Eich cyf

Ein cyf/Our ref: MA/P/VG/7146/16

Dr Dai Lloyd AM

Chair, Health, Social Care and Sport Committee

Cardiff Bay

Cardiff

CF99 1NA

8 November 2016

Dear Chair

Thank you for your letter of 28 October setting out the main themes you want to focus on at the Health, Social Care and Sport Committee, which is scheduled for 17 November to discuss winter preparedness.

Please find the evidence paper attached. A Welsh version will follow.

Yours sincerely

Vaughan Gething AC/AM

Ysgrifennydd y Cabinet dros Iechyd, Llesiant a Chwaraeon

Cabinet Secretary for Health, Well-being and Sport

Cc: Rebecca Evans AM, Minister for Social Services and Public Health

SCRUTINY SESSION WITH THE HEALTH, SOCIAL CARE AND SPORT COMMITTEE – 17 NOVEMBER 2016

NATIONAL ASSEMBLY FOR WALES: HEALTH, SOCIAL CARE AND SPORT COMMITTEE

Date: 17 November 2016

Venue: Senedd, National Assembly for Wales

UNSCHEDULED CARE PRESSURES & PREPAREDNESS FOR WINTER 2016/17

Context

1. Delivering against key emergency care access targets is an increasing challenge for all areas of the United Kingdom and for a variety of reasons:

a. Growing demand: there were over one million attendances at Accident & Emergency Departments (A&E) in Wales for the first time over the course of a financial year in 2015/16 with a 2% growth in numbers of presentations when compared with the previous year. Despite a marked increase in activity at A&E at times last winter when compared with the previous year, more people were admitted or discharged within the four hour target during December, January and February 2015/16 than the corresponding months in 2014/15.

b. Unrelenting demand: pressure on the unscheduled care system is no longer restricted to winter and is recognised throughout the UK as a year round reality. For example, an average day in 2015/16 NHS Wales saw nearly 2,765 people through it’s A&E departments; received 1,232 999 ambulance calls; received over 800 NHS Direct Wales calls; and over 1,500 out of hours care calls. The latest available figures demonstrate the level of evolving demand with the highest number of attendances reported in September 2016, for a September, for eight years.

c. Despite this increase in demand the vast majority of patients are still admitted or discharged within four hours of their arrival. The latest available information also shows the average time spent in A&E departments by a patient is 2 hours and 7 minutes, demonstrating that the majority of people receive the care they need in a timely manner usually well within the four hour target.

d. Welsh Ambulance Services NHS Trust (WAST) information suggests the number of ambulance arrivals at A&E departments has reduced when compared to 2015. Health boards have been asked to work with the ambulance service to understand all contributory factors. It is likely that the clinical modernisation of the ambulance service is a key factor following investment in paramedics and nurses to work on a ‘clinical desk’ in 999 contact centres to assess the needs of callers in more detail. Latest available information for October also show that this team prevented over 1,000 ambulance dispatches by providing advice and alternatives to patients. The National Programme for Unscheduled Care Board will review local analysis of this information in December with a view to building on this success in other parts of the system.

e. The changing nature of demand: the proportion of people aged over 85 and presenting at A&E has increased by nearly 16% since 2011/12. These patients often have more complex needs as well as higher levels of dependency and generally have longer spells in hospital before it is safe to send them home or to another part of the care system.

f. Patients more appropriately seen elsewhere: evidence from Scotland suggests that around 15% of patients would be more effectively cared for in other parts of the system (including through self care). This would amount to approximately 150,000 patients choosing to attend A&E who we could support differently elsewhere.

2. Around 72,000 adults in Wales are receiving social care at any one time in Wales. Of these, around 18% are in residential care, the rest in community based services. For children, over 26,000 assessments were carried out in the past financial year, with just over 3,000 children on child protection registers.

3. Lifestyle changes and the success of the NHS in keeping people alive for longer means demand for health and social care services is rapidly rising and predicted to grow rapidly in coming years.

4. To put into context, the recent Health Foundation report on the NHS in Wales calculated that the total population of Wales is predicted to grow by 5.6% between 2015 and 2030, an average of 0.4% a year. However, the age profile will become older, with the number of people aged 65 and over predicted to grow by 28.5% over this period. The report assessed the annual increase in demand on social care would be 4.1%. We have already seen how these year on year increases impact on Delayed Transfers of Care (DToC) amongst patients over the age of 85. People in that age group are more likely to have a range of complex conditions which make it more difficult to determine the most appropriate placements to meet their long term care needs.

