The Welsh Ambulance Services NHS Trust welcomes the opportunity to provide evidence to Committee as part of its general scrutiny sessions with NHS Trusts and health boards. This briefing paper will provide members with an organisational profile, as well as an outline of the breadth of the work of the ambulance service and recent performance pressures by way of background. The challenges and issues faced by the Welsh Ambulance Service How the organisation’s IMTP is making an active contribution to the delivery of A Healthier Wales Waiting times, call management procedures and categorisation of calls In recent years, the ambulance service has changed significantly, moving from what was predominantly a transport service to one which now provides clinical care and clinically focused transport services to some three million people across Wales, an area of almost 8,000 square miles, spread across a diverse and challenging urban, coastal and rural landscape. Our unscheduled care services (emergency and urgent care) provide support to patients with illnesses that are immediately life-threatening through to minor injuries. We are increasingly providing services and pathways to keep patients out of hospital, treating them at home or on scene where it is clinically appropriate to do so. Each year, our Non-Emergency Patient Transport Service (NEPTS) supports hundreds of thousands of patients with a clinical need for transport to get to their hospital and medical appointments and home again, including for life sustaining services like renal dialysis and cancer treatment.

5_blue_steps-with border of white 10. NHS Direct Wales (NHSDW) provides telephone and online advice to patients who feel unwell, helping to signpost patients to, or arrange, the most appropriate care for them. 11. The 111 service, which we host on behalf of NHS Wales and which was introduced from 2016, is being rolled out across Wales and provides the basis for a more integrated model of future health and care provision. A Commissioned Service 12. Ambulance services in Wales are commissioned on a collaborative basis by the seven health boards through the Emergency Ambulance Services Committee (EASC) and the Chief Ambulance Services Commissioner (CASC). Both emergency and non- emergency ambulance services are commissioned in this way. 13. The Commissioning Quality & Delivery Frameworks for Emergency Medical Services and Non-Emergency Patient Transport Services (CQDFs) set out what is expected of us by our commissioners and focus on how we can make real improvements for our patients. Both are based on a five step model of service delivery, which breaks down the patient journey by need.

Demand Profile 15. The data below highlights the level of activity in terms of Welsh Ambulance services in 2018/19. 16. However, during 2019/20 we have seen the pattern of demand for services continue to change, particularly in respect of Red demand, which has shown a significant increase. 17. This, together with a range of other factors, has led to a deterioration in response times, with a commensurate impact on patient safety. These issues, and the ambulance service’s response to them, are outlined in more detail later in this document. The Clinical Model 18. Committee has asked specifically for information on the clinical model used by the Welsh Ambulance Service and the way in which calls are categorised. 19. In October 2015, a revised clinical model was introduced, which focused on prioritising those patients whose condition was immediately life-threatening. Following a pilot period and independent review, the model was confirmed as permanent in early 2017.

23. In terms of the categorisation of calls, the Welsh Ambulance Services uses the internationally recognised and globally used Medical Priority Dispatch System (MPDS). 25. MPDS involves caller being asked a set of standard key questions. These questions allow the call handler to categorise the call by chief complaint which sets a priority relating to the severity of the patient's condition, i.e. red, amber or green. 26. In 2019, the Trust’s Medical Director reviewed and compared the placement of MPDS determinants by category with that of NHS England’s recently introduced Ambulance Response Programme (ARP). This work found minimal variation with England in terms of categorisation.

28. This award is recognition of the high standards of use of the Medical Priority Dispatch System (MPDS) by the Trust’s call handlers and all colleagues in the CCC who receive, process and dispatch help to our patients. 29. There are more than 3,000 emergency medical dispatch centres using MPDS worldwide, managing around 65 million incidents per year. Only 250 have achieved accreditation as a Centre of Excellence Performance over the last 12 months 30. It has been a challenging year across the health system in Wales and, regrettably, it has meant that we have not always been able to deliver the quality and timeliness of emergency response services that we would want and the public should expect. 31. For the first time since the introduction of the new clinical response model in October 2015, our Red response has fallen below the 65% target and our response to Amber patients is longer than it should be. 33. We also continue to work in close collaboration with our health board and other partners to tackle the system-wide issues facing NHS Wales by embracing opportunities to deliver large scale transformational change quickly.

