding the increase in CTA staff). There will be afour-tier frontline workforce: emergency carepractitioners; registered paramedics, a reducednumber of emergency medical technicians andemergency care assistants (title under review). Thiswill create a front-line clinical workforce withalmost 80 per cent of staff providing direct care topatients being professionally trained together withan increase in those with basic training. Themajority of existing emergency medical technicianswill be up-skilled through professional training toparamedic status complemented by the recruitmentof university-trained paramedics.

Consultation with Staff side and a full partnershipapproach will be taken to progressing the

workforce plan, which will be reviewed annuallyand will take account of any future changes tonational or local policy or any new servicedevelopments, such as provision and expansion ofOut of Hours services.

Further work is to be undertaken to identify futurerequirements for call-taking and despatch staff,Patient Transport Service staff and supportdepartment staff.

More detail on the short term and longer termplans is provided below:

Workforce plan 2007/08

The Trust will consolidate the existing expandedworkforce and begin to introduce the desiredchange to skill mix in order to meet the needs ofthe new service delivery model including the FutureClinical Response model These plans currentlyassume no additional funding to support thechanges in response time measurement (CallConnect) to be introduced in April 2008. The planwill therefore change should the Service besuccessful in its bid for additional funding in thisrespect.

The main focus for 2007/08 will be to begin theprocess of enhancing the skills of those staffcurrently in post rather than recruiting additionalstaff and the overall staffing numbers will thereforeremain unchanged.

The costs of existing emergency care practitioners(ECPs) will be absorbed into the Service’s baseline budgets so as not to be reliant on annual funding negotiations with individual PCTs.This will give the stability required to continue todevelop the individuals in these roles and give the Service the confidence to roll out the ECPmodel further throughout the organisation in future years.

The number of paramedics is expected to increaseby about 150. This will be achieved through acombination of recruitment of university-trained


paramedics and internal paramedic training ofemergency medical technicians (of which themajority will be EMT4s).

Staff employed in the new A&E support role (title ofemergency care assistant is under review), isexpected to increase from 99 to 126.

External recruitment within this year will thereforeconcentrate on the paramedic role together withsome anticipated recruitment to the new A&Esupport role and the filling of existing vacancies forclinical telephone advisors.

Workforce plan to 2013

From 2008 onwards the Service will continue theprocess of enhancing the skills of its existingworkforce and will also begin to increase itsnumbers in response to the assumptions ondemand and change in service delivery. Over theperiod of the plan the Service will:

• Increase the numbers of ECPs by 130 (one ECPscheme per station complex) in order that thisrole can be used appropriately, responding tothe patients who require their level ofknowledge and skill

• Increase the number the number of dedicatedtrainers on stations

• Continue the programme of universityrecruitment and internal training and therebyincrease the number of paramedics to 1,911(from 815 in 2007).

• Continue to develop existing techniciansthrough the career progression route withparamedic training. This will be supported by anHR framework agreed through a jointpartnership working group. Staffing numbers inboth the EMT3 and EMT 4 roles will reduce overtime. It is anticipated that by 2013 the majorityof EMT3 staff will have progressed to EMT4 orparamedic roles and approximately 120 EMT4swill remain

• Increase the numbers of A&E support staff by345 to 444

• Expand Clinical Telephone Advice, with doublethe numbers of clinical telephone advisors (100by 2013)

• Consider within the plan staff resourcing for theOlympics, HART and Call Connect

• Continue to provide a limited number of trainingplaces for a revised EMT role to allowprogression for A&E support staff.


Education & Development Restructure

Introduction

The context within which ambulance servicesprovide education and training for their staff ischanging nationally. With greater emphasis on themerging of internally delivered training with highereducation (HE)-based development, the workforcereview and the emerging financial/fundingpressures for all training outside medicine andnursing, there is a need for a fundamental shift inthe way that ambulance service’s design, plan anddeliver staff training and development.

For the Service this will mean that over the next fiveyears:

• Greater emphasis will need to be placed onfront-line staff’s clinical development andcontinuing professional development than iscurrently the case

• With the proposed changes to the workforceprofile and skill mix, the main focus will move toparamedic development


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• There will need to be an enhanced internalcapacity for upskilling EMTs, and developingexisting EMTs to paramedic level (bearing inmind the anticipated increase in the academicstanding of the paramedic award fromcertificate to diploma), and in upskilling existingparamedics to the new standards of proficiency.

The above, in addition to many other servicedevelopment initiatives, is given focus in the workthat is currently being undertaken to establish newways of working, and the establishment ofenhanced clinical leadership, on each stationcomplex. This work, which commences in 2008beginning with three ‘early implementer’ stationcomplexes.

