WP 10

Ymchwiliad i barodrwydd ar gyfer y gaeaf 2016

Inquiry into winter preparedness 2016/17

Ymateb gan: Conffederasiwn GIG Cymru

Response from: Welsh NHS Confederation



The Welsh NHS Confederation response to the Health, Social Care and Sport Committee Inquiry into winter preparedness 2016/17.


Nesta Lloyd – Jones, Policy and Public Affairs Manager, the Welsh NHS Confederation.



8 September 2016



1.       The Welsh NHS Confederation represents the seven Health Boards and three NHS Trusts in Wales. The Welsh NHS Confederation supports our members to improve health and well-being by working with them to deliver high standards of care for patients and best value for taxpayers’ money. We act as a driving force for positive change through strong representation and our policy, influencing and engagement work.


2.       We welcome the opportunity to contribute to the Health, Social Care and Sport Committee inquiry into winter preparedness. Operational planning processes need to be in place all year round however experience demonstrates that the winter months pose particular challenges for health and care organisations. Unscheduled care services face further pressures during the winter months and it is an area which impacts on how patients and the public experience health and care services. The reasons for the year-round pressures on unscheduled care services are well known.


3.       The unscheduled care system is faced with increasing activity and patient acuity and is compounded by workforce supply pressures during the winter. However when the Committee considers these pressures and challenges it is vital that the whole health and care service, and not only the acute hospital services, are considered. Unscheduled care performance is a whole-system issue that is significantly affected by community, social care, primary care and preventative care services.



i.                    The current pressures facing unscheduled care services, and how well prepared the Welsh NHS and social services are for winter 2016/17;

4.       There are a number of significant pressures facing unscheduled care services in Wales, however Local Health Boards and Trusts, through their Integrated Medium Term Plan (IMTP) processes and winter plans, are ensuring that they are prepared for this year’s winter. Winter plans cover the period between October 2016 to May 2017.



a)      Pressures facing unscheduled care services


Rising demand

5.       Changes in how people live their lives and the success of the NHS in keeping people alive for longer means demand for care is rapidly rising. An ageing population, combined with more people having increasingly complex needs, means that demand for health and social care services is predicted to grow rapidly in coming years. Wales currently has the highest rates of long-term limiting illness in the UK. Between 2001-02 and 2010-11 the number of people with a chronic or long-term condition in Wales increased from 105,000 to 142,000.[i] All these factors affect people’s health and increases demand on health and care services.


6.       The ageing population has a significant impact on demand for health and social care services all year round, but particularly during winter months. The ageing population, accompanied by increasing co-morbidity, medicalisation, frailty and social isolation, is a long term driver of unscheduled care demand. As people live longer but have fewer children, there is an increased proportion of the population who are dependent on care. On average, older people have lower baseline functions, greater frailty and lower resilience. This leads to greater need for support for the activities of daily living, tipping over into acute ill health at a lower threshold, and slower recovery from illness, which places increased demand on health and social care services.


7.       While attendance at Emergency Departments (ED) remains generally static, the complexity of patient need and other influencing factors have resulted in performance not improving despite numerous initiatives focussed on ED efficiency. The complexity and severity of conditions of those admitted places a huge strain across ED. The most significant issue is not the numbers of people presenting at ED but the ability to provide alternatives to admission alongside the ability to transfer patients safely and quickly from hospital to their place of residence and to prevent readmission.


8.       In addition to ED, the pressures on critical care units can increase during the winter. Critical care provides specialist support for patients with acute life-threatening injuries and illnesses, often when one or more organs have failed. As highlighted within the Annual Report 2016 for the Critically Ill,[ii] critical care beds are not always used appropriately due to problems with patient flow through the hospital. For example, not all patients in critical care beds require that level of care but some might be awaiting discharge to hospital wards and this delay to hospital wards can increase during the winter months. This then has a knock on effect and can result in cancelled operations or patients who require critical care being transferred to other hospitals who have a critical care unit.


Seasonal factors and respiratory infections

9.       Hot and cold weather are both associated with increased demand for unscheduled care services. Respiratory illnesses have a distinct seasonal pattern, with an increase in winter largely due to influenza infection leading to hospital admission and excess winter mortality. Other viral infections, such as noro virus, are also common in the winter. Both viruses can place significant short term strain on unscheduled care services.


