My visit to London Ambulance Service's headquarters a fortnight ago arose from my concerns regarding the treatment of its under-pressure front line staff, suggestions of a culture of fear, and in particular its handling of the Edmund Daly case - a respected 30-year veteran paramedic who was dismissed for gross misconduct for refusing to attend a 999 call after 11 hours without a break.
As a result of my criticisms, I was invited by LAS communications officer Anna Macarthur to learn more about LAS's culture and to speak with the chief executive Dr. Fionna Moore and Director of Operations, Jason Killens.
From a personal perspective, it is fair to say that the short ride-out I experienced in the first part of my day was very much within my comfort zone. It was a familiar activity and one which made me wistfully remember my years on the front line. It took conscious effort to remind myself of how painful, exhausting and infuriating it was toward the end of my 12-year career. Despite the positivity and enthusiasm I had encountered from most LAS staff throughout the morning, it was those darker memories I needed to remind myself of if I was to be able to represent the disenfranchised and the beleaguered road crews I felt were being swept under the carpet.
If attending a couple of 999 calls was in my comfort zone, an audience with two of the most powerful people in the UK ambulance firmament absolutely wasn't. I was keenly aware of what an unprecedented opportunity it was to bring to their attention the problems which have been laid bare by the countless frustrated comments and emails my work thus far has solicited, but I would be a fooling myself if I was to say I, a rusty paramedic and itinerant blogger, wasn't a least a little intimidated.
Dr. Fionna Moore, LAS Chief Executive
I'd done my homework, studying LAS figures and understanding the roles that Fionna Moore and Jason Killens held. I'd even communicated with various sources regarding what to expect from the two execs. Fionna seemed highly respected and well-regarded, but it was Jason about whom I had the most concerns. Reports I'd received, along with my impressions of him from studying the Edmund Daly case, made it hard for me not to view him as an adversary. Possibly quite a hostile one.
However, on being escorted into the meeting room by Anna Macarthur, I was greeted warmly by Fionna Moore and Jason Killens. The four of us sat and a brief, polite conversation saw Fionna show her credentials as a knowledgeable clinician as she explained to me some key indicators of my career-ending retrolisthesis (or 'slipped vertebra' as I call it). The topic soon slid into more LAS-specific territory almost without me realising, at which point I started recording.
Attrition, Utilisation and Opportunity
It soon became clear that my carefully prepared list of questions were not going to define the format of the interview as Jason Killens took centre stage, taking up the baton from Fionna's opening pitch describing how paramedics are 'much more valuable and saleable assets in the employment market because they can get jobs not just in other ambulance services but also in other parts of the NHS.'
Jason Killens, LAS Director of Operations
Jason was quick to show that he too had done his homework, describing the changing face of the paramedic job market in relation to the start and end of my career. Pre-empting my concerns about LAS's rate of staff attrition, he explained,'...when we analyse the leavers from here, around half of them are going to other NHS jobs not in ambulance services. And that would never have been the case in 2000 or in 2010. It's good for the individual because they've got greater opportunities, it's good for the profession, because it makes it more credible as the profession grows. So the individual gets a benefit, they get a better job - enhanced scope of practise and so on, it's good for patients as a result of that. But it's good for the paramedic profession because they've got greater opportunity to support the health system outside of what would traditionally have been done back in the 90s and the 2000s.'
In past interviews (The Spectator, Aug 2014), Jason has been very focused on this opportunity-rich job market as a leading cause of his front line staffing challenges, but I was keen to see what other causes he was aware of.
'I talk about four reasons why people leave. Okay, so you’ve got pressure of work, you've got career opportunities, you've got environmental stuff; kit, equipment, vehicles that kind of stuff, and you've got leadership. Four reasons. You could bolt on cost of living if you wanted to. ... So you've got pressure of work. Certainly from a London perspective, we've got the highest utilised ambulance service in the country. Our average ambulance utilisation is at about 85%, peaking at 95% at the weekends. So pressure of work is a real issue for our people because they can, if they want to, choose to go and work at an ambulance trust that are on our borders, so East of England, South East Coast, South Central.'
I pointed out that front-line staff in the services he mentioned were also experiencing intolerable demand and that things weren't much easier there. He referred to the utilisation figures as evidence that it's worse in LAS. After detailing some specifics regarding each of the reasons for staff 'voting with their feet', he went on to explain how the problem is being addressed.