5. Despite an overall downward trend in DToC and whilst there are monthly fluctuations, the level of DTOC have remained fairly steady – however, regions are actively working to achieve further improvements.

6. It is important to emphasise that demand is made up not just of unscheduled care services such as ambulance and hospital based services, but also services in primary care and the community, with a focus on the whole patient pathway. There is increasing demand being placed on primary care, particularly GP services, both in and out of hours. GPC Wales has indicated contracted GP services provide approximately 19 million appointments each year and demand increases over the winter period.

7. Health boards also have to balance their elective activity and we saw a 4% increase elective activity between January to March 2016 when compared to the same period in 2015. We have also seen a 14% reduction in short notice cancellations for non-clinical reasons between 2013/14 and 2015/16.

8. The above describes the difficult circumstances our NHS and social care services are facing and the rising demand will continue to be a challenge during the winter and beyond. This reinforces the need for a whole system approach and the Welsh Government will continue to work collaboratively with the services and build on the strengthened integrated services we have seen in recent years.

9. In response to these challenges health boards have developed delivery plans and we expect to see improvements on Referral to Treatment (RTT) waiting times by the end of March 2017.

10. The Welsh Government has provided an additional £50m for NHS Wales to deal with the rising demand during the winter. This is in addition to the £42.6m Primary Care Fund and the £60m made available through the Intermediate Care Fund (ICF) for 2016-2017 to help prevent unnecessary hospital admissions and delays in discharges.

11. The Chronic Conditions Management Plan aims to identify those people at risk of developing poor health and early intervention to prevent or delay exacerbations.

12. There has been a huge amount of work undertaken between NHS Wales and social care to ensure they have strong plans in place in preparedness for winter but there remains a number of general risks to contend with such as:

· staffing challenges across the health and social care system, the challenge to local authorities of demand for adult social care (most notably older people);

· 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;

National activity to support local health and care systems to cope with demand on unscheduled care services

13. Health boards, Local Authorities and the Welsh Ambulance Service have been required to develop integrated winter plans each year since 2012/13. In recognition of the significant unscheduled care pressures experienced during winter, the Welsh Government instructed our services to commence planning earlier than ever this year. Crossing the boundaries innovatively is a key step forward to delivering the high quality, integrated and sustainable services we all want to achieve. As part of these arrangements, Welsh Government has required a clear understanding of risks from winter pressures and the mitigating actions put in place by all key partners.

14. The Welsh Government continues to hold quarterly national Seasonal Planning events to inform the development of seasonal plans, which include preparedness for the winter period. This involves identifying lessons learned from previous years and fostering a collaborative whole system approach through sharing of good practice across the NHS community. All integrated winter plans have been made publically available.

National Programme for Unscheduled Care

15. The National Programme for Unscheduled Care balances long-term commitment to transform services and engage with the public, with short-term performance commitments and promotes a whole system approach which ensures a shared responsibility for each part of the system and the impact on other parts of the system.

16. The Programme is currently focusing on understanding existing A&E models of care and how they function in granular detail. It will act as an enabling vehicle for the design of improved local models of care that are based on local patient need. The Programme has produced an ‘Urgent Actions Checklist for Unscheduled Care’ to outline the areas that should be reviewed locally to support improvement. Organisations making progress against the majority of areas identified in this checklist should be better placed to offer good care, and improve performance against key targets.

17. National work is already under way to support, including through:

· the establishment of daily flows of information for all A&E departments to foster shared understanding of the daily demand experienced within local emergency care systems, and the resources required to meet those demands;

· health board participation in NHS Benchmarking Network audits to look at the detailed workings of A&E departments, Minor Injuries Units and a focus on older people in acute settings (as well as other parts of the unscheduled care system); and

· learning from models delivered in other parts of the UK.

18. We are also working closely with the Royal College of Emergency Medicine to improve understanding of the challenges to local emergency care systems.

19. The Programme is overseen by Stephen Harrhy, Director for the National Programme for Unscheduled Care and delivery against the Programme is monitored by the National Unscheduled Care Programme Board, chaired by the Chief Executive of NHS Wales.

Collaboration across national programmes

20. The key focus of the National Programme for Unscheduled Care has been on achieving optimum patient flow through in-hospital services, but other national programmes and key partners are essential to ensure alignment with whole system working and provide a clear direction of travel for NHS organisations and partners to work collaboratively to deliver the best service to their communities.