10.   Seasonal influenza and other respiratory virus infections can significantly affect demand for unscheduled care in the winter. Fortunately, in recent winters seasonal influenza has not reached the “higher than average activity” threshold but primary and secondary care systems still need to ensure that they have the surge capacity to respond to such increase in demand as they are likely to occur every few years.



11.   The NHS ability to respond to winter challenges is constrained by a number of factors, including the NHS workforce. Recruitment issues exist within all staff groups and core medical, nursing and therapy workforce capacity impacts on the NHS ability to find the increase in the workforce required during the winter. In some Health Boards workforce capacity remains fragile in areas such as ED, Acute Medical Services and District Nursing, despite proactive recruitment at home and overseas, and introducing changes to workforce models to provide sustainability.


12.   While workforce strategies, including overseas recruitment for nursing/therapies, are in place recruitment and employment processes have been, and continue to be, challenging. For example nursing and senior nurse cover are co-ordinated to ensure robust arrangements are in place, however this is always challenged by sickness and vacancy impacts, and can lead to an increased use of agency and bank staff. The availability of bank and agency staff can be limited during peak holiday periods and experience has proven that the reliability of agency staff attending for their shifts can be problematic for some Health Boards.


Infrastructure constraints

13.   One key aspect of winter planning for this year is the ability to manage surges in activity from the heralded emergency caseload whilst maintaining levels of elective activity. Most hospitals in Wales have very few surge areas available to them during the winter. This limits both the creation of additional bed capacity for winter and the options for managing infection prevention and control outbreaks.


14.   Within acute services, difficulties can be encountered with the number of acute emergency admissions presenting and as a consequence the ability to accommodate this caseload alongside planned elective activity. Furthermore, available bed capacity often becomes compromised by bed closures resulting from infections, particularly of a viral gastrointestinal nature.


Delayed transfer of care

15.   In order to ensure a smooth flow of people through the care system (primary, community and acute health and social care), it is imperative that all patients are able to be transferred or discharged in a timely fashion when their episode of care is complete. One way of measuring flow efficiency, particularly between various parts of the care system, is to measure delayed transfers of care. While there are still some significant issues around delayed transfer of care, and Health Boards are fully aware they need to be reduced further, a number of initiatives are happening across Wales which is improving delayed transfer of care.


16.   Across Health Boards there is a focus on patients who are medically fit, ensuring the assessment and discharge process is timely and any delays are escalated and dealt with at a senior level. Discharge standards are in place across community and Local Authorities to ensure patients are assessed and discharged within agreed timeframes. Collaborative working between community and acute managers is now a routine way of working across Health Boards to ensure appropriate levels of discharge is maintained. Examples where this is done include;

·         ‘Bullet rounds’ – daily multidisciplinary rounds to discuss progress of patient recovery and plan interventions to support discharge;

·         Weekly meeting and teleconference calls to monitor discharge planning of complex patients against Estimated Date for Discharge (EDD);

·         Weekly multi-agency review meetings held with each ward manager; and

·         Daily reports shared across health and social care identifying patients on the Discharge Working list.


Changes in non-NHS service provision

17.   A range of community services are under pressure and are providing less support in the community, leading to backward pressure on the discharge of patients from high intensity inpatient care. There has been pressure on social services budgets over a number of years with changes in the threshold at which individuals receive access to support. In some demographic groups there are incentives to look after the frail elderly at home to avoid the high cost of residential or nursing home costs. The timescales at which assessment progresses for residential or nursing home care are widely recognised as a factor contributing to delayed discharges from hospital care.

Fragility of the private sector domiciliary care market

18.   A recent exploratory analysis undertaken by the Welsh Government suggests that there has been a fall in private sector residential and nursing home beds in Wales[iii] which can impact on delayed discharges from hospital care. Some areas are also reporting a reduction in home care packages. These factors reduce the overall pool of resource available and contribute to increased backward pressure on NHS inpatient services.


19.   Last winter a number of domiciliary care providers across a number of Health Boards handed back packages of care. This impacted on capacity within Health Boards community resource teams and their ability to take on new hospital discharges, as well as supporting patients in their own homes. A careful balance has to be struck between releasing community capacity to help reduce delayed transfers of care from hospitals, whilst not saturating available capacity in the community. This issue has continued through the year with a number of private providers leaving the market, but this is not just a winter issue.



b)      How well prepared is the Welsh NHS.

