Darren Millar AM

Chair

Public Accounts Committee

National Assembly for Wales

Cardiff Bay

Cardiff.  CF99 1NA                                                                                                    

Our Ref: DS/

31 October 2013

Dear Darren,

WAO REPORT - UNSCHEDULED CARE: AN UPDATE ON PROGRESS

I am writing in response to your invitation to attend the Public Accounts Committee and provide evidence on the above matter.

We worked closely with the Wales Audit Office as they undertook their review. I attach a summary of related issues and our actions. I will, of course, provide further information or any necessary clarification in response to its various recommendations on 12 November.

Yours sincerely

Kevin Flynnfor

David Sissling

Cc:     Kevin Flynn, Welsh Government

          Ruth Hussey, Welsh Government

Enc.   Annex 1 – Evidence Paper

Annex 2 – Wales Audit Office Report Recommendations

Annex 1

PUBLIC ACCOUNTS COMMITTEE

INQUIRY INTO WALES AUDIT OFFICE REPORT: UNSCHEDULED CARE – AN UPDATE ON PROGRESS

Date: 12 November 2013

Venue: Senedd, National Assembly for Wales

Title: Inquiry into Wales Audit Office (WAO) Report: Unscheduled Care – an Update on Progress

INTRODUCTION

1. The Welsh Government welcomed the Wales Audit Office report on Unscheduled Care: an update on progress when it was published in September.  We generally accept the recommendations and we are already taking the necessary responsive action in each area.

PURPOSE

2. This paper provides evidence on the Welsh Government’s response to the WAO’s Report: Unscheduled Care – an Update on Progress, published on 12 September 2013. The paper was requested by the Committee Chair to inform the Public Accounts Committee session to be held on 12 November 2013.  At the request of the committee this will particularly focus on Primary Care.

CONTEXT

3. Responsibility for delivering the recommendations featured in the WAO Report is shared between the Welsh Government, Local Health Boards, Public Health Wales and the Welsh Ambulance Services NHS Trust (WAST).

4. Activity undertaken to date and additional plans put in place by the Welsh Government and NHS Wales for the future in response to each recommendation are described in annex 2. It should be recognised that a number of recommendations are specifically intended for NHS Wales to discharge.

5. The Report clearly recognised the complexity of delivering unscheduled care services and the improvements made since April.  These challenges cannot be underestimated, and are evident across the UK.  In particular, future demographic trends clearly indicate increasing demand pressures over the next 5 to 10 years. Within Wales, the population aged 65-74 is projected to increase by 27.2% between 2008 and 2019 compared to 26.1% in the UK over the same period.

6. Evidence shows that the largest % increase in patients admitted as an emergency are in the age 85+ category, with a 57.7% rise in the number of patients aged 85+ admitted via emergency departments over the past 9 years.

7. A higher proportion of these older people arrive at A&E in emergency ambulances, and there is a higher risk of admission from A&E compared to seeing a GP for the same medical problem.

8. In April 2013, the Minister for Health and Social Services delivered an oral statement which set out a wide range of actions designed to enable improvements in the short, medium, and longer term.

9. In response, the National Work Programme for Unscheduled Care was developed by NHS Wales’ Chief Executives in collaboration with Welsh Government. Amongst the Programme’s objectives are to improve the way health and social care work together to ensure hospitals focus on those who need them and all get excellent care in the best place when they need it.

10. The Work Programme  is led jointly by Andrew Goodall, Chief Executive of the Aneurin Bevan Local Health Board and Elwyn Price-Morris, Chief Executive of WAST. It includes the Ten High Impact Steps to Transform Unscheduled Care and the following projects:

• Development of an escalation system for NHS Wales that is owned, understood and used properly by Health and Social Care staff and organisations;
• Creation of a genuinely integrated health and Social Care system for Unscheduled Care where priorities are aligned and owned by all sectors (from primary care, through community, acute, social care and back into primary care);
• Establishment of an Unscheduled Care Collaborative for Improvement;
• Creation of a national approach to GP Out of Hours, 111 and Community Hubs that acknowledges local differences whilst delivering improved services quickly;
• Identification and delivery of actions that change the health and social care system from ‘push’ to ‘pull’; and
• Implementation of the Ambulance Review findings (i.e. the Ambulance Reform Programme).

11. The Wales Audit Office report, Unscheduled Care: An Update on Progress published in September 2013 made a number of recommendations for NHS Wales, Welsh Government and partners. The majority of the recommendations featured in the report are aligned to work streams which are already underway through the Work Programme for Unscheduled Care. Outstanding recommendations are being integrated into the work undertaken by the Programme.

Welsh Government Action

12. The Welsh Government required Unscheduled and Scheduled Care Plans from all Local Health Boards and WAST in May 2013. Expectations were made clear that assurances about preparedness for winter 2013/14 should be included within the Unscheduled Care Recovery Plans.

