WMAS Board Meeting Minutes – Wednesday 28th May 2025

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 M Fessal – Non-Executive Director 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
• 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
• Ms R Farrington – Staff Side Representative
• Mrs P Wall – Head of Strategic Planning / FTSU Guardian
• Mrs L Butler – FTSU Guardian
• Mr I Syme – Member of the Public

Minutes

05/25/01 – Welcome, Apologies and Chairman’s Matters

Apologies for absence were received from Ms Diane Scott.

The Chairman welcomed everyone to the meeting.

05/25/02 – Declarations of Interest

There were no conflicts of interest declared by anyone attending the meeting in relation to any matters on the agenda. The Chairman reminded Board Members to please ensure their entry is correct as it will be posted on the website. 

05/25/03 – Questions from the Public

There were no questions.

05/25/04 – Board Minutes

To agree the minutes of the meeting of the Board of Directors held on 26 March 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).

05/25/06 – Board Assurance Framework (BAF)

The Board Assurance Framework was submitted

The Director of Nursing advised the Board that all Strategic Risks have been reviewed.  SR3 and SR4 – Culture Review of Ambulance Trusts has also been included in this review along with the gap analysis. 

The Trust remains on REAP status 2, which has been consistent throughout April and the start of May. The Director of Nursing pointed out that from January – May 2025 none of the risk scores have changed although we do have target scores set for after mitigation. 

The Chairman sought clarity in relation to Strategic Risk 6 Cyber Security.  The Director of Nursing responded that the Trust have mitigation in place, but clearly it is impossible to give complete assurance that an attack will not get through, but the fact it is on our BAF demonstrates that the Trust has assessed risk and put the mitigation in place which includes testing the Trust’s resilience to such an event.  The Director of Finance explained that the Trust has everything in place that we can to mitigate against an attack.  Mrs Jasper advised the Board that the Audit Committee receives updates from the internal auditors and has asked for a cyber terrorism awareness workshop and the role of the Board later in the year.

The Director of Nursing suggested that a review the risks is timely.    The Medical Director said it was right to have the target scores with mitigation included but pointed out it is not always possible to reduce the underlying risk.  Mr Fessal said generally if there is no change in the risks and controls the score remains unchanged and the gaps identified would remain.  It would be helpful to understand what we are doing with the gaps in control themselves.  Perhaps we could have an update on the gaps in control.  The Chairman suggested this be picked up at a future Board development session.

 Resolved:

1. That the report be received and noted
2. That the Board approved the Board Assurance Framwork
3. That the Board Secretary schedule a review of the BAF and the Risk Appetite to take place at a Board Briefing session later this year

05/25/07 – Chief Executive Officer (CEO) Update

A report of the Chief Executive Officer was submitted.

05/25/08 – Executive Scorecard & ICS Scorecard relating to Performance for the Month of March 2025

The Executive Scorecard of Key Performance Indicators (KPIs) for the month of March 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.  

05/25/09 – Winter Plan

The Winter Plan was submitted

The CEO gave an update and informed the Board of Directors that this Plan builds on the Winter Plan submitted earlier this year.  Last year the Winter Plan served us well during a challenging period.  However, a review of the implementation of the plan last year has been undertaken and this plan has been developed based on that learning. 

Mrs. Jasper said receiving the draft plan in May well before the Winter period was a great idea to assist with planning and asked how it fits into the ICB’s overall planning. The Strategy & Engagement Director explained that at some point during the year the ICB will ask all organisations to share their plans.  We have already informed colleagues that we are working on our plan.  The Chairman referred to page 18 and the year on year comparisons of DCA hours.  The Chief Operating Officer explained that this table is only shows baseline hours.  It does not include overtime, relief etc.  The Chairman asked for this element to be reviewed and updated prior to sharing externally.  The Director of Nursing asked if we could start the QIA for the contingency arrangements now and the CEO agreed.  The CEO confirmed the plan would be reviewed and updated where necessary when the national guidance is issued and submitted back to the Board.

05/25/10 – The Green Plan

The report of the Director of Finance was submitted.

The Director of Finance informed the Board that NHS England have asked for all Trusts to submit a Board approved revised Green Plan by 31 July 2025. This plan sets out the Trust’s work over the next 5 years as part of the NET zero plan of the NHS.  The Director of Finance explained that as a Trust we are limited by our capital allocations for some of the requirements we would need to have in place and an example of this is the development and building of electric vehicles. 

Professor Hopkins referred to proposals to increase the use of AI and whether this would also have an impact on our carbon footprint as the NHS moved to a much more digital strategy.

