NHS ambulance trusts

NHS publishes independent culture review into ambulance trusts

An independent review has set out a series of recommendations to improve the culture within the ambulance sector.

The review was carried out by Siobhan Melia, chief executive at Sussex Community NHS Foundation Trust, and commissioned by NHS England (NHSE).

“This is an essential and careful review by Siobhan Melia…”


The report notes that ambulance trusts have reported better working relationships with NHSE, with a shift from top-down messaging to a more collaborative approach that recognises operational pressures.

Operational performance is often prioritised over people and culture, however, creating a disconnect.

The extensive geographical reach of ambulance services poses a challenge to leadership too.

The report also says the prevailing ‘command and control’ leadership model in the ambulance sector only works for a short amount of time and is not sustainable. There is a growing understanding for a more adaptive management style.

Moreover, an NHSE culture assessment of three ambulance trusts showed that competing pressures often lead to poor behaviours. Capacity prioritisation takes precedent over misconduct management.

The report highlights that, while there is already action to tackle challenges in the area, there is “urgent need” for policy to spearhead the development of inclusive, equitable work environments.

Ambulance trusts believe there should be a bespoke EDI plan for the ambulance sector.

Bullying and harassment – including sexual harassment – is “deeply rooted” within ambulance trusts, according to the report.

“We are committed to moving away from outdated and inappropriate attitudes…”

Harassment, discrimination and bullying claims are regularly met with scepticism and delayed action. Clear expectations of staff need to be set out as well as the right way to approach the post-incident procedure.

The sector is exploring different ways of handling conflict, with one trust implementing a pre-action review meeting, while another uses a resolution hub.

The benefits of digitising and streamlining human resources processes were particularly highlighted.


Based on its findings and the insight of key stakeholders, the report has six primary recommendations for NHSE, integrated care boards (ICBs), and ambulance trusts. These include:

  • Balance operational performance with people performance
    • NHSE – embed culture improvement alongside operational targets in planning and delivery oversight
    • ICBs – review lead ICB commissioning targets
    • Ambulance trusts – routinely review workforce culture and operational performance
  • Focus on leadership and management culture, and develop the ambulance workforce
    • NHSE – develop a bespoke leadership and management offer
    • ICBs – facilitate sharing learning across ambulance trusts
    • Ambulance trusts – have a registered paramedic on the board, and protect time for individuals to receive leadership training
  • Improve the operational environment, line management and undergraduate training
    • NHSE – review health and wellbeing frameworks
    • ICBs – offer portfolio working opportunities to paramedics
    • Ambulance trusts – review the paramedic operating environment and management models
  • Make a bespoke EDI strategy for the ambulance sector from the NHS’s EDI improvement plan
    • NHSE – work with the ambulance sector to develop a bespoke EDI plan
    • ICBs – monitor the implementation of ambulance trust EDI strategies
    • Ambulance trusts – deliver EDI priorities, including addressing barriers to recruitment
  • Allow the freedom to speak up and target bullying and harassment
    • NHSE – monitor the delivery of the national sexual safety charter, with a particular focus on the ambulance sector
    • ICBs – monitor bullying and harassment
    • Ambulance trusts – uphold policies and provide training to all staff including managers
  • Prioritise, support and develop human resources and organisational development functions
    • NHSE – collaborate with trade unions on a statement to support cultural change
    • NHSE/ICBs – develop a bespoke human resources and organisational development offer
    • Ambulance trusts – introduce measures for an effective speak up culture, including trained investigators for the most complex cases

Health leaders’ reaction

Responding to the report, Sir Julian Hartley, the chief executive at NHS Providers, says: "It is essential that staff feel confident to speak up and this review sets out welcome practical actions to address serious cultural problems within ambulance services.

"Trust leaders agree there's no room for bullying and harassment in the NHS and no room for complacency. Staff and patients must be and feel safe.”

He adds the NHS is working hard to safeguard staff wellbeing, improve leadership and action the EDI plan while also meeting operational targets, but more can be done.

NHS Employers’ chief executive, Danny Mortimer, describes the review as “essential and careful”.

“It recognises the steps that ambulance leaders and their staff representatives are already taking to improve cultures that have for too long been characterised by poor behaviours,” says Mortimer.

“At the same time, it rightly challenges the ambulance service to do much better for its staff and patients, and offers clear support to meet that challenge.”

Managing director of the Association of Ambulance Chief Executives (AACE), Anna Parry, adds: “We know that there is much still to be done to ensure that NHS ambulance services offer a safe, inclusive, well-led working environment for all their people where inappropriate behaviour will not be tolerated and concerns will be responded to appropriately and compassionately.”

Parry says AACE is committed to “moving away from outdated and inappropriate attitudes” within the sector.

AACE’s chair, Daren Mochrie, highlights that “extensive programmes of work are already well advanced” in the majority of the areas mentioned in the report.

Mochrie says: “Today’s review provides us with a further impetus to continue to build upon this vital work and create meaningful and lasting change – for the benefit of our people and our patients.”

Image credit: iStock

NHE March/April 2024

NHE March/April 2024

A window into the past, present and future of healthcare leadership.

- Steve Gulati, University of Birmingham 

More articles...

View all
Online Conference


2024 Online Conferences

In partnership with our community of health sector leaders responsible for delivering the UK's health strategy across the NHS and the wider health sector, we’ve devised a collaborative calendar of conferences and events for industry leaders to listen, learn and collaborate through engaging and immersive conversation. 

All our conferences are CPD accredited, which means you can gain points to advance your career by attending our online conferences. Also, the contents are available on demand so you can re-watch at your convenience.

National Health Executive Podcast

Ep 42. Leadership in the NHS

In episode 42 of the National Health Executive podcast we were joined by Steve Gulati who is an associate professor at the University of Birmingham as well as director of healthcare leadership at the university’s Health Services Management Centre.