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The
Intelligent
Ambulance
Board

November 2006
Steering group

Sir William Wells

Chairman, The Appointments Commission (Chairman)
Peter Bradley
Chief executive, London Ambulance Service NHS Trust and National Ambulance Advisor, Department of Health
Simon Davies
Director of finance, South Western Ambulance Service NHS Trust
Tony Dell
Chairman, North East Ambulance Service NHS Trust
David Griffiths
Ambulance and Emergency care sector lead, Healthcare Commission
Paul Phillips
Chief executive, East Midlands Ambulance Service NHS Trust
Sigurd Reinton
Chairman, London Ambulance Service NHS Trust
Heather Strawbridge
Chairman, South Western Ambulance Service NHS Trust
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Dr Foster research team

Helen Rowntree, editor
Nina Barnett, senior researcher
Jake Arnold-Forster

Dr Foster production team

Jacqui Gibbons
Kati Lopez
Jenny Wackett

This report has been produced by an independent steering group of experts from the
NHS. They were not remunerated but were supported by research and production
teams at Dr Foster Intelligence, who also funded the printing of the report.

Dr Foster Intelligence is an independent organisation that undertakes research and

analysis and provides information about the quality and availability of health services.
It was launched in 2006 as a joint venture between Dr Foster and the Health and
Social Care Information Centre, and aims to set a new standard in information for
health and social care providers and their users.

The Dr Foster Unit at Imperial College London is directed by Professor Sir Brian
Jarman, a former member of the Bristol Royal Infirmary Inquiry, and Dr Paul Aylin,
an expert witness at both the Bristol and Harold Shipman Inquiries.

Dr Foster is legally required to follow a code of conduct that prohibits political bias
and requires it to act in the public interest. The Dr Foster Ethics Committee is an
independent body, empowered to adjudicate on complaints and oversee the code
of conduct. The Committee is chaired by Dr Jack Tinker, emeritus dean of the Royal
Society of Medicine.

Supported by

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Contents
Foreword by Sir William Wells 4

1 Introduction 5
The Ambulance Service: context and challenges 6

2 Challenges 9

3 Intelligent information for boards 10

Principles 11
Emergency service indicator list 13
Patient transport service list 17

Annex 1 Analysis of current practice 20

Annex 2 Sample board agenda 21
Annex 3 Annual board cycle 24

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Foreword
Following the reconfiguration of ambulance trusts in
the summer of 2006 I was approached by a number of
ambulance trust chairs and chief executives asking me if
I could work with them to put together a working guide for
ambulance trust boards, which would enable them to rapidly
and effectively move their new organisations into the centre
ground of healthcare provision and away from their old image as the transport and trauma
function of the health service.

I hope this document does just that, as there are huge benefits to be gained by both
patients and the NHS if ambulance trusts are able to play a more active part in the early
diagnosis and treatment of the patient they are called to help. This should not only further
improve outcomes but also ensure that patients receive the most appropriate care in the
right environment. Every year, approximately a million patients are transported to Accident
and Emergency departments in hospitals when they could be treated at home,
in the community or in specialised units.

For this to be a success it is essential for the ambulance service to work within a common
information framework, which should be considered as a minimum standard. The real
challenge is for each organisation to have its own local aspirations for more stretching
targets and outcome measures. In addition it is important that there is a concerted and
urgent drive to break down barriers between the separate organisations delivering care
along the patient pathway so that there is timely, reliable and anonymised information on
clinical outcomes so that the efficacy of the early decisions on the location and type of
treatment can be measured.

These changes can bring significant improvements to patient care and I am confident that
The Intelligent Ambulance Board will play a major role in enabling them to come to fruition.
This report should be read as an addendum to The Intelligent Board, which was published
in early 2006. The information requirements for boards, set out later in the report, should
be seen as a first iteration; they will undoubtedly evolve as the service undergoes
unprecedented change and we will revisit them in a year’s time.

I should like to thank all those who formed the steering group for their pro-active and
forward-looking advice and also Dr Foster Intelligence for its excellent support work.

Sir William Wells

4
Chairman, the Appointments Commission
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1
Introduction
1. The Intelligent Board
The Intelligent Board identified the key information requirements of effective NHS
boards. The first report, for providers of healthcare, was published in January 2006,
and was followed by The Intelligent Commissioning Board in July 2006, which focused
on the information needs of PCT and SHA boards to effectively commission and
performance manage healthcare services respectively.