The Director of Finance said that the strategy would be updated to reflect changes to NHS planning to cover it.  The Medical Director informed the Board that IA has already come up in some of the Clinical Groups.  This is certainly coming our way we need to look at where it can help us.  Our Research Team are looking at this. 

The Chairman asked about the financial consequence of fuel being burned whilst vehicles are kept running outside of hospitals with patients on board and whether this should be included in this plan.  The Director of Finance pointed out that it is the cost of fuel, and also the impact on the environment and of course the vehicles kept outside hospitals are unable to respond to patients so there costs as well as patient and environmental impact of handover delays.  The Chairman pointed out that there are other parts of the NHS that could significantly improve our performance if Trusts achieved the 45 minute handover.   The Chairman asked for the concerns and impact of handover delays to be added into the plan. 

05/25/11 – Report of the Communications Director – Press and Communications Annual Report

A report of the Communications Director was submitted.

The Communications Director gave an update and informed the Board that while not as busy as 2023/24, the team continue to deal with hundreds of media enquiries.  Media organisations continue to use social media as their primary source of information which can lead to misinterpretations of what might have happened.  The Director of Communications said it has been a very good year with a great team, and he wanted express his appreciation for their hard work. 

We continue to have a very substantial presence in social media compared to other NHS organisations.  The social media enables the Trust to engage with the public, particularly communities that we might otherwise struggle to reach, but also for getting messages to our staff; we know that many follow our social media accounts.

Mrs Jasper asked about the viewing number for the weekly briefing magazine and pointed out that the number of views seemed high.  Mrs Jasper sought clarity on what the Trust understood about the number of viewing whether there was any duplication. The Director of Communications said that the viewing numbers were good but there were still staff who just do not read it even though it is a valuable source of information. 

Mr Nat asked whether more could be done to highlight to the public the location of defibrillators and also whether there could be more information on prevention. The Director of Communications explained that the project was working with a range of stakeholders on a campaign to identify and advertise the location of defibrillators that could be added to the National Defibrillator Database. The Director of Communications indicated that the Trust does do a lot on prevention and will continue to work with partners using the data available to highlight messages on prevention as well as defibrillator locations.

The Chairman thanked the Communications Director and his Team, for all the work undertaken both proactive and reactive.

05/25/11 – Fit and Proper Persons Annual Assurance 2025/26

A report of the Director of People was submitted.

The Director of People advised the Board that since 27 November 2014, NHS provider organisations have been required to meet regulatory requirements, in particular to ensure that new director level appointments meet the ‘fit and proper persons test’ which were integrated into the CQC registration requirements.  These requirements fall within the CQC regulatory and inspection approach and are reviewed under the ‘well-led’ domain.  The Trust have reported compliance with this framework since its inception and have an agreed process as documented in the Recruitment and Selection Policy.

Based on the regulations which came into effect in September 2023, all individuals holding posts as deemed applicable by the Trust as set out in the report have had checks completed. Each individual has completed an annual Self Attestation form to declare their suitability for post.  As per the regulations, the Chair has reviewed all the documentation for each post holder and the Senior Independent Director has reviewed the Chair’s documentation.

The completed declarations and the outcome of the searches have been saved on each personal file, updated on the Electronic Staff Record (ESR) and will be reviewed again annually. The findings of the review, on approval by the Board of Directors will be submitted to the NHS England Regional Director for review as per the national guidance.

The Appendix 1 to the report confirms that all current and newly appointed Directors (both permanent and interim) of the Board satisfy the requirements the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Fit and Proper Persons Test amended September 2023. Each Director is responsible for identifying any issues which may affect their ability to meet the statutory requirements and bringing these issues on an ongoing basis and without delay to the attention of the Director of People or Trust Chair.

The Board approved the annual Fit and Proper Persons Test (2024/25) for submission to NHS England.

05/25/11 – Report of the Director of Finance

13a Finance Update

The Director of Finance gave an update and informed the Board that full reporting does not take place for Month 1 as most organisations are in the process of closing the prior financial year in the same period.  However, at Month 1 the Trust has an in month reported deficit of c£200k against a plan deficit of £300k.  The forecast year end position is breakeven as per the plan.  The Trust’s CIP delivery is at a very early stage but is expected to deliver the target required across the financial year. Capital resources used in the first month is minimal but there is a full plan in place for the financial year.  The Better Payment Practice Code results continue to deliver above the required standards.

In relation to 2024/25 the draft accounts and annual report were submitted as per the deadline dates of 25 April 2025 and 6 May 2025, respectively.  External Audit are now undertaking the year end assurance work. Following the period of audit, the statements audited are due to be submitted by 30 June 2025.