36. Figure 4 demonstrates that demand is growing in acuity (Red and Amber demand), and is fairly static in the lower acuity category (Green). This is in line with that is being reported by health boards in terms of the acuity of patients they are seeing via their emergency departments. 37. Figure 5 demonstrates the increase in Red demand profile, with Red demand increasing over the year from approximately five per cent of call volume, to some seven per cent of call volume.

38. Some of this increase is accounted for by an update to call handling practices in the summer of 2019 as part of the continual review of the clinical response model to ensure the appropriate categorisation of calls. This is particularly in relation to the categorisation of respiratory calls and further work is being undertaken to understand this change. 39. Against a backdrop of rising demand, while the target of 65% has regrettably been missed for two consecutive months in November and December 2019, the ambulance service is actually getting to more patients within eight minutes. 40. By way of example, in December 2019, our performance against the Red target was 62% for 3140 calls (1946 Red incidents within eight minutes), compared with equivalent data for December 2018, which recorded performance at 72.78% for 2414 Red calls (1757 red incidents within eight minutes). 41. While we are not complacent about missing the Red performance target, this is an example of where the percentage performance level can be misleading. While December 2019 performance was indeed 62% (itself an improvement on November 2019’s figure of 61.4%), these figures demonstrates that we reached 189 more patients in eight minutes in December 2019, compared to the same month in 2018. 42. The reasons for diminished performance do not, however, rest solely on increased demand. The constraints on our performance, particularly in terms of extended 8

delays to handover at hospitals, have significantly worsened this year, which has had a material impact on the organisation’s ability both to meet its Red performance target and to respond in a timely manner to patients, predominantly in the amber category, who are experiencing extended waits in the community while resources are delayed at hospitals. 43. Such delays have had a significantly deleterious effect on the availability of ambulance resources. Ambulance availability was one of the key determinants of improved performance highlighted by the November 2018 Amber Review. 45. Taking the same chart and overlaying it with Red response time, as in Figure 7, highlights a clear correlation between performance against target and the level of delay.

46. The impact of delays is also evident in the deteriorating experiences of our patients, whether that is the result of an initial extended delay in ambulance attendance or a subsequent delay at hospital. 47. Many of these patients will be in the amber category. Given the pressure on ambulance availability, it is often these patients who experience extending waiting times for an attendance. 48. Amber performance remains a concern. The underlying trends for amber response times are increasing. In November 2019, amber median, 65th and 95th percentile response times all continued to increase compared to previous months. All amber response times are considerably higher than the same period the previous year. 50. While the level of concerns received from patients, their families and carers has seen a steady increase, there has been an equally worrying trend in the reporting of serious adverse incidents, a significant proportion of which again relate to patients in the amber category. 51. Many of these remain under investigation, often jointly with the relevant health board, but emerging themes suggest that delayed arrival of an ambulance is a contributory factor in many of these incidents.

53. There is a correlation between those health board areas where SAIs are most commonly reported and those health board areas where handover delays are most significant, notably in the Swansea Bay and Aneurin Bevan Health Board areas. 54. Conversely, where handover delays have improved compared with previous years, for example Betsi Cadawalader University Health Board, reported serious adverse incident numbers have reduced.

Improving Performance and Transforming the Service 56. Significant work has already been undertaken to address performance and improve care for patients. 57. As an ambulance service, we have taken steps to take a system leadership role in respect of unscheduled care more broadly and, supported by Welsh Government, we are currently working through how this will operate in practice. 58. That said, our pan-Wales footprint and perspective, coupled with our role often as a “barometer” of the unscheduled care system, position the Welsh Ambulance Service well in terms of understanding the profile and nature of changing demand and the likely impact on the broader system. 59. Similarly, developing and using the skills of our staff and volunteers in different ways, both to improve outcomes for patients and, where possible and clinically safe, to maintain people at home or treat at scene, thus avoiding conveyance to hospital, has been an increasing focus of our work. 60. Our advanced paramedic practitioners (APPs) are able to treat patients with complex conditions more effectively at home, thus reducing the need for a hospital admission. 62. Similarly, we have invested in services to support patients who have fallen, as well as those with dementia or mental ill health, as well as investing significantly in clinicians in our clinical contact centres who have a key role to play in supporting patients and our road staff. 63. By way of example, our “hear and treat” rates, where clinicians are able to support and signpost patients over the telephone, thus avoiding dispatch of an ambulance, continue to improve. 64. The Clinical Service Desk (CSD) and NHSDW (Hear & Treat) achieved 8.6% performance in November, compared to 7.7% in November 2018 and 8.5% in November 2017. 3,630 ambulances were stopped in November 2019, compared to 2,895 in November 2018. Indeed, conveyance rates in general are reducing. 65. We continue to work with health boards on referral pathways for a number of conditions, which ambulance service colleagues can refer patients to and/or gain direct access to community-based services. 66. On an organisational level, we continue to address unacceptably high levels of sickness absence, recognising the impact of “moral injury” as a result of frustratingly long handover delays on the wellbeing of our people. 12