This report should be read in conjunction with both of the above reports as the
principles of The Intelligent Board remain directly relevant to ambulance trusts.

2. Principles of the Intelligent Board

The Intelligent Board introduced a set of principles for board level information.
These include:
u A focus on strategic issues. Boards should spend approximately 60 per cent of their
time discussing strategic matters. For ambulance services, the focus should be on the
trust’s strategic plan and delivery against it. The effective use of information should
ensure that they need to spend less time discussing operational performance.
u Information should be presented showing trends and forecasts in order to anticipate
future performance.
u Reporting should be by exception wherever possible, to prevent information overload.
u Information should be timely and clearly presented.

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The ambulance service:

context and challenges
1. Context
In recent years, the ambulance service in England has been the subject of discussion
about its role and configuration. The 2005 Department of Health report, Taking
Healthcare To The Patient, recommended a reconfiguration of the service. In July 2006,
following subsequent discussions, the number of ambulance trusts was reduced from
31 to 12. Some trusts now cover areas of over 5,000 square miles and as many as
seven million people.

Public demand for emergency ambulance services increases every year, with six million
calls made in 2005/06 – an increase of six per cent on the previous year. The number of
emergency calls made has doubled since 1992/93. Figure 1 shows the increase in
demand over the past ten years.

Figure 1: number of emergency calls (millions)

7
6 u
u u
5 u u
u
u
4 u
u
u u
3
2
1
0
1995/ 1996/ 1997/ 1998/ 1999/ 2000/ 2001/ 2002/ 2003/ 2004/ 2005/
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

6
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In contrast to emergency activity, patient transport service (PTS) activity has decreased
in recent years, as shown in Figure 2. Overall there were 14.9 million journeys in
2000/01; by 2005/06 this had reduced to 12.3 million. PTS activity, as a proportion of
the trust’s overall activity, varies between trusts. In some trusts the proportion of PTS
turnover is 20 per cent; in others this figure is under five per cent.

Figure 2: number of special/planned journeys (millions)

14
u u u u u u
u u
12 u
u
10 u

8
6
4
2
0
1995/ 1996/ 1997/ 1998/ 1999/ 2000/ 2001/ 2002/ 2003/ 2004/ 2005/
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

2. Recent improvements across the ambulance service

Over the past few years, ambulance trusts have made some significant progress in
service improvement, including:

i. Meeting challenging emergency care targets and improving response times

Emergency calls are currently prioritised according to Categories A, B and C, according
to a national list of conditions. Government response time targets for category A and B
calls have been met across the majority of services, despite the year-on-year increases
in public demand.

ii. Developing the workforce and making a career in the ambulance service an
attractive option
Existing roles have been enhanced and a number of new roles created, in particular
the introduction of Emergency Care Practitioners. Some services have integrated
community paramedics into GP practices, enabling the efficient use of ambulance staff
time in more isolated areas. But there needs to be further development and training in
types of care for other than life-threatening emergency situations, particularly long-term
conditions, and working jointly with social care agencies.

iii. Developing technological capacity

New, modern vehicles have been rolled out, equipped with new technologies including
diagnostic quality 12-lead ECG machines and mobile data transfer.

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iv. Improving clinical outcomes, for heart attack in particular

The introduction of national clinical guidelines, coupled with fully trained ambulance
staff to administer pre-hospital thrombolysis, means that more lives are being saved.
Over 5,000 patients to date have received pre-hospital thrombolysis. Some services
are now, where possible, using other, more effective, interventions, such as diagnosing
myocardial infarction and transporting patients directly for primary angioplasty in
specialist cardiac centres.

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2
Challenges
There are a number of significant challenges facing the newly reconfigured ambulance
service. Taking Healthcare To The Patient sets out key principles for the future operation
of ambulance trusts. Boards will play a key role in implementing these new ways of
working to improve performance by providing the necessary strategic leadership and
oversight to their organisations.

i. To become a key player in the provision of healthcare rather than a transport agency
Historically, the ambulance service was seen as an emergency service, with a focus on
trauma and life-threatening conditions, such as breathing difficulties and heart attacks.
While targets focus on emergency care, the majority of callers to the ambulance service
have a primary or social care need. Only ten per cent of patients calling 999 are in fact
facing a life-threatening emergency. Falls among older people account for ten per cent
of incidents attended. Social care and mental health needs and long-term conditions,
such as diabetes and chronic obstructive pulmonary disease, also account for a large
number of calls. A&E departments are often not the best places for these patients.

