Present
- Prof. I Cumming – Non-Executive Director (Chairman) and voting member
- Mr AC Marsh – Chief Executive Officer and voting member
- Prof. A Hopkins – Non-Executive Director (Deputy Chair)
- 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 N. Henry – Paramedic Practice & Patient Safety Director
- Mr N Hudson – Chief Operating Officer and voting member
- Mrs J Jasper – 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
- Ms D. Scott – Interim Organisational Assurance Director
- Mr P. Higgins – Governance Director and Trust Secretary
- Ms K Freeman – Private Secretary, Office of the Chief Executive
- Ms R Farrington – Staff Side Representative
- Ms K Molland – People Promise Manager
- Mr J Mullan – Stoke Development Operations Manager
- Mr I Sidhu – Governor
- Mrs E Cox – Lead Governor
- Mrs P Wall – Head of Strategic Planning / FTSU Guardian
- Mrs L Butler – FTSU Guardian
- Mr A Williams – Member of the Public
Minutes
03/25/01 – Welcome and Apologies
Apologies for absence were received from Mr Mohammed Fessal.
The Chairman welcomed everyone to the meeting.
03/25/02 – Declarations of Interest
There were no conflicts of interest declared by anyone attending the meeting in relation to any matters on the agenda.
03/25/03 – Questions from the Public
There were no questions.
03/25/04 – Board Minutes
To agree the minutes of the meeting of the Board of Directors held on 29 January 2025.
Resolved:
That the minutes of the meeting of the Board of Directors held 29 December 2025 be approved as a correct record.
03/25/05 – 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
10/25/12 (a) Board Skills Matrix
The Skills Matrix was attached to the Action Log for final approval.
The Director of People advised the Board that an additional item has now been included for the Medical Director regarding Equality & Diversity.
Resolved:
The Board received and approved for publication of the Board Skills Matrix as submitted.
On this basis the Board agreed that this item could be discharged. (Discharged)
03/25/06 – Board Assurance Framework (BAF)
The Board Assurance Framework was submitted
The Director of Nursing advised the Board that the BAF has had no changes since the January submission. An updated BAF will be submitted to the Executive Management Board (EMB) on 1 April prior to submission to the next Board meeting.
Resolved:
That the report be received and noted
03/25/07 – Chief Executive Officer (CEO) Update
A report of the Chief Executive Officer was submitted.
The CEO advised the Board that regarding the NHS England (NHSE) reset His Majety’s Government has announced that the NHSE is to be abolished and merged with the Department of Health & Social Care (DHSC). There has also been notification that there will be a 50% reduction in ICB running costs and 50% reduction in corporate cost growth. Given that this is an evolving situation further updates will be submitted to the Board of Directors as the details crystalizes especially any impact on this Trust.
Resolved:
That the report be received and noted.
03/25/08 – Executive Scorecard & ICS Scorecard relating to Performance for the Month of January and February 2025
The Executive Scorecard of Key Performance Indicators (KPIs) for the month of January & February 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.
Resolved:
That the Scorecards be received and noted.
03/25/09 – Planning Guidance Priorities 2025/26
A report of the CEO was submitted.
The CEO informed the Board that the paper submitted has been superseded by the recently announced changes to the NHSE leadership and the announcement by HM Government in relation to the NHSE. The Trust is continuing to monitor and apply the action plan developed and attached to the report now submitted. The Assistant Chief Ambulance Officers and CEO are meeting on 31 March to further review the action plan, and the action plan will continue to be reviewed and submitted periodically to the Board.
Mrs Jasper stated to reassure the Board members that the action plan has had more detailed scrutiny at the Finance & Performance Committee meetings.
Resolved:
That the report be received and noted.
03/25/10 – Report of the Freedom to Speak Up (FTSU) Guardian
A report of the FTSU Guardian was submitted
Mrs Wall gave an update and informed the Board that this is the six-month cyclical update to the Board. The Annual Report will be produced for submission to the next Board meeting.
Mrs Wall advised the Board that on page 4 of the report there is a mis match between the columns and data and asked the Board to note these, which are presentational issues. Mrs Wall has updated the report and will circulate an updated report to Board Members.