It is within this context that the changes detailed inthis section are being made. The objective of thechanges is to meet the above stated challengesthrough:

• Increasing the number of training deliverypositions

• Putting more of those posts into complexes

• Modernising our use of managerial positions

Education & Training Delivery

The new structure places most emphasis on the roleof education and training delivery. This is dividedinto two parts:

Workplace Based Education & Training

As part of the ‘New Ways of Working: TransformingClinical Leadership’ programme:

• Team-based working and flexible rostering willbe introduced on all complexes, with self-rostering and protected training time built intowork time. As part of the station complex team,trainers will work in this flexibly rostered way

• Wherever possible a dedicated, appropriately

equipped training room/learning resource will beestablished on each complex to allow trainersand team leaders to deliver the CPD modules fortheir staff on site. Where this is not possibleaccessibility through a local education centre willbe maintained

• There will be two dedicated trainer positions oneach station complex (a total of 52) who willreport to the AOM, with professionalaccountability to the area practice learningmanager. The main purpose of these posts willbe to manage the delivery of all CPD activity forthe frontline staff on that complex, as well assupplementing any recruitment training activity

• In addition, the posts will provide supportive andfacilitative line management to the station’steam leaders, with visible clinical andeducational focus for the role and enabling aclear link into both education and clinicaldevelopment.

The Training Services Group will continue to set thelevel of centralised training activity. As the majorityof trainer roles will be based on stations, theresourcing of trainers onto recruitment coursesbased in education centres will be drawn from thatpool, and will necessitate a greater degree offorward planning and cooperation betweentrainers, AOMs, PLMs and the resource function atFulham to ensure that appropriate levels of trainerresources are maintained at both stations andeducation centres.

In Control Services, the current structure will remaineffectively unchanged with the exception ofchanges to job titles to mirror those used elsewherewithin clinical education.

Diagram 1 (overleaf) shows the new stationcomplex level structure

(Further details of the entire departmentalrestructure are available on the pulse)


Paramedic Education & Training

Over the next five years a greater emphasis will beplaced on:

• Enhancing our internal, HE accredited capacityfor upskilling/developing existing EMTs toparamedic level (bearing in mind the anticipatedincrease in the academic standing of theparamedic award from certificate to diploma)

• Developing a greater degree of Service in-housecontribution to the education and developmentof ECPs

• Strengthening our contribution and support tothe Paramedic Science HE programmes.

In order to achieve this, the new structure containsa number of dedicated paramedic tutor positionswhose role will primarily be to provide thepreviously stated paramedic programme.

These tutors will report to either the HE ProgrammeManager or the Education Centre Manager at

Fulham. They will all be involved in all aspects of theparamedic education and developmentprogramme.

In addition to the above detailed changes to linereporting, flexible rostering (including unsocialhours) and place of work, the job description andperson specification for station-based trainers willreflect the inclusion of line managerial responsibilityfor team leaders.

Tutor Development

Although there will be two distinct trainer/tutorroles within this new structure, a system ofexchange/buddying will continue to exist that willallow trainers and tutors to interface with station,centre and university based education anddevelopment.

Course Content Development

A new steering group will be set up in early 2008,jointly chaired by the Medical Director and AssistantDirector of Organisation Development, todetermine the design and content of all clinicaltraining courses and modules.


Working Practice Modernisation

In order to achieve the vision for clinical leadershipon complexes, there are a number of existingpractices that will need to be modernised to allownew ways of working, teamwork and leadership toemerge and be developed.

Working Patterns

Current working patterns (rosters) do not allow formany of the core principles of good leadership to

be fully developed, including good, reliable face toface communication, consistent management andleadership, genuinely flexible workingarrangements, the development of strongrelationships between people, and theestablishment of real teams.

The following describes how the above could beachieved through changes to working patterns,including the potential introduction of a watchsystem, self-rostering teams, and annualised hours.


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Self-rostering teams

Traditionally crew staff are placed on a station rosterafter having served their time on a relief roster.Once given a permanent shift line on the stationrosters, staff would remain with the same crewmate and would follow the same shift patterns withset rest periods and set shifts. This is not a flexiblesystem and invariably leads to either too little or toogreat a resource on duty for the demand at anygiven time. With the current rosters we very rarelyachieve congruence between resources anddemand. Self-rostering will provide teams with theopportunity to better match available resource todemand by providing greater flexibility, which canbe predetermined by the team members themselveswho will decide their own shift patterns.

Effectively each team would be contracted toprovide an ambulance or a single response vehicle24 hours per day 7 days per week. A relief factorwould be included within the team make-up so asto provide for annual leave, training anddevelopment and an anticipated level of sicknessabsence. Each team would comprise of 14members, including the team leader - this numberis based on having a 30 per cent relief factor foreach ambulance or two single response units.Within the current roster provision there is arequirement for 9.6 WTE per week to provide oneambulance 24/7 (based on the 39 hour week), thisaccounts for 10 of the team, the additional teammember’s account for the 30 per cent relief require -ment with the team leader being supernumerary,giving greater flexibility for clinical supervision.

The team members would cover their ownabsences to ensure that the vehicle is alwaysavailable; this of course may at times require thesupport of a centralised pool of relief staff or by therelease of additional overtime hours for teammembers. This would occur when the absencelevels in the team exceeded the inbuilt relief factor,however in most cases an unexpected absencewithin the team would be covered by a teammember. Certain parameters may need to beagreed so as to ensure a balance of provision across

the teams within a station or complex such asensuring all the vehicles do not start and finish atthe same time etc.

Within pre-determined parameters such asminimum cover requirement, maximum andminimum shift lengths etc, the team membersthemselves would decide what shift patterns areworked and what length the shifts will be. Tomaximise flexibility there may well be, built in to theteam contract, provision for additional shifts or fordropping of shifts at the request of the complexmanagement team based against increases ordecreases in demand.

