WMAS Board Meeting Minutes – Wednesday 30 July 2025

Present

• Prof. I Cumming – Non-Executive Director (Chairman) and voting member
• Mr AC Marsh – Chief Executive Officer and voting member
• Ms S Banks – Non-Executive Director and voting member
• Ms C Beechey – Director of People and voting member
• Mrs C Eyre – Director of Nursing and voting member
• Mr M Fessal – Non-Executive Director and voting member
• Mr M Khan – Non-Executive Director and voting member
• Mr V Khashu – Strategy and Engagement Director
• Mr M MacGregor – Communications Director
• Mr S Nat – Non-Executive Director and voting member
• Ms K Rutter – Director of Finance and voting member
• Dr R. Steyn Medical Director and voting member
• Mr P. Higgins – Governance Director and Trust Secretary
• Mr A Brown – CEO Chief of Staff & Head of Enhanced Care
• Ms K Freeman – Private Secretary, Office of the Chief Executive
• Mr P Green – Staff Side Representative
• Ms A Giles – CQC
• Mr I Syme – Member of the Public
• Cllr Carol Little – Local Authority Appointed Governor (Dudley MBC)
• Mrs E Cox – Lead Governor (Staffordshire)
• Ms S Lawson – Staff Governor
• Mr D Fitton – Regional CFR appointed Governor
• Mr R Cooke – Public Elected Governor (Staffordshire)
• Mrs B Richards – Public Elected Governor (West Mercia)
• Mr B Murray – Public Elected Governor (Coventry and Warwickshire)
• Mrs K DaSilva (Head of Financial Transformation and Efficiencies)

Minutes

07/25/01 – Welcome, Apologies and Chairman’s Matters

Apologies for absence were received from Professor Alex Hopkins, Mrs J. Jasper, Mr Nathan Hudson, Mr Nick Henry, and Ms. Diane Scott.

The Chairman welcomed everyone including the FT Governors in attendance to the meeting and reminded colleagues of the Annual Meeting of the Membership that was being held that afternoon.

07/25/02 – Declarations of Interest

There were no declared conflicts of interest by anyone attending the meeting in relation to any matters on the agenda.

07/25/03 – Questions from the Public

There were no questions.

07/25/04 – Board Minutes

To agree the minutes of the meeting of the Board of Directors held on 30 May 2025.

05/25/05 – Board Minute Log

The Board Log that contains the schedule of matters upon which the Board have asked for further action or information to be submitted. Matters on this log can only be deleted through resolution of the Board. (For the avoidance of doubt unless specified below all matters contained on the Board log will remain on the log until the Board resolves that the matter can be discharged).

Action 05/25/06c – Board Assurance Framework (BAF).   The Head of Risk will attend the Board Briefing in October 2025 to enable the Board to carry out a more detailed review of the BAF and the corporate risk appetite. In addition, it was reported that the Board will also review the corporate risk register.  On this basis the Board agreed that this item could be discharged from the Action Log. (Discharged)

Action 10/24/11a – Policy & Procedure Update.  An update will be submitted to the Board in November 2025.  This has been added to the schedule of business. On this basis the Board agreed that this item could be discharged. (Discharged)

Action 05/25/10 – the Green Plan.  As requested “The Plan” was updated to include appropriate wording on achieving the 45 minute handover and the environmental consequence of vehicles being kept running outside of hospitals. On this basis the Board agreed that this item could be discharged. (Discharged)

Action 05/25/15c – Draft Quality Account.  Under the delegation approved by the Board at its meeting under Minute number 05/25/25, the EMB authorised the Quality Account to be published on the Trust’s website by the statutory deadline of 30 June 2025.     On this basis the Board noted the action taken and agreed that this item could be discharged. (Discharged)

07/25/06 – Board Assurance Framework (BAF)

A report of the Director of Nursing and Head of Risk was submitted.

The Board was advised that all strategic risks have been reviewed and updated.    The IM&T management group was currently reviewing the cyber security processes for clarity on some areas of risk.  It was reported in the BAF that the Audit Committee has requested work regarding the corporate governance around the use and effect of Artificial Intelligence (AI). The External Auditors through the Audit Committee had requested that the Board receive appropriate Assurance in relation to risks, mitigation and controls of the use of AI. To this end the Digital Transformation & Oversight Group has established task and finish group of key leads for this purpose. This includes (but not limited to) Basic AI Guidance for Staff, Acceptable Usage of AI, AI Risk Assessment and AI Self-Assessment. The Trust’s internal auditors, KPMG, are supporting an AI benchmarking exercise imminently. This includes (but not limited to) Basic AI Guidance for Staff, Acceptable Usage of AI, AI Risk Assessment and AI Self-Assessment, KPMG are supporting AI benchmarking exercise imminently. It is understood that clear guidance on AI usage, including terms and specific examples of work, may improve efficiency for the Trust.  The Chairman stated that that Dr Hatim Abdulhussein the NHSE lead for Clinical AI will be joining the Strategy Session on 1 September and we can pick up these points during that session. He indicated that Dr Abdulhussein had also agreed to meet with IM&T management team after his presentation to the Board.

