In sport and business, education and healthcare, the concept of ‘marginal gains’ is being used to find creative ways to be better. Marginal gains is where a goal is broken down into smaller constituent elements, each improved on, with the net result being an overall enhancement of the original goal. The potential cumulative benefits of this type of thinking and action may be significant.
This has proven true for individuals, as well as for complex healthcare organisations such as a large NHS ambulance service pledged to making improvements and delivering high-quality and compassionate care (NHS, 2015a).
The marginal gains concept was to be tested on busy 999 crews attending two large urban emergency departments (ED) over a 3-month period, beginning in December 2019.
The aim was two-fold: to enhance staff welfare by providing refreshments and uphold ambulance performance in terms of the job cycle when data for previous winter periods indicate extended waiting times at hospitals (NHS, 2015b).
In terms of welfare, this meant providing cups of tea and coffee to crews. It would also be an opportunity to talk, let off steam and take a moment to unwind.
If staff morale can be boosted through the provision of hot drinks at hospital, talking together frankly and being listened to supportively (Murphy, 2020), frontline staff would feel refreshed, with positive attitudes restored. This would be a marginal gain.
NHS employers are tasked with looking after the health and wellbeing of their staff and this is a core responsibility for management (National Institute for Health and Care Excellence (NICE), 2017). Staff who feel valued are also likely to have more empathy for patients and provide a better quality of care overall (NHS England, 2016).
In terms of the ambulance job cycle, marginal gains would aim to reinvest the accumulated minutes driving to ambulance stations to restock consumable and other items, into responding to patients. Adequately stocked vehicles are essential and if replenishable equipment can be provided to crews at hospitals on some occasions, then a journey to an ambulance station simply to restock can be avoided. Cumulatively, this tiny clawing-back of resources could benefit patients waiting for ambulances. Time is a finite and precious commodity in terms of ambulance availability and for emergency operations centre (EOC) resourcing, it is preferable to use this time attending to patients rather than driving to ambulance station stores.
Prioritising staff welfare
The welfare van was a resource without an operational call sign and, as such, was a hidden asset in the context of EOC planning and resource availability. Local management were explicit that crews must be able to consume a refreshment drink in addition to formalised meal breaks and rest periods endorsed by working time directives, as long as this had no detrimental effect on turnaround times. Crews were to be trusted not to abuse this and this message was explained when surprised crews asked about the new welfare van resource. Not every crew took a drink and operational staff are aware that delaying turnaround times just for a cup of tea is inexcusable, though EOCs do endorse this after a particularly challenging job, such as a cardiac arrest.
In all walks of life, breaks are good for you, and frontline ambulance staff were amazed that management trusted staff to enjoy a supplemental drink provided by the employer simply to replenish energy levels and take a mental break.
Winter planning
Ambulance trusts work hard to look after staff wellbeing and recognise that sustained physical, psychological and emotional pressure on frontline staff rises in winter. NHS trust leaders also recognise staff burnout as winter pressures loom (NHS Providers, 2020).
The concept of a welfare resource for frontline operational staff during the winter period was agreed by local managers, with the funding covered by the ambulance trust strategic winter planning budget for 2019–2020.
NHS organisations and leaders prepare for winter in advance at a strategic and corporate level. Pressures have been building on EDs and ambulance trusts for several years, and can increase significantly during winter because of a rise in the numbers of people admitted to hospitals (NHS England, 2017), leading to delays to ambulance turnaround times.
An unmarked rental van was hired, eight new hot water flasks purchased and equipment items provided by local stores. This concept was put into action initially as the ‘welfare bus’.
A similar concept was used at the same time by Hampshire Police Federation where the term ‘well-being wagon’ was used, offering cups of tea, somewhere to sit and keep warm and dry, as well as offering blood pressure checks, sleep and diet advice, and psychological screenings (Hampshire Police Federation, 2019).
For this winter ambulance service project, the term ‘welfare van’ became widely accepted and adopted by the operational staff it was serving.
Agreements with local hospitals
Ambulance hospital liaison managers present at busy EDs advised seeking out the nurse in charge and asking permission to provide cups of tea to staff waiting in corridors with patients. Common sense and judgement would come into practice here. Professional image and trust were other elements of sustaining goodwill between hospital staff unable to have a break. In return, ambulance staff were willing to help move patients, clean patient trolleys and put out linen if it helped transfer a patient off the ambulance stretcher or wheelchair.
Common sense also had to be factored in when parking at hospitals. No emergency driving exemptions could be claimed for parking across pavements or double yellow lines. As the vehicle was unmarked, a laminated ambulance trust sign was displayed in the windscreen to alert hospital security staff to the provenance of this dark grey anonymous-looking van.
Gradually, crews became familiar with the unmarked van and would approach discreetly and take drinks back to the ambulance or hospital corridor. There was no provision to sit inside the welfare van as with Hampshire Police Federation. Requests for equipment, including medicines and personal protective equipment (PPE) were infrequent.
Feedback
Leaders asked for feedback from frontline staff and a formal questionnaire survey was suggested but not actioned, though verbal comments were recorded, anonymised and relayed to local management. Crews were also invited to provide work email addresses for any reflective comments that could be used to compile an evidence base for keeping the project going beyond the winter season. Unfortunately, much of these email data have become lost.
Feedback from crews has been overwhelmingly positive. Tea, coffee and time to talk are always going to be a popular idea. Initial concern was raised regarding where drinks should be consumed and possible negative public perceptions of the professionalism of crews on tea breaks in busy ED corridors. Whether it would be better to invite crews outside to the welfare van was considered; however, problems were avoided when prior consent was obtained from hospital ED staff.
