HSC(6)-20-23 PTN 8

Eluned Morgan AS/MS

Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services

Russell George MS Chair

Health and Social Care Committee

SeneddHealth@senedd.wales

4 April 2023

Dear Russell,

HSC Committee letter and questions, 17 February – related to monitoring progress against the national planned care recovery targets.

Thank you for your letter of 17 February in relation to your role in monitoring progress being made against the programme for transforming and modernising planned care and reducing waiting times.

I am pleased the committee has noted the progress the NHS has made in this area; I too acknowledge that more pace is required. I and my officials are very clear on our expectations and together with the NHS, we are working hard to deliver against the plan. I have responded to each of the questions you have raised and have provided you with a summary position. As there are a large number of questions raised, the responses have been placed in an Annex to this letter.

I hope the Committee finds this information helpful.

Yours sincerely

Eluned Morgan AS/MS

Y Gweinidog Iechyd a Gwasanaethau Cymdeithasol Minister for Health and Social Services

Canolfan Cyswllt Cyntaf / First Point of Contact Centre:

0300 0604400

Gohebiaeth.Eluned.Morgan@llyw.cymru Correspondence.Eluned.Morgan@gov.wales

Bae Caerdydd • Cardiff Bay

Caerdydd • Cardiff

CF99 1SN

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi.

We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding

Annex

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No.

Question

Recovery targets

1

Despite the publication of the Welsh Government’s planned care recovery plan, waiting times in Wales are still rising in some specialities. Projections based on progress to date suggest that unless activity significantly increases, the

Welsh Government’s recovery targets are unlikely to be met. What steps are being taken to address this.

Response

We acknowledged that the targets we set in our plan were a challenge. However, we felt it was important to drive pace in the delivery of recovery. While our first target has not been achieved, we have seen significant progress.

Total waiting times have shown an overall reduction in the last four months, something that England has not achieved in their approach to recovery. Variation across health boards and challenging specialities will be prioritised for action in 2023/24 as regional plans are developed and implemented and national pathways are developed to deliver value-based care pathways.

Transformation: delivering things differently is key to addressing the growing imbalance between demand and capacity. We need to not only recover but ensure we build more sustainable, prudent and timely services moving forward. The refreshed Outpatients Transformation Strategy 2023-26 reflects this. This will also be supported by a new policy (national service specification) currently being development to promote, prevent and prepare people effectively for treatment. This builds on the concept of “Waiting Well”, the first phase of the specification is to be issued in June.

£50 Million of the recovery fund has been held back from individual issue to health boards to support the development of local and regional solutions. Particular areas being diagnostic and treatment capabilities. This resource will be allocated during 2023/24 to take forward schemes to increase capacity in line with the priorities identified in the recovery plan.

2

What impact do you anticipate the 2022-23 winter pressures and recent industrial action taken by NHS Wales staff will have on planned care and the achievement of the recovery targets, in particular the first target (no-one waiting longer than a year for their first outpatient appointment by the end of 2022).

Response

As indicated with the publication of the December data, the target to reduce outpatient waits to below 52 weeks was not achieved.

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Significant progress however has been seen. We prioritised a target for outpatient waits in Wales as we understood the importance of getting an early review as part of a patient’s pathway. Undoubtedly industrial action and winter pressures have impacted on the of patients waiting in excess of the milestone target. Management information however demonstrates that activity has quickly returned and that the overall volumes of outpatient and treatment activity is now consistently above our 2019 pre-covid levels.

While the target was not achieved, in excess of 320,000 pathways were removed from the waiting lists from January 2022-December 2022.

A more significant factor in the non-delivery of the OPD milestone relates to the differential in urgent and routine patients being seen by health boards pre and post pandemic within the first 9 months of 2022/23 60,000 more urgent patients were seen than in the same period pre pandemic. The prioritisation of urgent pathways reduces the available capacity to provide care to patients clinically prioritised as routine who then wait longer.

In recent months we have seen the highest number of suspected cancer pathways (over 10,000 each month) downgraded (telling patients they do not have cancer). This demonstrates our commitment to balance our approach to prioritise both clinical priority and long waiters.

As of December 2022, just under 9 out of 10 outpatient pathway waits over 52 weeks were across just seven specialties, with 33 specialities with none or less than 100 open pathways.

Have any revisions been made to the improvement trajectories for each health board to address their delivery and meet the nationally agreed measures to clear the backlog? If so, what changes have been made, and are all health boards on track?