The restructuring and clustering of the commissioning groups was being risk assessed in relation to its impact on the Trust. This raises the risk that the ICSs focus may be directed towards acute, community, mental health, and primary care provision so ability for ambulance to access national transformation funds for example or capital may continue to be constrained. This has been raised at EMB who support the risk.

The CEO advised the Board that the BAF is reviewed regularly at EMB, so we are clear of the risks and actions taken.  Mr Khan explained that the BAF is also reviewed regularly at the Finance & Performance Committee.

07/25/07 – Chief Executive Officer (CEO) Update

A report of the Chief Executive Officer was submitted.

The CEO advised the Board that the paper summarises the various meetings between May and July 2025.  The CEO explained that the Trade Union (Facility Time Publication Requirements) Regulations 2017, which came into force on 1st April 2017, implemented the requirement introduced by the Trade Union Act 2016 for specified public-sector employers, including NHS Trusts, to report annually a range of data in relation to their usage and spend on trade union facility time. The facility time data for West Midlands Ambulance Service University NHS Foundation Trust is for the period 1 April 2024 to 31 March 2025.  For this period there was a decrease in time as the year before increased due to industrial action.  A report will be submitted to the People Committee and then published on the website.

The CEO wished to record his thanks to all the senior Staff Side Reps for the great work they do to help this Trust be the best organisation we can for the benefit of our patients and staff.

The Chairman advised the Board of Directors that we should acknowledge that Mark Axcell, CEO from Black Country ICB has announced he is stepping down from his role.  We wish to record our thanks for his support to us and his contribution to the NHS.

07/25/08 – Executive Scorecard & ICS Scorecard relating to Performance for the Month of June 2025

The Executive Scorecard of Key Performance Indicators (KPIs) for the month of June 2025 were submitted. The key indicators and trends were set out for review by the Board. The indicators covered operational performance, finance, workforce, and high-level clinical indicators. The scorecard was submitted in addition to the Trust Information Pack which contains Trust wide performance data and information and is circulated separately to the agenda.  

The CEO explained that the dashboards have also been discussed in detail at the Finance & Performance Committee.  Mr Khan wished to congratulate the Team, for the excellent work undertaken in progress of the Cat 2 target. 

07/25/09 – Winter Plan

The Winter Plan was submitted

The CEO informed the Board of Directors that the report is as presented.  This is the second time the Board had been requested to review the Winter Plan given its importance in terms of preparing for the Winter. The Trust was keen to ensure the learning from last winter is built into the plan early enough to plan the resources required.  The contingencies built into the plan build upon the guidance issued by NHS England.  We hope that the Winter plan will be sufficient this year but if not, we can add in the contingency items. 

The CEO pointed out that the Trust has always been a sector leader regarding the flu vaccination programme and the Trust is committed to continuing along with the covid vaccines if they become available. The Chairman asked if it was possible for the Trust to offer covid vaccinations along with the flu vaccination.  The Director of Nursing pointed out that unless the vaccine has changed, the cold storage requirements presented a challenge to be able to store covid vaccine in sufficient quantities.   

The CEO explained that the Board Assurance Statement (BAS) requires submission by 30 September 2025.  The draft checklist was attached to the bundle for review and comment. WMAS are awaiting dates for a region led exercise.  The QIA and EIA for the Winter Plan are attached which provides assurance to the Board. 

Mr Nat acknowledged the positive actions regarding “hear and treat” and asked about the continuation of actions.  The CEO said the Trust was committed to making sure patients get the right pathway of care and we will further strengthen the Clinical Validation Team as part of the Winter Planning. 

The CEO’s Chief of Staff / Head of Service Transformation explained that the QIA is a generic assessment.  If any items need implementation, we will then submit a specific QIA.  Mrs Banks advised the Board that the Quality Governance Committee (QGC) is undertaking some focused work on hear and treat.

The Strategy & Engagement Director informed the Board that the Winter Plan will be shared with the Black Country ICB, the Urgent Care Board, and other key stakeholders.