21. There is a developing level of integration between the national programmes for planned care, primary care and unscheduled care, in an effort to achieve the best overall outcomes, and to achieve the adoption of a whole system approach to the planning and delivery of health and care services across all health and care pathways.

22. There is significant cross representation among the programme boards and sub-groups and regular engagement between programme leads.

Winter communications campaigns

23. The Choose Well campaign is nationally led with health boards and other organisations participating in local and national activity using the identity, targeted materials and messaging from the national campaign. For the coming winter, Choose Well will complement other winter health campaigns such as Beat Flu; Stay Healthy This Winter; Spread the Warmth (Age Cymru); and Prudent prescribing / Choose pharmacy.

24. The campaign will have an increased focus on targeting parents of young children and older people and their carers. It will help:-

· Ensure target audiences have access to information about what services are available as alternatives to A&E in their area, including pharmacies, minor injuries units and GP out of hours;

· Increase awareness of community pharmacy services and increase the number of people accessing community pharmacy services when they have a minor ailment;

· Increase the number of people accessing self-care information and advice from NHS Direct Wales when they have a minor ailment;

· Promote NHS Direct Wales as a source of information on local services and alternative services to A&E;

· Increase awareness among target groups of the actions they can take to avoid A&E in non-urgent cases, and benefits of those actions to them.

25. Minor Injuries Units (MIUs) are examples of services where patients with non-serious conditions and injuries can be safely navigated and treated quickly. As an example, the latest information reported at Ysbyty Cwm Rhondda and Barry MIUs show the standard time spent by patients in these units from arrival to departure ranges between 38 and 51 minutes.

26.The most comprehensive recent review covering ‘inappropriate’ attendances at A&E was a report from the Primary Care Foundation in 2010. This suggested that approximately 16% of A&E attendances would be more appropriately dealt with in the Primary Care sector. Evidence from Scotland suggests that these patients tend to be young, with symptom duration greater than 24 hours, with conditions not related to injury and a high proportion will have consulted their General Practitioners. Given the National Programme for Unscheduled Care has an objective to enable citizens to attain care in the right place and at the right time, efforts are currently being directed to developing policy and guidance to navigate patients to the most appropriate setting.

Monitoring and surveillance

27. Public Health Wales influenza and infection control surveillance will support health boards with weekly updates. Daily national executive-level emergency pressures conference calls will be held at 11am, seven days a-week.

28. Fortnightly calls will be held between the Welsh Government and a nominated health board winter resilience lead between 1 December 2016 and 31 March 2017 to track delivery against actions described in local winter plans.

29. Weekly calls will be held over the winter months between the Welsh Government and Directors of Social Services to monitor unscheduled care pressures. This will help to ensure that decisions are based on the very best information available and that good practice and learning is disseminated effectively and in a timely manner.

30. As part of a series of visits to all health boards to discuss issues around delayed transfers of care - and specifically, their DToC Action Plans - we will be reinforcing the need to ensure compliance with the Choice guidance. These visits commenced on 23 October with completion in early December. All regions have been asked to provide targets for improvement and work will be undertaken to look at other measures that would be helpful across the health and social care system to monitor progress. The outcomes we are seeking to achieve is more people receiving care and support outside of hospital.

NHS Wales Delivery Unit

31. The NHS Wales Delivery Unit (DU) has been working with all health boards to support improvements in unscheduled care delivery. The DU has provided ongoing support to highlight areas where patient flow and risk-based escalation can be improved at all Type 1 A&E Departments, and has undertaken a comprehensive audit of discharge practices at all district general and community hospitals.

32. All health boards have been given bespoke reports with recommendations to deliver improved patient flow and experience by enabling patients to be discharged earlier in the day. I wrote to chairs of all NHS Wales organisations in October to reinforce expectations that these recommendations are implemented as soon as practicable.

33. Guidance on improving patient flow and preventing unnecessary waiting for patients will be issued by the Welsh Government by the end of the year.

National escalation and de-escalation action plan

34. NHS organisations are actively and consistently using the National Emergency Pressures Escalation and De-Escalation Action Plan, which was developed using an operational multi-agency approach to the effective management of capacity and escalation processes across Wales.

35. The plan ensures a formal structure to the approach taken with the management and co-ordination of responding to emergency pressures experienced throughout the year, designed to enhance the effectiveness of patient flow and maintain patient safety through the implementation of procedures that support best practice through proactive management.