20.   Health Boards and Trusts, as part of their IMTP process, review previous winter plans and performance each year and then develop plans for the forthcoming winter period. As part of this process Health Boards implement their unscheduled and urgent care improvement plans and consider the priorities that have been confirmed as part of their individual IMTP process for 2016/17. The Health Boards also consider guidance that has been issued by Welsh Government and once completed winter plans have to be submitted to the Welsh Government. The Welsh Ambulance Services NHS Trust (WAST) also has robust winter plans in place at strategic, operational and tactical levels. More information on this can be found in the evidence from the WAST, which is the subject of a separate submission to this inquiry.                                                   


21.   Health Boards continue to develop a whole system view of urgent care that allows them to take early decision making across the patient pathway, knowing that pressures often manifest early in their primary care services prior to the surge in secondary care. When developing their winter plans Health Boards consider the demand through mapping against the previous years, however this needs to take into account significant events e.g. prolonged snow/cold weather and outbreaks of the norovirus, especially as last year was a mild winter with no significant outbreaks of norovirus.


22.   In order to provide assurance to their Executive Boards, likely demand is mapped against previous years and a number of bed modelling scenarios undertaken to deliver the capacity required for unscheduled care. While demand is mapped against previous years the most difficult part of planning for winter is the scale of variation in demand from one winter to the next, particularly in relation to medical bed capacity. For some Health Boards the range can be an additional 10 beds or an additional 100 beds. Given the financial, workforce and infrastructure limitations it is not always possible to prepare for all eventualities and the NHS can usually only plan for a typical winter rather than the extremes.


23.   When managing winter pressures a suite of integrated plans are produced and implemented by Health Boards, including;

·         Seasonal Pressures Plan: Cold weather plans to ensure that services are maintained in the event of adverse weather conditions;

·         Escalation and Capacity Plan;

·         Community Hospital Capacity Management Plan;

·         Hospital Discharge Policy and Procedure;

·         Immunisation Plan, to increase the uptake for staff and vulnerable patients;

·         Demand Management (5 Step Care Pathway);

·         Capacity Management;

·         Escalation Management; and

·         Infection control: Enhancing support in relation to infection control/ respiratory equipment which sees a peak in demand during the winter months.


24.   The main aims of the plans are to implement actions in order to manage surges and variation in demand, enable improved flow across the system and maintain service levels in all areas to improve access for patients.


25.   As previously highlighted, when developing their plans Health Boards review and evaluate last year’s performance over the winter period and put in place actions to improve responses to winter pressures this year. Some of the key priorities highlighted by Health Boards to be taken forward this year include;

·         Full implementation of discharge improvement plans;

·         Right sizing community and core services capacity;

·         Implementing new processes and pathways that reduce ambulance conveyance to Emergency Departments;

·         Implementation of the 111 service in Abertawe Bro Morgannwg University Health Board;

·         Maintain patient flow improvements and ward processes;

·         Redesigning front door services/ models of care;

·         Improving escalation processes;

·         Unscheduled Care Programme established to ensure improvements are made to the unscheduled care system looking at 5 key areas; informatics, in hospital flow, discharge, locality development and workforce to build resilience for the future;

·         Primary and Community Out Of Hours services need to be enhanced to avoid increases in attendances and referrals to hospital services;

·         Further development of ambulatory care pathways can reduce the pressure on both admissions and Emergency Departments;

·         Improved discharge planning for complex care patients is vital if length of stay is to be managed and delays to discharge minimised;

·         Dedicated site management improves flow and the Health Boards ability to de-escalate; and

·         A specific plan for March and Easter needs to be developed as winter continues.


26.   Health Boards are also using information to drive their decision making with tools that allow them to predict speciality requirements month on month. The challenges that Health Boards have rest on the ability to change their workforce requirements to meet the type of demand, particularly in difficult to recruit groups of staff. Health Boards capacity to meet demand is focused more on the teams who care for patients as opposed to the place where they care for patients (beds, trolleys, clinics etc). Therefore Health Boards are developing a range of options that will be dependent on the staffing resource models available.


27.   The provision of an integrated seasonal plan is seen as one element of Health Boards system wide approach to improving unscheduled care and urgent care services and cannot be viewed in isolation, albeit that the winter presents some different challenges to the all-year-round system demands. To ensure the production of a single integrated winter plan, Health Boards develop their plans in conjunction with the Welsh Ambulance Services NHS Trust (WAST), primary care colleagues, Local Authorities, voluntary and the independent sector. This highlights the whole system approach to the management of unscheduled care which maximises the contribution of every service, with the aim of caring for patients in the right place, at the right time and by the right care team. It is part of a three year rolling IMTP, which has been prepared against the background of the NHS Wales vision for unscheduled care.


