WP 14

Ymchwiliad i barodrwydd ar gyfer y gaeaf 2016

Inquiry into winter preparedness 2016/17

Ymateb gan: Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru

Response from: Welsh Ambulance Services NHS Trust



Welsh Ambulance Services NHS Trust: Submission to Health, Social Care and Sport Committee Inquiry into Winter Preparedness September 29, 2016




1.       The Welsh Ambulance Service welcomes the opportunity to submit evidence to the National Assembly for Wales’ Health, Social Care and Sport Committee in support of its inquiry into winter preparedness.


2.       The challenges faced by the Welsh NHS in managing the demands of the winter season have been well-documented in recent years. An older and increasingly unwell and frail population, the seasonal impact of potentially adverse weather and higher levels of sickness, both within the community and among NHS staff, coupled with long-standing system issues, can inhibit the ability of patients to be cared for in the community. This is often because of pressures on community-based health and social care services, which combine to affect detrimentally the quality and timeliness of services provided to patients.


3.       What has become apparent more recently is that system pressures now persist across the year to a greater or lesser extent and, while planning for the winter is clearly a key element of the Welsh Ambulance Service’s annual planning cycle, the need to think in a more integrated and innovative way about managing demand is something which has become a feature of the Trust’s work throughout the year.


4.       This is, in part, why the Welsh Ambulance Service has taken a more integrated approach to planning for the winter season this year, ensuring that plans developed at local level are more closely aligned with health board planning, while developing a multi-level, Wales-wide organisational plan that covers strategic, tactical and operational issues.




5.       Following a protracted period of poor performance, poor employee relations and intense public and political scrutiny, the Welsh Ambulance Service has been on a journey of recovery and improvement since the autumn of 2014.


6.       Under the leadership of a largely new Board and Executive Management Team, the organisation has made measurable progress on its journey of improvement to tackle some of its long-standing organisational issues, working closely with its staff and trade union partners to deliver a step change in performance and in outlook.


7.       The introduction of commissioning arrangements through the Emergency Ambulance Services Committee and the Chief Ambulance Services Commissioner has also provided a strong national focus on care standards and improvement, through a collaborative commissioning and delivery approach involving all health boards and the ambulance service.


8.       The standards required of the Welsh Ambulance Service are set out in the Commissioning and Quality Delivery Framework, which sets out a Five-Step Ambulance Care Pathway.  This details the steps in the delivery of emergency ambulance services in NHS Wales.  The Ambulance Care Pathway encourages a focus on the way patients flow through the unscheduled care system as a whole and covers the journey from helping patients choose the right service for them (Step 1), to taking very ill patients to hospital  or another place of care (Step 5).


9.       The advent of a new Clinical Model in October 2015, for an initial pilot period of 12 months, has further improved performance and has firmly repositioned the Welsh Ambulance Service as a clinically-led and quality driven service.


10.   However, the impact of seasonal pressures on performance, and on the quality of service provided to patients, is something of which the Welsh Ambulance Service has been very aware in its 2016/17 planning. Detailed below is an indication of the approach adopted and some of the interventions proposed to ensure that both quality and timeliness of service are maintained during the 2016/17 winter period.


Planning for Winter: Assumptions and Previous Learning


11.   In developing its Winter Plan, the ambulance service has been cognisant of the need both to learn from its experiences, particularly of last winter, and to balance this learning with a set of strategic and operational assumptions.


12.   An over-riding assumption in that planning has been that the new Clinical Model, which the Welsh Ambulance Service has been piloting for a 12-month period from October 1, 2015, would continue for the duration of the plan. This has now been confirmed with Welsh Government’s recent notification of an extension of the model until March 2017.  This is welcomed.


13.   Similarly, the Winter Plan contains some critical elements which are not resource neutral and require additional funding in order to realise. At the time of writing, this funding has yet to be secured through the commissioning process, although discussions are continuing.