Advantages

Self-rostering teams as described are best suited tothe provision of a 24-hour vehicle in that the teamcontract is for exactly that. Team members can trulydecide when and how long they work for as longas the vehicle is staffed. However, to manage thisprocess effectively team members would need to beplaced on an annualised hours contract.

Annualised Hours

Annualised hours is a method of organising workover a period of one year calculated on the basis ofthe number of hours to be worked rather than thenumber of hours per week. This allows for greaterflexibility to meet individual needs within a teambut also meets the varying demands of the Service.The actual number of hours worked by each teammember in a given week can be flexed to matchworkload requirements and individual availability,although the average working hours will need tocomply with the Working Time Directive. The basicprincipal of annualised hours is that instead ofdefining the traditional working week as 37.5 hoursa commitment is made to provide for a set numberof hours per year. This principal can be furtherdefined within a quarterly period or even a monthlyperiod. As previously stated there will be the needfor predetermined parameters such as maximumand minimum shift lengths, maximum hoursworked in any one week etc.


There is a standardised formula for calculating thecontracted hours for staff and as an example amember of staff with less than five years’ service onan annualised contract would be paid for 1,955hours per year and be contracted to work for 1,693hours per year, the difference being annual leaveand bank holiday entitlement.

Advantages

Annualised hours schemes are especially attractivein areas which have uneven demand or seasonalvariations.

Advantages to the Service would include:

• Increased flexibility with core resources

• More predictable pay costs spread evenlythroughout the year

• Less reliance on temporary staffing solutions.

For staff, potential benefits include:

• Stable income

• Potential to take time off when needed e.g.school holidays

• Improved work/life balance

The Watch System

A watch system is devised by splitting the totalnumber of staff within a unit, department, stationor complex into teams of equal or near equal size innumber. Each team or watch is given its ownidentity and a management or leadership structureto oversee and co ordinate the work and tasks ofthe watch or team. The watch leader is responsiblefor all of the good management associated withleading a group of people, such as welfare, trainingand development, mentoring and performancemanagement for example.

A clear example of a watch system already exists

within the Service. Staff within the EmergencyOperations Centre (EOC) already belong to a watchteam, each headed by an AOM supported by twooperation centre managers. The total numbers ofstaff within EOC are divided amongst five watchesso at any one time approximately 20 per cent of theworkforce is on duty. The watch system ensuresthat this 20 per cent all belong to the same team.Both Police and Fire services operate the watchsystem in various forms but these watch systemsinclude an inbuilt relief factor which could result inthe potential to have more resource on duty thanrequired but in reality is absorbed by annual leave,training and development and other absence suchas sickness.

One of the weaknesses of the watch systemsdescribed is the need for a rigid roster system i.e. allteam members need to be on or off duty at thesame time and it could therefore be perceived asinflexible. However, with vision applied there is noreason why we could not adopt a watch systemwith some inbuilt flexibilities. For example, we couldset a minimum cover level with the watch teamproducing greater hours than resource requirementfor this minimum, and flex this against theoptimum cover when demand dictates. This wouldrequire us to absorb relief into the watch team toachieve this level of flexibility. It could be that at anygiven station there is a requirement to cover twoambulances and two FRUs 24 hours per day, sevendays per week. This will require at least six staff ofthe watch on duty as a minimum. However, if theplan was to have nine on duty we could provideadditional vehicles at periods of high demand orbuild in development opportunities for the surplusresources at periods of low demand. This invariablywill be early shifts on some weekdays.

Advantages

All staff would belong to a team and would be onduty at the same time. This would foster team spiritand may produce an element of healthycompetition between watches which could improveall facets of performance. Communication of allissues could be more easily achieved face to face ina timely fashion. The unpopular relief system could


be disbanded with all staff now being part of thewatch team. This would also remove the previouspractice of having a permanent crew mate aspotentially anyone could work with anyone else ona daily basis, dependant of skill requirement. Therewould be an inbuilt flexibility that could result inchanges to duties on a shift by shift basis, aidingprocesses such as the PDR.

An additional advantage to a watch system wherehealthy team spirit and pride in collective working isevident is the potential for not wanting to let theteam down and this could lead to lowerabsenteeism and better individual performance onresponse times and hospital turn around broughtabout by peer performance.

Self Rostering team vs. the Watch team

There are of course some difficulties to overcome inintroducing any new schemes and clearly self-rostering schemes do not sit easily within a watchsystem. The watch system requires all staff on dutyat any given time to belong to that individualwatch. This requires a more rigid roster system andfollows what already exists in our own EOC.However, certain changes could be engineered suchas watch members self allocating against the shiftrequirements of the predetermined watch roster,thus giving some personal flexibilities.

The advantages of a watch system previouslydiscussed and simply put are that team spirit ismore easily fostered and communication withwatch members can be achieved face to face moreeasily.

Self-rostering teams working in the way describedwill not be on duty at the same time, indeed bydesign only two or three will be. However, thestrength of this team is developed by mutualinterest and benefits to individual team members.With strong leadership and good communicationlinks self-rostering teams may be as effective as awatch team but may, if developed well, providegreater flexibilities to match demand patterns. Self-rostering teams will not only require a highcalibre of team leader capable of managing

complex rostering and resourcing issues, but willalso require a high degree of individual selfdiscipline from team members if this effectiveness isto be achieved.