36. The plan was developed in 2012 and the Welsh Government has since been working closely with NHS organisations who have been further developing their approach to escalation following review and improving their local escalation arrangements, which have a stronger focus on risk management. We have also supported organisations in strengthening the daily executive level conference calls ahead of the winter.

Evaluating delivery of services over winter

37. A Welsh Government and National Programme for Unscheduled Care sponsored review event will be held in Spring 2017 to support NHS and local authority colleagues to evaluate delivery and performance over the past winter period, and inform planning for winter 2017/18.

38. A review of overall delivery and performance during the winter period will also be presented to the National Unscheduled Care Programme Board.

Local measures taken to increase resilience over for winter

39. Health boards, the ambulance service and Local Authorities have integrated plans in place for winter and specific measures undertaken include:

Accident & Emergency Departments and in-hospital

· Health boards are working with the NHS Wales Delivery Unit to strengthen their understanding of the flow of patients within local emergency care systems. To support this work, as directed by the National Programme for Unscheduled Care, daily demand and activity analysis information will be routinely shared with health boards to stimulate and inform debate locally and nationally about where reductions can be made in lengths of stay. This work will commence on 31 November.

· Streaming of patients at the front door to ambulatory care, designed to reduce waits and improve flow through A&E departments by enabling clinicians in the main department to focus on patients with more complex conditions. Ambulatory care pathways are now available in many district general hospitals in Wales and a new clinic will open at University Hospital of Wales, Cardiff in January.

· Strengthened senior management and clinical presence (including GPs, therapy and social workers) both in-hospital and in the community at times of peaks of pressure to improve decision making, support admission avoidance, enable earlier discharges and enhance patient flow.

· Focus on reducing delayed transfers of care and lengths of stay of over seven days through increased use of discharge lounges; and using Intermediate Care Fund (ICF) monies to strengthen early provision of adaptations and equipment to reduce falls.

· Establishing ‘care bundles’ of direct access and alternative pathways in each health board area which are clearly communicated to paramedics, with explicit clarity on when they can be accessed, to limit conveyance rates and patient handover delays.

· Increasing seven-day working in the hospital system, including pharmacy, radiology, pathology and cardiac diagnostics.

· Reducing admitted elective activity immediately prior to Christmas to create non-elective bed capacity; and postponing some outpatient activity to free senior decision makers to enhance ward presence to enable earlier discharge where appropriate.

· Stronger joint working between A&E departments and out-of-hours services; including increased GP cover for face-to-face and triage capacity, and use of advanced paramedic practitioners and nurse practitioners.

· To manage the expected demand, the integrated plans have identified over 370 additional beds or bed equivalents across the system to manage the pressures. Organisations are also considering the way they use their surgical and medical beds to best manage unscheduled care pressures. It is also important to note that in view of the staffing challenges and the impact this can have on opening surge capacity, health and social care organisations have also focussed on prevention, admission avoidance, reducing lengths of stay and improving discharge.

Primary and community care

· Commencing the 111 pathfinder pilot in the Abertawe Bro Morgannwg University Health Board region in October. The non-emergency 111 service will provide a real opportunity to co-ordinate and manage the demand of unscheduled care for NHS Wales, meet the needs of patients within their own communities, avoid unnecessary hospital admission and reduce demand on acute hospital services. An independent evaluation of the pathfinder will begin after the first three months of the pilot have concluded.

· Integrating health agencies’ work and bring in key partners from local authorities; third sector agencies; homeless services; criminal justice system; GPs; and others to provide a comprehensive and collaborated response to the needs of people who frequently attend A&E.

· Avoiding inappropriate attendances by encouraging people to seek help from the most appropriate service through national and local ‘Choose Well’ campaigns.

· Increasing capacity in the community, including Community Resource Teams and strengthening District Nursing teams to avoid unnecessary admissions.

· Improved working with residential and nursing homes to support admission avoidance for people with D&V.

· Additional step up/down capacity and re-ablement services.

· Creating virtual Ward models which help people receive their care at home or as close to home as possible, avoiding admission.

· Increasing the Welsh Ambulance Services’ ‘Hear & Treat’ Capacity in Clinical Contact Centres to safely discharge people over the phone without necessity for an emergency ambulance response, reducing pressure on A&E.

· Community Paramedic pilots in Powys, Vale of Glamorgan and Rhondda to work with primary care and out of hours services; avoid unnecessary admission; and to undertake domiciliary visits.

Primary Care

40. GPs play a key role in encouraging preventive interventions such as immunisation, providing advice to support parents and carers and recognising and acting on signs of concern. Parents also seek information and advice from NHS Direct Wales via telephone or online. GPs contact paediatric services when they are concerned that more complex or urgent care is required. This is facilitated by local access arrangements such as direct line access and same day assessment clinics.