Mrs Jasper said it was good that the Director of Finance has submitted a Month 1 report as most organisations do not report against month 1 movement.  Mrs Jasper took the opportunity to remind colleagues that the detailed review of the annual report and accounts was taking place during the following week. 

Mr Khan stated that the Finance & Performance Committee received a full update on finance at its recent meeting where there had been detailed discussion.  Mr Nat confirmed the discussion at the Finance & Performance Committee.

13b Security Management Strategy

The Strategy was submitted.

The Director of Finance gave an update and advised the Board that the processes outlined in the Security Management Strategy support the Trust’s values and behaviours of openness, collaboration, compassion, accountability, and continuous improvement. Incident reporting, regular risk assessments, and robust investigation procedures foster transparency and learning. The use of tools such as CCTV and body-worn cameras promotes safety and accountability, while collaboration with internal teams and external partners demonstrates our commitment to working together. Ongoing staff training and engagement empower individuals, encourage responsibility, and ensure that security practices align with the Trust’s culture. The Strategy was reviewed by EMB on 13 May 2025 and approved, subject to Board approval.

The Director of Finance explained that during its life we will expand the Strategy to ensure it remains relevant and concurrent.   Mrs Banks supported the content and indicated that the Head of Security submits helpful  and detailed quality assurance reports to the QGC.  Mrs Banks asked who was the lead NED for Health, safety & Risk.  This was confirmed as Professor Alex Hopkins. 

The Strategy & Engagement Director noted the need to draw this Strategy into the reporting cycle along with the other suite of documents.

05/25/14 – Combined Clinical Director Quality Report

A report of the Clinical Directors was submitted, following its review at the meeting of the Quality Governance Committee.

The Paramedic Practice & Patient Safety Director gave an update and informed the Board that hospital handover delays continue to impact the service delivery and contribute to delayed responses to patients in the community. The month of April did see higher numbers in delays of 35,000 hours lost which is over 11,000hrs more than April 2024.  The increase in hospital handover delays is also having a direct impact on corporate services such as the increase in the Learning from Deaths workload, which is being supported by the Trusts Learning Leads to manage the demand.

The Incident Reporting System (IRS) project work was completed.  PSIRF has seen 11 responses identified in April compared to 23 in April 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 learning from the learning responses in quarter 2.

05/25/15 – Quality Account

A report of the Strategy & Engagement Director was submitted.

The Strategy & Engagement Director gave an update and informed the Board that the draft Quality Account is enclosed for review and approval.

Achievement of the priorities agreed for 2024/25 are reported within the document along with all other updates in respect of activities across the Trust.  The new priorities for 2025/26 are also identified. The document has been approved by Quality Governance Committee for presentation to the Board of Directors on the basis that any further amendments are shared with members of Quality Governance Committee so that feedback can be provided prior to final review by EMB.

05/25/16 – 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 at its meeting in March 2025, the Board received the Guardian Report including activity up to 20 March 2025.   The report is now attached to confirm the full year activity.   To supplement this report, a summary Annual Report is also attached, which will be published on the Trust website to support the Quality Account.   The Annual Report details the achievements from last year together with the plans for this coming year.  Additionally, the National Guardian’s Office publishes FTSU Comparison data by Trust, which has been analysed and presented as a benchmarking report with all other Ambulance Trusts.  This report is attached, including data for the first three quarters of 2024/25. 

Mrs Wall highlighted to the Board the number of anonymous concerns raised which were higher than other Services.  Mrs Wall confirmed they were looking at what may be the cause and how to encourage people to report more openly. 

Mrs Butler gave an update and explained that having reviewed the new framework published by the National Guardian’s Office, we have identified a recommendation for line management arrangement of FTSU Guardians.   However Mrs Wall and Mrs Butler the Trust’s Guardians were satisfied the current arrangements that the current reporting arrangement meets the needs of this Trust and the staff in the team.  

Mrs Butler informed the Board that t a high level review of the concerns over the last two years.  A summary learning and outcomes document is also attached to demonstrate in narrative form, the nature of concerns received, and a summary of learning and outcomes generated.  48% of the concerns received were anonymous.  The concerns received from corporate services regarding staffing resources were received before the recent NHSE letter regarding reductions in corporate growth costs was received. 

The Chairman asked in relation to the anonymous reporting was this a culture issue.  Mrs Wall said initially we have made it very easy for staff to pick up a form and report anonymously. The Trust now has a new structured form to enable confidential or anonymous reporting as some people will truly want to report anonymously.  The Strategy and Engagement Director explained that reporting confidentially enables us to provide feedback.   Mr Nat pointed out from the evaluation feedback the positive scores show the professional way this is managed. 