Whichever system is adopted, there will be a greatdeal of work required to successfully design andimplement what will be considered a significantcultural and practical change to long establishedpractice. There is a full programme of change towork practices which underpins new ways ofworking in teams, including:

• Dynamic deployment of vehicles where staffaccept they will be mobile for most of their shiftreturning to their base only for their rest break.To maximise the benefits of dynamic deploymentthis will be linked with the introduction oftechnology for the automated dispatch ofambulances similar to that which already existsfor the fast response units

• The rest break agreement will be revised toaccommodate dynamic deployment and withinthe revision staff will be encouraged to takeresponsibility for ensuring they have a rest break

• The annual leave arrangements will be reviewedin light of whichever team system is chosen toensure that all leave is taken within the leaveyear and that when leave is taken it is moreevenly spread across the shifts and within theteam relief factor.

Much of this work is already being planned or is atthe stages of early discussion and should be viewedas a springboard for new ways of working withinteams.


Organisation Development & Leadership

Through the introduction of the New Ways ofWorking, and the specific elements of theOrganisation Development (OD) & PeopleProgramme that forms part of the ServiceImprovement Programme 2012, the following keyareas of OD will have a different look and feel inthe Service of the future, not only on stationcomplexes but throughout the organisation.

Performance Management

Within the Service, performance management willbe perceived as a positive, comprehensive systemthrough which good performance and theachievement of personal, business anddevelopment objectives are identified, recognisedand rewarded, and through which below standard

performance and non-achievement of objectives is fairlyappraised and monitored, withappropriate support anddevelopment available, and clearand consistent performancecapability processes being appliedwhere necessary.

All staff, regardless of positionwithin the organisation, will beprovided with regularperformance appraisals from theirline managers, tying in progressachieving business objectives withachievement of personaldevelopment targets. There will beactive promotion of the use of realand comprehensive performancemanagement as a means ofmotivating staff in theachievement of both personal andwider departmental andorganisational objectives andgoals. In a wider sense, the samewill be applied to team as well asindividual performance.


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Talent Management & SuccessionPlanning

The organisation will put in place a framework ofaccess to dedicated, targeted development for anymember of staff from across all departments whohas been recognised (or who recognise themselves)as having the raw talent for leadership.

Through a process of initial selection and appraisal,the strengths and potential of these individuals willbe explored, and with their managers, adevelopment plan will be designed that enablesthem to work toward reaching that potentialthrough promotion.

Staff on this programme will become part of anaccelerated promotion pool, based purely onstrengths and ability. This will enable managers toanticipate who the future leaders of theorganisation are, and provides talented managerswho know and understand the organisation.

Through this programme, the organisation will bebetter able to:

• Recognise and capitalise on talent

• Allow staff to progress in their career accordingto their choice and at their own pace

• Provide accelerated development andprogression for talented staff

• Provide development for staff wishing to takepart in accelerated progression

• Anticipate upcoming vacancies and/ordevelopment opportunities

• Target staff at specific opportunities andvacancies

• Provide equitable access to opportunities forprogression

• Initially recruit to selected managerial positionsfrom the accelerated promotion pool.

Leadership & ManagementDevelopment

Whilst a transactional, managerial approach issometimes necessary, and is an important part ofany leader’s toolkit, it will no longer be the defaultstyle for the Service, where empowering,transformational leadership will secure theprevalent style. We approach the leadership of theorganisation in the same way we approach patientcare - that is, by engaging and communicating withindividuals to better understand and meet theirexisting and emerging needs, and by motivatingand inspiring them to develop both themselves andthe organisation to enable continual growth,effectiveness and success. In addition, the seniormanagement team will act as role models,providing example of transformational, values-based leadership in action.

To this end the Service has planned its owncomprehensive Leadership & ManagementDevelopment Programme comprised of thefollowing elements:

1. The Exploring Leadership & Self Awareness(ELSA) programme for middle managers andthe complementary programme for seniormanagers (currently being designed). Withself-awareness being a fundamental, basecomponent for quality leadership thisprogramme provides the means for ongoingdevelopment of effective leadership skills inmanagers at both middle and senior positionswithin the organisation

2. Development for clinical leaders (i.e. clinicaltrainers and team leaders), based around theCertificate of Education for trainers, and theInstitute of Leadership & Management (ILM)Certificate in Team Leading for team leaders

3. Specific training in performance managementfor all managers

4. Provision of self-awareness development forall managers. A complementary strand to the


ELSA programme, which has limitedaccessibility (i.e. places on courses), thisdevelopment allows a variety of self-appraisaltools to be made available to all managers toenhance their PDPs and provide a groundingfor further leadership development

5. Provision of coaching development for seniormanagers and BME staff. The LeadershipDevelopment plan includes promoting andmaintaining a coaching culture within theorganisation. Matching non-operational andoperational managers, this programme aidsinformation sharing and cross-functionalworking. Our ability to coach internally hasreduced the need to draw on externalresources, reducing ongoing costs

6. Provision of a modular Management Skillsprogramme available to all managers anddelivered in-house. There are a number ofelements available (e.g. time management,conducting appraisals etc) that are deliveredthrough a combination of facilitatedcoursework and self-directed distance andweb-based learning. Elements are combinedto provide specific courses for new managersin particular roles (e.g. AOMs).