Three-quarters of emergency calls result in the patient being taken to hospital. It is

estimated that at least half of these patients could be cared for more appropriately
in the community, in line with the wider shift to local services as set out in the
government’s white paper, Our Health, Our Care, Our Say.

Taking Healthcare To The Patient sets out a number of potential new ways in which
ambulance trusts may provide healthcare, including more care in the home, more
treatment on the scene and referrals to other community-based services (‘see and
treat’). The benefits to patients and the local health economy are significant. At least
one million people currently taken to A&E every year could be treated outside hospital –
either at the scene or closer to home.

Ambulance staff will need further training, for example, to carry out and interpret
diagnostic tests, prescribe medication or refer patients to specialist units or social care
services. For patients with long-term conditions, ambulance staff may undertake routine
assessments to enable improved management of their own health and reduce
unnecessary emergency admissions.

ii. To provide advice and help over the phone to reduce ambulance usage
A further mechanism to reduce hospitalisation is the provision of clinical advice over the
telephone to non-urgent callers (‘hear and treat’). Diabetes patients, for example, might
be offered support to help them manage their condition, or a referral to their GP or an
emergency nurse. Ambulance trusts must ensure that the intervention is safe and
9

1
Department of Health, departmental report, 2006. www.dh.gov.uk
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reliable; that consistency with, for example, NHS Direct, is maintained in the provision of
clinical advice; and that it forms part of the patient’s records. Where it is decided that
an ambulance response is not needed, if for example, a referral is made to a falls
service, there should be a seamless transfer of care and patient information.

iii. To reduce the number of Category A calls significantly by improved screening

techniques and information
Currently, 30 per cent of calls are categorised as Category A (life threatening), but in fact
a significant number of these are not life-threatening emergencies at all. Improvements
in telephone prioritisation should reduce the number of calls that are inappropriately
classified as Category A, as will improved information systems. Reporting of ambulance
service performance has come under scrutiny with the Department of Health’s audit
of response times, which found inconsistencies in the measurement of Category A
response times. This emphasised the need for accurate data – essential for correct
benchmarking, comparing performance and transparency.

iv. To accurately measure outcomes to ensure continuous improvement to services

Response times have historically been the only measure of ambulance trust
performance. Ambulance services now need to develop effective measures of clinical
outcomes and the quality of care. Taking Healthcare To The Patient makes the point
that non-Category A calls should be judged by clinical outcomes, rather than response
time, and by April 2009, Category B targets are due to be replaced with clinical
outcome measures. Acute hospitals will need to make their patient outcome data
available for analysis by ambulance trusts.

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3
Intelligent information for boards
An analysis of ambulance board papers (see annex 1) showed that current performance
reports tend to be lengthy and heavily focused on activity levels and the government
response time targets. Boards need to scrutinise the operational performance of an
organisation, particularly given that board assurance is now a key element of the
Healthcare Commission’s annual performance assessment process. But they can really
add value through their strategic role. The Intelligent Board sets out the aspiration that
“boards should aim to spend around 60 per cent of their time on strategic matters”,
recognising that this may be challenging to some organisations.

Ambulance trust boards face a particular challenge in driving change and ensuring
that this is in the best interests of the patient. This section aims to support them by
suggesting some key principles that they might adopt, as well as a framework for the
presentation of information, which may be adapted to fit with local circumstances.

Principles
Strategic information for the board should:
u Be structured around an explicit set of strategic goals.
u Show trends of performance for finance, quality and the experience and satisfaction
of patients.
u Provide forecasts or trends and anticipate future performance issues.

Information about operational performance should:

u Provide an accurate and balanced picture of current and recent performance,
including financial, clinical, regulatory and patient and staff perspectives.
u Focus on the most important measures of performance – and highlight exceptions.
u Include measures of clinical outcomes, which are appropriately standardised for
factors such as age and the deprivation profile of patients.
u Enable comparisons with the performance of similar organisations.