'[W]e're doing more 'hear-and-treat' in London now than any other ambulance trust in the UK. We're doing over 50% of the country's hear-and-treat here in London. We're doing three-and-a-half to four-thousand calls a week that are being dealt with on the phone and not getting an emergency ambulance.
'We've got investment this year, recently announced two weeks ago... we're just in the final throes of securing a £27m investment package this year from Commissions. That is designed to bring ambulance utilisation down to the middle of the national pack, so when you benchmark us against other ambulance trusts it gets us about in the middle. Which is good from where we are at the minute as the top-end outlier.'
How Long is a Career?
This sounded encouraging, but with LAS's Category A response times being so far short of the 75% target (as low as 48% in December 2014), surely even a significant increase in resources would be absorbed by the need to improve those figures over utilisation concerns, meaning that little benefit would be felt by any individual crew.
In response to my concern, Jason described a new 'non-emergency transport service' which would deal with 2,500 calls a week. He and Fionna described 'growth' in their front line staffing numbers, despite the attrition. Where in previous years they had experienced a decline in numbers, that has now been reversed, with roughly 150 additional posts being filled this year. 'In the last quarter we've had more joiners, nearly double the number of joiners than we've had leavers,' Killens explained. 'We have to get utilisation of the fleet down, for a whole bunch of reasons. And one of them, at the top of the list, is about the experience that the employee, paramedic, our people, our workforce have. At the moment we are a national outlier and we need to fix it. So, as starters come in, utilisation goes down, attrition goes down, people feel better about the place.'
100 Aussie paramedics are already on the road, 100 more coming soon.
Of course, much of this success could be put down to the induction of paramedics from overseas, particularly Australia, which could be viewed as a short-term fix papering over the problems of the rising attrition rate. Would these 'cohorts' of international paramedics really make much difference in the medium- to long-term, given that both Fionna and Jason accepted that many would likely return home in 3 years? We talked about this ‘churn’ (expected to rise from 12 to 30 staff per month), with Jason describing the in-flow of clinicians from various sources, the 'old EMT route', the more modern 'UK domestic paramedics from universities' and the internationals. He finished with, 'what I would say is that gone are the days where the majority of the people that join the organisation are in for 30 or 40 years. That's gone.'
On questioning further this worrying belief that staying 'on the road' is no longer viewed as a viable career-long prospect, they returned to the explanations of the migration of skilled staff into other roles, with Fionna providing South East Coast Ambulance as an example, 'they are seeing a significant number of their paramedic practitioners, so the ones who are undertaking placements in GP's surgeries, getting jobs in GP surgeries. They're very attractive to primary care.'
So it would seem that there is an accepted belief that working on the front line until retirement age is not something that is expected of staff any more. Which is bad news for those who are still out there clinging onto the expectation of doing exactly that.
Where Should You Turn?
Assuming that, as claimed, half of LAS's leavers are as a result of moving onward and upward, what about the others? I was concerned that this not insignificant proportion of the the workforce was being ignored, predicted to wither away as a result of a job they're not expected to be able to withstand in future decades. I brought up the worrying volume of staff who I'd been in contact with, who felt under-served and abused, the rising evidence of Post-Traumatic Stress Disorder among staff unable to find respite.
Fionna Moore said, 'I think that it would be fair to say that the vast majority of people working in the service are proud of the LAS, they're proud of what the LAS has achieved and the reputation the LAS has as a world-class ambulance service. I think they would also say that it's been pretty tough over the last year or so. And, as always, that there is always more that we could do to support staff. We've got lots of initiatives in place. I mean, if you look at the things we done to try and reduce the pressure on front line staff, both in terms of going out trying to get more investment, in maxing the hear-and-treat, introducing schemes like the LINC scheme[Listening, Informal, Non-judgemental, Confidential], which is I think really very successful. It's supported by us but very much driven by the staff.’ She described other initiatives such as ‘employer assistance programmes’ and ‘childcare vouchers’. She emphasised that staff welfare is very much a concern, ‘So yes, this is a priority for us. Could we do more? Yes of course we could. Any organisation could.'
