Executive summary

NHS England South West Workforce, Training and Education (WT&E) have led a quality improvement process with South Western Ambulance Service NHS Foundation Trust (SWASFT) as part of the quality assurance process and Intensive Support Framework. 

WT&E are responsible for assuring the quality of the learning environment, the educational governance, support for learners and supervisors and delivery of approved curricula for healthcare education. 

The initial quality visit was in January 2023 with a follow-up visit in September 2023.

This report highlights key findings from our latest series of follow up visits with undergraduate student paramedics (UGSP) and practice educators (PE) in May and June 2024, with feedback provided to the SWASFT senior leadership team in August 2024. The follow up visits were designed to assess the impact of SWASFT improvement actions and to review the current learning environment.

We found that the majority of UGSP reported a positive welcome in stations where they were placed.  Most UGSP wished to work as a paramedic and the majority would be happy to take up a post in SWASFT.

We found positive feedback regarding changes made by SWASFT to personnel working in the resource operation centre (ROC).  Year 1 UGSP were positive about SWASFT involvement in their induction which highlighted wellbeing and support, Freedom to Speak Up system and whistleblowing.  Those UGSP who had completed placements were very positive about the new practice educator facilitator role as a point of liaison and support, working between SWASFT and the Approved Education Institute (AEI).

PE were positive about being in the role of a supervisor and educator and were positive about the training provided for this role.

We noted a high level of awareness of the sexual safety charter among UGSP and PE and good awareness of the ‘Crossing the Line’ training (acceptable behaviour training) with all PE having completed this.

Incidences of inappropriate behaviour were reported to be less frequent than on previous visits as part of this quality review.  The panel had the impression of a positive change in culture within SWASFT.  Where incidences of inappropriate behaviour remained it was clear from UGSP and PE that how these are handled within a station, positively or negatively, will have a significant impact on learners and staff and will affect their likelihood of reporting inappropriate behaviour in the future. 

Despite most UGSP and all PE being aware of the Freedom to Speak Up (FtSU) system we noted that the majority lacked confidence in this being a confidential service.  The numbers of those who had used the FtSU system was significantly lower than the number of those who had observed or experienced inappropriate behaviour, however, other channels of reporting were used in some cases.  Both UGSP and PE reported concern that those who raised a complaint would often suffer a worse outcome than the person being complained about.

The practical challenges of consistency of PE for a learner and how to learn during long waits outside hospital were reported.  The wider NHS challenges lying behind these were acknowledged by UGSP and PE and some suggestions shared about how best to mitigate these.

Requirements for ongoing monitoring of improvements have been set. 

Ongoing cultural change will be required to move all staff and UGSP from a point of awareness of inappropriate behaviour to a point where they are confident to speak up, confident to be an active bystander and have confidence in the reporting system within the organisation.  However, significant improvements have been made with a positive impact on learners who are now keen to remain in SWASFT once qualified.

WT&E South west will continue to work in partnership with SWASFT, the AEIs and our learners to support quality improvements.  

We will not arrange another follow-up triggered visit but will continue to monitor improvements using current intelligence sources such as the National Education and Training survey, the National Student Survey, established AEI placement evaluation processes and any escalated concerns.  The South West Paramedic Education Network, with representation from NHS England WT+E, SWASFT and the AEIs will be used as the forum to review progress.

Review overview

Background to the review

In January 2023 NHS England South West WT&E triggered a quality review process due to concerns received from two independent local Approved Education Institutes (AEIs) that provide undergraduate paramedicine courses and place students at South Western Ambulance Service NHS Foundation Trust (SWASFT). The triggered review process identified reports of unacceptable behaviour towards learners, lack of confidence in reporting mechanisms within SWASFT, concerns about the learning environment and some difficulties with practical aspects of the placements.

SWASFT engaged with the education quality improvement process and implemented a range of improvement actions, (SWASFT summary of actions in appendix 2 for information). 

A follow-up visit held in September 2023 confirmed the positive impact of many of these initiatives including UGSP access to the SWASFT app, ‘Crossing the Line’ training for staff and awareness of the sexual safety charter and Freedom to Speak Up (FtSU) policy.  The September 2023 visit heard reports of ongoing inappropriate behaviour in some SWASFT stations and felt that a longer timeframe would be needed to see the positive impact of cultural change, so arranged this further review in 2024.

Who we met with

We spoke to 116 Undergraduate Student Paramedics (UGSP) from both the University of Plymouth (UoP) and the University of West of England (UWE) which were the two AEI where initial concerns originated. UWE and UoP have on average 580 learners placed within SWASFT.  These UGSP shared feedback based on their experience of being placed at a range of ambulance stations across the south west including Swindon, Weston, Bristol, Yeovil, South Gloucester, Burnham, Minehead, West Somerset, Kingsbridge, Plymouth, Chippenham and Barnstaple.