All information should:

u Be clearly and simply presented, including graphic overviews supported by a brief
commentary.
u Be updated in a timely manner.
u Direct the board’s attention to significant risks, issues and exceptions.
u Provide a level of detail appropriate to the board’s role.

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Ideally, directors should be able to access key information about a trust’s past and
present performance online, off the premises and in between meetings. Currently, this is
not possible with all trusts, but considerable progress is expected to have been made
by boards in one year’s time, when there will be a review of this framework.

The key tests of the success of any information resource should be the extent
to which it:
u Prompts relevant and constructive challenge.
u Enables performance improvement.
u Supports informed decision-making.
u Is effective in providing early warning of potential financial or other problems.
u Develops all directors’ understanding of the organisation and its performance.

A framework for considering strategy and operational performance at

board level
Boards should make a clear distinction between strategic and operational matters,
focusing their attention on a limited number of key aspects of each. The proposed
framework seeks to:
u Support boards to make more efficient and effective use of information – and to
spend more time on strategic matters.
u Structure the process of formulating strategy-shaping plans and reviewing progress.
u Enable a balanced focus when scrutinising current and recent operational
performance.

The framework is flexible enough to:

u Balance the crucial ingredients of success in financial, operational and quality terms.
u Cover the perspectives of patients, commissioners, clinical staff and managers, along
with regulatory requirements.
u Allow organisations to select and modify those indicators that are most relevant to
them in light of their own particular strategic priorities and/or trends and issues in their
own performance.

Proposed minimum data-sets

The indicators outlined in the following tables are structured according to six headings:
u Context/strategy: current and future activity and local intelligence
u Patients’ experience (including feedback from patients and their relatives on staff
attitude, responsiveness and communication)
u Clinical quality; in particular, measures of clinical outcome
u Access/targets, including PTS targets
u Finance including income and expenditure and cash flow
u Efficiency, such as use of alternative responders and call timings
u Workforce; including workforce planning, violent incidents and satisfaction
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This information should be as up to date as possible and presented by trend in order

to anticipate future performance.

The indicators are described in further detail overleaf. Some of the information is only
available at a local level, and is variable in format and quality. Ambulance services
therefore need to work hard to ensure that the data is an accurate reflection of what is
happening to patients. The reconfiguration of ambulance trusts is an opportunity to
benchmark performance.

Some indicators are not currently universally available. This is because information is
not routinely collected or there is a lack of agreed performance measures. In particular,
clinical outcomes are not universally measured and reported, but are due to replace
current access targets by 2009. Payment by Results is also due to be introduced over
the next two years and will have a significant impact on the information required at
board level. Boards can play a key role in anticipating these changes by driving
improvements in information and the development of new measures.

Indicators for emergency services and PTS services should be received separately by
trust boards and are therefore shown here in two separate tables.

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Emergency service indicator list

Indicator Comment Frequency and Standards
presentation for better
health
Strategy

Contextual summary: This section gives board members an Current position,

• Population served (deprivation, socio-economic overview of the trust, consisting of trend and
groups, tourism) • Key facts, such as the area covered and forecast
• Geographical area covered number of vehicles
• Number of emergency frontline vehicles • Trends to show how the market is
• Patterns in response time performance (particular changing
geographical areas, hours of day, days of week, • National policy and guidance
season and traffic)
• New national guidance and technology updates,
such as Improving Working Lives practice plus
status and roll-out of electronic staff record

Activity compared to business plan (by Activity indicators such as these should be Quarterly, trend
category and geographical area): included for ambulance trusts that are
• Percentage transport rate running other services, such as walk-in
• Number of calls received by category centres and out-of-hours services
• Numbers of activations and conversion rate
• Number of A&E responses and patient journeys
• Average number of patients conveyed
• Use of voluntary services by type (eg, call
answering, conveying patients)
• Number of emergency transfers
• Number of direct referrals to other services (eg,
walk-in centres, minor injuries units, falls service,
substance misuse service)
• Top ten conditions/reason for call