67. We have increased our shift cover during key periods of the winter period using a system of incentives linked to attendance to ensure that we are resourcing our teams appropriately at times of peak demand. 69. Our approach to public messaging has influenced demand at peak times, as well as increased use of other sources of support, for example the online symptom checkers provided by NHS Direct Wales. 71. Following the challenging winter of 2017/18 and deteriorating response time performance for calls in the Amber category, a review was launched in May 2018 to look at Amber performance, commissioned by the Chief Ambulance Services Commissioner. 72. The Welsh Ambulance Service worked closely with the review team and our health board partners to understand the system issues which were adversely affecting Amber performance. The overall conclusion of the Review was as follows “We have found that there are a number of patients in the amber category that are waiting too long to receive a response. The overriding factor in improving this is the availability of ambulance resources and not the categorisation of these patients as amber. .”

74. Since the Amber Review reported in November 2018, the Welsh Ambulance Service has worked closely with the Chief Ambulance Services Commissioner and his team, as well as health boards, to address the Review’s findings and recommendations, notably the fact that 'ambulance availability' was the single main determinant for the timeliness of Amber response. 75. Progress has been made against these recommendations, many of which have been detailed elsewhere in this document, but it is acknowledged that more work is needed across the unscheduled care system to realise the necessary improvements in ambulance delivery. 76. In January 2020, Minister for Health and Social Services, Vaughan Gething, announced the establishment of a Ministerial Ambulance Availability Taskforce to lead: implementation of recommendations from a recently commissioned independent “Demand and Capacity” review rapid delivery of alternative pathways and community-based solutions to prevent avoidable conveyance to emergency departments optimisation of the ambulance patient handover process improvement in Red performance, and build on progress made by the Amber Review Implementation Programme. 77. The taskforce will be jointly chaired by the Stephen Harrhy, Chief Ambulance Services Commissioner and Professor David Lockey, EMRTS Cymru National Director, with membership from relevant leaders from across the health and social care system. 78. This approach will focus not only on Amber responsiveness, but also on the need for wider improvements to reflect and respond to the changing environment, such as the changing picture of demand and performance for Red calls, increasing handover delays and the wider health and social care landscape. 79. In addition, the Minister announced the development of a system of incentives to improve the timeliness of ambulance handover at hospitals, recognising the impact such delays can have on patient experience and clinical outcomes through limiting available ambulance capacity. 80. The Welsh Ambulance Service is committed to playing its full part in these developments as part of a full system approach to improving ambulance availability and patient experience and outcome. Demand and Capacity Review 81. Ambulance availability is a product of demand, ambulance hours produced (in turn a product of investment and efficiencies) and lost hours.

82. One of the key recommendations of the Amber Review was that we would work collaboratively with the Emergency Ambulance Services Committee to commission an independent review of emergency medical service (EMS) demand and capacity for the next five years (to 2024). 83. The Demand and Capacity (D&C) Review was undertaken by ORH Ltd, to a brief developed collaboratively with commissioners. It aimed to model the resources required to efficiently meet current and future demand and to deliver a significantly improved range of response times. The Review encompassed both EMS and Clinical Contact Centre (CCC) services. 86. The Review’s summary report went to the November 2019 meeting of EASC, with the full final report (plus associated implementation programme plan) expected to go to the January 2020 EASC meeting. There is a recognition that final agreements on key WAST and system efficiencies may affect the overall number of staff required over the next five years.