We spoke to 15 Practice Educators (PE) from a range of stations across the south west including Liskeard, Salisbury, Okehampton, Bridgwater, Taunton, Helston, Blandford, Ilminster, Cinderford and Newton Abbot.

Review Panel

Education Quality Review Lead   

• Helen Waters, Associate Dean for Quality

Specialty Experts   

• Carrie Biddle, Regional Head of Allied Health Professions, Psychological Professions and Healthcare Scientists
• Sarah Todd, Senior Specialist in Education – Urgent and Emergency Care

External Specialty Expert    

• Sarah Ashley-Maguire, Workforce Transformation Lead

NHS England Education Quality Representatives        

• Laura Grieve, Quality Officer
• Sophie Rose, Quality Officer
• Dominic Oliver, Quality Officer      

Review findings

Domain 1: Learning Environment and Culture

87% of UGSP present reported feeling welcomed in most of their placements.  They shared positive examples where PEs showed them round the station, shared a cup of tea with them and included them in social events. They felt that most PEs were supportive and helpful and some asked if they could nominate their PEs for an award. Some reflected that when other station members engaged well with them (not just their direct crew) it added to a positive experience.  Those who were in year 3 of the programme reported an improvement over the last 3 years with staff in stations being more friendly and respectful. 

Most of the UGSP were aware of the sexual safety charter. They reported that SWASFT staff were also aware of the charter and were receiving ‘Crossing the Line’ training.

Both UGSP and PE reported individuals in some stations that were still displaying unacceptable behaviour and reported that they are often known about in stations and tolerated. Both UGSP and PE reported incidences of learners being warned to avoid these staff members as a result of their behaviour. 

16% of UGSP surveyed as part of this review process reported observing inappropriate sexual behaviour and 3% personally experiencing this within the last year. This is a reduction from the reports shared in the review visit in September 2023.

10% of UGSP surveyed as part of this review process reported observing inappropriate racial behaviour and 3% personally experiencing this within the last year.

42% of UGSP surveyed as part of this review process reported observing bullying or undermining behaviour and 12% personally experiencing this within the last year.

40% of UGSP surveyed reported that they neither observed nor experienced any inappropriate behaviour, which is a significant reduction compared to our initial visit where 75% of UGSP reported experiencing or observing inappropriate behaviour.

These figures show a reduction in inappropriate behaviour compared to the review visit in September 2023. There was also a reported improvement in behaviour overall, with the majority of staff being welcoming and supportive in contrast to some individuals who were identified as still having inappropriate behaviours.

25% of UGSP reported having seen another member of staff call out inappropriate behaviour as an active bystander, which was a positive experience. PE reported generally feeling comfortable to speak up on behalf of UGSP or new colleagues.

Domain 2: Educational Governance and Commitment to Quality

We heard an example of positive handling of an incident of unacceptable behaviour. The UGSP had a named contact throughout the process, was provided with support and was informed of the outcome of the process. The UGSP stated that this gave them confidence in the process and had a positive impact.

Other UGSP reported seeing poor behaviour reported with no evident actions or outcome from the process which they reported would mean that they would not report similar inappropriate behaviour in the future.

Many reported a lack of faith in the FtSU system, stating that they felt it wasn’t confidential or anonymous. A few reported that individual SWASFT staff make it clear that to speak up will cause problems, that use of FtSU is ‘tale telling’ and that ‘what happens in station stays in station’.

Some reported incidents of what they termed “victim blaming”; being told that their report could ‘lose him his job’. 

Some reported the fear of a risk to their reputation if they reported incidents as everyone knows what has happened in a small station. Some reported concern that reporting incidents via any route could affect one’s academic sign-off or assessment of competencies.

Some PEs reported concern about speaking up, commenting that the reporter often comes out worst.

We surveyed the UGSP involved in this review to ascertain their involvement in reporting inappropriate behaviour within the last year.

4% of UGSP had used the FtSU system to report inappropriate behaviour. 20% had reported inappropriate behaviour using another route, such as speaking to their PE, another station member or their university tutor.

The NHS England Freedom to Speak Up information and the WT&E Escalating Concerns form was shared with all UGSP attending feedback sessions.

The UGSP spoken to in these sessions suggested that SWAST let people know what the process is if they complain and share the data and actions from FtSU, to give confidence in the process. We note that the FtSU process offers to keep a reporter up to date with the progress of their reported issue and that, where possible, they will share the full investigation report, but that some outcomes may not be shared to respect the confidentiality of others.

Domain 3: Developing and Supporting Learners

The first year UGSP reported a good induction with involvement of SWASFT staff which included information on wellbeing and support, FtSU and whistleblowing.

The UGSP at UWE spoke very positively about the recent practice educator facilitator role linking UWE and SWASFT. They identified this as one of the best and most significant changes over the years they had been on the undergraduate paramedicine program. The person in this role was visible, provided a point of liaison, was helpful to UGSP with health needs, to those making a complaint or to those struggling and was helpful in the allocation of mentors. 