13. The Welsh Government required all Local Health Boards and the Ambulance Trust to produce unscheduled care performance improvement trajectories against the 4 hour A&E and 8 minute ambulance response time targets. Reductions of patients waiting in excess of 1 hour for handover from ambulance crews to A&E staff, and those spending longer than 12 hours in the department before admission, transfer or discharge were also required. 

14. Weekly phone calls with each Local Health Board and the Ambulance Trust were established by the Department for Health and Social Services in May 2013. The calls were initiated to provide assurance that the integrated recovery plans were being delivered within the confirmed timescales.

15. Responsibility for the daily Executive-level National Emergency Pressures Conference Call was transferred from Welsh Government to Local Health Boards in June 2013. The transfer was designed to encourage greater ownership of unscheduled care escalation arrangements, in addition to encouraging greater engagement and collaboration between NHS Wales’ organisations.

16. Welsh Government require Local Health Boards to report delays experienced by patients in excess of 12 hours at A&E on the call, and to provide assurance that patients and families are being kept informed of reasons for the delay and when patients are likely to be admitted, transferred or discharged.

17. Welsh Government initiated the publication of data on the number of patients spending longer than 12 hours at A&E before admission, transfer or discharge from May 2013 to provide greater transparency to the public on the timeliness of care provided at A&E departments across Wales. Greater emphasis will be placed on health boards recognising  long  waits as they occur and taking  the appropriate action.

National Clinical Lead for Unscheduled Care

18. Dr Grant Robinson was appointed as the Unscheduled Care Clinical lead and commenced work at the beginning of September 2013.  Dr Robinson has been working with leaders from health and social care to secure improvement across pathways of urgent and emergency care.

National Conversation on Needs of Ageing Population (Baroness Illora Finlay)

19. Baroness Illora Finlay agreed to start the new ‘National Conversation’ on how care services in Wales can best meet the needs of our ageing population, and took up this role in May 2013.

20. Baroness Finlay has met with key stakeholders and has chaired a number of Think Tank events. She is planning further meetings with patients and other groups to inform her report to the Minister.

NHS Wales Action

21. All Local Health Boards and WAST have developed Unscheduled Care Plans that describe their strategic and operational approach to drive improvements to quality, patient safety and how they will deliver against national targets. 

22. Welsh Government required all organisations to provide further assurance about preparedness for winter 2013/14 and develop winter plans with partners ie WAST, LHBs and Local Authorities.

23. The Unscheduled Care and Winter Plans set out the actions to be delivered by NHS Wales’ organisations to relieve pressures on unscheduled care services ahead of and during the winter period, and beyond.

Improving Integration between Health and Social Services and Provision of Care in the Community

24. Welsh Government have recently published two documents relating to integration of services, these include  Delivering Local Health Care - accelerating the pace of change, published  in June 2013 and the Integration Framework for older people with complex needs, published for consultation  in July 2013. These documents highlight a range of both short and longer-term actions for Health Boards, Local Government and partners to improve the services, care and support for people across Wales through new service models and more effective partnership working.  This closer working was demonstrated in the development of the joint winter plans.

Unified Assessment Process for Older People

25. A task and finish group was commissioned by Welsh Government to develop interim guidance to replace the existing guidance on the Unified Assessment Process for older people. The purpose of this interim guidance is to develop more effective integrated assessment arrangements between health, local government and partners. This Framework will be published in December as interim guidance and will operate for a limited period of time until the implementation of the Social Services and Wellbeing (Wales) Bill. It will not change the existing eligibility framework in the short term.

Delayed Transfers of Care

26. Joint meetings between the Minister for Local Government;  the Minister for Health and Social Services; and the Deputy Minister for Social Services with Local Health Boards and Local Authorities have taken place, with further ones planned over the winter. Discussions have taken place about what local health communities are doing to reduce delayed transfers of care and how to accelerate social care assessments and discharges in their areas.

27. The Community and Hospital Interface (CHI) Task and Finish Group was established on 30 April 2013. The Group is chaired by Sue Evans, Chief Officer for Social Care and Housing at Torfaen County Borough Council and a member of the Association of Directors of Social Services Cymru (ADSSC). Within ADSSC, Sue is the nominated lead for unscheduled care.

28. The primary purpose of the group is to improve the patient’s experience and journey through the whole pathway of care and improve transfers of care. The CHI group has produced a draft report which will be finalised in November, outlining short and longer term actions for improvements.  

The McClelland Strategic Review of Welsh Ambulance Services

29. Andrew Cottom, formerly Chief Executive of Powys teaching Health Board, was appointed as Programme Director for the Ambulance Reform Programme in July 2013. Mr Cottom has been tasked with leading NHS Wales and the Welsh Government’s response to the McClelland Review and with implementing the recommendations made.   A range of reforms will be in place by 1 April 2014, including:

• The establishment of a new National Ambulance Commissioning Committee;
• The re-naming of the Welsh Ambulance Services NHS Trust;
• The appointment of a new substantive Chair and a refreshed non-executive Board; and
• Implementation of new ambulance measures which better demonstrate the quality of care being provided to patients.