Response

As stated above, the targets set in the plan were a challenge and despite the original targets not being achieved we continue to drive the delivery of the targets with revised dates of June 2023. These adjustments recognise the scale of the challenge and the continued need to balance resources between clinical urgency and long waiters.

I have tasked the Planned Care Improvement and Recovery Team in the new NHS Executive to support and challenge health boards on the actions that will support delivery of this requirement together with my officials to hold the NHS accountable for their delivery in this area.

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You have previously said that “it will take a full Senedd term and a lot of hard work to recover from the impact of the

pandemic”.1 Are you still of the view that planned care can return to pre-pandemic waiting time levels by the end of this Senedd?

Response

Yes, it will take a full Senedd term to recover. However, I am pleased to note that as stated in a previous response that we have started to see some early signs of change due to the hard work of the NHS staff in Wales. Since the end of October, we have seen a monthly reduction in our total waiting list, something not seen in England with their total waiting list continuing to increase.

We are committed to not only reducing the backlog but also to build sustainable service models where we will redesign planned care pathways based on value-based care which will deliver better outcomes for the people in Wales.

Data granularity

Are you willing to share more granular data (or management information recognising the limitations of this data) with the Committee relating to the number of closed pathways by setting out exactly how many of the closed pathways are a result of a patient starting treatment and how many patient

Response

An RTT pathway can be closed for a variety of reasons. Commencement of treatment is only one of the reasons. We do not hold, or report closed pathway data based on what reason they were closed. The majority of non-surgical pathways will close in outpatients after diagnosis and a treatment plan is commenced, in response to patient choice or clinical requirement to close a pathway for a period of time.

The reason for closing a pathway is not currently available on the PTL (Patient Tracking List). However, the Modernised Outpatient Dataset work stream is exploring the consistent recording and reporting of more detailed outcomes data. This is being explored for 2023-24.

Pathways have been removed from the list for other reasons (i.e. what the impact of the waiting list validation exercises has been and whether the results are consistent across health boards).

Response

Validation is part of effective management of waiting lists, and regular review is seen as good practice. During Covid this validation was not always carried out. Planned care funds have been utilised by a number of Health Boards to deliver internal validation of waiting lists and reductions have been noted in these Health Boards. However, given the scale of challenge to meet our

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ambitions for maximum waiting times, a validation exercise was commissioned across four Health Board areas namely Betsi Cadwaladr, Cwm Taf Morgannwg, Hywel Dda and Swansea Bay to support the accuracy of their waiting lists. As of 23 March, 141,000 patients were validated of which 9,500 were removed and a further 5,000 were recommended to the health board for further contact and review.

Recovery of different specialties

There are several specialities where waiting times are particularly long, such as trauma and orthopaedics, ENT and ophthalmology. Based on current projections, which specialities do you anticipate will achieve each of the recovery targets, and which specialities will not.

Response

Currently it is believed that seven specialities will not achieve the 104 -week total RTT wait target by March 2023 by more than 1,000 patients for each speciality area (Orthopaedics, Ophthalmology, ENT, General Surgery, Urology, Gynaecology and Oral Surgery).

Orthopaedics will account for a third of the total volume of pathways likely not to achieve the target.

Management data indicates a further six specialities will have between 100 and 500 pathways which will miss the target.

What does success look like for you in terms of “most

specialities” achieving the recovery targets (i.e. 50 per cent, 95 per cent etc).

Response

We continue to drive the challenge across all specialities but recognise that some are more challenged than others: surgical specialities in particular.

Currently we have seven areas where most health boards are challenged to deliver the targets against. We are refocusing the national clinical groups in the planned care programme to provide leadership and challenge to share good practice and support the implementation of new ways of working to transform service delivery and drive down waits in these areas.

As of June 2023, management data projects that ophthalmology, ENT, dermatology and urology will still have significant numbers of people waiting over 52 weeks. A further three specialities are expected to have up to 1,000 patients waiting in excess of the milestone target. These three areas reflect service specific challenges in individual health boards rather than national areas of concern.

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With respect to the 104-week target, management data currently suggests five of the seven specialities that will miss the March target will continue to have significant challenges with respect to the delivery of the target by June, in particular orthopaedics, general surgery and urology. We continue to explore how we can further mitigate against this.

Trauma and orthopaedics

For Trauma and orthopaedics, the health boards have developed action plans to implement the GIRFT (Getting it Right First Time) proposals and the national pathways. Have these actions plans been published and if so, can they be shared with the Committee.

Response

Progress against implementation of the local GiRFT reports forms part of the targeted NHS Executive support through the Planned Care Improvement and Recovery team.