87. However, EASC has acknowledged that, in all scenarios, there is a significant investment required in front line staff within the EMS service, and has set out its expectation that a minimum of an additional 136 whole time equivalents will be recruited and operational by March 2021. 91. It is important that we continue to develop the longer term, sustainable solutions to delivery of a high quality and effective service. Without that focus, the service, and wider NHS system, will continue to fire fight, which drains the system, and its people, of resources and energy. Our IMTP and Delivering a Healthier Wales 92. Our IMTP is framed around the national policy context and describes our organisational response to support implementation of the ‘A Healthier Wales’ strategy for health and social care in Wales and the long-term ambitions outlined in 16

93. A Healthier Wales is Welsh Government’s plan which “sets out a long term future vision of a ‘whole system approach to health and social care’, which is focussed on health and wellbeing, and on preventing illness.” It sets out a Quadruple Aim to frame the transformation required across health and social care in Wales. 94. As an ambulance service, we recognise the importance of our contribution towards achieving the future vision for health and social care services that is built on the foundation of the Quadruple Aim (improved population health, a sustainable workforce, better quality and accessible services and higher value care). 95. Our role is two-fold. Firstly, we have to deliver on our commitments to continuously improve our core services, whilst also capitalising on our unique position as a national delivery organisation with an ability to connect issues, processes and people across the Welsh health and care system through collaboration and partnership working. 96. Secondly, we have framed our Long Term Strategic Framework ‘Delivering Excellence’ and this IMTP around our response and commitment to ‘A Healthier Wales’ and the Quadruple Aim. The table below provides an overview of what each of the aims means from an ambulance service perspective. Improved population health and wellbeing We have an important role to play in helping to improve the health of the population whilst also advocating the importance of active and healthy lifestyles to prevent poor health. We have developed our first public health plan that describes our approach to help improve the health of the population and our staff Wellbeing Strategy. A motivated and sustainable health and social care workforce A highly motivated and committed workforce is crucial to ensure that we can provide the highest quality care today and for future generations. We describe our approach in our People Strategy. Better quality and more accessible health and social care services Higher value health and social care Delivering the best value and outcomes for the patient is central to this plan. Through adopting a value based care approach, we aim to improve patient outcomes through optimising the efficient use of our resources. This is another of our “Golden Threads”.

The Well-being of Future Generations (Wales) Act and Collaboration 97. The Well Being of Future Generations Act (WBFGA) requires public bodies in Wales to think about the long-term impact of their decisions, to work better with people, communities and each other, and to prevent persistent problems such as poverty, health inequalities and climate change. 98. Whilst the Welsh Ambulance Service is not named in the Act and is, therefore, not subject to the legislation, we have embraced its ethos and have committed to working within its spirit. As a national organisation, we recognise the vital and important contribution we can make through improved awareness and focus on the longer term impacts of the decisions we make. collaboration and working across organisational boundaries. To further improve this, we have also developed a detailed and Board-approved Engagement Framework, which further embeds our commitment and approach to further our engagement and collaboration with all of our stakeholders and, in particular, how we are engaging with Regional Partnership Boards.

Continue to Provide the Best Possible Care, Outcomes & Experience to our Patients Enable our People to Be the Best They Can Be 6. Implement the People and Culture Strategy 7. Develop and Implement a Wellbeing Strategy 8. Implement our Transforming Education and Training Strategy - Staff will have a great colleague experience, safer working environments, & will feel valued & cared for. - Staff will have better access to local, quality education & training, & will maintain & improve - Overall improvements in staff engagement (survey) score & achievement of workforce KPIs. - Sickness rates reduced for all direct staff across each of the steps