14.   Historically, winter planning at the Welsh Ambulance Service has not sufficiently balanced strategic imperatives and operational requirements. This year, an approach has been adopted which attempts to do this, while also ensuring the plan is underpinned by more tactical plans to address specific pinch points, for example the Christmas and New Year period.


15.   The introduction of Ambulance Quality Indicators (AQIs) means that there is an agreed data set to review patient flow and performance over the 2015/16 winter period and also to predict patient flow for the coming winter.


16.   For the purposes of clarity, the Welsh Ambulance Service’s Winter Plan has been presented using the Five-Step Ambulance Care Pathway as a template.


Figure 1: Five-Step Ambulance Care Pathway

5_blue_steps-with border of white



17.   In developing a Winter Plan for 2016/17, the experience of winter 2015/16 has been reviewed in detail, looking at four determinants of patient flow and performance, namely:


-          prevention;

-          “hear and treat”;

-          patients treated at scene or referred to more appropriate healthcare providers and

-          maintaining response capacity during the winter period, e.g. actual hours, handover delays.


18.   In reviewing the 2015/16 winter period, a number of issues stood out:


-          Demand continued to increase at a rate of 4.89% year-on-year. An increase of approximately 4% is the norm across ambulance services, both in the UK and worldwide and may reflect a variety of factors: 24/7 culture, ageing populations with increasing clinical acuity, access to primary care. Whatever the cause, it is reasonable to assume that this increase in demand will continue through the 2016/17 winter period.


Figure 2





-          Incidents ended as a result of “hear and treat” via the Welsh Ambulance Service’s Clinical Desk showed an improving trend


Figure 3


-           incidents treated at scene/referred to alternative healthcare providers showed no discernible improvement


 Figure 4


-          significantly,  while conveyance numbers into hospital peaked in December 2015, with levels before and after Christmas not significantly different, handover delays and, therefore, ambulance hours lost to them, were significantly higher in the new year, with a drop in RED performance (calls identified as life-threatening) and AMBER patients having to wait longer.









Figure 5


19.   Of critical significance is the impact of protracted delays and system issues on patient experience and outcome. During the winter period of 2015/16, there was a marked increase in the number of Serious Adverse Incidents reported to Welsh Government, with12 SAIs reported in February 2016 alone attributed to handover delays as a contributory factor. 


20.   What is less well recognised is the risk posed to patients in the community who need intervention from the Welsh Ambulance Service but for whom no resource is available because of ambulances delayed outside Emergency Units.


21.   While the number of patients adversely affected in terms of outcome is less easy to quantify (SAI notifications provide one mechanism), there is always the clear and present risk that a patient who is the subject of a RED call in particular will come to significant harm if there are insufficient available ambulance resources. There is a direct correlation between handover delays, the availability of emergency ambulances and risk to patients, therefore.


22.   In addition, the impact on staff morale and wellbeing is also adversely affected by such system problems, which in turn can have a detrimental impact on sickness levels within the Welsh Ambulance Service, compounding an already difficult problem.


23.   It is with all these factors and evidence in mind that the Welsh Ambulance Service has approached its planning for winter 2016/17.


Winter Plan 2016/17


24.   The key tenet of the Welsh Ambulance Service’s Winter Plan 2016/17 is to ensure the safe delivery of care to patients. This has meant looking at more innovative measures than in previous years to ensure that high standards of care and availability of emergency ambulances can be maintained.


25.   It has also meant ensuring that planning is integrated with that of health boards at a local level to ensure the system works in a cohesive and effective way.


26.   The Plan has been modelled using the Five Step Ambulance Care Pathway and a flavour of some of the proposed actions contained therein is detailed below.


Step 1 – Help Me Choose


27.   There will be an increased focus on public and patient engagement through NHSDW/111 and the Trust’s Communications and Engagement Teams.


28.    Planned rosters will reflect winter demand patterns and the use of bank staff will also be planned. There will be reduced levels of annual leave over the festive period and managers will undertake calls for 20% of their time. 


29.   The work which has been undertaken successfully on managing frequent callers more effectively will be extended to focus on locations like nursing homes and hostels which generate a high volume of calls.


