Increasing Ambulance Demand: Need for a Strong Leadership and Positive Culture

Article by: Paresh Wankhade, January 26, 2017

The growing pressure on the NHS ambulance services as a result of increased ambulance demand has been a subject of media attention in the recent weeks. This is also accompanied by a growing academic interest in the examination and exploration of work intensification in prehospital care settings. Staff retention and staff recruitment is proving to be difficult and the shortage of paramedic staff is becoming a national problem.

Ambulance services are witnessing a period of turbulence. Amidst the progress on the professionalisation of the paramedic agenda, individual trusts are facing challenges in form of staff attitudes towards meeting performance targets, coupled with rising demand, fear of loss of contracts and private competition. Historically and in the new commissioning framework, performance (and payment) of individual ambulance trusts is still guided by the achievement of the eight-minute response time target. This has implications for patient safety, high sickness absence rates amidst increasing ambulance demand.

It doesn’t come with much surprise that the recent inspections reports from the Care Quality Commission (CQC) have highlighted some of the issues discussed above. The latest report for the North West Ambulance Services NHS Trust published last week reported regional variation in the culture across the trust:

“Staff in some areas felt very positive about the culture, but in other areas, they felt that there was a high degree of pressure and the focus was on performance targets rather than care for patients (p. 39).”

The report also highlighted staff vacancies across all areas of urgent and emergency care services and the overall vacancy rare was 5.7%. (p.3)

The increasing pressure to meet performance targets was also picked up in the CQC inspection report for the South East Coast Ambulance Service NHS Trust in September 2016:

“However, many staff reported a culture of bullying and harassment. Much of these reports stemmed from style of contact and lack of support during sickness…Staff also attributed the bullying and harassment culture to the organisation drive towards attaining performance targets. In particular the pressure placed on middle and junior managers, many of whom have not had developmental support to deliver their role”(p.31).

The CQC report highlighted a culture of operating in a crisis by ‘ fire-fighting’ and a lack of step down process and medium and long term planning led to a lack of sustainable change.

The CQC inspection report for the London Ambulance Service NHS Trust in November 2015 while giving the Service a ‘good’ rating for its care of patients, highlighted a number of areas of concern and judges the Service to be ‘inadequate’ overall and recommended to place the Service into special measures. It reported (p.2) that the trust was operating with a shortage of trained paramedics in the light of a national shortage and due to paramedics leaving its service for a number of reasons including better pay elsewhere. Paramedics from Australia and New Zealand were recruited to address the shortage. The report expressed significant concerns about a reported culture of bullying and harassment in parts of the trust:

“Bullying and harassment was a major concern for the organisation. Several frontline ambulance staff perceived that they were bullied by managers; and an independent, external review into bullying and harassment in the organisation found that the problem was widespread.” (p.5).

It’s worth mentioning here that in the latest inspection by CQC, it has been reported4 that the trust has focused on bullying and harassment with workshops, and holding conversations instead of resorting to formal processes (p.3). Issues of bullying and harassment could be reported via ‘pulse’, an internal website staff could access, and there was a telephone line to report any incidents of this nature (p.20). The bullying and harassment policy had been revised, relaunched and is now called ‘dignity at work’.

While these initiatives need to be welcomed, issue raised above have significant management and leadership implications for devising appropriate employment practices across the ambulance trusts. It raises questions about whether it is possible and sustainable to motivate staff and/or retain and recruit new ambulance staff while moderating these negative influences. Development of strategies to prevent significant levels of sickness and occupational health issues, to combat prevalence of general and specific ambulance specific stress factors needs immediate policy and management attention.

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Paresh Wankhade


I have a PhD in healthcare management from University of Liverpool, UK. My research and publications focus on analyses of organisational culture, organisational change and interoperability of the emergency services, especially the ambulance services, including strategic leadership in the public services. I have been chairing tracks on emergency services management at prestigious international management conferences including the annual European Academy of Management (EURAM) Conference; British Academy of Management (BAM) Conference and the Public Administration Committee (PAC) Conference. My published work is contributing to inform debates around interoperability of emergency ‘blue-light’ services and challenges faced by individual services. I am keen to hear from individuals who are interested in reading for a PhD in leadership and management of public services or related themes. Contact Paresh