Jason Killens followed up with, 'I think what I would say though Mat, is that people who are still working, from my perspective, those people who are working for London, if they're LAS staff, yeah, and they are continuing to work for us now, then they need to be talking to us, not you. And I don't mean that in a difficult way.'
So why weren't they?
Jason responded by talking about the national NHS staff survey and identified that staff don't feel that they are listened to or supported by their managers. '[O]ne of the other big changes we're going through at the moment is changing the entire operational management structure. So we've been operating the same structure for the last 11 years and the organisation and the system, the health system in which we operate has changed immeasurably in that time and it's just not keeping up the pace. So I'm changing the management structure currently to put more managers back on the front line, to have a static, named individual responsible for a station that's there from Monday to Friday which we don't have at the moment. And we're moving, from July this year, to have all of our team leaders, to have a named team of 1 to 16 staff and those team leaders will have 50% of their time protected, non-front line, non-operational, to do that welfare/pastoral support for their staff which doesn't exist now and hasn't for the last 2 years.'
Despite that, Jason was aware of the challenges that would face any attempt to provide support to staff, '[I]n a highly dispersed model which we and every other ambulance service operates across the country, getting sensible, decent leadership, management, whatever you want to call it, at the point at which a member of staff needs it is very difficult.'
Out with the Crew Room, In with the Manager's Couch
It is true that, in a pre-hospital emergency environment in which there is little opportunity for respite, the debilitating effect of endless stress and trauma is what leads to PTSD in ambulance workers. Fionna is aware of this, 'it's the drip-drip-drip of that for months and years that causes problems.' She also recognises the increasing challenges facing staff trying to deal with it without the ability to decompress at any time during a shift. 'It doesn't happen any more. You're in, you're out. So to some extend I think managers are taking that on even more seriously, because they are now fulfilling the role that used to be the coffee room chat.'
The problem that I foresee here is to do with the culture within the service as much as the logistics. Do staff feel comfortable discussing their darkest experiences and most intimate fears with management staff? Where would this contact take place even if they did? Outside A&E? When they’re rushing to book off of a vehicle to head home an hour late? And is a network of trained management staff even an appropriate alternative to having the opportunity to rest and reflect?
Both execs went to great lengths to assure me that there is no 'culture of fear' and that the vast majority of LAS staff are thriving in a culture of positivity and pride. That is certainly the environment that they ensured I witnessed during my visit. They also described other initiatives such as a private Facebook group which allows staff to speak freely about issues of concern, and their willingness to be engaged directly by staff without reprisal.
Jason emphasised this empowerment and the desire for better staff engagement, ‘This is our organisation. Not Fionna's, not mine. Ours. Our organisation. And our people are important to us. We've got a bit of work to do to rebuild trust because of where we've come from, but at the same time we've got to fix all these issues we've got about utilisation, about vehicles and all that kind of stuff, but we absolutely believe in our people, we want them to be out there being autonomous practitioners delivering high-quality care for patients and they do it day in, day out in difficult circumstances. And we want to create the environment where they can do more of it to better standards. But it's not going to happen in a fortnight.’
Answers? Or More Questions?
Overall, I got a sense that being at the heart of the organisation does engender a feeling of positivity, supportiveness and empathy. I recalled that same phenomenon when attending staff training and other non-operational activities. I certainly gained the impression that there are good intentions and a grasp of the issues at the top.
But it's lonely out on the road. The hours are long, the work is brutal, and front-line staff are a long way from the comfort of headquarters. It's almost like two different worlds exist within one organisation, and I'm still not sure that either is fully in touch with the other.
Furthermore, Dr. Moore’s and Mr. Killens’ assertions that the readership of this blog is a tiny, disgruntled, vocal minority in a sea of loyalty and enthusiasm gives me uncomfortable pause.
What do you think? Do Fionna Moore’s and Jason Killens’ words give you some encouragement? Could you escape to a job elsewhere in the NHS or do you feel trapped in the bloody hamster wheel of front line ambulance work? Are you confident of your employer’s efforts to support you? How much is it your responsibility to remain positive in the face of relentless working conditions? Just what is the workforce ratio of enthusiasm to despair?
Please let me know. Comments on this blog can be made anonymously and I would be very interested to read both positive and negative responses.
I’m sure both Dr. Moore and Mr. Killens will be reading.