28.   Finally, many Health Board plans, as in previous years, have been underpinned by significant investment in their unscheduled care services. This includes additional staff appointments, extended day working and the introduction of new models of care. The unscheduled care improvement plan is also being supported using a service improvement approach to developing sustainable change going forward.



ii.                  Whether there has been sufficient progress in the fourth Assembly in alleviating pressures on unscheduled care through integrated winter planning across health, social and ambulance services, and lessons learned;

29.   Overall there has been sufficient progress in the fourth Assembly in alleviating some of the pressures on unscheduled care. A number of initiatives and policies have been introduced and implemented during the fourth Assembly. The NHS works with partners in their local areas to manage the pressures facing health and social care during winter, with collaborative working taking place throughout the year to enhance joint activities to support and improve service delivery and reduce system pressures. While progress has been made a number of challenges still exist which will be responded to by the NHS in Wales.


Unscheduled Care Reports and Tools

30.   A number of unscheduled care reports and tools have been introduced over recent years to support the NHS in Wales to respond to and alleviate the unscheduled care pressures that they face. These have included:

·         A Toolbox of Actions to Address Pressures in Unscheduled Care (January 2015): This document forms a concise reference guide for NHS Managers in Wales. It lists thirty actions which might be used to address pressures in the unscheduled care services in NHS Wales.

·         What Drives Demand for Unscheduled Care Services in Wales? (January 2015): This report describes a wide range of important ‘drivers’ which contribute towards the growing gap between demand and supply in unscheduled care.

·         Atlas of Variation in Unscheduled Care (November 2014): This interactive atlas presents indicators from across the unscheduled care system in Wales, relating to both the need for services and their utilisation. The web resource, introduced by the Public Health Wales Observatory, aims to stimulate discussion, improve understanding and inform decision-makers on local factors and their influence on the unscheduled care system.

·         External Factors Affecting Long Term Trends and Recent ‘Pressures’ on Unscheduled Care Use and Performance in Wales (June 2013): This report examined the external factors affecting long-term trends and pressures affecting the unscheduled care and performance in Wales, especially for major A&E departments during the winter and spring of 2012/13.

·         Unscheduled Care Analyses (March 2013): The Public Health Wales Observatory has published a series of analyses for health boards which have emergency departments (EDs) within their boundaries. The analyses include information from the Emergency Department Data Set (EDDS).




Programme for Unscheduled Care

31.   The NHS Wales Programme for Unscheduled Care has supported the NHS to alleviate some of the pressures on unscheduled care. The Programme sets out a 10 step patient pathway that recognises that actions taken outside of an emergency facility can have a major impact for the demand for, and use of, such a facility. This reflects the approach that Health Boards have adopted in recent years where their Unscheduled Care Improvement Plan has successfully focussed on:

·         Providing services that reduce unscheduled care demand in the first place, especially for emergency care; and

·         Ensuring that once an acute episode of care is complete, the transfer back to the community is timely and safe.


32.   Increased collaboration has also been key to ensure improvements. Overall, Health Boards have a positive track record of joint working to manage the pressures facing health and social care during winter, with collaborative working taking place throughout the year to enhance joint activities to support and improve service delivery and reduce system pressures. Through working collaboratively Health Boards have ensured that actions within the plans are implemented in order to manage surges and variation in demand, enable improved flow across the system and maintain service levels in all areas to improve access for patients.


Prudent healthcare

33.   Informed by the work of the Bevan Commission and others around the world, the NHS in Wales has taken on the principles of prudent healthcare as it responds to the growing challenges it faces. The prudent healthcare principles were introduced in 2014 and puts NHS Wales at the front of a growing international effort to get greater value from healthcare systems for patients. As part of prudent healthcare the NHS in Wales is ensuring that people access care at the right level for their needs; right care; right time; right place; right people. As part of this principle healthcare is provided to fit the needs and circumstances of patients and avoids wasteful care. This includes keeping people healthy and living independently in their own homes and communities as much as possible, thus reducing inappropriate demand on more acute healthcare services, and returning people back to their communities from acute care as quickly as safety allows, thus improving the flow through the healthcare system.