Self-managing Teams

As a consequence of a prevalent transformationalleadership style and use of comprehensiveperformance management, the degree of localempowerment of teams will grow steadily withinthe Service. There will be a real sense of teamworkacross all departments. Local leaders will know theirteams well, and will themselves be known by theirteams. Team members will be better able tounderstand each others’ preferred ways of working,exploit each others’ strengths and balance eachothers’ weaknesses. Teams provide supportive yetchallenging environments which stretch each teammember to give their best, and strive to be better.

There will be minimal centralised management

directly affecting teams, and micro-management bysenior managers will become a thing of the past.Local managers will be provided with the skills andresources to manage their team’s performance tomeet organisational, as well as specificdepartmental and team, objectives. Theseobjectives will be known by all team members, andthrough each leaders’ use of appraisal andfeedback, each team member will be enabled tounderstand their personal role in the team’sachievement of these objectives.

Members of successful teams trust each other.Those leading successful teams trust their seniormanagers. Local managers will not be second-guessed by senior managers. There will be anacceptance of diversity in reaching goals; not everyteam will do things the same way. Rather thanbeing seen as risky inconsistency, this will be viewedas adding richness to the culture, encouraginginnovation and producing results, and learning from those results, that would be impossible ifevery team was constrained by doing things thesame way.

Within the Service the goal is for teams to be real,happy places to work within. Teamwork, and thetrust it engenders, hand in hand with realleadership and staff development and performancemanagement, will become a key enabler in oursuccessful programme of cultural change across theorganisation.


Access programme – Delivery for the New Ways of Working: Clinical Leadership on Complexes


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Introduction

This section sets out a high level vision for how theAccess Programme will support the ‘New Way ofWorking.’ It suggests how the Service could derivereal business benefits utilising IM&T systems andservices from 2009 and beyond. Each component iswritten as an independent issue, not in priorityorder.

Key components

• A new suite of services will be available forpeople who do not speak English, and/or whocannot use the telephone as an able bodiedperson would. This includes direct internetservices, and text messaging via translatorservices that then interact with the control room.New national targets have been agreed for thesetypes of calls as eight minutes from initial callanswer is recognised as being not realisticallyachievable.

• Electronic PRFs are fully installed in all responsevehicles. Details of the call automaticallypopulate the ePRF ‘tablet’ (hand portable PCdevice) and where patient details are known,appropriate medical information is downloadedfrom the Spine. Mandatory fields ensure 100 percent data compliance. If the patient is to betransported then all recorded details aredownloaded to the receiving centre (hospital orurgent care centre of some type), estimated timeof arrival is automatically calculated, hencereception staff know who to expect and when.

• The ePRF tablet also acts as information centrefor the paramedic. It has access to variousclinical guidelines, and provides basic translationsoftware for deaf people and commonly usedlanguages. It is in continuous development as avital paramedic aid.

• Staff training and education has evolved. Allemployees are required to have a basic level ofIM&T literacy, irrespective of their role (e.g. e-mail, basic word processing). Many trainingmodules are now delivered by web based e-

learning packages, including many clinicalmodules. Traditional classroom based training isstill delivered, but it is more of an exceptionrather than normal practice. Importantly, staffaccept that they are responsible for theirongoing training – this is not something that is‘done to them’ by managers.

• The Service has fully implemented Airwave.Every crew member carries a digital radio thatprovides point to point communication for crewmembers, direct access to the control room anda panic button in case of emergencies. Data isnow routinely passed across this system alertingstaff to calls, and in the case of non-MDTvehicles, passing the actual call details.

• ESR is the single repository for all staff data,including records of personal issue equipment.Application forms are now all electronic andfrom the moment of initial enquiry, the entireemployee process is automated. Extractionroutines take data from ESR and populate othersystems that need data about people (e.g.telephone directory). This includes setting theaccess level that each member of staff has forinformation systems. Self service is fullyimplemented, allowing staff to self-managecertain personal attributes (e.g. bank details,address, telephone extension).

• All staff book on/off duty electronically, timerecording will therefore automatically satisfy therequirements of the Working Time Directive.Additionally, when booking on duty all clinicallyqualified staff will be issued with an Airwaveradio, that in turn will show their availability tothe CAD system. All clinically-qualified staff willbe expected to be available to respond to localcalls to perform physically local BLS duties,irrespective of their other duties.

• All managers who have a justifiable businessrequirement will have a laptop computerequipped with full remote access, allowing 24/7access to all corporate services. All staff will haveaccess to basic e-mail (known as web mail) from


any internet terminal – essentially giving freeaccess to Service e-mail from home computersor internet cafés. Vitally, a new culture will haveemerged where staff use this technology towork smarter, not harder – this access will notsimply be work added to the ‘day job’.

• The concept of IM&T Super User is now wellestablished. This role is a recognisedresponsibility undertaken by appropriate staff ateach main Service location. The person provideslocal user support and has a direct liaison withthe IM&T Customer Services Department, whoprovide ongoing support and training.