Telephone Advice and Information Service

30. Work is underway to develop a single telephone service, provided through the 111 number, to simplify access to non-emergency, urgent healthcare.  The service is not intended to replace normal in-hours contact with GPs.  It will provide advice and information at any time of the day for people who do not know who else to contact.  It will also manage and triage GP out of hours calls.  The service will be supported by a comprehensive national directory of services.  NHS Direct Wales will be an integral part of the consideration and decision making process in relation to the service.

Planning and Solutions for Winter Pressures in 2013/14 and Appropriate Capacity to Meet Demand

31. The Seasonal Planning Group, consisting of senior representatives of Local Health Boards, WAST and Local Authorities, has been planning for winter 2013/14 since its meeting in March 2013.  Additional assurance was sought by Welsh Government from all Chief Executives in August in respect to capacity and demand modelling for winter 2013/14.

32. A National Winter Planning Forum was launched by the Minister for Health and Social Services on 10 September 2013, and attended by executive level representatives of  Local Health Boards, WAST, Public Health Wales and Local Authorities (including the President of ASSDC).  Since then, all Local Health Boards have submitted their winter plans, developed jointly with their Local Authorities and WAST addressing issues across the whole system.

33. The Welsh Government is developing the NHS Wales Integrated Unscheduled Care Dashboard to include near-live information on bed capacity levels linking this to other parts of the unscheduled care pathway – including Primary Care, Ambulance and A&E data. This data is designed to assist Local Health Boards’ understanding of when to escalate locally and nationally. The next stage of this development will be investigating the inclusion of real time data and social care information.

34. There is a more routine daily understanding of occupancy rates and a clearer link to the flexing of capacity to meet predicted demand. The evidence of last winter is that the prolonged bad weather had a significant impact on both the number and type of attendance. Work has been undertaken to develop understanding of the impact of the weather on demand for services and the best response. LHBs are building this into their planning and this is being shared with partner agencies.

35. NHS Wales has further developed its approach to escalation. As part of the Work Programme for Unscheduled Care, the National Escalation and De-escalation plan is being reviewed and updated, this includes a refresh of the daily conference call.

PRIMARY CARE SERVICES

36. In 2010 the WG published Setting the Direction, the delivery framework for primary and community care.  Following this, locality networks have been established in all Health Boards as a vehicle to relocate care in a community setting, and to build pathways of care around service users.

37. Primary Care services are delivered through the network of GP practices, out of hours services and community pharmacies, as well as dentists and optometrists.  GPs work in collaboration with community nurses, social care and voluntary sector providers.  The majority of primary care unscheduled care contacts are delivered by GPs and out of hours services.

38. Although data is not routinely collected to measure demand for GP services, it is recognised that increasing prevalence of chronic disease;  expanding programmes  of  immunisation; risk management of patients; and greater complexity and comorbidity of frail elderly patients all increase the requirement for Primary Care support.

39. Consultation rates rise significantly for older aged groups from an estimated average of less than 6 contacts per year at age 60 to nearly 14 contacts per year for patients over 85 years. This differential has increased as a more proactive approach to chronic condition management has developed.

40. There is also a significant workload in relation to medicines management, particularly for complex co morbidity in frail elderly patients.  As frequency of contacts increases with age it will be important to match workforce capacity and skill mix with the pattern of need.

41. The Public Health Wales analysis of demand across the system will help to inform the more detailed analysis of these pressures and workforce requirements.

Welsh Government Priorities

42. Improving access to GP services is a key commitment for the Welsh Government. Work has been progressing to make services more accessible to working people. In 2012/13 the Welsh Government focus has been on ensuring adequate capacity and distribution of appointments between 8.00am and 6.30pm and on reducing the number of practices with half day or lunchtime closing. Good progress has been made in delivering better access during these hours. Published GP access statistics for 2012 indicates that 94% of GP practices in Wales now offer appointments between 5.00pm and 6.30pm at least two nights per week.

43. One of the Welsh Government’s priorities is to increase the availability of appointments outside contracted hours during the week after 6.30pm. Health boards are currently reviewing extended opening arrangements to ensure that such services are meeting local needs and make best use of available resource. Currently, 11% of GP practices offer appointments after 6.30pm at least one day per week.

44. There has been development of “My Health On Line” which gives patients the opportunity to book GP appointments and order repeat prescriptions on line.  Currently 56% of GP practices in Wales, involving over 19,000 patients, have signed up to this approach.

45. In a number of areas practices are exploring the increased use of telephone triage to improve access to primary care advice and to direct to the most appropriate management. This work includes analysis of demand, capacity, and flow through systems based on examples of good practice from across the UK. Initial work has been discussed through the primary care clinical and managerial networks and these routes will be used to share good practice.

46. Boards are seeking to support local analyses and problem solving. The Local GP networks will continue this work informed by the developing Public Health Wales analysis of demand across the system.