Supporting those at highest risk

34.   Health Boards are identifying those patients at high risk of admission and are particularly focusing on the frail elderly. To support this, within primary care, some Health Boards have purchased a software package to risk stratify patients who will then be discussed at primary care Multi-Disciplinary Team (MDTs) meetings. These MDTs proactively develop management plans to reduce the risk of avoidable hospital admissions.


35.   Community Services play a significant role in maintaining patients at home and avoiding unnecessary hospital admissions. Health Boards have identified resources and services to address the surges in activity experienced during the winter months when levels of patient acuity can increase. There is a focus on providing re-ablement, rapid response domiciliary care service and step up facilities to avoid hospital admissions. This is supported by the development of roles to focus on and develop community resilience with the third sector. Through funding from the Intermediate Care Fund, IMTP and Cluster Networks, community teams have been strengthened.


36.   National pathways have been developed with the WAST which includes Falls, resolved Hypoglycaemia and resolved Epilepsy. Further pathways are being developed with the implementation of 111 service in 2016 in Abertawe Bro Morgannwg University Health Board. In addition, there are a number of more local pathways, a good example of which is that for mental health in Cardiff and the Vale University Health Board. The Frailty Pathway is also being developed across a number of hospital sites to provide timely elderly assessment to avoid admissions. Frequent hospital attenders are also reviewed jointly between Health Boards and the WAST and management plans are put in place to avoid hospital conveyance and admission where appropriate. Again, there is more detail about this in the separate evidence submission from the WAST.


Choose Well campaign

37.   The Choose Well campaign was developed in 2011 to give people more information and to help them make the right decision on which services they choose based on their symptoms. This helps people access the right treatment and professional advice when they need it. Health Boards and Trusts are working to educate their local population in regards to the provision and availability of alternative services. The Choose Well campaign is promoted at every opportunity by the NHS in Wales, including in any public engagement events and through social media.


38.   In addition to the Choose Well campaign the Welsh Government has introduced Choose Pharmacy. Originally it was piloted in 32 pharmacies, 19 pharmacies in the Betsi Cadwaladr University Health Board and 13 in the Cwm Taf University Health Board area in October 2014. It provides patients access to free treatment for a rage of common ailments from the pharmacy rather than them having to make an appointment to see the GP. In March 2016 Choose Pharmacy was extended to cover the whole of Wales and the scheme should help to free up GP time to deal with people with more complex needs – up to 18% of GPs’ workload and 8% of emergency department consultations are estimated to relate to minor ailments,[iv] such as coughs, colds, ear ache, hay fever, conjunctivitis and head lice. A review[v] into Choose Pharmacy has already highlighted several positive outcomes, including improved patient access, better use of pharmacists’ skills and resources, and improved public understanding of the support available at their local pharmacy.


Joint working with Public Health Wales NHS Trust

39.   There has been a significant amount of work between Health Boards and Public Health Wales NHS Trust to plan for the flu campaign. This has executive director leadership and senior management support in many Health Boards. Flu champions are identified within nursing teams and community nurses have undergone training to immunise patients on their caseloads.


40.   There has been collaborative working between Health Boards and Public Health Wales NHS Trust in relation to adverse weather forecast and anticipatory planning to support anticipatory management of respiratory conditions.  Also Public Health Wales NHS Trust provide intelligence in terms of any impact specific issues can have e.g. norovirus impacting on nearby Health Boards to enable early warning triggers.



iii.                The actions needed to produce sustainable improvements to urgent and emergency care services, and the whole system, ensuring the Welsh NHS builds resilience to seasonal demand and to improve the position for the future.


Vision for NHS Wales

41.   There is a huge degree of consensus across health and care organisations on the key challenges facing the health and care system as a whole. If we are to better meet people’s needs and ensure taxpayers get the best possible value from the money we put into health and care services then change will be necessary. Recognising the need for action, the Welsh NHS Confederation is calling on the Welsh Government to develop a long term vision and ten year strategy for sustainable health and care services in Wales. The development of an explicit vision and strategy for health and care would help NHS organisations to develop and implement new service delivery models and transformational change with greater pace and scale. It will provide a strong strategic context for change that is understood and supported by politicians, partners and the public.