A positive example of support for learners was reported when the Operations Officer called the UGSP after a challenging call-out, providing a debriefing and signposting to support. PEs suggested that debriefings, (known as TRiM- trauma risk management), should be automatic after challenging events and not based on an UGSP requesting it.

UGSP rely on the Resource Operating Centre (ROC) to manage their shifts in placement. The UGSP reported that SWASFT-led changes in ROC over the last year were very positive. They reported ROC staff as more understanding, which had a significant positive impact on UGSP experience. They noted that ROC provided shift support and help with continuity in a placement.  Some noted that out of hours ROC staff did not appear as well trained and aware of systems as the in hours ROC. An example given was of ROC out of hours not understanding how to appropriately manage UGSP sickness on shift.

The UGSP reported that the best part of their placements was getting out on the road, seeing patients and doing the job of a paramedic. By contrast, the worst part of placements was time spent in an ambulance queuing outside hospitals. PEs reported being able to use SWASFT iPads to complete continuous professional development (CPD) during long waiting periods outside hospitals (known as stand-by CPD) and felt this may be a useful tool for UGSP, if iPads were available for them.

Domain 4: Developing and Supporting Supervisors

We spoke to PE in a session within an educator training day. They all reported the educator training days as positive and noted that the attendance payment was a positive factor in their attendance, which is in non-working time.

They all valued the role of PE and reported that they felt it kept their practice up to date. Some mentioned that there are still a few PEs who are not interested in the role as an educator but have taken the role due to the advantages of a pay uplift and their ability to manage their own shifts. 

As queuing is the new normal, but wasn’t the case when most PE were learning, they reported being interested in a better understanding of this new learning environment and in exploring methods of training in this environment. One PE talked about prompting the UGSP to initiate a learning topic during long waits or having a topic ready such as ‘drug of the week’. This could be a helpful PE training topic or update within a SWASFT newsletter.

PEs reported valuing time after a call-out to debrief, discuss and teach on a case prior to ‘going green’ and being available for the next call.

All PEs had completed mandatory training in sexual safety and ‘Crossing the Line’.

Domain 5: Delivering Curricula and Assessments  

SWASFT have funded a new practice educator facilitator role linking UWE and SWASFT and being a point of liaison. This was reported by UGSP as a positive initiative and one that had made a significant difference in their paramedicine training.

As before both UGSP and PE reported a challenge in the numbers of learners vs educators. As a result, some UGSP had many PE for shifts in one station placement and reported that this could negatively impact on their learning. They reported each new PE had to ascertain their competence and learning needs rather than building on previous time working together. They felt that inconsistent mentoring affected their ability to complete learning objectives and pass each year. Both UGSP and PE acknowledged that complete consistency in supervision was not possible where PE worked less than full-time or where there was sickness. It was suggested that groups of mentors or a system with co-mentors would provide better PE cover in cases of sick leave or less than full-time working.

Domain 6: Developing a Sustainable Workforce

Most UGSP wished to work as a paramedic and most reported that they would take a permanent job with SWASFT. This represents a significant improvement since the quality visits in September 2023.

Issues reported by UGSP and PE that threaten retention on programme included travel time and travel costs. It was acknowledged that the South West is a large geographical area. We heard reports of an UGSP setting off at 4am to get public transport to their ambulance station for a 7am start and repeating that journey at the end of a 12-hour shift, which their PE did not feel was safe. We heard of UGSPs driving 90 minutes to return home at the end of a 12-hour shift and using techniques such as naps in lay-bys to remain safe to drive. UGSP would value any changes in the system of placement allocation that would reduce travel time. Reclaiming expenses was reported to be a slow process and UGSP often were left out of pocket, which they could not afford. We recognise that the NHS learning support fund process, which reimburses expenses, is not the responsibility of SWASFT. Improvements in placement allocation could reduce the need to incur expenses.

Areas that are working well

Good practice is used as a phrase to incorporate educational or patient care initiatives that, in the view of the Quality Review Team, deliver quality above and beyond the standards set out in the Education Quality Framework.  Examples of good practice may be worthy of wider dissemination.

Areas for improvement

Mandatory requirements

Recommendations

Recommendations are not mandatory but intended to be helpful, and they would not be expected to be included within any requirements for the provider in terms of action plans or timeframe.  It may however be useful to raise them at any future reviews or conversations with the provider in terms of evaluating whether they have resulted in any beneficial outcome.

Report approval

Report completed by: Helen Waters, Associate Dean for Quality, NHS England SW, Workforce, Training and Education
Review lead: Helen Waters
Date signed: 16 August 2024

NHS England authorised signature: Dr Geoff Smith, Regional Postgraduate Dean
Date signed: 16 August 2024

Final report submitted to organisation: 1 October 2024

Publication reference: PRN01548