47. Local Management information shows that  the GP out of hours service in Wales receives  in excess of 700,000 calls per year, of which around 560,000 receive advice from a GP or nurse.   Of these, approximately 40% are given telephone advice and around 55% are seen by a clinician in a Primary Care Centre, at home or as an in-patient.  About 5% of patients are transferred to A&E or the ambulance service. Welsh Government officials have been in regular discussions with Health Board Executive Leads for GP out of hours services and  Health Boards have been working together to ensure resilience of existing services.

48. Closer working with other unscheduled care services is being taken forward across Wales.  Joint protocols with the Ambulance Service have been developed in Gwent and North Wales for out of hours GPs to provide support to paramedics.  Out of hours services are co-located with Emergency Departments and Minor Injury Units in a number of sites across Wales; and some hospitals regularly receive referrals directly to wards from out of hours GPs.

49. As part of the work being undertaken to make information more meaningful, we are looking into better ways to gather and use Primary Care information about out of hours.  This includes integrating elements of the out of hours data into the NHS Wales Unscheduled Care Dashboard.

50. In recognition of reports of recruitment difficulties a survey of GPs has been undertaken to inform understanding of enablers and barriers to engagement with Out of Hours provision.  This  will provide insight to a range of issues relevant to in hours and out of hours General Practice.

51. The Welsh Government is establishing the Choose Pharmacy service in pathfinder sites in Cwm Taf and Betsi Cadwaladr Health Boards. Research suggests that an estimated 18% of general practice workload and 8% of emergency department consultations each year are for common ailments which could be effectively managed by community pharmacists.  Choose Pharmacy will involve approved pharmacists offering confidential NHS consultations, and where appropriate treatment to patients who would otherwise present with common ailments at other NHS services.  The service will be subject to a robust evaluation of benefits and will be rolled out nationally if it can be demonstrated that it reduces demand in other sectors.

Developments though the GP contract to support Welsh Government Priorities

52. The Quality and Productivity Domain of the GP contract has been used to facilitate the development of GP networks. This has supported practices to work collaboratively to peer review local A and E and emergency admission activity.  The purpose is to develop care pathways for the management and treatment of patients that aim to reduce the need for emergency admissions. Networks have also been tasked to identify opportunities for service design improvements. These suggestions will be considered in local unscheduled care programmes.

53. Networks were provided with guidance to support the management of care. This included: -

· The ‘Focus On’ work to support referral management initiatives

· High Impact Changes document

· Guidance on Significant Event Analysis to identify alternative management options.

54. Through agreed changes to the GP contract for 2013/14, GP practices are undertaking risk stratification to ensure that active management plans are in place for patients most at risk of unscheduled admission.   Whilst this will focus on the small proportion of those most at risk, the aim of this work is to identify opportunities to improve systems of care more generally and the findings will feed into whole system urgent care service development.

55. A number of care pathways have been developed, determined by local need, including the active management of respiratory conditions, management of falls and risk stratification for childhood fevers.

56. GPs also provide specific programmes of care that support the management of unscheduled care pressures including

• The influenza immunisation for those aged 65 and over and other at-risk groups.
• Enhanced diabetes care
• Holistic assessment and planned reviews of care in Care Homes 

57. Delivering Local Health Care supports the delivery of care in the community and is dependent on service redesign to focus resources where care is needed. The GP contract has been used to facilitate the development of local structures and processes that will now be further developed to support the increasing emphasis on local prioritisation.

58. All of the Health Boards in Wales are developing or implementing at least one model that will assist in the development of community health care services.  All of the models include partnership working across a mix of services, including primary care partners, secondary care services, Local Government, Social Services and/or third sector organisations.   Examples include: the Enhanced Care at Home project in Betsi Cadwaladr that increases care at home to avoid hospital admissions and support earlier discharge; and the Wyn campaign in Cardiff and Vale UHB that supports people to regain and retain independence, using the HB/LA communications hub to provide a single point of contact for a range of local services.

CONCLUSION

59. The Wales Audit Office recognises the challenges facing NHS Wales in delivering the Unscheduled Care agenda.  We welcome the scope of the report and believe it is evident that we have used its recommendations to help inform our planning and work programme. 

Annex 2

Welsh Government Response to Wales Audit Office Recommendations Unscheduled Care: An Update on Progress