• There is a 24/7 IM&T Support desk that acts as asingle focal point for all IM&T support. Utilisinginteractive tools the support technician is able toremotely access the faulty equipment or service.70 per cent of the calls receive a ‘fix’ at the pointof the call being received. That is, the technicianis able to restore at least a basic service to thecustomer, and where necessary complete faultresolution to be undertaken in slow time.Increasingly customers will use ‘self service’.Through a web browser they will be able to logon to the service desk and report their problem.They will also be able to access a series of toolsand help scripts to assist in ‘self fix’ and alsomonitor progress of their fault.

• ‘IP’ communications has enabled the Service toimplement a fully integrated digital network.Voice, data, video are seamlessly passedbetween Service locations, and four digit diallingconnects any voice device (not necessarily atraditional telephone). ‘Hot desking’ is commonplace, with staff having a transportabletelephone number (can by moved to any fixed ormobile handset) and are able to log onto theiruser accounts and files from any Service PC.

• There is a new, fully integrated CAD systemsupporting two control rooms (each with 100per cent spare capacity for resilience). Reliabilityis 99.9% plus with complete system failures nowunheard of. New functionality is released twice a

year through upgrades provided by thecommercial provider of the CAD software.

• All data is input once, as close to the originalcollection point as possible, normally via a webbrowser. Hence through streamlined businessprocesses and work flow applications paperforms are no longer sent to data input functions.Once entered, data is then re-used by a definedsuite of systems, hence removing the need forduplicate data entry.

• Management Information is provided by a suiteof reporting tools that reside on all desktop andremote access computers. There are differentlevels of tools, and staff are able to generatereports as and when they require them,according to their access rights. The centralManagement Department provide expertanalysis for the most complex queries, report onoverall trends, provide predictions, continuallydevelop the tools and act as guardians of datastandards

• Software provision is split between in-housedevelopments (normally under six months fromconcept to delivery) and commercial packages.Large scale bespoke software development isnot undertaken and where necessary, businessprocesses are adjusted in order to implementpackage solutions.


New Ways of Working: Operational Support

for Station Complexes


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Operational Support is being transformed by anumber of initiatives and corporate projects tosupport the new front end Operational Model andClinical Leadership model.

Fleet, Logistics, and Make Ready are gradually beingintegrated into a single command unit to improveco-ordination and achieve maximum synergy.Geographically-based operational support centresare being considered to support the corporate OSDstructure in delivering customer-focussed services.

There is a comprehensive review of Fleet SupportServices being undertaken which is considering thefuture sizes and numbers of workshops, staff levels,hours of work, and additional services. Largerworkshops, increased hours of work, additionalmobile workshops, and a 24/7 call centre are beingplanned. Ensuring that vehicle resourcing ismanaged and maintained will be a key task.

Logistical support will be delivered centrally by anintegrated Tender/Equipment Support PersonnelService operating from the Logistics Support Unit. Arobust relief factor will be introduced to ensureservices can be fully maintained. The mergedoperation will cover all services such as drug packexchange, equipment exchange, blanket exchange,and post collection/delivery. Medical consumableswill also be managed centrally and local storesmaintained to minimum/maximum levels byLogistics staff. The Logistics Support Unit willoperate a 24/7 service. Electronic asset tracking andinventory control projects will be implemented toimprove oversight and make efficient use ofresources.

The local Operational Support Centre will contain afleet workshop, Logistics Co-ordinator, and MakeReady operative. Vehicles will be deep cleanedwhen they come in for servicing. Daily cleaning andequipping will be carried out by mobile services.Spare vehicles will be held at these centres.


Partnerships in Health and Social Care


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We are witnessing big changes in London’s healthservices. Fewer hospitals will provide full A&Eservices but there will be more places where peoplecan get treatment for minor emergencies. And theaim is that, in order to provide the best care forpeople with serious conditions like major trauma,stroke and acute coronary syndromes, we will betaking patients to specialist units which may not bethe nearest hospital, but will be geared up to be thebest.

So, the automatic assumption was that all ourpatients would go to an emergency department,and pretty much the only other option was to leavethem at home.

Ambulance staff will in future have a much biggerrange of options for their patients and much moretraining to support good decisions about which tochoose. Ultimately we will arrive at our patientsknowing that we are better able to provide whatthey actually need.

In fact we will usually know a good deal aboutthem before we get there, because we will haveaccess to lists of patients with long term andterminal conditions, alongside real-time access tohealth and social care databases. This means that if,for example, the patient is under the care of acommunity matron for their chronic respiratorycondition, we will know what clinical signs andsymptoms would be normal for that patient and wewill be able to contact their community matron ifwe don’t think they need to go to hospital. This willmake our clinical assessment much more thoroughand better-informed.

Also, if a dying patient has chosen to be put on aregister, we will know ahead of time if they wouldprefer to die in their home, with their family aroundthem, and we won’t be taking them to hospitalagainst their wishes.

If a patient does need to travel we will be able totake them to minor injuries units and walk-incentres, urgent care centres, and polyclinics insteadof the emergency department. We will also be able

to refer them to district nurses, psychiatric crisisteams, falls teams and intermediate care – schemesdesigned to support patients in remainingindependent in their own homes. We will have linksto community matrons who support patients withlong term conditions so that they are much lesslikely to require hospital admission. Many GPs willhave made appointment slots available for thepatients we go to and will become available toconsult with over the phone. We will also have linkswith social services and voluntary sector groups.