The Chairman referred to page 18 of the plan and the reference to Double Crewed Ambulance hours and pointed out that the year on year hours was 240,000 but then it falls off to 140,000 hours and sought clarity from the CEO.  The CEO explained that this was because the new staff, relief staff etc were not factored into these numbers.  The CEO to amplify the point referred the Board to paper 6e which refers to the DCA hours each month.    The Chairman thanked the CEO for the helpful update and suggested to stop other people asking the same question there should be some narrative added to explain the point. 

The CEO confirmed that James Williams will be leading on the Winter Plan with each of the Assistant Chief Ambulance Officers responsible for their respective areas.  The CEO was confident the Winter Plan will serve the Trust, patients and public well.

The CEO will present a separate briefing on the plan to the Governors in the Autumn. In addition the CEO pointed out that the Board Assurance Statement was not required to be submitted to 30 September 2025 and on that basis asked the Board to note the content and that it would be submitted to the Board meeting on 24 September 2025 for formal sign off.

07/25/10 – The Board of Directors Terms of Reference

A report of the Governance Director / Trust Secretary and the Organisational Assurance Director which provided an update and informed the Board that a review of the Terms of Reference of the Board of Directors has been undertaken.  The report asked for the Board to review and approve the Terms of Reference of the Board of Directors.  The changes have been track changed for transparency.    In relation to the membership the Medical Director asked for reference to Staff Side attendance to be amended to show as there “will be an invite for Staff Side to attend the meeting”.   

The Governance Director / Trust Secretary pointed out that in consultation with the Chairman and CEO at least one of the Board Briefings will include a session on Basic Life Support.  The Chairman pointed out that those clinical trained members of the Board do not require this training.  We will offer the training to the non-clinical members of the Board, but this would be a voluntary drop in session not mandated.  This will take place after one of our future Board Briefing sessions. 

The Governance Director / Trust Secretary explained that in addition, to note that the members of the Board will be asked to complete a self-assessment questionnaire which will be sent separately by the Trust Secretary as part of its annual evaluation of its function and effectiveness. The intention will then be to report the returns to a Board Briefing along with the summary of the Board Committee self-assessments.

07/25/11 – Report of the Director of Finance

11a – Month 3 Finance Update

A report of the Director of Finance was submitted.

The Director of Finance gave an update and informed the Board that the Trust reported a £5M deficit (this is £5.9M deficit against a plan of £0.9M deficit).  This reported deficit is because of no planned income agreements in place for the lost hours relating to hospital handover delays.  Black Country ICB, as the Trust’s lead commissioners, are engaging with the other West Midlands ICBs to agree to the funding requirements, pending no improvement to the level of handover delays.

The forecast remains at breakeven on the assumption that the planned levels of income agreed in the plan will be forthcoming from the responsible ICBs.  The Trust and the ICB are now unfortunately at a contract dispute stage.

The capital programme will be fully delivered over the year with associated resource fully utilised. 

The Chairman asked if the HART expenditure was something new or an ongoing cost due to the expanded team. The Director of Finance explained that this was a new section additional to HART.  The staff are funded and were previously shown in E&U.  The Director of Finance will update this for the next meeting.

Mr Nat confirmed that discussions took place at the recent Finance & Performance Committee meeting. 

The Chairman asked whether given the uncertainties in terms of the contract dispute whether the Trust is still forecasting break even at year end.  The Director of Finance confirmed that was the Trust’s position. 

11b – Delegation of Approval of the Internal Audit Charter

A report of the Director of Finance was submitted.

The Director of Finance explained that the purpose of the Internal Audit Charter is to define the scope, authority, and responsibilities of the internal audit function within the Trust. It outlines how internal audit contributes to the Trust’s governance, risk management, and internal control processes. This charter ensures that internal audit provides independent and objective assurance to the Accountable Officer (or equivalent) and the Board, helping them to fulfil their responsibilities for effective management and oversight. 

It is standard practice that this charter is approved by the Board, and regularly reviewed, by the Audit Committee on behalf of the Trust.  KPMGs Charter was reviewed in the March meeting of Audit Committee and is now reported to the Board for completeness.

07/25/12 – Report of the Director of People

12a – Diversity and Inclusion Annual Report 2024/25

A report of the Director of People was submitted.

The Director of People advised the Board that the Trust has a statutory responsibility to publish an annual Equality report and demonstrate the Trust’s compliance with the Public-Sector Equality Duty (PSED).

