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Aim Ambulance services are experiencing increasing volumes of emergency calls. In response, they have increased the proportion of patients not conveyed to an emergency department (ED). Alternatives to transporting patients to an ED include the provision of telephone advice only, treatment at the scene, or transport to another facility. Variation in the rates of different types of non-conveyance (NC), and in NC overall, exists between ambulance services in England. We explored variability in perceptions of the organisational culture within each individual ambulance service and show this in the context of NC rates. Method We undertook 50 qualitative telephone interviews with ambulance service providers and commissioners in the 10 larger ambulance services in England, to identify factors that may explain variation in rates of ambulance NC. Data was analysed using a Framework model. Results Amongst interviewees there was variation in the perceptions they held regarding the organisational culture of the ambulance service which they were employed by. Recent management restructuring within the ambulance service, perception of management support across the organisation, motivation of the organisation to undertake NC, and perceptions of support for staff undertaking NC varied across the ambulance services. There appeared to be a relationship between some of these factors and NC rates. Conclusion Organisational culture is a complex issue but one which is potentially modifiable. Building a greater understanding of ambulance service organisational culture and how this relates to ambulance NC may help identify ways of improving service delivery across all ambulance services. Conflict of interest None Funding National Institute for Health Research (NIHR) Health Services and Delivery Research Programme.

Aim In England in 2017ambulance services responded to around 11 million calls. Half of patients were not transported to hospital. 11% received telephone advice only and 38% were discharged at scene. For the ten large regional ambulance services, rates of calls ending in telephone advice varied between 5% and 17%. Rates of discharge at scene varied between 23% and 51%. The aim was to explain variation in non-conveyance rates between ambulance services Method A sequential mixed methods study: a qualitative interview study of managers and paramedics (totalling 49 interviews) followed by analysis of one month of routine data from each ambulance service (6 15 618 calls). Results Interviewees identified factors they perceived affected non-transport. Rates of discharge at scene were associated with patient-level factors e.g. age, deprivation and skill level of attending crew. However, variation between ambulance services remained after adjustment for patient-level factors. Variation was explained by ambulance service-level factors:% of calls attended by paramedics with extended skills (odds ratio 1.05 (95% CI: 1.04 to 1.07)), the perception of ambulance service staff that paramedics with extended skills were established and valued within the workforce (odds ratio 1.84 (1.45, 2.33), and the perception of ambulance service staff that senior management was risk averse regarding non-conveyance within an ambulance service (odds ratio 0.78 (0.63, 0.98)). Conclusion Ambulance service management can take actions to reduce a variation in practice. Conflict of interest None Funding National Institute of Health Research.