Emergency planning and preparedness: Ambulance trusts need to ensure compliance Twice yearly C24
• Status with the Civil Contingencies Act 2004. Board
• Testing level reporting would include lessons learnt
• Training from emergency planning exercises and the
• Risks number of trained personnel

Patient experience

Patient experience and satisfaction: The board should receive a summary of the Quarterly D8
• Summary of initiatives and outcomes work that has been carried out to measure
• Engagement with local involvement networks the patient experience, such as focus groups
(LINks) and local surveys, and the outcomes of these
initiatives. Ambulance services need to
develop their own indicators to measure the
patient experience

Patient and public involvement annual report: Annually C17

• Summary of lessons learned
• Planning for the year ahead

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Emergency indicator list (continued)

Indicator Comment Frequency and Standards
presentation for better
health
Patient experience (continued)

Complaints and appreciations: Monthly trend, C14c

• Trends by type (timeliness, attitude, quality of care) annual report
• Complaints per 1,000 journeys
• Percentage responded to within 25 working days
• Percentage acknowledged within two working days
• Percentage of complaint recommendations
implemented
• Number referred to Healthcare Commission

Workforce

Staff involvement and satisfaction: The board needs to be aware of changes Annually C8a, D7
• Staff satisfaction surveys that have been implemented as a result of
• Annual report of changes made as a result of listening to staff
staff suggestions

Workforce planning: Monthly C11, D5

• Establishment against trajectory trend and
• Ethnicity forecast
• Turnover
• Sickness

Training: monitor variance against training Quarterly C11a

plan by exception
• Clinical training
• Skills training
• Statutory and mandatory training

Staff safety: Reported C1a

• Number of incidents of violence to staff monthly/
• Number of staff accidents weekly trends

Clinical quality

Clinical outcomes: calls made to ambulance Clinical outcome indicators need development. Monthly trend Clinical
service; number of people treated; outcomes. Cardiac arrest survival is the only outcome and forecast and cost
Analysed by location of treatment (A&E, walk-in centre; indicator that is currently collected. In the effectiveness
ambulance; home). Examples include: meantime, boards could identify activity-based
• Cardiac arrest survival (to discharge and primary clinical indicators as key performance indicators
ROSC, 30-day survival rate) and report against them by exception.
• Aspirin administration in AMI patients Hospital outcome data is available through
• Pain management administration by age group HES data. Ambulance services report
• Oxygen administration in suspected MI and angina problems with access to hospital data due to
patients patient confidentiality issues. In addition, not
all services have full-time clinical audit staff to
look at outcomes data
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Emergency indicator list (continued)

Indicator Comment Frequency and Standards
presentation for better
health
Access and targets

Progress against standards compliance Twice a year All

• Standards for Better Health
• CNST

Response targets: These indicators need to be broken down Monthly trend C19
• Percentage of Category A calls responded to to show the effect of alternative responders
within eight minutes on response time targets (percentage of
• Percentage of Category A/B calls responded to responses that meet the target and
within 19 minutes percentage of contribution to response
• Percentage of Category C calls responded to time). These include solo responders in
within locally defined standard cars, community-first responders and
• Percentage of GP urgent calls meeting 15 minute emergency service co-responders (eg,
target police). This should also show performance
• Annual check of compliance with KA34 statistical of employed responders against contractors.
return DH data from KA34 is available annually.
For 2005/06 the national average percentage
of Category A calls responded to within
eight minutes was estimated at 74 per cent

Thrombolysis: There are approaches other than pre-hospital Monthly trend C19
• Per cent of eligible patients receiving thrombolysis. For example, London
thrombolysis within 60 minutes of a call for help Ambulance Service provides direct referral
• Average call-to-needle time to primary angioplasty for suitable patients,
rather than thrombolysis.
In July 2006 it was reported that 96 per
cent of eligible patients receive thrombolysis
within 60 minutes, with an average call-to-
needle time of 38 minutes. This data is
available nationally, annually and quarterly

Waiting times for walk-in centres, home visits Where ambulance trusts run other services, C19
such as walk-in centres and out-of-hours
services, access indicators should be
produced. These should include waiting
times, time it takes to be seen in the walk-in
centre and the time it takes for patients to
go through clinics. These times are currently
hidden within the A&E four-hour wait figures

