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Impact Case Studies Research

How a business school is helping to improve performance management and staff wellbeing in NHS Ambulance Services

11th July 2023

Institution: Edge Hill University Business School, UK.
Leading Academic: Professor Paresh Wankhade



Ambulance services play an essential clinical role in delivering pre-hospital care in the English NHS; however, they are under-researched in management studies. They are subject to stringent response time performance targets as the primary measure of success, but this lacks robust clinical evidence and is attained at the expense of staff wellbeing and resilience.

Ten ambulance services in England and one each in Wales, Northern Ireland and Scotland provide NHS pre-hospital care support in the UK, dealing with over 12 million 999 calls every year, often having to deal with the consequences of patients’ lack of access to other healthcare services such as GPs and adult social care. A traditional hierarchical ‘command and control’ structure with few leadership opportunities, accompanied by the highest sickness absence rates among the entire NHS workforce along with issues in staff recruitment/retention impose further challenges.

Benefits and impacts

Research undertaken at Edge Hill Business School has been unique in underlining the need to move away from a myopic and dysfunctional dominance of response-time targets on organisational service delivery and to place greater focus on staff welfare.

Theme One Shaping the Ambulance Response Programme (ARP)

In 2017, NHS England implemented new ambulance standards to overhaul a decades-old system. Professor Wankhade’s research has long argued for the refinement of ambulance performance management metrics which have been used by NHS ambulance services since 1974. These targets persisted despite a lack of robust evidence that they actually lead to good clinical care and the potential dysfunctional effects on staff wellbeing. The old system was also susceptible to manipulation and gaming by way of dispatch of a rapid response vehicle (car) in order to meet the headline target of 8-minute response (from a 999 call to arriving at the scene) while the patient might wait for an ambulance to be taken to the hospital. This resulted in hidden delays to some patients, inefficient use of ambulance resources whilst negatively affecting the emotional and physical wellbeing of patients and staff, especially due to ever increasing 999 demand. The resultant ARP, rolled out nationally in 2017, gave ambulance staff more time to assess 999 calls so that patients can get the right response care first time. It also updated and changed response time categories; that aligned clinical and resource allocation requirements and response options for 999 dispatch codes.


There has been a discernible shift towards a more balanced and meaningful analysis of the performance metrics, allowing greater staff involvement. This means that Trusts no longer need to rush multiple resources to one 999 call to meet the 8-minute target but can take longer in the control room to assess the caller before sending the most appropriate response and also giving more time to frontline crews to drive safely and respond appropriately.

Theme 2 Informing the Welsh Amber 999 Review and Outcomes

The Welsh Ambulance Service responds to all 999 calls in Wales. Each call is placed in one of three categories: ‘Red’ (immediately life-threatening), ‘Amber’ (serious but not immediately life-threatening) or ‘Green’ (not serious or life-threatening). There was a concern that the Amber group is too large and is not sufficiently robust in terms of prioritising patients with high acuity illness, and that for some calls this is resulting in unacceptably long waits. This resulted in the commissioning of the independent ‘Amber Review’ in May 2018. As a result of his published research expertise in the area, Professor Wankhade acted as the academic adviser and contributor to the recommendations in the final report.

The report published in November 2018 looked at the evidence from the clinical response model being used in Wales. The review found that the prioritisation of ‘Amber’ calls is complex since there is a range of different responses depending on the patient’s condition. However, receiving a quick ambulance response but ensuring this is the right response for their condition is equally important to the public. It concluded that measures of quality are as important as response times and such measures should be refined to reflect the whole patient journey rather than one requiring a new time based target, unlike the practice in England.  


The National Assembly for Wales applauded the Review’s key recommendations, especially the ones relating to the recommendation against the imposition of any new targets for responding to these categories of calls; a direct recommendation from Professor Wankhade’s research.