Mrs Wall informed the Board of a data breach incident which occurred in November 2024 and detailed in the report, the breach was internal to WMAS. The Information Governance Team had stated that the breach was not reportable to the Information Commissioners Office and the action plan as a result has been implemented, which included exercising our duty of candour and reporting the breach internally to key committees, executive directors amongst several others.
Mr Khan sought clarity in relation to the table on page 4 which showed higher reporting at some sites and how does the FTSU Guardian respond to this data. Mrs Wall explained that they review the complaints to see if there is any correlation or trends that link the complaints and may identify an underlying issue that needs to be looked at in detail. reporting was related to the concerns at each site related. Mainly the concerns reported here are small and isolated and not related but that didn’t mean that they were not reviewed and progressed as normal. Mrs Wall explained that if they are a collection of related concerns then we ensure the Director and Senior Operations Managers are aware and also the Chairman, CEO ad the NED FTSU Lead receive a quarterly update on the complaints received. The Strategy & Engagement Director also pointed out that some sites are proportionately larger than others which can also skew the numbers. Mr Khan thanked the FTSU Guardian for the clarity and it gave reassurance to the Board that these
Mrs Butler highlighted the salient indicators set out in the report. Based on the data the FTSU Guardian was specifically looking at how to encourage staff reports with confidence rather than anonymously. Mrs Wall explained that they receive very few feedback forms and will be focusing on promoting these going forward as they are useful reflection documents. Mrs Wall said there has been low reporting of detriment and wants to ensure we are following best practice and there is a need to differentiate in definitions of detriment and this is being reviewed based on the published best practice. In conclusion spoke about FTSU also having a positive element where the positive actions of staff are also reported and the Team would like to develop this positive use of FTSU in raising its profile. The Strategy & Engagement Director reminded colleagues of the ongoing need for Board to receive FTSU awareness training and he would liaise with the Secretary to run this on a Board Briefing day.
Resolved:
That the report be received and noted.
That Mrs Wall will circulate an updated table with the correct information on page 4.
03/25/11 – Report of the Director of Finance
11a – Policy and Procedure Update
A report of the Director of Finance was submitted.
There has been a significant amount of work undertaken to ensure an improved position on the report submitted to the meeting of the Board in January 2025. Further report will be in six months of this meeting.
Resolved:
That the report be received and noted
An update will be submitted to the Board in 6 months. The Governance Director & Trust Secretary will add this to the schedule of business and include in the Action Log.
11b – 2025/26 Opening Budget (including CIP)
A report of the Director of Finance was submitted.
The Director of Finance gave an update and advised the Board that the paper sets out the 2025/26 Opening Budget for approval by the Board of Directors.
The opening budget triangulates with the Trust’s Workforce Plan and the Performance Plan for 2025/26. It is predicated on:
- lost hours due to handover delays of 370,000.
- National growth funding to be received in full.
- A CIP target of £19.8M which includes an element of non-recurring from 2024/25.
- £6.9M schemes are fully or well developed.
- A further £13M of opportunities to be identified.
The Chairman pointed out that there have been numerous discussions at Board level on the details behind this budget that is presented today, including scrutiny in the Board Committees.
The Chairman asked for clarity on securing additional income in respect of lost hours (£22.9M) and whether this is now secured or was it a risk. The Director of Finance informed the Board that this item is rated as red as the Black Country ICB is the lead but given the geographical footprint of the Trust there must be concurrence with other ICBs in the region. The Director of Finance explained that the Black Country ICB have signed up to our Plan. The regional NHSE is aware of the position. However, if the funding is not received, then there will be in deficit, and we have been clear about this with partner organisations.
The Chairman pointed out that we are also predicting what the number of lost hours will be for this year. The CEO agreed with what has been said but pointed out we have been clear we still have a CQC Improvement Notice in relation to patient safety as a result of the ongoing handover delays. The Board has previously and consistently stated that such a notice cannot be ignored due to the impact on patient safety. Mr Khan supported what the CEO had said as a Board it had supported the CEO when it took the decision regarding the CQC Notice and put an improvement action plan in place which required the investment of significant resources. The Board agreed that it had been a challenging period and in particular the impact on patient safety.