Finance

Income and expenditure analysis (actual This should be shown at trust level, and Monthly trend and C7f
against budget forecast) by locality broken down by sector (emergency, urgent forecast, annually
care, PTS, other) and function (eg, operations,
finance, HR) – with run rate. Cash releasing
efficiency savings (CRES) should be presented

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Emergency indicator list (continued)

Indicator Comment Frequency and Standards
presentation for better
health
Finance (continued)

Balance sheet and key indicators Full balance sheet: beginning of financial year; Monthly C7f
Including capital expenditure current and projected year-end position; main
areas of risk; capital expenditure analysis –
capital resource limit, high-level expenditure
plan by category, eg, IT, fleet – with plan, actual
and forecast

Cash flow forecast Cash flow – high-level cash in and out Monthly forecast C7f
analysis by month. External finance limit
analysis. Debtor analysis by exception in line
with public sector payment policy

Benchmarked data – reference costs Reference costs for the current year and Annually C7f
previous year

Efficiency

Percentage of patients treated by disposition: Broken down to show 999 calls, out-of-hours Monthly trend Clinical
• Treated at home services and referrals. There is currently and cost
• Referred to primary care variation between trusts in the detail reported effectiveness
• Transported to hospital for this indicator. With Payment by Results
being introduced for ambulance services in
2008/09, there is conflict between the need
to reduce A&E attendances, yet ambulance
trusts being paid for activity carried out

Per cent of calls answered in five seconds There are a number of stages in the time taken. Monthly trend C19
Where a problem is identified, boards should
be able to drill down, as appropriate, to:
• Call connect • Call answer
• Assign vehicle • Vehicle mobile
• Arrive scene • Leave scene
• Arrive treatment • Patient handover
centre • Vehicle clear

Vehicle utilisation, for example: The key measure is whether there are appropriate Monthly
• Unit hour utilisation resources available. There are variations in trend and
• Calls per unit available utilisation between rural and urban areas forecast
• How time is spent (eg, time spent in the community)
• Vehicle accidents per 10,000 miles

Information technology, for example: Quarterly D6

• Percentage of IT-critical systems downtime

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Patient transport service indicator list

Indicator Comment Frequency and Standards
presentation for better
health
Context/strategy

Local PTS market analysis This section provides board members with Annually.
an overview of PTS providers, in and out of Current position,
the area, served by the trust. The PTS trend and
market is changing – many PTS contracts forecast
are being awarded to private ambulance
services

Contextual summary: These indicators give board members the Annually

• Number of non-emergency frontline vehicles key facts about the trust's PTS provision
• Number of patient journeys
• Use of voluntary service

PTS activity against contract An activity summary should give the board Quarterly
an overview of where the trust is over or
underperforming against the PTS contract

Patient experience

Patient experience and satisfaction: The board should receive a summary of the Quarterly D8
• Summary of initiatives and outcomes work that has been carried out to measure
• Engagement with local involvement networks the patient experience, such as focus groups
(LINks) and local surveys and the outcomes of
these initiatives. Ambulance services need
to develop their own indicators to measure
the patient experience

Patient and public involvement annual report: Annually C17

• Summary of lessons learned
• Planning for the year ahead

Complaints and appreciations: Monthly trend, C14c

• Trends by type (timeliness, attitude, quality of care) annual report
• Complaints per 1,000 journeys
• Percentage responded to within 25 working days
• Percentage acknowledged within two working days
• Percentage of complaint recommendations
implemented
• Number referred to Healthcare Commission

Workforce

Staff involvement and satisfaction: The board needs to be aware of changes Annually C8a, D7
• Staff satisfaction surveys that have been implemented as a result of
• Annual report of changes made as a result of listening to staff
staff suggestions

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Patient transport service indicator list (continued)

Indicator Comment Frequency and Standards
presentation for better
health
Workforce (continued)

Workforce planning: Monthly C11, D5

• Establishment against trajectory trend and
• Ethnicity forecast
• Turnover
• Sickness

Training: monitor variance against training plan Quarterly C11a

by exception
• Clinical training
• Skills training
• Statutory and mandatory training

Staff safety: Reported monthly C1a

• Number of incidents of violence to staff and weekly
• Number of staff accidents trends