This report provides information about the work being done and what has been achieved over the previous year including information and progress on projects such as: Equality Delivery System report and grading, The Workforce Race Equality Standard (WRES), the Disability Workforce Equality Standard (DWES) and the Gender Pay Gap data and action plans. 

The report also provides a brief on the Trust’s  performance against regulatory compliance and its commitment to promoting a culture of inclusion for patients and staff through our vision for the future.

12b – Culture Review & Sexual Safety

A report of the Director of People was submitted.

Mr Fessal explained that the report and contents of the appendices was extensively discussed at the People Committee meeting.  Mr Nat thanked the Director of people and her Team for the transparency of their work. 

The Chairman reminded Board colleagues to complete the paperwork for all ‘Days in the Life’ visit undertaken and also when out and about with Trust staff, and return to the OD department.  It is important to complete the paperwork for each visit not only as part of the assurance framework, but also to record findings and themes to be recorded.

12c – Job Evaluation Assurance

A report of the Director of People was submitted.

The report was submitted to provide assurance and oversight of the Job Evaluation scheme at WMAS in response to the letter received from NHS England.

12d – Professional Registration & Medical Revalidation Assurance

A report of the Director of People was submitted.

The Director of People informed the Board that the Trust has a duty of care to ensure that all healthcare professionals employed by the Trust or undertaking work on behalf of the Trust are appropriately registered and licensed to practice in the United Kingdom. Paramedics registration runs from 1 September of odd numbered years for a 2-year period i.e., 2021,2023. This differs from Nurses and Doctors, whose registration can run from any time during the year based on the date that they first registered. Paramedic registrants can only re-register once every 2 years.

The registration process for Paramedics will take place in 2025, with all Paramedics required to have renewed their registration prior to 1 September 2025. The Director of People said there were no risks or concerns.  The Chairman asked if we did have a paramedic who has not renewed his registration would he then change to a technician.  The Director of People confirmed that in that situation the paramedic would operate at a technician level for a 2 week period.   It was noted that staff can pay for their registration annually or quarterly.

 07/25/13 – Combined Clinical Directors Report

A report of the clinical directors was submitted.

The CEO Chief of Staff & Head of Service Transformation gave an update and informed the Board for Asssurance that to cover the Controlled Drugs Accountable Officer (CDAO) role, he underwent the CDAO training, and the CQC, Home Office and NHS England will be updated. This training took place on 23 & 24 July.

Hospital handover delays continue to impact the service delivery and contributes to delayed responses to patients in the community. The month of April did see higher numbers in delays of 35,000 hours, 30,000 in May and 28,000 in June.

PSIRF has seen 8 responses identified in June compared to 23 in June 2024 and the Trust continues to work with staff, the ICB and system partners.

There is further work to develop the themes and trends of the Trust’s Incident Reporting System (IRS).  The project work is completed and now live and is embedding well.

Due to sickness in the clinical audit department, there has been a delay in the development and implementation of the automated clinical audit process. This will be monitored and supported by the CEO Chief of Staff & Head of Service Transformation with relevant updates provided.  Clear actions have been identified going forward. 

07/25/14 – Service Delivery Report

The Chief Operating Officer submitted a report in his absence.

The CEO gave an update and informed the Board that the trust has 3.7% more E&U activity than last year.  The Cat 2 target is 28 minutes and year to date the Trust is achieving just over 21 minutes.  Call answering is the best in the Country.  In June the Trust reported seven over 2-minute delays.  Of note the highest number amongst the other ambulance services was 1,382.  Hospital handover delays are higher than the first quarter last year.  Sickness is less than 4%.  Mandatory Training for all service lines will be complete by Winter.  Clinical Supervision shifts are scheduled in.  Attrition is the lowest in the Country.  Hear & Treat is over 20%.

Mr Khan echoed the CEO’s comments and highlighted the Trust’s performance given the difficult circumstances due to handover delays.  The Trust is operating in a very challenging environment.

The Chairman acknowledged that sickness is generally good across the organisation but noted that PTS sickness was at 7% for June.   The Chairman asked if this was being reviewed.  The CEO reported that generally PTS does have higher sickness than other areas, but the Non-Emergency Services Delivery Director was monitoring the position. 

The CEO wished to thank CQC colleagues for their support regarding the hospital handover delays and the impact this was having on patients.

07/25/15 – Report of the Strategy and Engagement Director

15a – Departmental Annual Reports 2024/25

The Strategy & Engagement Director explained as colleagues are aware a number of annual reports were submitted to the Board in May for approval.  The remaining annual reports are submitted today for approval by the Board.  Mrs Banks advised the Board that her QGC report also highlights these reports for approval. 