Resolved:
That the report be received and noted.
That approval be given to the 25/26 opening budget as set out in the report submitted to enable the Trust to continue to operate within an approved financial plan.
At the request of the Director of Finance, the Board agreed to bring forward the Capital Plan to the next item of Business.
11c – Capital Plan 2025/26
A report of the Director of Finance was submitted.
The Director of Finance reported that the 2025/26 the capital plan has been compiled from the 2025/26 element of the 10-year plan which was submitted to Black Country ICB earlier in the year. Capital allocations have now been confirmed by the Black Country ICB and NHS England (pending DHSC approval).
As approved at the November and December Board meetings, orders have been placed for the DCA fleet replacement including conversions to ensure delivery is possible in the 2025/26 financial year and that the capital allocation is used effectively. The Director of Finance explained that the Black Country ICB received notification on the previous day of a £6M reduction in capital. The Director of Finance confirmed if an element of this is passed to the Trust, we will manage this over the year.
Resolved:
That the report be received and noted.
That approval be given to the 25/26 Capital Plan as detailed in the submitted report
11d – E&S Workforce Planning 2025/26
A report of the Director of People was submitted.
The Director of People gave an update and informed the Board that the plan is predicated on 370,000 lost hours, forecast workforce attrition of -216 WTE and forecast training and abstractions throughout 2025/26. On this basis 35 Student Paramedics and 84 Graduate Paramedics are proposed to be recruited as part of the 2025/26 E&U workforce and recruitment plan to mitigate the above factors and proactively manage attrition. This budgeted establishment has been reflected and built into the financial plan for 2025/26. Regular workforce planning monitoring will continue throughout the year as we have done effectively in previous years and any adjustments made to reflect forecast v’s actual positions and / or changes in demand activity and hospital handover delays to remain within budgetary control.
Anything under the establishment of 4,155 WTE will be offset through the utilisation of planned overtime which has been factored into the modelling and can be operationalised as and when required to cover shortfalls in operational shifts, enabling the Trust the flexibility should any significant deviations occur to the forecasted assumptions whilst remaining within the overall financial enveloped allocated.
The E&U Recruitment Plan for 2025/26 has been built ensuring there is sufficient resilience in the recruitment and selection arrangements for a candidate pool to be created, enabling a rapid response through “draw down” from pre-selected candidates when vacancies occur. Similarly, the way in which the recruitment plan is designed, allows cohort sizes to be reduced, increased and / or turned on or off as and when required throughout the year.
The Board of Directors approved the Workforce Plan for 2025/26.
Resolved:
That the report be received and noted.
That the Board of Directors approved the Workforce Plan for 2025/26
11e – Training Days Analysis (TDA) & Training Needs Analysis (TNA) 2025/26
A report of the Director of People was submitted.
The Director of People gave an update and explained that the paper provides the Board with an overview of the operational workforce training requirements for 2025/26. The Training Days Analysis for E&U operations in 2025/26 year is attached at appendix 5. This details the number of training days required and planned to be delivered resulting in an abstraction from operational deployment and availability. E&U staff will receive two days training and PTS Staff one day’s training.
The statutory and mandatory training updates for E&U and NEPTS for 2025/26 will commence in April 2025 and for E&U operational staff will be concluded by the first part of Q3.
The Board of Directors approved the TDA and TNA for 2025/26.
Resolved:
That the report be received and noted.
That the Board of Directors approved the TDA and TNA for 2025/26
11f – Going Concern Statement
A report of the Director of Finance was submitted.
The Director of Finance gave an update and explained that the Audit Committee had reviewed the contents and was recommending that it is appropriate to prepare the Trust’s 2024/25 accounts on a Going Concern basis.
It was explained that NHS organisations are required to prepare their annual financial statements in accordance with international financial reporting standards (IFRS) which require preparation on a going concern basis unless management either intends to liquidate the entity or to cease trading or has no realistic alternative but to do so.