Access

PTS performance: There are no government targets for PTS. As Monthly trend C19
• Percentage of patients spending more than (locally such, there is no standard reporting data-set
defined) standard time on vehicles and targets are locally defined. Further, the
• Percentage on time of patients’ journeys level of service quality and tolerance in
• Percentage of 'same day' patient bookings meeting standards varies between contracts

Progress against standards compliance Annually All

• Standards for Better Health
• CNST

Finance

PTS contract analysis Finance indicators are included within the sector Monthly trend C7f
analysis as part of the emergency service sector. and forecast
Plus, an analysis of contracts/SLA and financial
performance should be included (eg, commis-
sioner and SLA type, block, cost and volume)

Effectiveness

Vehicle utilisation, for example: The key measure is whether there are Monthly
• Unit hour utilisation appropriate resources available. There are trend and
• Calls per unit available large variations in utilisation between rural forecast
• How time is spent (eg, time spent in the community) and urban areas
• Downtime trend
• Vehicle accidents per 10,000 miles

Average length of time on PTS vehicle per patient Monthly trend C19

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Annexes
Annex 1: analysis of current practice
Annex 2: sample board agendas
Annex 3: annual board cycle

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Annex 1: analysis of current practice

Dr Foster Intelligence carried out an analysis of board papers from 15 board meetings
that took place between November 2005 and July 2006. The papers covered 13
current and former ambulance trusts.

Key findings:
u Frequency of meetings varies, with trusts meeting monthly, bimonthly and quarterly.
u The volume of paperwork appears to be less than that for SHA and PCT boards: the
total number of pages ranged from 50 to 324 (although the latter included the annual
report and business plan).
u The items discussed at board meetings appeared to be relatively consistent between
trusts.
u All board meetings included a performance and finance report.
u Performance reports were heavily focused on the response time targets and activity
summaries.
u Due to the timing of this analysis, many board meetings focused on the
reconfiguration of ambulance services, either planning for the reconfiguration or
establishing the new trust’s governance structures.
u Board discussions appeared to have quite an operational focus, focusing on current
issues such as standards for better health, current response performance and agenda
for change.
u More strategic discussions were around commissioning, strategic direction and the
use of community paramedics to develop rural services.
u Papers were reviewed from the following trusts or former trusts: Staffordshire,
London, Gloucestershire, North West, Oxfordshire, Great Western, Sussex, North East,
East Anglian, Mersey Regional, West Country, Hereford & Worcester, Royal Berkshire.

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Annex 2: sample board agenda

Ambulance trust boards should review the principles for putting the information
framework into practice outlined in The Intelligent Board. Set out below is a sample
board away day agenda, which boards may find helpful to adapt to their local
circumstances. For routine meetings, boards will need a more focused agenda, an
update on strategic issues and a review of operational performance, by exception.

Sample board away day agenda

Puddle region Ambulance Service NHS Trust
Meeting of the trust to be held at Puddlesham Town Hall on:
7th October 2006 at 10am

1. Chairman’s welcome and note of apologies

2. Minutes of the previous meeting
3. Matters arising
4. Strategic review
4.1 Emergency services – forward analysis of patient and community needs
Strategic questions What do we know about the health needs of our local community
and how they are changing? What will this mean for the services we provide? Do new
services need to be developed or existing services to be reconfigured?
Information set Analyses of local community in terms of key geo-demographic
factors, data on activations, conversions and admissions and the health needs that
can be inferred from this.
Availability of information Tools exist for trusts to carry out this analysis.
4.2 Patient transport services – market and business development
Strategic questions How well is the trust positioned in its market? How is it
performing compared with competitors?
Information set to include
n Local PTS market analysis
n PTS performance against contract
Availability of information Trusts should be able to provide this information now.
4.3 Key trends and forecasts
Strategic questions What income, expenditure and cash flow do we anticipate
across key areas of our business – by year-end; for the next two to three years?
From our routine oversight of operational performance, in which aspects do we have
particular strengths on which to build and weaknesses to address?
Information set: graphic presentations, with commentary as necessary
n Projected activity growth
n Cash flow forecasts
n Selected trends/forecasts relating to stronger/weaker aspects of performance regarding

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finance, efficiency, patients’ experiences, clinical quality, access/targets