Ambulance staff will be much more familiar withhow these services work, often because the nursesand other professionals have provided training andfamiliarisation. Continuing ProfessionalDevelopment of ambulance staff will include timespent with these teams to gain a fullerunderstanding of how they work and whichpatients they can accept.

As clinical leaders, team leaders, trainers, and ECPswill be able to provide support and advice in thedecision-making required. They will more often beinvolved in negotiating the arrangements in the firstplace and will be able to ensure that the guidelinesfor referral are kept up to date and usedappropriately. They will be able to resolve anydifferences of opinion and follow up any problemsthat are experienced.

The AOM will be a regular member of the PCT’surgent care network and it is part of his/her role toseek out new opportunities for co-operation withother parts of the health and social care system.


Community Engagement

On each ambulance complex there is a member ofstaff, the community involvement officer, who isdesignated to lead on patient and publicinvolvement (PPI), public education and buildingrelationships with partners in their area. This is a fulltime, dedicated role. Post holders do not get drawninto dealing with operational pressures or othertasks. In fact they do not have to have a Serviceoperational background to be selected for the role.

PPI and public education is now ‘core business’.There is a budget, held on the complex, allocated tomeet the costs of community engagement work.The community involvement officer reports directlyto the AOM and his or her performance ismonitored against clear objectives and a PersonalDevelopment Plan.

The community involvement officer has identifiedother people on the complex who (a) already enjoy


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doing PPI and public education work, and have theskills to do it well and (b) those who would like toget involved, or for whom it would be a gooddevelopment, but whose skills and knowledge needto be improved. In this way, no-one who isinterested in this work is excluded. All of the peopleso identified have PPI and public education work intheir Personal Development Plans and personalobjectives, and are supported to develop and toparticipate in this work.

When they take part in PPI or public educationactivity, staff get paid for it as they would if theywere working a normal shift. Staff are no longerexpected to do this work for nothing, as it isrecognised as being of enormous benefit to thepublic, as well as helping the Service to comply withlegislation, achieve its external targets and its ownstrategic goals.

The learning from PPI and public education activityis not restricted to this group of people, though.The community involvement officer, working withthe AOM, runs regular information-exchangesessions with all staff on the complex. Staff are keptinformed about the health needs of the localpopulation, about the learning from recent PPI andpublic education events, and about the feedbackpeople from the community have given about theService. Other managers are sometimes invited tothese meetings (e.g. PPI Manager, DiversityManager), as are key partners from otherorganisations … and patient representatives ofcourse.

The community involvement officer has good linksboth within the Service and externally. Keyrelationships within the Service are with the Events& Schools Team, the Community ResuscitationTraining Team, the Diversity Team, theCommunications Team, the PALS Team and the PPIManager. Quarterly development sessions are heldfor all the community involvement officers, toensure they have opportunities to share learningfrom their areas and can get some central input interms of key messages and materials. There is acentral resource bank for materials (pictures,

“give-away” items etc) and other key information is available on the public education pages of the pulse.

Externally, the community involvement officer hasworked hard to get to know their counterparts atthe local authority, the Overview and ScrutinyCommittee, PPI leads in the PCT and local hospitals,the other emergency services, voluntary sectororganisations and patient groups (e.g. expertpatient networks). As Local Involvement Networks(LINks) are developed, the community involvementofficer makes sure, along with the AOM for thatcomplex, that the Service is represented on thatgroup. LINks are a good way of recruiting patientsfor PPI activity both locally and centrally.

The community involvement officer also has a rolein addressing the needs of frequent callers to theService in their area, working with the PALS Teamand other agencies to ensure a care package isdeveloped for them. He or she also liaises with theService Development Team about the developmentand promotion of alternative care pathways in thearea. Working with the PALS Team, the communityinvolvement officer has a role in acting on staffconcerns via the incident reporting system, forexample liaising with care homes or GP surgeries.He or she also works with Service colleagues andexternal partners to review the status of patientspreviously identified as posing a possible risk tostaff.

The community involvement officer also has linkswith informal networks, and has got to knowpeople in local business, sports facilities and socialenterprises, as well as support groups for peoplewith a variety of medical conditions, older people’s“tea clubs”, residents’ associations etc.

Staff on the complex are encouraged to attendlocal public events. The community involvementofficer hears about these in plenty of time toarrange for staff to be released from operationalduties, as he or she has built up such good linkswith a variety of community groups. Staff aretherefore developing a good understanding of the


people they serve, and ‘us and them’ tensions arediminishing.

When a large public event is being planned, thecommunity involvement officer liaises closely withtheir AOM, the PPI Manager, the Events & SchoolsTeam, Diversity Team and community resuscitationtraining officers in their area, to ensure the Servicestand has the right materials, messages andactivities to meet the objectives of the event, theneeds of the community, and Service objectives. Forall events, he or she ensures that a risk assessmentand event plan are completed.