For public sector bodies, such as NHS bodies, this means focusing on whether the services provided by the entity are going to be continued rather than whether the entity providing the service will continue to exist.
NHS foundation trusts were intended to operate on a similar basis to commercial organisations, so they must operate effectively, efficiently, and economically and remain a going concern.
Preparing statements on a ‘Going Concern’ basis means that there is a reasonable expectation that the Trust has adequate resources to continue in operational existence for the foreseeable future with no necessity or plans either to liquidate or cease operations.
Mrs Jasper confirmed that discussion had taken place at the Audit Committee recently with the Auditors who agreed with the decision to continue as a ‘Going Concern’.
Resolved:
That the report be received and noted.
That approval be given to the 2024/25 financial statements being prepared on a Going Concern basis
11g – Month 11 Financial Position
There was a presentation from the Director of Finance submitted
Resolved:
That the presentation submitted be received and noted.
11h – Delegation of Authority to Audit Committee to Approve the 2024/25 Annual Report and Accounts
A report of the Director of Finance was submitted.
The Director of Finance gave an update and explained that the Audited financial statements for the financial year 2024/25, along with the Annual Report, are required to be approved by the Board and submitted by the published deadline of 30 June 2025. The Board was requested to confirm the delegated authority to the Audit Committee to approve the Annual Report and year-end financial statements along with the requisite audit opinions. To this end an additional Audit Committee has been convened on 13 June 2025 in order that the appropriate scrutiny can be applied and that the audited statements can be submitted in line with NHSE filing deadlines.
The end of year accounts preparation timetable also includes a session for the Non-Executive Board members to review the accounts during the audit period to aid the final approval process.
Resolved:
That the report be received and noted
That approval be given to the delegation of authority to the Audit Committee in relation to the approval of the 2024/25 Annual Report and Accounts as set out in the report now submitted.
11i – Update to the SFIs / SoD
A report of the Director of Finance was submitted.
The Director of Finance gave an update and explained that SFIs are designed to maintain propriety in terms of financial transactions by the Trust. SFIs define the purpose, responsibilities, legal framework and operating environment of this Trust. SFIs should be read together with the Standing Orders (Sos) and Scheme of Delegation (SoD) which form part of this update.
Amendments recommended by Internal Audit following internal risk based review findings include:
- Detailing approvers and approval limits for those transactions which fall within the Fleetwave and Orderwise systems. These have been included in the Scheme of Delegation; and
- Specific inclusion of the authority to approve overtime shifts – this has been added to Section 9.4 of the SFIs and included in the Scheme of Delegation.
Following its review, the Audit Committee have recommended approval to the Board.
Resolved:
That the report be received and noted
That approval be given to the amendments to the Standing Financial Instructions and Scheme of Delegation following Audit Committee recommendation as set out in the report submitted
03/25/12 –Reports of the Director of People
12a – Gender Pay Gap 2023/24
A report of the Director of People was submitted.
The Director of People explained that the gender pay gap is the difference between the average earnings of men and women, expressed relative to men’s earnings, while equal pay is about men and women being paid the same for the same work. There is a requirement to publish the data on the Trust’s public-facing website by 31 March 2025. As the national reporting deadline is the end of March each financial year (e.g., 31 March 2025) for the previous year’s data (e.g., 1 April 2023 to 31 March 2024), the Trust proposes to produce the 2024/25 data report much earlier than required in May 2025. Subsequently both the 2023/24 and 2024/25 data will be reviewed collectively this year to consider the most up to date and relevant data to inform our interventions and actions required to address any further pay inequality. This will align the in-year action plan to the most recent position and data available.
The action plan will be developed to further address gaps identified in consultation with the members of Diversity and Inclusion Steering and Advisory Group and the Women’s network.
For the purposes of good governance and transparency, the Governance Director & Trust Secretary said that the wrong report was initially loaded onto the Board App and the correct report had now been uploaded. This meant that as the report does not need to be published until 31 March 2025 if colleagues have any comments, please forward these to the Director of People by close of play on 30 March 2025. We can then report the action taken at the next Board meeting.