This area will be managed and reported through the Assistant Director for Orthopaedics, NCSOS and the dedicated health board representatives. The progress will be monitored and reported through the orthopaedic clinical implementation network ensuring clinical leadership and guidance.

Non-delivery or concerns around pace of delivery will be escalated as required to form part of Welsh Government accountability meetings. Reporting will formally commence from April 2023 as part of the redesign of the clinical groups of the planned care programme.

In December 2022 you wrote to us to say that following the Ministerial orthopaedics summit in August, the Deputy Chief Medical Officer wrote to health boards to “outline the position with regards to long waiting patients and that those waiting over 104 weeks should be placed in the same category as urgent patients when booking appointments”.

Could you confirm whether this applies only to trauma and orthopaedic pathways, or to all patient pathways.

Response

It applies to all long waiting pathways. However, clinical priority is the authority of the local clinicians. The clinical leads across the planned care clinical groups will be tasked as part of implementation to work with local clinical teams to understand how clinical priority, long waiters and clinical sub-specialisation are being managed and to increase the treat in turn rate.

Diagnostics

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In December 2022 you told us that a national diagnostics programme board was established in May 2022, and that it was “currently finalising a diagnostics strategy for the long- term sustainability of services”. You also said that the strategy would include measures such as regional diagnostic hubs to increase capacity. Could you provide an

update on the work of the programme board, including when the diagnostics strategy will be published and progress in developing regional diagnostic hubs and other measures to increase diagnostic capacity.

Response

The planning framework for 2023/24 set out the establishment of diagnostic hubs as a key requirement for Health Boards by March 2024. £50million of the £170Million recovery fund has been retained to support the delivery or diagnostic hubs and regional increased capacity.

With the Llantrisant site now purchased by the Welsh Government, the southeast Wales region are working up plans for a Diagnostics Regional Hub as part of a managed service contract so that the requisite workforce to manage these facilities sustainably can be developed over this period. Whether the site can also accommodate a regional Endoscopy Unit including two theatres that can be utilized as an Endoscopy Clinical Skills Training Academy is also being explored.

Discussions are ongoing with the southwest and North Wales regions regarding their plans for sustained diagnostic capacity. Further demand and capacity modelling and procurement processes will be required to achieve implementation of hubs locally.

The diagnostic strategy is due to be published in April and will detail further measures for the recovery and enhancement of diagnostic services.

In November 2021 the Welsh Government announced £51m investment to “help ensure NHS Wales has up-to-date diagnostic facilities using the latest imaging technology.

Image quality will be improved, supporting earlier and more accurate diagnosis of many common diseases, including cancer”. Could you provide an update on progress in upgrading diagnostic equipment and imaging technology.

Response

The National Imaging Equipment and Capital Priorities project is moving to phase two of the project. This phase prioritises and develops the recommendations for capital replacement of imaging equipment at a national level. See table as of appendix 1 with summary of progress to date on the £51M investment

Cancer

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An area of concern within the data is performance against the cancer target, with only 53.9 per cent of patient pathways achieving the recovery target in November 2022. Please provide an update on action being taken to improve cancer waiting times, specifically for the cancers with the longest waits such as gynaecological, head and neck and urological.

Response

Backlog removal is impacting on achievement of this target, as cancer pathways are reported by closed pathway. Health boards are prioritising the removal of pathways already over the target 62 days. While thy are reducing them, this impacts the target which looks at the percentage of pathways treated each month under 62 days.

The end of March Cancer summit has asked health boards to provide a summary of their local plans to improve delivery in the three areas you have highlighted. They will be monitored against these plans going forward.

Please provide an update on the outcomes of the Ministerial summits held in late 2022 in respect of ophthalmology, emergency care, and ear, nose and throat.

Response

There have been a number of Ministerial summits that have taken place, including ophthalmology, emergency care, ENT and more recently, a second orthopaedic summit.

These summits have provided the service with an opportunity to update officials on the progress they are making in implementing the recommendations made in the various reports, including GiRFT reports and the recommendations of the Six Goals Programme.

All the summits considered the challenges the service is facing to return to a level that meets the needs of the population they serve, with a particular focus on specific areas. In the ophthalmology summit it was cataract and glaucoma; in the ENT summit, sustainable pathways, interventions not normally undertaken and cancer; and in the orthopaedic summit, it was progress made by organisations since the first orthopaedic summit.

There were presentations from health boards, providing both an individual update and a regional one, discussions on how we can support each other to improve and the opportunities that were available to organisations to implement nationally agreed pathways.

Workforce

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To what extent are workforce challenges in health and social care affecting progress in achieving the recovery targets?