41. Cluster working describes local collaboration between GP practices and other local services to more effectively identify and meet the needs of local populations. Out of Hours primary care teams have undertaken a particularly detailed analysis of the needs presenting – showing high use by concerned parents and young adults. Services are being enhanced to respond to these demands – including the recruitment of paediatric nurse specialists to Out of Hours Primary Care teams.

42. The Welsh Government’s national primary care plan makes clear that primary care is the core element of a sustainable health and wellbeing system now and in the future. This is why I make action to achieve sustainable primary care, improve access and deliver more services locally a priority.

43. We have recognised GP services, in particular, both in and out of hours, are under increasing pressure and we have and are taking action. One of our 100 day commitments has been to take urgent action to recruit more GPs and other primary care workers and we launched our national and international recruitment campaign on 21 October.

44. We have and continue to work with health boards and GPC Wales to change the national General Medical Services contract to reduce bureaucracy and to enable collaboration between individual GP practices and between GPs and other front line services in their communities, through the 64 primary care clusters, to agree the effective and prudent use of available resources, not just those of the NHS.

45. We have facilitated the national GP service sustainability framework to underpin discussions between individual GP practices and health boards on the need for and type of additional support. This framework is currently being refreshed in the light of experience.

46. We have provided additional investment through our national primary care fund, which has 3 aims, to archive service sustainability, improve access and deliver more services locally. The fund in 2016-17 of £42.6m is supporting a wide range of spending plans drawn up at health board and cluster level. Many of these are designed to make effective use of the wider primary care team, freeing up GPs for more complex care and making workloads more manageable for everyone as well as ensuring people see the right professional first time.

47. For example, many primary care clusters have funded additional pharmacists and physiotherapists to work alongside GPs to help achieve sustainability and improve access. For example, in Aneurin Bevan between April to June 2016 practice based pharmacists spent 2819 hours undertaking work that would normally have been undertaken by a GP.

48. Several health boards are investing in Primary Care Support Teams which provide immediate support for GP practices struggling to manage the workload and keep patient services sustainable. Results indicate the benefits of a proactive approach to assist practices, with the support team working in partnership with the practice team to increase their resilience and sustainability, creating space to work differently and find new ways of working.

49. Two health boards are using funding for pathfinders to test new ways of directing calls to GPs to the right professional using GPs and nurses to triage. Implementing these spending plans is dependent on successfully recruiting to new posts and this can take time but the funding is in place.

50. I expect the planned roll out of the 111 Pathfinder service and action by our national professional lead for primary care to systematise access for people to the wide range of well-being services to contribute significantly to quicker and more appropriate access for people to the right professional and service.

51. On 13 October, I held an open and honest discussion with each health board on their progress on improving primary care. Progress is being made although I accept we still need more pace and scale. This is why primary care remains a priority and I will maintain a close dialogue with health boards.

Dental Services

52. The Welsh Government has reinforced the requirement of the NHS dental contract that practices should put in place arrangements for dental services for their patients for the hours and days that fall outside normal surgery hours and how a patient may contact such services. Over holiday periods this may involve arrangements with other practices i.e. it is not just a case of referring everyone to the health board out of hours/unscheduled care services. Health boards check on these arrangements including ‘mystery shopper’ calls.

53. Health board dental leads have been reminded to continue their dialogue with dental practices about appropriate cover for the holiday periods, and to assure themselves that this is in place.

Pacesetter/Pathfinders

54. Through the National Primary Care Fund 2016-17, £3.8m has been invested to support a national programme of innovative pathfinders and pacesetters projects with the aim of testing new and innovative ways of planning, organising and delivering primary care services. Examples of these projects include:

· Primary Care Support Units/Teams as referred above.

· The Hub model uses triage to direct patients to the appropriate professional within an enhanced MDT, so patient access is improved and the practice caseload is managed by professionals best placed to manage the presenting conditions. The GP has time and resource to manage more complex cases, often earlier in the patient pathway, thereby reducing the chances of admission.

Primary Care clusters

55. £10m has also been invested from the national Primary Care fund in the development of primary care clusters. This funding is to support GP teams, pharmacists, community nurses and therapists, dentists, optometrists, mental health teams, social workers and third sector workers and enable them to work together, to plan and provide the right care at the right time by the right person as locally as possible. It will clearly take some time before we see the full benefits of this investment but this commitment will inevitably help strengthen the level of resilience over the winter period and help patient receive the care they need.