	Recommendation	Response	Update
1a	To supplement existing quality assurance and risk management practices, Health Board medical directors and directors of nursing should carry out joint, urgent reviews to make sure they fully understand the safety implications for patients in their Emergency departments. The reviews should identify the extent of safety issues, and produce specific action plans that seek to reinforce what is acceptable and what is not acceptable practice.	Accept	All Local Health Boards and WAST have developed Unscheduled Care Plans that describe their strategic and operational approach to drive improvements in quality, patient safety and how they will deliver against national targets. These will identify risk and ensure that there are mitigating actions. All organisations are required to have robust clinical governance processes in place to identify and mitigate risk through the use of quality triggers and other tools, such as the 1000 lives plus executive safety walk rounds. Patient safety incidents are reported centrally and  thoroughly investigated.  HBs are required to have a comprehensive programme of quality improvement in place which takes into account lessons learnt from incident investigation, complaints and clinical audit.  The annual Fundamentals of Care Audit tool was revised this year and now has  specific questions for patients receiving unscheduled care, eg in ED. The tool is also being piloted by WAST. Data are being gathered in every organisation during October and November. Results will be submitted to Welsh Government in March. A summary of all NHS organisational reports is published annually on the Welsh Government (WG) website.
2a	Health boards’ progress in delivering their unscheduled care plans should be reported robustly and regularly to their board meetings, to the Welsh Government and within the new national programme;	Accept	The Welsh Government required each unscheduled care plan to be signed off at Board level and expect these to be published.   The Welsh Government monitor Local Health Board and WAST unscheduled care plans as part of a robust strategic and performance management framework which includes regular Quality and Delivery meetings with Boards and Chief Executive meetings. The plans are considered to be ‘live’ documents which should be updated frequently, aligned to the overarching National Work Programme for Unscheduled Care and promote shared ownership across local health economies.
2b	Those charged with developing the new unscheduled care programme should ensure the programme specifically addresses the issues presented in this report and in the Ten High Impact Steps to Transform Unscheduled Care (USC).	Accept	The National Work Programme for Unscheduled Care includes the Ten High Impact Steps to Transform Unscheduled Care
3a	As a matter of urgency, Health Boards and the ambulance service should implement the new national framework for patient experience and ensure that they are routinely asking patients about their experiences of unscheduled care, across the whole system and not just in the emergency department.	Accept	The Framework for Assuring Service User Experience was issued to NHS organisations in May 2013 along with a bank of generic questions. All organisations reported to Welsh Government at the end of September  that they are working to fully implement this Framework across their services during 2013/14. Data from the use of the generic questions is expected in November.  See also 1a for the expansion of the annual Fundamentals of Care audit to include unscheduled care areas in the data collection round for 2013. The national survey for Wales contains questions on how the public feel about the health service. Questions related to individuals’ health service experience will continue in future surveys. Results are fed back to NHS organisations for them to act upon.
3b	Unscheduled care indicators used by each Health Board and reported to their board members should include a much wider suite of measures that cover, as a minimum, patient experience and outcomes, primary care access, performance of out-of-hours primary care, ambulance service and local NHS Direct Wales performance, 4-hour and 12-hour waiting time performance in emergency departments, instances of corridor nursing and overnight stays in the emergency department, performance of community-based unscheduled care services and measures related to patient flow, including responsiveness of inpatient specialist teams in responding to referrals and requests to review patients from the emergency department.	Accept	The key indicators are already regularly collected and used by Health Boards. Each Health Board have developed performance trajectories that provide  a basis for the reduction of 4 hour waits, and the elimination of 12 hour waits and 1 hour handover delays. These trajectories provide the basis of and focus for management actions.    A great deal of work is currently being undertaken to make a range  of information more comprehensive, relevant and current.  As part of this, work is underway to develop an Integrated Unscheduled Care Dashboard that identifies and reports key information in real time, or near real time, across the Unscheduled Care Pathway, including Primary Care, ambulances and hospitals into social care.
3c	The Welsh Government should work with Health Boards to ensure the national Emergency Department Data Set (EDDS) is completed consistently and comparably across all units and that the data are used effectively to understand demand.	Accept	WG are taking a wider view of A&E data that aims to link data collection to the clinical management of the patient through A&E.  The NHS is currently undertaking a procurement for purchasing new local A&E systems. This will mean that there would be a preferred national A&E system which will ensure that data is collected consistently and comparably across Health Boards.  Aligned to this, WG are also exploring different options around the way we centrally collate A&E information, that may mean that EDDS in its current form is superseded by something that can work better with local systems to give more accurate information centrally. The aim is therefore to have more timely, accurate and consistent information available to local and central organisations to analyse and understand reasons for demand within A&E departments.
3d	In line with new standards issued by the Welsh Government, Health Boards should make it a priority to significantly improve their clinical coding performance.	Accept	The Welsh Government recognise that this as an important issue and wrote to the NHS in January 2013 outlining the new standards for coding completeness. Coding performance has improved since then and a regular report has been developed to monitor progress. This shows that a number of organisations have been achieving these standards on a regular basis over the past year. Additionally , the worst performing organisations have made encouraging progress towards meeting the standards by the end of the 2013/14 Performance against these standards form part of the Tier 1 Performance Framework and are discussed at Quality and Delivery Meetings with each Health Board and Chief Executives meetings with WG.