Mr Nat pointed out that the report is very transparent and asked if we need the full details regarding the bonus gender gap or would a statement not suffice. The Director of People explained that the content is mandated but she was happy to review this.
Resolved:
That Gender Pay Gap Report for 2024 was received and noted
That the Board approved the report for submission of national reporting to the relevant regulator and publishing on the Trust’s public facing internet by 31 March 2025
12b – 2024 Staff Survey Results Action Plan
A report of the Director of People was submitted.
The Director of People gave an update and explained that the paper provides Board members with an insight into the 2024 NHS staff survey results and the actions that are in place. The information in this report has been extracted from the initial reports provided by the staff survey contractor Picker Europe Ltd and the final benchmark reports provided by the Staff Survey Coordination Centre. This report is for information only. There is no action required from Board members.
The initial results and findings were shared with the Executive Management Board (EMB) on 21 January. Findings were discussed at the People Voice Action Group (PVAG) Meeting on 30 January. Results and findings were presented to People Committee (PC) on 10 February. A task and finish group from PVAG met on 10 February to create a Trust Action Plan and this was presented to EMB on 4 March.
The staff survey was open from 16 September to 29 November 2024. 6,922 staff were invited to take part in the 2024 staff survey and 4,698 staff returned a completed survey compared to 2,661 in 2023. The response rate for WMAS is 68% compared to 40% in the 2023 survey. This is the highest response rate that the Trust has ever achieved. The average response rate for similar organisations is 55%. There was a significant increase in the number of BAME staff responding to the survey on this occasion. 357 BAME staff returned the questionnaire in 2024, compared to 147 in the 2023 staff survey. This report highlights some of the key findings and themes and provides an overview of the actions in place. A dashboard has been developed which is much more interactive.
The Director of People said the Trust Wide Action Plan was attached to the report submitted. In addition, there are local action plans which will be developed by the end of May. All work is monitored through the People Committee. The Director of People said it is planned that a couple the Staff Survey leads will attend a Board meeting later in the year.
Mr Khan congratulated the Director of People as the report shows much more engagement with a lot of detail. There were though areas of concern the Board must acknowledge and asked how we ensure we are making inroads into these concerns. The Trust is operating in a challenging environment with a lot of changes places a lot of pressure on staff and that it is pleasing to hear that the Board will receive feedback and also the relevant Committee will monitor the implementation of the action plan. How do we make sure we are making inroads into some of the areas of concerns such as leadership & management where there are lots of red boxes how do we as an organization address these.
The Director of People pointed out that the local action plans are important in addressing the concerns as the results can vary between areas and local support and guidance can be applied. Some sites vary in size, so there is a difference in culture between a large site with 500 people as opposed to a smaller site with less people. Hence concentrating on local areas can allow the Trust to get into the detail that underpins the results.
Mrs Jasper pointed out that there are actions due for completion in August and suggested that an update to the Board in September may be helpful to monitor progress as well as receiving any detailed assurance via the People Committee. The Chairman agreed and suggested having an update at a future development session to enable time to drill down on this more. Mrs Banks agreed and said the increase to 68% is important as this provides much more rich information for the Trust to work on.
Resolved:
That the report be received and noted.
That an update would be scheduled for a development session later in the year.
03/25/13 – Combined Clinical Directors Quality Report
The report Clinical Directors report was submitted following the review of the contents at the recent meeting of the Quality Governance Committee was as submitted.
The Paramedic Practice & Patient Safety Director gave an update and advised the Board that hospital handover delays continue to be the highest risk for the Trust on the BAF. The consequential impact on patient harm also increases the workload on the Patient Safety Team. The capacity within the Team has created some delays but work has been done to mitigate this. There are 86 incident reports that have breached the 3 months’ timeframe. To note the commencement of the new incident reporting system from 1 April will increased the workload on the Team using both systems for 6 months or until all ER54’s are closed.