30.   Recognising the volume of incidents which relate to non-injury fallers, there will be focused used of Community First Responders (volunteers) to respond to these calls, thus freeing up emergency ambulance resources.


Step 2 – Answer My Call


31.   The Welsh Ambulance Service has developed a service change initiative for Enhanced Hear and Treat, which would see the recruitment of an additional 12 whole time equivalent members of staff to support the Trust’s clinical desk. This development has been supported by the Emergency Ambulance Services Committee (EASC) via its Quality Assurance Improvement Panel (QAIP) but funding is still awaited at the time of writing.


32.   As an interim measure, pending confirmation of funding, the Welsh Ambulance Service has committed to resourcing four members of staff at its Clinical Control Centre in Llanfairfechan in North Wales to provide Clinical Desk cover and support calls for clinical assistance received from the police force.


33.   An increase in Hear and Treat rates does not feed directly through into reduced conveyance to hospitals, as a patient may still be conveyed by private motor vehicle or taxi; however, it does mean fewer ambulances are deployed to scene and fewer patients are conveyed to hospital in ambulances, which means there is increased capacity to respond.


34.   The Trust has also recently reviewed its escalation arrangements and agreed a Combined Escalation Toolkit.  The toolkit includes a Resource Escalation Action Plan (REAP) which includes trigger points split into levels with pre-planned actions for each level of escalation. 


35.   The Clinical Contact Centres (CCC) have a CCC Demand Management Plan, with specific planned actions to support each stage of the REAP including a Logistics Desk to be deployed during Winter pressures, using the triggers and actions within REAP and Local Escalation Action Plans (LEAPs) to escalate and manage delayed resources, with a particular focus on handover delays.  These plans include the use of clinical staff to support the Clinical Desk and the use of support function administrative staff to support the CCCs.




Step 3 – Come to See Me


36.   The main focus in this step is on the targeted use of WAST’s resources to boost capacity to respond through the winter months, for example:


·         the Trust is planning to recruit 162 front line staff (including Non-Emergency Patient Transport Service staff) during the period October 2016 to May 2017.


·         the Trust has introduced a new process of proactively managing and tracking use of private ambulance providers and St John. This has resulted in a reduced spend on these during the first half of the year, with a profile of planned spend developed to cover the winter period where planned increase is accounted for within the current financial plan.


·         a more pro-active and pre-planned use of bank staff to match identified periods of high demand.


·         the Trust is also planning to pre-plan the use of Locality Managers, Medical Directorate managers and secondees into the winter rosters (one shift per week 01 November 2016 to 31 March 2017).


·         the pro-active and pre-planned management of Community First Responders (CFRs) to encourage them to take shifts during known demand peaks, for example, in the festive season. There has been investment in new mobile, handheld technology making it easier for CFRs to be alerted to, and respond to, appropriate calls in their community.


·         Three “community paramedic” trials are planned for the winter period in Powys, the Vale of Glamorgan and the Rhondda.  Community Paramedics will operate in these geographical areas and will attend 999 calls, as well as working with primary care and Out-of-Hours services to undertake appropriate domiciliary visits.


Step 4 – Give Me Treatment


37.   The focus of this step is on delivering treatment at scene and referral to alternative providers, much of which is reflected in the local plans developed on an LHB level, contingent on available care pathways, for example.


38.   Each WAST LHB Winter Plan includes an action to maximise the use of existing pathways i.e. referral to alternative providers during the winter months, with Cardiff and Vale providing a good example of working closely with the Cardiff Mental Health Crisis Team on providing additional hours during periods of high demand. 


39.   Each WAST LHB Winter Plan also includes specific actions on pathways around diarrhoea and vomiting and flu, which the Welsh Ambulance Service is working on with LHBs to deliver.









Step 5 – Take Me to Hospital


40.   The Welsh Ambulance Service’s conveyance rates are largely in line with the average for UK ambulance services. In June 2016, 17,278 patients (69.8%) who called 999 were conveyed to hospital following a face-to-face assessment.