3e	Public Health Wales should build on its recent analysis of unscheduled care demand by providing health boards and the ambulance trust with support to strengthen local demand analysis. This support should aim to strengthen local organisations’ abilities to predict and pre-empt peaks in demand, across all unscheduled care services and not just the emergency department.	Accept	Further work is being undertaken by Public Health Wales (PHW) on unscheduled care. This is being used to support the NHS unscheduled care planning for this winter, in particular the detailed work in relation to demand and capacity analysis and planning. Public Health Wales has also started some in depth modelling of the unscheduled care system in Wales. This will utilise system data - including this winter’s data - and is intended to assist decision making for next year and future years. Public Health Wales have developed a process around cold (and hot) weather alerts. In line with their report, this is aimed at providing advanced warning of increases in demand associated with changes in temperature. This will link with the health boards’ escalation processes.  WG is exploring how best to use this information in the Unscheduled Care dashboard.
4a	If the Welsh Government decides to continue with the Choose Well campaign, it should: • Ensure the campaign complies with the National Social Marketing Centre’s good practice principles. In particular, the campaign should set clear, measurable targets and should be robustly evaluated. • Consider whether Choose Well would benefit from using the Mindspace18 methodology to optimise the approach of changing public behaviours.	Accept	Welsh Government intends to continue with the Choose Well campaign building on the foundations already laid. In line with the WAO recommendation, a workshop has been held with LHBs on understanding and using behavioural change techniques (Mindspace methodology and the good practice principles as set out by the National Social Marketing Centre) to help inform future activity at a local level. Welsh Government is currently obtaining information to identify which groups are the most frequent inappropriate users of unscheduled care services, to devote efforts to targeting these groups more effectively.
4b	The Welsh Government should take the following actions in relation to the 111 service: • as part of the decision-making process about the future of the 111 call service, come to a clear decision about the strategic direction of NHS Direct Wales; • develop a model for 111 that avoids all of the issues experienced in the English 111 service pilots; produce a detailed timeline setting out clear milestones that must be achieved before the final implementation of 111 in2015; • ensure that the 111 service has supporting electronic systems to gather information on call casemix and volume to help contribute to a better understanding of unscheduled care demand and patients’ urgent care needs; and • use the public communication campaign that will be needed to launch the new 111 service as an opportunity to communicate clearly and widely to the public about how best to access unscheduled care services.	Accept	NHS Direct Wales continues to provide a valuable health advice and information service for the people of Wales, distinct from the changes NHS Direct has undergone in England.  They also provide an important and integral part of the ambulance service’s clinical model for handling non-emergency 999 calls.  For this reason it will be an integral part of the consideration and decision making process in relation to 111. Work is about to begin to understand how the information from NHS Direct Wales can be used to understand pressure and demand.  Part of this will be to regularise the information, performance management and monitoring of NHS Direct Wales services. Plans for a 111 service for Wales are still being developed.  WG are keen to ensure that we use this opportunity to develop a service that is right for Wales and avoids unintended or unanticipated consequences.  Our priority is to ensure that the service will be robust and effective at the point of introduction and we are using the learning from NHS England and NHS24 in Scotland.  This is complex and as such timescales are still being considered at this stage.
4c	The Welsh Government should use the opportunity of the hospital network reconfiguration to develop national definitions of unscheduled care services and facilities, to improve public understanding of what these services provide.	Accept	The Minister has decided to defer decisions in respect of NHS nomenclature in Wales pending the outcome of a similar review taking place in England. He is keen to ensure, where possible, commonality of NHS terms for the people of England and Wales.
5a	The Welsh Government should facilitate a Wales-wide exercise to share good practice, from Wales and further afield, in the use of Emergency Nurse Practitioners (ENPs).	Accept	WG expects the sharing of best practice in relation to advanced practice roles, which encompasses ENPs.  An awareness raising event to celebrate advanced practice developments in NHS Wales has been planned for 9 December, which the Minister for H&SS will be attending. The object of this day is to illustrate the breadth of roles being undertaken and the potential for such roles in future, including  roles based in emergency and unscheduled care. Developing and changing the skill mix of the workforce through the introduction of new and extended roles has been a policy position for some time.  The introduction and development of Advanced Practitioner roles is a key enabler to meet the service and workforce challenges in NHS Wales. To support development of all advanced practice roles in Wales, Welsh Government issued a Framework for Advanced Practice in 2010. A review of implementation of this Framework was conducted by NLIAH (now WEDS) across all NHS Wales organisations and reported to Welsh Government in July 2013. Findings from the review are being discussed with NHS organisations to determine next steps in role developments.
5b	Health boards should monitor their use of ENPs to ensure they are not routinely drawn into core nursing roles and they should ensure that ENP roles are fully considered in their workforce plans for unscheduled care.	Accept	There is on-going research commissioned by the Welsh Government and being undertaken by WEDS workforce research fellow (hosted by Cardiff University) to explore the role and preparation of Advanced Practitioners in the NHS in Wales.
