Written evidence submitted by Dr Roger Cooke

1. Introduction and Background

I am writing this submission in the hope that it will provoke discussion of a number of issues relevant to the ambulance service.  I am a doctor and my own experience is with West Midlands Ambulance Service (WMAS), for whom I worked as a volunteer responder for 20 years, and subsequently as a medical adviser and then medical director.  I left that role in 2010.   Hence my comments below are based on personal experience, but also reflect the views of a number of colleagues, who felt unable to comment directly.  I believe that there is a culture of bullying and a lack of candour within that service, a view that is shared by those colleagues, some of whom continue to work there, but are afraid to speak out because of the potential consequences on their career and employment. 

I established and am a member of a confidential on-line “chat room”, which now has over 70 members, being current and ex-employees of West Midlands Ambulance Service.  The following reflects comments on that forum, which are therefore hearsay, although there is an element of consistency with known facts that suggests there may be an underlying truth. 

2. Response times

Much play is made of response time data, and that WMAS achieves national targets in that regard.   When I was working there, a company called Lightfoot Solutions undertook a consultancy project that was also undertaken in other ambulance trusts.  One of the comments presented during that project was that focusing resources on urban areas would produce an improvement in overall performance figures.  They produced what was referred to as “8 minute footprints” being the areas in which the 8-minute response times could be easily achieved, and thereby achieve the overall performance response time targets.  This was seen by some as morally and politically inappropriate, since it was, by definition, producing a healthcare system based on postcodes.   The data attached at the end of this submission is in the public domain as information provided by WMAS in response to a freedom of information request.  The data shows average response times for emergency calls.  It is immediately apparent that Birmingham postcodes have a better response time than others.  While this could conveniently be attributed to longer travelling distances, many operational staff feel that the reality is that resources are leached from outlying areas to boost the performance figures in the conurbation, leaving outlying areas without cover.  I attach as a second appendix comments I have received today from current members of staff at WMAS.

The WMAS data is notable for a second reason.  It refers to average response times.  The national target is for 75% of these calls to be reached in 8 minutes.  Given that these are average times, this means that in the areas highlighted less than 50% achieve this response time.   The fact that many responses in Birmingham are within 5 or 6 minutes cannot be overlooked and does appear to support the suggestion that the postcode basis of ambulance healthcare suggested by Lightfoot has actually been implemented, although whether by intent or default is unclear.  However, I have received a comment on 13th March 2017 from a member of staff who said that whenever he questioned whether or not his was the most appropriate vehicle to respond, he was told “silver has put your name on it” – in other words the silver commander (a senior manager) had decided to send that resource, suggesting a high level decision to take such an approach.

It should also be noted that the data provided may have been adjusted.  In WMAS a “performance cell” was established to check all red calls, and particularly those slightly outside the target response time, to determine whether or not they could be reclassified, and thereby improve the overall performance data.  I understand that process still occurs.  This may be important for a number of reasons – firstly, it demonstrates the considerable focus on response times, secondly, calls should attract a response based on the information presented to the call handler, and thirdly if only the borderline red call cases are open to reclassification, the data may be skewed.

3. Shortage of staff and stress

It is a truism to say that most healthcare workers start that career because they want to care for people.  That must apply to paramedics and emergency medical technicians as much as to other groups.   Yet there is a high turnover, implying that after training many of those subsequently leave that role.  The role of stress in the morbidity and turnover of emergency service staff is well recognised.  In the ambulance service this is regarded at least in part as being due to a high and unrelenting workload.  However, there is evidence that a corporate culture, including bullying, is present in some ambulance services.  It was identified in South East Coastal Ambulance Service, with the press reporting that as being associated with the then Chief Executive and Chairman each of whom resigned.  I have submitted evidence to the Health and Safety Executive of a similar culture within WMAS, and it was an issue included as part of a whistleblowing investigation that followed me raising concerns.   That report stated that “concerns raised by others under the banner of culture and leadership when viewed in the context of the Trust’s own definition of bullying could appear to have some relevance”. The HSE response is that they do not investigate complaints of stress in the same way that they do other occupational diseases.   However, if there is indeed a culture of bullying, and of failure to listen to the staff, that is likely to result in demotivation of staff, high levels of turnover, and increased sickness absence, each of which will independently adversely affect the performance of the organisation.   The comments included below have been made to me because those involved are in fear of reprisals should they speak out.

I must emphasise again that I recognise that some of the above is hearsay evidence, and as such may not be provable. Some is personal experience and some is fact.  However, taken together there is a consistency that suggests management approaches may be contributing to the failings of the ambulance service.

March 2017

Comments from WMAS staff regarding deployment of resources and photographs of the lists the union asked crews to complete to provide evidence that resources are "leached from outlying areas into Birmingham".   

"A couple of months ago I heard of a Staffs crew being tasked from Longton in Stoke on Trent, Staffs to Nuneaton on a red call with lights and sirens. It took them 50 mins  - how is that good performance and how is it safe for the crews, patients and the public road users??!!!"

"When WMAS took over Warwickshire our then chief said we would never cross the border except in extreme circumstances. In a year I attended 90% of calls outside my designated area, the worst being a 35 mile journey taking 45 minutes to a collapse in the far side of Birmingham thus leaving ...........deprived of half of its cover as no back up was sent to stand by........all the jobs outside the time are peripheral to the area and ex county areas!"

"Re crews being moved to other areas this seems to be a West Mercia problem. Mr M has got student paramedics to sign a contract that makes them work weekend s and nights. They then  all end up on Friday to provide extra cover. This leads to double the normal crews. Mr M's new line is "no patient should wait" and routinely asks H&W and Shropshire crews to do urgent calls out side of area. Once they are in Birmingham they are just used for 999 calls there"

"Crews being dragged into Birmingham from Worcestershire seems deliberate and systematic. Especially afternoons in weekdays to cover GP admissions"

"There was lists done by union at Worcester where crews were being sent on urgent in Birmingham ,few times crews have cleared at Worcester and been given an urgent to Solihull , Yardley to Heartlands , and before Xmas a crew were just by the Alex (Redditch) and given a cat 2 in Coventry cv1 at 5 pm took nearly 50 mins to get there".