In anticipation of sustaining the welfare van beyond the 2019–2020 winter period, crews were briefed that provision of evidence would make the case for shaping how this project unfolds going forward. These qualitative data could inform ambulance management of the ultimate success or failure of the project, offer insight into potential modifications, and whether it would be worthwhile to repeat the enterprise in future.
The following responses were typical of the ambulance staff who accessed the welfare van.
‘It's a nice idea and it's good for morale.’
‘It's a good initiative particularly in winter months, when there are possible long corridor waits.’
‘It's a really good idea. It's great for team morale.’
‘Making every member of the team feel welcome.’
‘My colleague and I used the facility for a brew which was appreciated and needed at that time. It was good to see what is on offer. While there, another crew made use by picking up supplies. I think it is a great idea and should continue.’
It should be noted that there are no formal quantitative data to detail the impact on crew turnaround times or resource availability.
Several crews commented that the welfare van could be useful in the community with provision of welfare support at significant events, such as roadside fatal trauma, out-of-hospital cardiac arrests (OHCA), homeless or ‘no-fixed abode’ patients. However, it would be essential to have a method of communicating with the welfare van to ensure it could be mobilised to such incidents. Engagement with EOC management could potentially have resulted in allocation of a welfare resource call-sign for this vehicle and, as such, improve its visibility in terms of EOC planning and manning. This may be a useful consideration in future.
Negative feedback concerned frustration that the vehicle was infrequently manned by just one member of staff on an ad-hoc arrangement, thus denying more staff this welcome resource. Crews work around the clock, every day of the year and road staff wanted the van to reflect this in terms of resource availability. Use of non-recyclable plastics and polystyrene cups also received criticism. No feedback was requested from EOC or hospital staff.
Consumables and equipment
Polystyrene cups, tea, coffee, hot chocolate, Bovril and hot water in flasks were available. Additionally, the ‘welfare van’ was kitted out with consumable stores items, trauma equipment such as a scoop stretcher, pelvic binders, bandages and dressings, medicine pouches and portable oxygen cylinders. Fully provisioned advanced life support equipment used in cardiac arrests was also available.
It is worth noting that quantitative data are available on turnaround times for OHCA. Crews may often be committed for extended periods when attending OHCA and management expressed a view that data of welfare van attendance at these incidents could be analysed for its impact on turnaround times. Ambulances would be restocked using consumables from the welfare van and crew down time scrutinised. It was anticipated that turnaround times would be shortened if travel time back to ambulance station stores to restock could be eliminated on some occasions but this hypothesis was never tested.
A proportion of OHCAs do result in patients being conveyed to hospital, and where they are not, road staff appeared uneasy about being visible in the community stood by the welfare van drinking cups of tea, particularly outside a home where a termination of resuscitation (TOR) has taken place.
The welfare van was manned by one member of frontline ambulance staff on ‘light duties’ familiar with local hospitals and known to ambulance colleagues.
Critical incident and reflective debriefing
On-scene times for incidents such as OHCA, fatal trauma or TOR in the community could feasibly be protracted where staff welfare is addressed immediately afterwards in a post-incident debrief (Snowdon, 2021). With engagement in reflection and review after critical incidents a requirement of the Health and Care Professions (HCPC) (2014) standards of proficiency for UK-registered paramedics, wellbeing of staff is integral to these debriefings. This could be an important area for the welfare van to become involved with in future, with consideration given to manning the van with staff trained in incident debriefing, peer support and knowledge of signposting to wellbeing services.
Communications
Face-to-face communications between ambulance crews and the welfare van were most effective. Simply asking crews what they wanted and taking notes is tried and tested in hospitality sectors as well as healthcare.
A handset radio was also tested as a means of the welfare van communicating with operational control centres and satellite centres monitoring service delivery and performance. Mobile phones were also occasionally employed. This digital technology had its place in providing up-to-date data on which hospital EDs were the busiest. It was found, however, that whichever ED the welfare van attended, there was usually one or several crews to assist and provide welfare to, if they wanted it.
Impact of COVID-19
As winter 2019 evolved into spring 2020, it was beginning to look like the welfare van project may become ‘mothballed’. COVID-19 then appeared to provide an extended lease of life for this worthy welfare van project. Generosity shown towards the NHS from the public and private sector businesses has also resulted in the ambulance service receiving donations of snacks and treats for staff. During 2020, the welfare and wellbeing of NHS staff appear to have become a part of the national conversation (e.g. ‘Clap for Our Carers’) and welfare vans have been provided by ambulance staff trade unions (GMB, 2020), volunteer ambulance community first responders and other local NHS ambulance trust management.
PPE has been added to the inventory of equipment stores available to crews at hospitals. With the wellbeing of staff being a core responsibility for NHS senior leaders, tea breaks and welfare vans show every sign of a permanent role beyond the original winter plan.
COVID-19 has also seen mobile cleaning staff deployed to acute hospital sites, decontaminating ambulance saloon interiors while clinical staff are handing over at EDs.
Perhaps this work could be the subject of a similar commentary piece and the effects of marginal gains recouped by cutting out a journey time traditionally taken to drive to an ambulance station for cleaning of vehicle interiors by operational clinical staff.
Conclusion
This welfare van project was founded on the principles of seeking out positive marginal gains and may be near impossible to evaluate and measure in the context of vast quantitative ambulance performance data.
Welfare van feedback confirms crews have been positively motivated through the simple experience of a cuppa and a chance to talk and be listened to. There is clear evidence of a tangible boost to morale, even if this is a tiny marginal gain that may not show itself through NHS or ambulance service performance data.
These enhancements to staff welfare, attitude and morale may well be immeasurable by conventional methods—but the marginal gains are there nonetheless, and this must surely perk up road staff, improve patient experience, and satisfy the overall performance commitments of the busy ambulance service organisation.