5c	The Welsh Ambulance Services NHS Trust should, as a matter of urgency, deliver transformation in the skill base of its staff so they have significantly stronger skills in assessing and referring patients.	Accept	The McClelland Strategic Review confirmed a new clinical vision for the  Ambulance Services that should be supported by appropriately trained clinical staff.  The Ambulance Trust is expected to develop a clinically robust workforce who are empowered to make decisions when treating patients that improve the patient outcome and reduce pressure on acute hospital services.  They have developed the competency framework that will now be used to inform future recruitment and to transform the skillbase of existing staff for future service delivery. As part of the Trust’s workforce planning, the Trust has developed over 20 Advanced Practitioner Paramedics (APPs). These highly trained paramedics have a more advanced skill set that allows them to treat patients within their homes, at scene or to convey them to other, more appropriate healthcare settings.  Encouragingly, the  latest figures from the ambulance Trust show that around 50% of patients who receive a response from an APP are treated at scene or at home. The Trust has also recruited two Emergency Medicine Doctors whose training, skill level and experience enable them to provide greater decision making and reduce the number of inappropriate conveyances of patients to hospital. They represented the first appointment of their kind in the United Kingdom. As part of the development of the clinical skills of its staff, the Trust has worked with Health Boards to develop alternative care pathways.   These pathways help to reduce the number of inappropriate ambulance journeys to busy A&E departments and reduce pressure by taking people to alternative healthcare settings other than A&E.. These pathways are now available in 5 of 7 LHB areas with agreement in principle to roll out in the remaining two Health Boards shortly.
5d	The Welsh Government should work with representative bodies and its counterparts across the United Kingdom to identify and address the root causes of recruitment and retention problems in the emergency department and primary care out-of-hours services.	Accept	The National Programme for Unscheduled Care is working in partnership with representative bodies such as the College of Emergency Medicine and the Royal College of Physicians. Key issues for recruitment and retention are the provision of a 21st-century care model, which is being addressed through service configuration initiatives.   An important principle is the appropriate concentration of senior clinicians to allow cover across the week, and effective job planning. This will enable the most unwell patients to be seen promptly by a senior clinical decision maker, and will help ensure staff are supported by a critical mass of colleagues at all times of the day and week.
5e	Based on local circumstances, health boards should consider revising their staffing models for unscheduled care services to include paramedics and nurses with extended decision-making skills. Health boards should also consider whether physicians and GPs can be used effectively in emergency departments to ease the recruitment and retention problems relating to middle-grade and consultant emergency medicine staff.	Accept	Local Health Boards are working in partnership with the Ambulance Trust to optimise paramedic pre-hospital models of care, and paramedics are already working within emergency departments as ambulance liaison officers. Local initiatives exist within health boards to use physicians within the emergency department, with the piloting of the use of GPs as emergency department decision makers in some health boards. Most health boards have recruited increasing numbers of acute care physicians in recent years, and a wide range of clinicians have a role working with emergency departments and the medical service to promote the effective flow of patients through hospitals.
5f	Given the increase in emergency department attendances from older patients, Health Boards should reassess the skill base of their staff for meeting the needs of older people.	Accept	Local health boards have initiatives in place to improve care for frail and older people, both as a response to national guidance, and as local initiatives. Local health boards are prioritising the recruitment of care of the elderly physicians as a key part of these initiatives. The CNO and Nurse Directors have commissioned  work on developing a framework to align nursing skills to patient need. This work is due for completion by April 2014 and is based on nurses developing a portfolio of evidence, in line with pre-registration standards and the Advanced Practice Framework. This will allow registered nurses to capture their skill base for meeting the needs of older people and provide organisations with detail with which to build their training programmes.
5g	Health boards should assess the levels and causes of stress within emergency department staff, with a view to protecting and supporting the workforce.	Accept	The winter planning arrangements specifically address how Health Boards will ensure staff well being is monitored and addressed, particularly at times of pressure.  The benefits of recognising and managing stress are significant, from the perspective of patient care and staff experience. The Minister for Health and Social Services has asked NHS Wales Local Health Boards and Trusts to plan to deliver a reduction of at least 1% in their levels of sickness absence by the end of 2014-15.  Intervention plans are to be submitted to the Welsh Government by 15 November 2013.
6a	Health boards should work with GPs to agree local standards for access to urgent primary care; and once agreed the extent to which these standards are achieved should be routinely monitored.	Accept	The General Medical Services Contracts requires the contractor to provide an essential service at such times within core hours, appropriate to meet the reasonable needs of patients and “to have in place arrangements for its patients to access such services throughout the core hours in case of emergency “. A clinical response may include telephone advice, face to face contact or referral. Discussions on the development of local standards for access to urgent primary care in hours will be taken forward with Health Boards and GPC Wales, with advice from the GP National Specialist Advisory Group.
6b	Health boards should strongly encourage general practices to implement access arrangements that reflect good practice. In doing so, Health Boards should highlight the benefits that these good practices can bring to patients as well as to those working in general practice.	Accept	Local standards of access are covered in 6a above. Examples of good practice have been shared through the Assistant Medical Directors (Primary Care) network and primary care development workshops. Further work will be done to encourage adoption of innovative approaches appropriate to the needs of particular populations. The BMA General Practitioners Committee  has issued  guidance Developing General Practice: Listening to Patients , which contains examples of good practice , covering  patient involvement, practice opening, appointments, consultations, patient information and staff training .