Availability of information Provided trusts have established approaches to costing
and have some expertise in forecasting methodology, this information should be
available now.
4.4 External developments in terms of policy, technology and other changes in
the environment
Strategic questions What changes to the environment in which we operate should
we be anticipating in the coming one to three years? What impact could they have on
our ability to achieve our goals? What might they mean for the way our services are
configured?
Information set Brief report, based on regular horizon-scanning, together with
analysis of possible impact.
Availability of information Trusts should be able to provide this now.
5. Experiences of patients and staff – quarterly report
Strategic questions Are we delivering on our goals in the eyes of our staff and
customers? What do their perceptions and experiences tell us about the priorities
we should be setting? Where do we need to improve?
Information set:
n Trend analyses of feedback from patients and staff on key areas of satisfaction
n Trend analyses of complaints (issue, process and outcome)
n Commentary on underlying issues
Availability of information Trusts should have complaints information readily available.
Most trusts have limited up-to-date information on patient satisfaction – implementing a
patient feedback system and building a robust and useable data-set could take up to a year.
6. Future strategy
Building on the data presented in the earlier part of the meeting, directors
would now discuss a draft framework of strategic goals and operational priorities.
7. Operational performance – by exception
Exception reports should, if necessary, highlight any significant areas of
current concern in the following areas:
n Finance
n Efficiency
n Clinical quality
n Access and targets
n Other key risks
Where possible this information should be presented graphically.

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Annex 3: annual board cycle

This possible annual board cycle is proposed merely as an example, which boards might discuss and adapt. Boards should
discuss how they allocate their time, not only within a particular meeting, but over the course of the year.

APRIL MAY JUNE JULY SEPTEMBER

Development meeting Board meeting Self-assessment meeting Board meeting Board meeting

Opportunity for board Review progress on Board and trust review Review issues arising Review any issues arising
development strategy from monitoring of: from monitoring of:
• Markets and business • Markets and business
Discussion planning development development
STRATEGY

on current issues eg, • Key trends and • Key trends and forecasts
foundation trust strategy; forecasts
agenda for change; Review progress on
Taking Healthcare To current year business plan
The Patient
OPERATIONAL PERFORMANCE

Exception reports on: Exception reports on: Exception reports on:

• Finance • Finance • Patients’ experiences
• Efficiency • Efficiency • Clinical quality
• Patients’ experiences • Clinical quality • Access and targets
• Clinical quality • Access and targets
• Access and targets In-depth review:
In-depth review: • Finance and efficiency
• Patients’ experiences

Review board assurance Review board assurance Exception report on

framework including framework including key risks
RISK

Corporate Risk Register Corporate Risk Register

Annual reports on risk Sign off accounts,

REGULATORY

and safety; LSMS; statement of

clinical quality internal control and
annual report
Healthcare Commission
declaration of NHSLA report
performance against
standards

Approve register of seals. Annual reports on

Approve register of infection control; research
OTHER

directors’ interests. and development; health

Approve changes to and safety; fire safety;
standing orders and SFIs emergency planning

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OCTOBER NOVEMBER JANUARY FEBRUARY MARCH

Development meeting Board meeting Strategic planning meeting Board meeting Board meeting

Board away day Review issues arising Review draft annual plan Ensure any issues arising Agree annual plan
from monitoring of: and budget from monitoring of: and budget
Review strategic priorities • Markets and business • Markets and business
in context of changing development development
needs and wider external • Key trends and • Key trends and forecasts
developments forecasts are incorporated into
annual business plan
Identify and develop Review and develop
options; priorities for issues identified at
annual business plan October away day

Budget re-forecast

Exception reports on: Exception reports on: Exception reports on:

• Finance • Finance • Finance
• Efficiency • Efficiency • Efficiency
• Patients’ experiences • Patients’ experiences • Staff
• Clinical quality • Clinical quality • Patients’ experiences
• Access and targets • Access and targets • Clinical quality
• Access and targets
In-depth review: • Top ten organisational notes
• Staff survey
• Report/plan

In depth review
• Access and targets

Exception report on Review board assurance Exception report on

key risks framework and key risks corporate risks

Review board assurance Sign off annual audit plan

framework including
Corporate Risk Register

Review and continuing Agree forward agenda plan

development
Board self assessment,
including review of integrated
governance policy and strategy

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