Empowering the UK’s ambulance workforce: From culture to clinical decision-making 

The reasons for these workforce and culture challenges are multi-faceted. Individuals are spending increasingly more time working independently from colleagues, at remote locations, and at unsociable hours – all within highly pressurised situations, including making life-impacting decisions. 

There are also significant added pressures on frontline managers who are required to adopt command-and-control leadership during incidents, and a more developmental and inclusive approach required for ongoing staff development, often without the relevant manager training. Most Ambulance Trusts are aware of these issues and see them play out in terms of retention or recruitment challenges or more worryingly with a large number of serious incidents being reported amongst staff.

By having a clear set of commitments about how the workforce can support one another (as well as patients), improved training and support for managers, and better access to decision-making tools, staff can feel empowered to operate at the top of their banding. This will go a long way to transforming service delivery and overcoming some of the historic culture challenges.

Co-create crystal clear values and behaviours 

Trusts need to establish a positive, safe, and inclusive culture where staff are happy to be at work. This cultural change requires the joint working of a dedicated executive team to establish and promote a clear articulation of the values and behaviours expected from everyone. This takes time to embed, and we know from our work with London Prison Group that leadership from the top and then buy-in from the middle tier of management is critical to shifting organisation culture and embedding new ways of working.  When this was impactful in London, we saw a significant and important shift in the leadership style from the top, setting the tone for the whole organisation. We also saw a growing sense of confidence, to stand up and do the right thing and for leaders to lead in a way that promotes this behaviour. 

Another important step in this culture shift was the importance of celebrating success and coming together to share positive stories of staff living the values and behaviours. This acted as a catalyst for ensuring the whole workforce is clear on what is expected and what is recognised and rewarded.

A clear vision and strategy for how care is delivered should sit alongside a set of common values – or staff charter - which all staff are committed to work by. This set of common values should be developed by staff from across the organisation so that they are meaningful to all. A collaborative approach will help all staff feel confident in living those values and demonstrating the required behaviours.

Identify and support natural leadership qualities across functions 

To support frontline and other operational managers, Trusts need to ensure there are clear expectations of what is required across the different managerial grades. We have supported Trusts through this by running workshops to review lines of accountability and responsibility, developing up-to-date and relevant job-descriptions, and rationalising weekly meeting schedules.

In addition, Trusts should adopt a strengths-based approach to recruitment and career development in general, which determines the natural aptitudes (as well as the technical competencies) required to be outstanding, and then ensures processes identify candidates who clearly demonstrate these. This helps to ensure managers are recruiting and promoting staff who will excel in these roles. 

The ambulance service continues to develop and become an ever more integrated member of the health and care system. As a result, there are opportunities to develop the career pathways of paramedics and other ambulance staff within the service more widely across the health and care sector. This can be done in ways that benefits staff, patients, and the wider NHS system.

For example, we recently worked with an acute Trust to understand the strengths that brilliant ward managers have in common. We identified 13 common strengths including ‘loving to make a difference’, ‘caring about doing the right thing’ and ‘enjoying being in charge’. You cannot make people like these things this no matter how much training or coaching you provide, so the key is to appoint people who naturally exemplify these behaviours in the first place. 

A good start for ambulance Trusts is to determine the strengths that makes frontline managers successful and ensure they are proactively working to promote people with these existing characteristics. This should include a balance of strengths – strong operational skills, as well as interpersonal and people skills.

Equip frontline staff with a better toolkit to make informed decisions 

As patient needs become more complex in terms of co-morbidities and long-term conditions, conveying a patient is not always the most appropriate course of action. Paramedics now need to determine when advice over the phone is sufficient, when a patient needs care on scene, or when alternative care pathways are available - often across large geographies and multiple providers. Enabling paramedics to make quicker and more accurate decisions for patients means improved care and more effective use of NHS resources.

As technology improves, more support has become available for this kind of clinical decision-making. Examples include having access to patient care records before dispatching a vehicle, speaking via video to hospital consultants before conveying, and having access to relevant alternative local pathways. In addition, Trusts now hold significant amounts of electronic data on patients they have seen and are seeing. 

Access to this data, augmented by technology (including AI) ‘in the right moment’ enables better and quicker decision making at the frontline. For example, ambulance crews could be prompted with a likely diagnosis and conveyancing decision before they reach a patient, or even before an ambulance is dispatched. Having a clear clinical strategy developed alongside Integrated Care System partners, supported by decision-making tools and real-time patient data, will help paramedics to make more complex decisions faster and with greater confidence.   

Setting the course for achievable change 

The ambulance service workforce is an extremely dedicated group of staff committed to delivering often critical treatment, in difficult situations, to the public 24/7. By providing a safe and inclusive culture, harnessing the strengths of all, and striving to continually improve decision-making it is possible for Trusts to affect a culture shift, as well as ensure services are equipped to face the challenges of the future.