6c	Health boards should strengthen the support, guidance and information they give to GPs in order to avoid inappropriate emergency admissions.	Accept	Guidance in relation to the data requirements for the Quality and Productivity Indicators within the Quality and Outcomes Framework  has been issued . Officials will be discussing with Health Boards what can be done to strengthen the support, guidance and information they give to GPs in order to avoid inappropriate emergency admissions , in particular, the need for Health Boards to ensure that: the quality of the data provided to GPs is robust;  the need to improve the sharing of information in relation to admission rates; and the need for information systems to be able to disaggregate attendances and admissions at a practice and doctor level. GP practices are also undertaking risk stratification to ensure that active management plans are in place for patients most at risk of unscheduled admission.   Whilst this will focus on the small proportion of those most at risk, the aim of this work is to identify opportunities to improve systems of care more generally  and the findings will feed into whole system urgent care service development
6d	Health boards should request that GPs provide them with data on their capacity and demand for seeing patients within the practice. Health boards should work with primary care providers to ensure these data are analysed and used to improve services.	Accept	Data on the number of appointments available to meet predictable demand from patients without the need for unplanned extra appointments is not currently collected by Health Boards.  Health Boards will need to consider how this new data can be collected through current GP practice IT systems without impacting significantly on the workload of GP practices. Analysing GP practice demand and capacity data will improve the ability of GPs to match the service needs of patients with their clinical capacity and skill mix thus improving the ability to plan the service.  Health Boards are seeking to support local analyses and problem solving. The Local GP networks will continue this work informed by the developing PHW analysis of demand across the system.
7a	Health boards should facilitate improved teamwork and mutual support between key staff groups involved in unscheduled care. This work should focus, in particular, on generating more shared ownership of the pressures and patient flow issues that exist in emergency departments by improving the links between staff in emergency departments, Clinical Decision Units (CDUs) and inpatient ward teams.	Accept	All health boards, along with WAST, are participants in the 1000 lives plus patient flow programme, which supports healthcare teams to improve unscheduled patient flow through a continuous improvement approach. This program is now sponsored by the National Unscheduled Care programme, and will have its next national collaborative meeting in December. The Unscheduled Care and Winter Plans address the pressures and patient flow across the whole patient care pathway.
7b	The Welsh Government’s Department of Health and Social Services should lead a specific programme of work to support better integration of health and social care with the aim of ensuring the timely discharge of patients that are ready to be discharged from hospital. This programme should use the forthcoming Social Services and Well-being (Wales) Bill as a key driver for change but it should not wait for the bill to be enacted.	Accept	Much progress is being made to drive forward greater integration of health and social care services with a particular focus on the more timely discharge of patients. For example, LHB Winter Plans were created jointly with local government with an emphasis on timely flows of patients through the healthcare system. Welsh Government has recently published two documents relating to integration of services, these include Delivering Local Health Care - accelerating the pace of change, and  Integration Framework for older people with complex needs. These documents highlight a range of both short and longer-term actions for Health Boards, Local Government and partners to improve the services, care and support for people across Wales through new service models and more effective partnership working. A Task and Finish group was commissioned by WG to develop interim guidance to replace the existing guidance on the currently complex Unified Assessment Process (UAP) for older people. The purpose of this is to develop more effective integrated assessment arrangements between health, local government and partners to ensure more timely and effective support to people in need.  This will be published in December and will operate for a limited period of time until the implementation of the Social Services and Wellbeing (Wales) Bill. It will not change the existing eligibility framework in the short term. Work is underway to revise the 2010 National Framework for Continuing NHS Healthcare (CHC). The revised Framework will address the issues raised in this year’s Wales Audit Office (WAO) report which looked into the effectiveness of existing CHC arrangements including joint working.  It will also complement the interim guidance developed to replace the UAP, introducing a streamlined assessments for CHC, resulting in more timely and effective decision making.  This, in turn, will facilitate the movement of individuals through the system and ensure they receive appropriate care and support. The Social services and Well-Being (Wales) Bill strengthens the duties on both Local Authorities and Local Health Boards to work collaboratively.  It also provides for new powers for Ministers to direct partnership working at local, regional and national level across local authorities and across local authorities and health. To support integration, as part of the Budget Agreement for 2014-15, the Welsh Government has agreed to establish an Intermediate Care Fund.  The Fund, totalling £50 million, has been established to incentivise integration of health and social services.  Further, the draft budget includes £15 million of capital for Housing and Regeneration and £35m of revenue in Local Government.  The intention is for both streams of funding to be managed as a single fund to support a coherent package of measures in local areas, based on the regional collaborative footprint. The aim is to drive integration of services and to help individuals stay in their own homes through avoiding unnecessary hospitals admissions and to ensure a timely discharge.  It is intended to increase the pace and scale of change and encourage service transformation. Examples of provision include: Re-ablement services – at home or in a jointly-commissioned bed at a residential home or convalescence bed at a community hospital; and 24/7 acute rapid response teams to avoid inappropriate admissions. Joint meetings between the Minister for Local Government;  the Minister for Health and Social Services; and the Deputy Minister for Social Services with Local Health Boards and Local Authorities have taken place, with further ones planned over the winter. Discussions have taken place about what local health communities are doing to reduce delayed transfers of care and how to accelerate social care assessments and discharges in their areas.