42.   Integration across health and social care is key. The health and well-being of the population is not the sole responsibility of the NHS - everyone must come together to play their part. To provide patient-centred care, collaborative working is vital. Integration needs to happen, both within and outside the health service. The NHS will not be able to rise to the challenges it faces without the help of our colleagues in other sectors, including housing, education and, in particular, those in social services. The new Public Service Boards, introduced as part of the Well-being of Future Generations (Wales) Act 2015, will enable public services to commission and plan collaboratively, ensuring that services are integrated and that care and support provided improves health and well-being outcomes for the local population. The Act should help drive collective decision making models within national and regional priorities, especially around service reconfiguration.



43.   Prevention and early intervention to improve population health is a national priority for the NHS in Wales. We all recognise that it is the key to improving the health and well-being of the whole population, while helping to manage demand on secondary care. Wales faces a significant number of public health challenges, including high levels of obesity, drinking above the guidelines, smoking and poor levels of physical activity. The impact of such behaviours on our health is resulting in significant demand being placed on the health service. Bold decisions are now required to make industrial scale change in our services and shift the funding to support people to make better lifestyle choices.



44.   The vision for unscheduled care in Wales is that people should be supported to remain as independent as possible, that it should be easy to get the right help when needed and that no one should have to wait unnecessarily for the care they need, or wait to go back to their place of residence. The NHS in Wales will achieve this by working with patients and carers as equal partners to provide prudent care.


45.   Self-care plays an important role in helping to reduce demand on over-stretched primary care and emergency departments during periods of increased demand. Self-care can prevent ill-health in the long-term, and can help reduce the burden on general practice in the winter. Furthermore there is a need for an open and honest conversation with the public about what the NHS can provide in the future. While the NHS is free at the point of contact, it is not free of obligation, and the public will need to be supported in taking more responsibility for their own health. Patients need to become partners in managing and improving their health, rather than passive recipients of healthcare. However, increased use of self-care and its promotion should only be one of many measures taken to increase the resilience of the NHS to beat the effects of winter pressures.


Service change

46.   With increase demand it is clear that the NHS needs to transform and adapt when it comes to the way it approaches care and treatment for people. For the sustainability of the NHS to be secured, and for it to continue to deliver high quality care, it cannot do things in the same way. This trend is likely to continue unless system change is addressed and a way of funding across pathways of care can ensure parity of resources aimed at primary and community based services, which are proven to keep people out of hospital settings.


47.   While social care is an important part of the solution, improvements and substitution of services will not manage all the pressures on the system. There is also a need to remove some of the complexity of different services that has been built into the system which can confuse the public. However, in the absence of accurate data outside hospital, fostering a better understanding of the way that local systems work will not be easy.


The role of primary care

48.   The OECD Review of Health Care Quality UK, raising standards,[vi] recommended that Wales should “Put Primary Care front and centre as a force for dynamic system change”. It proposes that this requires the continued growth and support of primary care clusters and their activities as well as fostering new models of care delivery, incentivising innovation and new ways of working. This reinforces the work that is already underway and requires a sharpening of focus and increase in pace of delivery.


49.   Implementation of ‘Our plan for a Primary Care service for Wales up to March 2018’,[vii]  has progressed over the last 12 months, supported by additional funding for Cluster Networks and pacesetters. However, significant progress will only be made if equal priority is given at both individual Health Board and national level to improving primary, community and social care alongside secondary care. This will require the development of a balanced approach at Health Board level to core funding of areas where real evidence demonstrates benefits accruing to the whole system.




50.   The NHS in Wales continues to work in an integrated and planned way to alleviate the pressures and challenges that it faces, especially during the winter period. In order to adequately respond to the pressures that health and care services are facing, it is vital that there is sufficient capacity across the entire health and social care system, including accident and emergency departments, general practice and social care provision.


[i] Nuffield Trust, June 2014. A Decade of Austerity in Wales? The funding pressures facing the NHS in Wales to 2025/26.

[ii] Welsh Government, August 2016. Together for Health: Annual Report 2016 for the Critically Ill

[iii] Health statistics Wales 2014, Summary results, Table 15.2 and Chapter 16, Table 16.1,

Welsh Government.

[iv] Pharmacy Research UK, January 2014. Community Pharmacy Management of Minor Illnesses (MINA Study).

[v] Welsh Government, July 2015. Evaluation of the Choose Pharmacy common ailments service.

[vi] OECD, February 2016. Reviews of Health Care Quality: United Kingdom 2016.

[vii] Welsh Government, February 2015. Our plan for a Primary Care service for Wales up to March 2018.