07/25/16 – Board Committee Reports and Minutes

16a – Audit Committee

The Chairs report on the meetings held on 3 & 23 June and 22 July 2025 was submitted along with the minutes of the meeting held on 3 June 2025 and the extraordinary meeting held on 23 June 2025.

Mr Nat explained that at the meeting on 23 June a very comprehensive “page turning” of the accounts took place. 

KPMG provided a comprehensive report on 3 June on the deep dive into the cyber security assessment framework. 

16b – People Committee

The report of the Chair of the meeting held on 2 June 2025 was submitted along with the minutes of the meeting held on 7 April 2025.

Mr Fessal advised the Board that it is important as previously highlighted by the Chairman to record the ‘day in a Life’ visits.  Equally for those visits that have been recorded, there is little information captured to support both direct learning and triangulation of information with other sources of data.  The voices of frontline staff are hugely valuable, and the members of the Board need to review how we can improve the work by senior leaders in this area.

The staff engagement survey results showed continued negative feedback on relationships with management. There has been a request for data on direct reports for each OM/SOM across the organisation to understand if there is any correlation with capacity.

The uptake of annual exit reviews is promising with 25% completion rate. The top 3 reasons for leaving are lack of opportunities, relocation, and work / life balance. There is a theme of people feeling a lack of compassion and support from managers. Some of this information triangulates with similar findings in surveys.

Engaging Leaders programme has ended with an evaluation being undertaken. This will be presented at the next Peoples Committee.  The Ofsted visit went very well.   Growth in disability and BAME workforce numbers is welcomed, however the 2% BAME annual target is unrealistic. Suggestions of an in-year recruitment target of approximately 20% is potentially a better ambition.

16c – Finance & Performance Committee

The Chairs report on the meeting held on 21 July 2025 was submitted along with the minutes of the meeting held on 22 May 2025.

Mr Khan explained that a lot of what is contained within the report has already been covered during the meeting today.   

16d – Quality Governance Committee (QGC)

The Chairs report of the meeting held on 23 July 2025 was submitted along with the minutes of the meeting held on 21 May 2025.

Mrs Banks gave an update and informed the Board that the Chief of Staff has covered a lot of the issues raised at the meeting already.  The risks from the previous meeting were reviewed.   Discussions took place regarding the IT team capacity and the risk to the information governance plan if we do not appoint an IG Manager.  Discussion also took place regarding the safeguarding team due to their capacity and workload.  Updates will be submitted back to the QGC.  The treatment of patients in the rear of ambulances was also raised and noted that it is to be made clear that paramedics are not to go beyond their scope of practice.  There has been an increase in verbal abuse of staff working in EOC and corporate functions. 

Mrs Banks explained that concern was raised about the internal culture in the ambulance service, but this was mainly due to external pressure on the Trust.  Restriction on overtime would impact on completion of investigations but this will be monitored. 

FTSU champions would benefit from more time being able to speak to staff.  Anonymous / confidential FTSU concerns would benefit from discussions with Luch Butler or Pippa Wall. 

An update on the CIP was received at the meeting and we felt a lot more assured.  The report submitted was very comprehensive.  Rob Till attended for the first time and gave an update on his work stream.  The Chief of Staff gave an update on the controlled drugs accountable officer in the absence of the Paramedic Practice & Patient Safety Director. 

Mrs Banks pointed out that with some Trust strategies merging the committee felt these need to be defined with clear timeframes and who is leading on these.  The Maternity Action Plan is going forward.  It was positive to note that in 95% of cases we are meeting the Duty of Candour (a legal and ethical obligation for healthcare providers to be open and honest with patients and their families when something has gone wrong with their care).

Mr Fessal pointed out that AI is important and he had raised a couple of areas the Trust could start looking at.  It is good to see the trust has started work on this.  Mr Khan reminded the Board that there are regulations that should be risk assessed by the Trust. The Chairman indicated that opportunities and risks of AI will be a subject that the Board will return to at its forthcoming strategy development discussions on 1 September 2025. 

The Chairman advised the Board that during a 1-1 with the Medical Director the day before the issue of engagement with GPs needed to be considered as to the correct process on how the Trust triages patients.    

07/25/20 – Board of Directors Schedule of Business

The Schedule of Business was submitted.

07/25/21 – Any Other Business

There was no other business.

07/25/22 – The Date of the Next Meeting

Wednesday 24^th September 2025.

The strategy discussion session is scheduled for Monday 1 September 2025 at Sandwell Hub.

There being no other business for this meeting, the Chairman brought proceedings to a close and thanked members for their attendance.