41.   This notwithstanding, the Service recognises that identifying alternatives to conveyance and admission, where clinically appropriate, are important elements in managing demand.


42.   The Trust has introduced Paramedic Pathfinder as a clinical decision support tool for paramedics, while work continues with health boards to develop alternative care pathways which avoid admission to busy Emergency Units. It is fair to say that the availability of such pathways across Wales is not uniform and models are varied, although national pathways are now in place for falls, resolved hypoglycaemia and resolved epilepsy.


43.   The Welsh Ambulance Service’s Director of Operations and Medical Director will be working with staff in advance of the winter 2016 period to communicate about safely managing risk, recognising that the Trust continues to develop the mentoring, clinical review and supervision mechanisms necessary to provide additional support and assurance for staff in their clinical decision-making.


44.   For those patients who are conveyed to hospital, the management of handovers is critical, both for reasons of patient safety and quality of experience, as well as the availability of ambulance resources in the community.


45.   The Welsh Ambulance Service is working closely with LHBs on the provision of Hospital Ambulance Liaison Officers (HALOs) by LHBs to support this important issue. WAST will provide training to support the implementation of the HALO model.


46.   Another key action will be the regular monitoring of Welsh Circular /2016/029 NHS Wales Hospital Handover Guidance v2, with appropriate escalation to NHS Wales/Welsh Government when required.


47.   The WAST National Winter Plan also includes the targeted use of Pre-triage Assessment Vehicles (PtAV) outside major hospitals, during high periods of escalation.  This element of the plan will be progressed through further discussion with a range of stakeholders, as well as being subject to a full risk assessment.



Enabling Actions


48.   The WAST National Winter Plan (and supporting WAST LHB Operational Plans) are SMART, i.e. the actions contained therein are specific, measurable, achievable, realistic and time-bound, with the template designed to enable active performance management of the agreed actions. 


49.   The Plan also includes a lessons learnt element and evaluation of the effectiveness of this approach to winter planning to help develop and embed this key process in the future.



50.   Other actions in the national plan include the boosting of capacity to respond to concerns during busy periods and seasonal flu campaigning, among others.


Welsh Ambulance Service Winter Plans at LHB Level


51.   The Welsh Ambulance Service organises its teams around Local Health Board boundaries. Each area is led by a Head of Operations who works closely with LHB colleagues throughout the year.


52.   In terms of winter planning, local teams have been collaborating with health boards on local plans, making sure that the plans of individual organisations “chime” and have synergy, to ensure the system works together to deliver improvements for patients.


53.   Examples of good practice in these plans include:


·         Fixed site alcohol treatment centres (ATCs) and the use of Non-Emergency Patient Transport (NEPTS) ambulances to provide additional mobile capacity and transport for inebriated patients during identified high demand periods;


·         Rapid handover Paramedic Pathfinder Framework to be implemented in Ysbyty Gwynedd and Ysbyty Glan Clywd emergency departments;


·         Targeted use of a six person cycle response team in Cardiff City Centre and Cardiff Bay (and other centres) during identified periods of high demand, including Christmas shopping period;


·         Pre-period liaison and forward planning with Swansea City Centre Rangers who act as city centre CFRs to match identified periods of high demand;


·         Additional recruitment of Emergency Medical Technician/paramedic staff for deployment in 2016


·         Accelerating the use of Armed Forces Medics as bank workers for WAST by undertaking a gap analysis for training needs and other army staff to respond as CFRs from their Brecon base.


54.   Every plan includes a focus on maximising unit hours production on the agreed roster through forward planning of annual leave and time off in lieu (TOIL), the active management of sickness absence and support to self-roster.


Christmas and New Year Tactical Plan


55.   Christmas and New Year present a variety of challenges to the Trust, with particular spikes in demand caused by the festive calendar, which is compounded by trying to maintain actual hours during a period when staff also wish to take leave. 


56.   Work is currently underway on a tactical plan for the period 23 December 2016 to 04 January 2017 which will assess the alignment between predicted demand and estimated actual hours.