The Chairman thanked Mrs Wall, Mrs Butler, the Strategy & Engagement Director and the wider Ambassadors Team on the work undertaken.

05/25/17 – Departmental Annual Reports

A report of the Strategy & Engagement Director was submitted.

The Strategy & Engagement Director explained that the Quality Account is supplemented by a suite of Departmental Annual Reports.  The leads of key corporate functions have produced reports to cover a summary of activities and achievements during 2024/25 and an overview of priority work areas for 2025/26.   A number are presented for approval today and the remainder will be presented where appropriate future meetings of the Board.

05/25/18 – Service Delivery Report

A report of the Chief Operating Officer was submitted.

The Chief Operating Officer informed the Board that this is the first report that includes the recently appointed Head of IEUC Report.  The main points of note were as follows:

• 7% increase in inactivity a lot of which has been due to the bank holidays.
• May has seen a 1% growth in activity compared to last year.
• Cat 2 mean for April was 21:39. 
• 35,000 lost hours in April 2025.  April 2024 was 24,337 hours.
• Good compliances on PDCs.
• Mandatory training has started well.  E&U operations are due to be complete by 16 November 2025. 
• Call answering performance is strong.
• In April, the Trust reported two over 2-minute delays which is a good start to the year given the increases in demand. 

Mr Nat explained that this report had been reviewed at the recent meeting of the Finance & Performance Committee where it was reviewed in detail.  Mr Nat pointed out that the Trust is doing remarkably well in a challenging environment.  It is on track to achieve Cat 2 despite an increase in activity and a record number of lost hours which is still a huge ongoing issue.

The Chairman asked about the delay in the mandatory training workbook and when it is due for release.  The Chief Operating Officer advised the Board that the workbook is due to go live this week.  Professor Hopkins thanked the Chief Operating Officer for his report which had very good contextual data included. 

05/25/19 – Board Committee Review

A report of the Organisational Assurance Director and Governance Director & Trust Secretary was submitted.

The Governance Director & Trust Secretary explained that a review has been undertaken on the administrative support and governance arrangements provided to the Board of Directors and its Pillar Committees. 

The governance route of the report was set out to provide assurance to the Board. The proposals and actions are shown in Appendix 1 attached to this paper. It was pointed out that there are a number of subgroups that were not part of this review as they were mainly executive and management meetings.

In addition the Board of Directors is requested to approve the Terms of Reference of each of its reporting Committees and the Executive Management Board.

In addition, each of the Committees and Executive Management Board have undertaken a self-assessment and the results of the self-assessment are available upon request.

05/25/20 – Board Committee Reports & Minutes

a – Finance and Performance Committee

The Chairs report on the meeting held on 22 May 2025 was submitted along with the minutes of the meeting held on 25 February and 29 April 2025.

Mr Khan said the report is as read.  Mr Khan reiterated the points already made that the committee had reviewed in detail a lot of the reports submitted here today.  Mr Khan had no further comments to make to those already made earlier today.

b – People Committee

The report of the Chair of the meeting held on 7 April 2025 was submitted along with the minutes of the meeting held on 10 February 2025.

Mr Fessal advised the Board that A Day in the Life visit by a NED to an operational hub had led to comments on what is perceived as rotas being unfair for new staff. This follows similar comments raised at the committee from a Day in the Life visit by a NED to a different hub. It was stated that the rotas are drawn up to meet the needs of the Trust and operational delivery.  Mr Khan said he understood that there needed to be the right balance but this is an issue that has materialized during engagement with staff.

The People Promise Manager role has been extended internally until September allowing completion of various workstreams. Work is underway to assess the impact of this role in delivering positive outcomes against investment.

Various workforce KPI indicators demonstrate strong delivery ranging from PDC completion rates and sickness to retention figures and achieving the recruitment plan.

The Chairman advised the Board that he had attended a senior Operations Meeting recently.  The level of scrutiny on sickness by not on the Senior Team was intense and welcome.  The Trust’s sickness absence is exemplary.

c – Quality governance Committee (QGC)

The Chairs report of the meeting held on 22 May 2025 was submitted along with the minutes of the meeting held on 19 March 2025.

05/25/21 – Board of Directors Schedule of Business

The Schedule of Business was submitted.

05/25/22 – Any Other Business

Board Development – Health, Safety and Duty of Care Training for Directors

The Board was reminded that the development session for Board members was being held that afternoon and attendance was encouraged.

There was no other business.

05/25/23 – The Date of the Next Meeting

Wednesday 30 July 2025 which will include the Annual Meeting of the Membership

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