PSIRF has seen 171 responses identified year to date and the Trust continues to work with staff, the ICB and system partners. Patient Safety Serious Incidents timelines and recommendations are within timelines. There remains only 1 open SI, and plans in place to close in March. The Medical Director re-emphasised that handover delays is not just a performance issue it is a patient safety issue, and we must ensue wider engagement with the acute trusts to address the harm that is created by handover delays outside of acutes.
Resolved:
That the report be received and noted
03/25/14 – Service Delivery Report
The Chief Operating Officer gave an update and advised the Board that PTS is on track to complete all training by the end of March. There has been an improvement in KPIs.
Call answering remains strong. There were 3 over 2 minute delays answering 999 calls during February 2025. YTD is 303. Hear & Treat is 21.4%. Category 2 mean performance is now under 30 minutes YTD and we achieved a mean of 29:41 within February 2025. We hope to continue to improve on this before year end. It was welcomed to see a reduction in hospital handover delays in February 2025, from the highest ever volume of lost hours seen to handover delays in December. In December, the trust lost 53,219 hours in December alone, which has reduced to 33,034 in February and is subsequently reflected in our improved performance. However, losing 33,000 hours was the highest February on record. All mandatory training and PDRs for 2023/24 has been completed. The Chief Operating Officer said despite the challenging year we have saved more lives.
The Chairman thanked the Chief Operating Officer and his Teams for everything that do daily it is quite remarkable. Mr Khan agreed and pointed out that the actions put in place to achieve Cat 2 sub 30 minutes whilst still dealing with hospital handover delays was remarkable. At the Finance & Performance Committee we keep coming back to the impact on patients of the clinical outcome of the handover delays.
The CEO reminded colleagues of the difficult discussions one year ago and since then the Trust has had the best 999 call answering in the Country, 380,000 lost hours but still achieved Cat 2 of 29 minutes. Best hear & treat in the Country. We provide very comprehensive training. The Trust has delivered what it said it would deliver now we are waiting for our external partners to deliver what they said they would.
Resolved:
That the report from the Director of the Chief Operating Officer be received and noted.
03/25/15 – Board Committee Reports & Minutes
15a – Quality Governance Committee (QGC)
The Chairs report of the meeting held on 19 March 2025 was submitted along with the minutes of the meeting held on 22 January 2025.
Resolved:
That the Chairs report of the QGC meeting held on 19 March 2025 be received and noted.
That the minutes of the QGC meeting held 22 January 2025 be received and noted.
15b – Performance Committee
The Chairs report on the meeting held on 25 February 2025 was submitted along with the minutes of the meeting held on 28 January 2025
Resolved:
That the Chairs report on the meeting held on 25 February 2025 be received and noted.
That the minutes of the Audit Committee meeting held 28 January 2025 be received and noted.
15c – People Committee
The report of the Chair of the meeting held on 10 February 2025 was submitted along with the minutes of the meeting held on 11 November 2024.
Resolved:
That the report of the Chair on the meeting held on 10 February 2025 be received and noted.
That the minuets of the meeting held on 11 November 2024 be received and noted.
15d – Audit Committee
The report of the Chair of the meeting held on 18 March 2025 was submitted along with the Minutes of the meeting held on 21 January 2025.
Resolved:
That the report of the Chair on the meeting held on 18 March 2025 be received and noted.
That the Minutes of the meeting held on 21 January 2025 be received and noted.
03/25/16 – Board of Directors Schedule of Business
The Schedule of Business was submitted.
Resolved
That the Board Schedule of Business be received and noted.
03/25/17 – Any Other Business – H&S Training
The Governance Director / Trust Secretary informed the Board that the Chairman and CEO had agreed to hold this training session on the role and obligations of the Board and directors after the Board Meeting on 28 May 2025.
03/25/18 – The Date of the Next Meeting
Wednesday 28 May 2025
New or Increased Risks highlighted as follows:
- Hospital handover delays and the continuing impact on patient harm.
- Continuing delay in 45-minute maximum handover implementation.
- NHSE and corporate costs announcement and await details
- Clinical Audit remains an issue
- 86 incident reports breached the three-months timeframe.
There being no other business for this meeting, the Chairman brought proceedings to a close and thanked members for their attendance.