56. Primary Care cluster arrangements will enable GPs working within a multi-professional Primary Care team to spend more time with acutely unwell patients and those with complex conditions, in addition to having protected time for leadership and innovation. Early findings indicate that an enhanced multidisciplinary team has the potential to contribute significantly to the sustainability of Primary Care and also reduce pressures on services in the acute setting.

Pharmacy

57. For pharmacy the NHS issue guidance that Friday 23 and Saturday 24 December and Sunday 1st January (for contractors with core hours on Sundays) are normal working days. Pharmacies have core and supplementary hours, they can change their supplementary hours giving the relevant health board three months’ notice. Core hours cannot be changed without approval from the relevant health board and three months’ notice is required. Health boards have responsibility for ensuring adequate pharmaceutical services are available on Christmas Day and the Bank Holidays on Monday 26th and Tuesday 27th December and Monday 2nd January, this is arranged through a rota system in which pharmacies are commissioned to provide additional hours. Some pharmacies have core hours on Sunday 1^st January 2017. This is not defined as a special day in the regulations unless it is also a bank holiday so the NHS will issue advice to those pharmacies with core hours on Sunday 1^st January to open for those core hours.

Fuel poverty

58. As part of its strategy to reduce fuel poverty in Wales, the Welsh Government implemented a demand-led fuel poverty scheme called ‘Nest’ to improve the energy efficiency of homes.

59. Emerging findings of a project that is using data linking techniques to explore the impact of the Warm Homes Nest scheme on health outcomes were reported in early October. In order to inform potential future demand-led fuel poverty schemes in Wales, this study examines the impact of the current scheme on hospital admissions and general health for recipients of home energy efficiency measures.

60. Levels of health service use were compared for 36,467 recipients of home energy efficiency measures and a control group of 36,070 individuals who were eligible but who had not yet received measures.

61. From a provisional, indicative analysis of the Warm Homes Nest data, the following key points have emerged:

· A positive impact on cardiovascular and respiratory admissions was found, with the recipient group having fewer hospital admissions for both cardiovascular disease and respiratory conditions than the control group for the winter after measures were installed.

· Although an increase was found in the number of GP Events and prescriptions in both the recipient group and the control group for the winter after measures were installed, the increase was smaller for the recipient group than for the control group. The findings therefore suggest that without the measures, the recipient group would have experienced a greater increase in GP Events and prescriptions i.e. the measures had a ‘protective effect’.

· Each of the individual home energy improvement measures e.g. insulation and heating upgrades, was found to have the same ‘protective effect’ on general health described above i.e. the group receiving each type of measure had a smaller increase in GP Events and prescriptions than the control group in the winter after measures were installed.

· The ‘protective effect’ on the health of recipients described above was observed for most age groups, from children aged less than 5 years to older people aged 75 years and over, with the exception of GP Events for 5 to 24 year olds i.e. recipients in most age groups had a smaller increase in GP Events and prescriptions than the control group in the winter after measures were installed.

Service Integration

62. Health boards, local authorities and the Welsh Ambulance Service have worked closely together, reflected on last winter and developed integrated plans. There is clear evidence of improved integration which include:

· The award winning ‘Bridging the Gap’ initiative – an integrated approach in the Cardiff area, which focuses on managing patients who regularly attend A&E departments or call the ambulance service and need support from multiple service areas – leading to an improvement in patient outcomes and reducing demand;

· The ‘Mon Enhanced Care Model’ in Anglesey– which builds on the ‘hospital at home’ model through Community Resource Team working, delivering intensive care in the home for acutely ill elderly patients.

· Western Bay Community Services Programme in Swansea – aimed at improving access to intermediate care services and helping people to keep well and remain independent through a multi-disciplinary team approach.

Regional Service Boards

63. The Social Services and Well-being Act provides for new regional partnership boards. These bring together health boards, social services, the third sector and care providers. Boards will be expected to respond to the population assessment that the Act also requires, to plan and deliver effective integrated care and support services.

64. Supporting statutory guidance sets out that boards must prioritise the integration of services in a number of areas. This includes a focus on people with complex needs and learning disabilities.

65. Making effective use of resources will be a key priority for the Boards. They will be required to establish pooled funds in relation to the provision of care home accommodation for adults from April 2018. In the meantime, health boards and local authorities must agree on capacity of services they need from care homes and provide and develop integrated commissioning arrangements.