Predicted Performance


57.   Given the number of variables involved, predicting performance is complex.  At this stage, the Trust’s view is that it can achieve the 65% RED pan-Wales target throughout the period of its plan; however, significant lost hours as a result of handover delays will manifest itself on AMBER performance levels.  The Trust’s current focus is on working with experts on a Demand and Capacity Review, which will test the impact of these variables on performance.


Financial, Staff and Resourcing Assumptions


58.   There are a number of financial and resourcing assumptions which underpin the Winter Plan. The need to secure the funding for initiatives such as the additional Hear and Treat capacity, well as support from health boards for the HALO concept, remains a priority.


59.   Other aspects of investment in the plan will need to be supported from within the existing resource envelope.


60.   The support of our staff and their representatives will be fundamental to the success of the plan and the plan has been developed in partnership with trade unions to ensure that this is the case. As further iterations and developments are identified, these elements will also be tested with trade union colleagues.


Resilience of the Wider Unscheduled Care System


61.   There can be no doubt that the resilience of the unscheduled care system is something which requires constant vigilance and innovative approaches to render it sustainable in the medium to long term.


62.   However, it would be wrong to assume that the answer to sustainability lies exclusively in further investment in the NHS. Many of the issues with which the unscheduled care system grapples, throughout the year, are societal and lie in the need to recognise the importance of developing social and domiciliary care, working closely with local government, the third sector and private sector providers, as well as in the need to educate the wider population on both responsible use of the unscheduled care system and on adopting healthier lifestyles, to reduce future demand on the NHS more broadly.


63.   It is recognised that much work is underway across the health and social care system on all these issues, and that the Well-being of Future Generations Act, and the creation of public service boards, provide helpful vehicles for progressing these important agenda.


64.   The role of the public in playing their part cannot be overstated and it is important that the sustainability of the NHS is seen as a collective and social responsibility, rather than one that lies exclusively with NHS organisations and/or government to resolve.


65.   Without doubt, further development of both primary and community services will be important in supporting patients to be cared for safely at home, reducing the need for ambulance conveyance to hospital and subsequent admission. The Welsh Ambulance Service is actively working with primary care clusters to develop new models of care, based on the community paramedic model, to support this agenda.


66.   On a positive note, there is more integrated planning taking place across organisations and sectors than ever before, which gives the system the best chance it is had in some time to develop long term, sustainable solutions to the challenges it faces. That is not to say that problems are easily or rapidly resolved, but there is a collective recognition that the situation that has pertained for a number of years cannot do so in the future.


Closing Observations


67.   From a Welsh Ambulance Service perspective, there is a clear need for the organisation to manage its own resources and people effectively over the winter period, and this will be a matter of great focus for the Trust.


68.   Similarly, it is important that LHB plans “hold up” and that there is positive and regular dialogue and communication between partner organisations to identify potential pressure points as early as possible and to find mutually helpful solutions.


69.   Finally, it is important that the wider public recognises the part it has to play in reducing pressure on the ambulance service, and the unscheduled care system as a whole, by recognising that there is a difference between “unexpected” and “emergency” and that misuse of the system puts the lives of others in danger.


70.   It is the role of government, the NHS, the third sector and all those involved in civil society to help inform and educate the public about their responsibilities, as it is wrong to “blame” patients for using a system which, for many, has become complex to navigate and confusing.


71.   The advent of the 111 pathfinder project in the Abertawe Bro Morgannwg University Health Board area during the late autumn of 2016 provides an excellent opportunity to simplify the system for local residents and will be an important step in helping the public identify the right service to meet their needs, building on the excellent work undertaken by NHS Direct Wales.


72.   The fact that the Welsh Ambulance Service is hosting the 111 service means there is positive synergy with the organisation’s preventive and advisory role, as well as its emergency and non-urgent response models.


73.   The 2016/17 winter period will be something of a test bed for many of these new approaches, and it will be important to evaluate their success in order to establish them as intrinsic to future planning.