Please outline what the specific workforce challenges are, and how they are affecting progress.

Response

There are workforce challenges in a number of health boards. In particular health boards have reported Anaesthetic, Ophthalmic and Urology consultant pressures, as well as theatre staffing challenges.

Health boards have indicated that these workforce challenges have reduced or slowed their capability to deliver historical levels of activity.

Are you confident that the national workforce implementation plan published on 1 February 2023 will adequately address these workforce challenges, and that there are sufficient financial and staff resources in place for the plan’s implementation? Please also outline how progress in implementing the plan will be measured and reported to the Senedd.

Response

- The National Workforce Implementation Plan was a commitment in the Programme for transforming and modernising planned care and reducing waiting lists in Wales published in April 2022.

- The Plan builds on the strategic direction in A Healthier Wales: Our Workforce Strategy for Health and Social Care Workforce Strategy, whilst recognising the need for rapid collective action on some key priorities in order to expand and accelerate progress in light of current pressures.

- A Strategic Workforce Implementation Board will be chaired by Judith Paget and will report to the Minister for Health and Social Services.

- The Board will ensure alignment for cross cutting actions and collective accountability.

- The Board will receive monthly progress and focused risk reports from each lead organisation and will report quarterly to the Minster for Health and Social Services.

- We would propose a yearly progress report to the Senedd.

Appendix 1

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Health Board

Priority

Site

System

Project costs (£M)

Project status @ 14 March 2023

Aneurin Bevan University Health Board

1

Various

Ultrasounds

£1.440

All delivered and in clinical service

2

NHH

CT

£2.120

Delivered and in clinical service

3

Various

4 DR rooms

£1.900

Delivered and in clinical service

4

R.Gwe nt

CT

£2.120

System being delivered 18 March 2023, in line with the programme for immediate commissioning into clinical service

£7.580

Betsi Cadwaladr University Health Board

1

YMH

MRI Upgrade

£1.040

Delivered and in clinical service

2

YMH

CT

£2.920

Delivered and in clinical service

3

Various

6 DR rooms

£2.345

3 units delivered. And in clinical service 3 in progress will enter clinical service April 2023

4

YGC

Fluoroscopy

£1.320

Delivered and in clinical service

£7.625

Cardiff and Vale University Health Board

1

UHL

MRI

£2.140

Unit in UK and will be in clinical service mid-2023. Minor delays due to mechanical ventilation lead times

2

UHW

4 DR rooms

£1.900

2 systems delivered and in clinical service, 3^rd being commissioned for clinical use commencing April and the 4^th is being installed in the new fracture clinic for clinical service in line with the programme in May 2023

3

UHL

Fluoroscopy

£1.430

Delivered and in clinical service

4

UHL

CT

£2.240

System being delivered 18 March 2023, in line with the programme for immediate commissioning into clinical service

£7.710

Cwm Taf Morgannwg University

1

PCH

Ultrasound and CT Injector

£0.160

All delivered and in clinical service

2

POW

C Arm

£0.120

Delivered and in clinical service

.

Health Board

Priority

Site

System

Project costs (£M)

Project status @ 14 March 2023

Health Board

3

POW

Gamma

£1.180

System undergoing final commission tests and will enter clinical service in April 2023.

4

Various

5 DR rooms

£3.250

All bar one in clinical service, final unit currently undergoing installation prior to entering clinical service in April

5

R.Glam

MRI Upgrade

£0.970

Installed and in clinical Service

£5.680

Hywel Dda University Health Board

1

PPH

CT

£2.400

Delivered and in clinical service

2

BGH

CT

£2.400

Delivered and in clinical service

3

Various

Ultrasound/Image Intensifiers

£2.292

Delivered and in clinical service

4

Various

4 DR rooms

£2.200

3 units delivered, Bronglias delivery 24 March 2023 for immediate commissioning into clinical service

5

Various

1 Fluoroscopy Rooms

£2.820

Delivery 24 March 2023 for immediate commissioning into clinical service

£12.112

Swansea Bay University Health Board

1

MOH

MRI

£2.790

Delivery 25 May 2023 for immediate commissioning into clinical service

2

Sing

CT

£2.400

Delivery planned for 24 April 2023 for immediate commissioning into clinical service

3

NPT

CT

£2.720

Delivery 9 May 2023 for immediate commissioning into clinical service

4

NPTH

Gamma

£2.180

Installation being designed, system ordered and expected to enter clinical service before November 2023

5

NPT

DR Room

£0.620

Delivery 3 April 2023 for immediate commissioning into clinical service

£10.710

Total

£51.417