Intermediate Care Fund (ICF)

66. The ICF was established in 2014-15 with the aim of improving public services by integrating housing, health and social services. This financial year £50m revenue and £10m capital funding has been awarded to continue to support existing initiatives which prevent unnecessary hospital admission, inappropriate admission to residential care, and delayed discharges from hospital. The fund has however been expanded this year to provide for the development of integrated care and support services for other groups of people including people with learning disabilities, autism, and children with complex needs.

67. Through the programme, a range of different integrated models of care and support have been established. These include preventative and re-ablement solutions, single points of access, housing and telecare improvements, rapid response teams, dementia care and seven-day social work support. ICF is delivered through a collaborative approach between health boards, local authorities, housing and the third and independent sector.

68. Prevention is at the heart of the Welsh Government’s programme to transform social services. It is vital that care and support services do not wait to respond until people reach crisis point. There is a need to focus on prevention and early intervention in order to make social services sustainable into the future. The third sector has a key role to play.

Seasonal Flu Immunisation Programme

69. The aim of the national immunisation programme is to minimise the health impact of seasonal flu through effective monitoring, prevention and treatment, including:

· Actively offering flu vaccination to 100% of those in eligible groups. Vaccination may also be offered to others where it is clinically appropriate.

· Vaccination of 75% of those aged 65 years and over.

· Vaccination of 50% of healthcare workers with direct patient contact. Six health boards/trusts achieved this target in 2015-16. It is expected that all will achieve increased rates in 2016-17 as we move towards a higher target in future years.

· Improving uptake for those under 65 years of age in high risk groups, including hard to reach groups.

· Midwives assuming responsibility for ensuring that all pregnant women in their care understand the importance of flu vaccination, and are offered it in an appropriate setting.

· Extending the childhood programme to all 2 and 3 year olds and all children in primary school reception class and years 1, 2 and 3.

· Recording all activity data by all providers such that accuracy of uptake data is improved.

The main changes to the programme this year are:

· Children’s Programme - The children’s programme in primary schools will be extended by an additional school year to include children in school year 3. Therefore, children in school reception class, year 1 (ages 5-6 years), year 2 (ages 6-7 years) and year 3 (ages 7-8 years) are to be offered the vaccine through the school nursing service;

· Adult Programme - Morbidly obese adults with a Body Mass Index (BMI) of 40 or more who have no other risk factors will be eligible as a specific group for vaccination. A top up allocation will be provided to health boards for this additional cohort.

70. In September, I also met with representatives of a range of organisations involved in delivering the flu vaccination campaign in 2016-17. Those attending included health boards, professional bodies, Welsh Local Government Association and the Care and Social Services inspectorate (Wales). The meeting focused on arrangements for integrated working to maximise uptake in at-risk groups. The importance of ensuring social care staff, as well as healthcare staff, are vaccinated against flu to protect their clients was also discussed. The WLGA was asked to consider scope for the inclusion of a requirement to vaccinate care staff against flu in contractual agreements with care providers. The Care Council for Wales is to be asked to reinforce the message to social care employers of their duty of care to protect their employees and those being cared for against the effects of flu.

Falls Prevention

71. Falls prevention is a key issue in the improvement of health and well-being amongst older people and can significantly help reduce the demand for unscheduled care services. There are a number of work streams in place to both prevent falls and to support people who have fallen and reduce the risk of them having further falls. This includes using Intermediate Care Fund monies to strengthen early provision of adaptations and equipment to reduce falls.

72. The Falls Prevention Network is co-ordinated by the Older People Commissioner’s Office and consists of representatives from the Welsh Government, Ageing Well Wales, health boards and a number of third sector organisations with an interest in preventing falls. The work of the Network helps older people to maintain their health and well-being, live longer in their own homes and remain active in their communities.

73. The Multiagency Falls Collaborative for Wales aims to support practitioners and community-based teams to improve care for patients who have fallen. The aim of the collaborative is to reduce mortality and harm to adults who have fallen, and are at risk of further falls, by providing a structure around which to align and develop community services.

Workforce

74. Effective workforce planning and deployment is essential to meet the additional demand for NHS care during winter months. It is the responsibility of local health boards and trusts to ensure they have workforce that is sufficient to meet local needs, including planning for the increases in demand due to winter pressures. Maintaining the quality of patient care is the priority and their planning includes balancing a range of approaches to address these additional pressures.