When planning his or her activity for the year, thecommunity involvement officer uses the dataavailable, to ensure that PPI and public educationactivity in the area reaches those with the greatestneed, setting and agreeing clear, measurableobjectives. Information is available from the PCT onthe health needs for the various populations in thearea, and this is linked with the government’shealth priorities and helps the Service to meet itsrequirement (in Standards for Better Health) toreduce health inequalities. As well as informationfrom the PCT and local authority, the communityinvolvement officer also uses Service data: ethnicmonitoring information, PRF data, EOC call data,clinical audit data, and information on LanguageLine usage. This helps to determine priority areasfor PPI and public education activity. Ad-hocrequests for visits from non-priority groups are onlyundertaken if there is a gap in the plan.

The community involvement officer facilitates visitsto the ambulance station, and holds occasional‘open day’ events there, inviting members of thelocal community via the links he or she has alreadymade, plus advertising in local media (includingnon-English and specialist ones). This gives staff atthe ambulance station the opportunity to meet thepublic on an occasion when they are not ill, helpingto emphasise that ‘patients are people’ andpotentially leading to greater respect andcompassion towards members of the localcommunity.

Working with the Community ResuscitationTraining team, the community involvement officerruns basic life support training sessions forcommunity groups, mother and baby groups,expert patient networks, and many others. They settargets (numbers) and priorities (target groups) forthe year and this plan is regularly monitored. Theiractivity is recorded centrally so that it can be easilyaccessed and used to plan future activity. Thetraining sessions are also used as an opportunity toobtain feedback from participants, not just aboutthe training, but also about any experiences theymay have had of using the Service. They are also anopportunity to find out from members of thecommunity what PPI and public education activitiesthey want or need.

Similarly, the community involvement officer worksvery closely with the Events & Schools Team. Schoolvisits are planned in advance, again depending onthe local priorities and target communities, and theschedule for these visits is recorded electronicallyand shared with the community involvement officerand the local community resuscitation trainingofficers. Representatives from these three groups(community involvement officer, Events & SchoolsTeam and local community resuscitation trainingofficers) meet regularly to plan their work, discussjoint working opportunities and share learning. Aswell as focusing on schools and colleges, thecommunity involvement officer - with support fromthe Events & Schools Team - has built up links withlocal youth groups.

Once a Public Education Coordinator has beenappointed (as recommended in the PublicEducation Strategy), the Coordinator will ensurethose records are maintained, kept up to date andheld centrally for others across the Service toaccess.

Public education activity is closely linked with therecommendations of the Public Education Strategy.Some of this activity is information-provision,explaining to communities how to use the 999service and also how to access other services, andwhich is appropriate in different circumstances. The


focus of this activity is not to put people off calling 999, or trying to divert them to other partsof the system. The way this message is deliveredwill include letting people know that we are here to help.

Some public education activities are carried outjointly with the PCT and/or local hospital. Togetherwe provide information about keeping healthy, aswell as what to do when people are unwell. Oneway of doing this is through ‘roadshow’ events,where Service and PCT (and perhaps social services)staff go together in a vehicle to some of the moredeprived housing estates, to provide healthinformation and advice on people’s doorsteps. Thisis a way of reaching people who have limitedopportunities to go out.

The community involvement officer, with supportfrom the PPI Manager, Equality & Diversity Managerand Events, Schools and Media Resources Managerand Communications team, is in discussion with thePCT and other NHS partners about getting keymessages out on local radio, TV channels and inlocal newspapers. A number of DVDs have alsobeen made, which can be used in different settingsfor a variety of audiences.

Patient representatives attend complex meetings,and have a say in local developments right from thestart, e.g. when an ambulance station is beingmoved or upgraded. Of course, wider consultationalso takes place when there is a significant changeafoot. Once people have taken part in this kind oflocal involvement, they may wish to becomeinvolved with more central Service developments.There is a mechanism for details of people wishingto become more involved to be passed to the PPIManager, who co-ordinates and advises on Service-wide PPI activity. The Community InvolvementOfficer is responsible for making this happen. Alongwith LINks, this is an important way of starting amembership list in preparation for the Trustapplying for Foundation status.

Some PPI activities are more informal. These includesporting events between Service staff on the

complex and the local community. There are cricketand football competitions, and Service staff also getinvolved with fund-raising campaigns for localcommunity groups and charities.

As there is a central record of all these activities, it iseasy for the PPI Manager, Head of Governance andothers to obtain information about them. This isused to provide evidence for external bodies (e.g.the Healthcare Commission) and also to ensure thatthis work gets the recognition it deserves within theorganisation, through reports to the Trust Boardand Clinical Governance Committee. Through thereporting mechanism, it is possible to identifytrends and key issues emerging from the public,which are fed regularly back into the organisation.

The community involvement officer has beentrained in evaluation techniques and uses a varietyof methods to ensure his or her PPI and publiceducation activities are meeting the needs of thecommunity. Evaluation reports are stored centrallyand key learning points are extracted from themand shared centrally on the Public Education pagesof the pulse. As a result, the Service‘s PPI and publiceducation activity is constantly evolving andimproving.


Details of the application process for stations, alongwith regularly updated Frequently Asked Questions,can be found on the pulse (http://thepulse)

If you have any queries or questions regarding the New Ways of Working project, please [email protected]


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Tel: 020 7921 5100Fax: 020 7921 5129

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