75. This includes developing and deploying their workforce in a flexible way, and on occasions deploying agency/locum staff to manage short-term peaks in demand. This includes utilising advanced nurse practitioners, advanced paramedics practitioners, social workers, pharmacists in the community and also realigning to local service models.

76. The Welsh Government has put in place robust scrutiny and assurance processes and support to organisations in the development of their plan where needed. Ongoing dialogue to do this is provided though the Integrated Delivery Board, monthly meetings with Chief Executives and bi-monthly Quality and Delivery meetings with the NHS.

77. Consultant, GP, nursing and overall staff numbers in the NHS are at the highest levels for over ten years, which demonstrates our commitment to ensuring our services have the resources to deliver vital services to the Welsh population. However, we recognise there remain some key challenges and at a time when other countries are also facing staff shortages, we are competing to attract, in particular medical specialities.

78. Health boards and Trusts have implemented plans focusing on staff health and well-being since sickness absence levels tend to increase in the winter period alongside the increasing demand on wider NHS services. These action plans include a range of initiatives, not only to address absence levels, but to improve the general health and well-being of NHS staff. Some examples of initiatives include running support sessions for those who require assistance in areas such as weight loss and smoking, access to occupational health support when required, and recruiting health and well-being champions.

79. The Directors of Workforce and Organisational Development from across the NHS in Wales are engaged in a collaborative programme to address the common issues identified through the planning process. This includes addressing the use and cost of using agency staff across NHS Wales and reducing overall demand for agency staff right across the NHS in Wales.

80. To support recruitment, we have launched a national and international campaign to market Wales and NHS Wales as an attractive place for doctors, including GPs, to train, work and live. The campaign is targeting medical students who are yet to choose a speciality, trainees coming to the end of their training to encourage them to work and live in Wales, recently qualified or those in the early stages of their career, and GPs nearing retirement or recently retired to promote other available options to encourage them to stay or return to practice. The launch of the campaign saw positive coverage across all forms of media and more then 280 enquiries have been generated over a two-day BMJ careers fair in London in October. This represents the first component of a longer term, sustained campaign to attract more doctors to Wales. The next phase will address the challenges faced by wider healthcare workforce across Wales.

81. While the number of district nurses has fallen, the overall number of nurses providing community services has increased by 17% over the past six years, from 3338 full time equivalent community nursing staff in 2009 to 3915 in 2015. This is largely because health boards are keen to develop a more effective skills mix at local level, using highly experienced district nurses to direct, lead and advise community nursing teams.

82. We continue to invest in education and training opportunities for a wide range of health care professionals. This September, for example, saw the highest level of nurse training places commissioned in Wales since devolution. There was a 10% increase in the number of nursing training places commissioned last year, which is in addition to the 22% increase in 2015/16.

Service Models

83. Welsh Government policy is for people to access the majority of their healthcare at, or as close to home as possible from a range of professionals working together in integrated primary care teams. There is national work underway through the programmes for planned, primary and unscheduled care to look at how people can be supported locally, at home or in care homes when they are ill, without requiring hospital admission.

84. We know co-location can work, and there are some good examples of out-of-hours services working alongside A&Es, but they are most effective when they are integrated and barriers such as cultural differences, leadership issues and communication challenges are resolved.

85. To support A&E clinicians to focus on treating acutely ill patients, the National Programme for Unscheduled Care has also required all local health boards to provide clarity on the accessibility or availability of direct access pathways (e.g. to specialty wards) for paramedics. Early evidence suggests that ambulance arrivals at A&E departments have begun to decline, although more work is required to understand all contributory factors:

· There is emerging use of other new pathways in Wales. Ambulatory emergency care pathways are being utilised at sites around Wales as part of the redesign of medical services to make it easier for acute patients to be diagnosed, treated and discharged on the same day. Evidence garnered through the unscheduled care programme suggests that hospitals initiating ambulatory care can convert a quarter of emergency admissions to ambulatory care pathways.

· The National Programme for Unscheduled Care Clinical Reference Group has recommended that the presence of senior decision-makers should be focussed in a location (e.g. the medical assessment unit) and at the time of day when their expertise is most likely to be required. Given the projections for an increase in the proportion of older people in Wales, shared decision making with people and their families could be deployed at the front door, as genuinely informed conversation may often result in people and families electing against admission.

· Regions are required to provide quarterly reports to the Welsh Government. The Welsh Government has also held learning events to share good practice and discuss what has worked within each region. A further event will be held early in the New Year (likely to be Feb/March). An independent report is also being prepared on the evaluation undertaken by regions.