9. 10. Implement our Leadership and Management Development Strategy 11. Implement the volunteering strategy (subject to Board approval) their skills & practice at the top of their scope of practice. - Staff will have more equitable access to development opportunities - Our volunteers will feel valued & engaged - There are staff appraisal processes in place Whole System Partnership & Engagement 12. Implement the Trust’s Engagement plan - We will be an integral part of health & social care partnerships with better collaborative opportunities to deliver better & more targeted services for our patients. 13. Implement & fully engage in the early evaluation of the Major Trauma Network - By ensuring appropriate clinical transfer to Major Trauma units patient outcomes will be improved. - Implementation of the WAST elements of the Major Trauma Network Business Case & WAST priorities 14. Engage with Aneurin Bevan UHB on the implementation of the Clinical Futures Strategy & opening of The Grange University Hospital - Ensuring a seamless & quality service for patients within Aneurin Bevan - Understanding, agreeing & quantifying impacts of Health Board strategic service change Ensure the Design & Infrastructur e of the Organisation are at the Forefront of Innovation & Technology 15. Develop a Digital Transformation Strategy - Staff will more readily be able to use new technology, & will be able to be more agile & efficient in their work; optimising the quality & efficiency of healthcare efficiency for our patients. - Collaborate, agree & deliver to milestones, a development plan for the transition to the NHS Number, prioritising the use of the number in the Clinical Support Desk 16. Improve & capture sharing & utilisation of information through improved business intelligence & advanced analytics - Patients will receive more timely responses as a result of Optima modelling; through better understanding of current performance, future demand & changes to the patterns of demand. - Staff & commissioners able to easily access information on services - Adoption of collaborative approach to optima predict modelling & implementation 17. Utilise technology to improve communication with staff - We are able to connect with staff quickly to ensure information is able to be transmitted in real time, especially where there is a pressing need.

18. Procure and implement a Welsh Ambulance Services NHS Trust Electronic Patient Clinical Records (EPCR) - Use of an effective digital solution will allow capture & recording of clinical data to further demonstrate & improve the quality of care we provide our patients - Provide significantly improved information for staff. - CAD/PCR data linked with effect from 01/04/20 - 19. Procure a NEPTS CAD System - Patients will more readily be able to use new technology to improve how they are able to access our service 20. Progress priorities of the Estates SOP for the next 3 years. - Staff will work from buildings & vehicles that are comfortable, safe & fit for purpose - Implications of the Demand & Capacity implementation programme are reflected into the estate SOP & BJC. 21. Develop & sign off an Environmental & Sustainability Strategy - Reduction in carbon footprint - WAST to demonstrate how they will meet statutory Welsh Government Climate Targets. Goal: Help patients & staff to stay healthy 22. Implement the Public Health Plan. - We will use our thousands of daily contacts with people to improve their health & wellbeing - Support resilient communities through programme of engagement & education - More of the public will have been exposed to education which will make them more confident in managing their health Goal: Help patients more easily access our services at the right time 23. Develop & implement a range of technologies to enhance the way our services can be accessed. - Patients will more readily be able to use new technology to improve how they are able to access the right services

Goal: Provide the right care in the right place, wherever & whenever it is needed 24. Implement an integrated clinical hub - Patients who call 999 will increasingly be able to be given advice, seen & treated by our staff or referred on to other appropriate community services, & will not need to be taken to hospital - Reduced pressure on EDs mean that there will be fewer patient in ambulances waiting for long period outside hospitals - Staff will benefit from increased opportunities in an expanded career framework 25. Work collaboratively with Health Boards to provide care closer to people’s home and to reduce the number of patients who need to be taken to emergency departments oContinue the expansion of the APP role oEvaluate & implement non-medical prescribing framework Agree & implement a number of national alternative care pathways - Utilisation of additional pathways made available by Health Boards - Proportion of patients referred to alternative pathways to increase hear & treat & see & treat - Reduce variation in conveyance rates across Wales. - Reporting of agreed clinical indicators which complement the benefit realisation assumptions for Band 6 Paramedic investment. 26. Develop & implement the Older People’s Framework including falls - Higher quality of service for our users & carers - Provide alternative pathways working with the voluntary sector/social care for staff to apply to support older people to stay in the community - Consider different support & ways of working for our ageing workforce - Collaborate & support EASC & HBs to develop a national model for transfer & discharge (including critical care transfers). 27. Continue to implement our Mental Health & Dementia Improvement Plans - Ensuring the best & most appropriate response to our users with mental health needs. - Our staff feel skilled, able & confident to respond to our patients

28. Pilot a transfer & discharge service (subject to service being commissioned) - Ensuring our patients are appropriately & safely transferred when necessary. Quality at the Heart of Everything We Do 29. Prepare for the Health & Social Care (Quality & Engagement) (Wales) Bill - A strengthened commitment to our duty of Quality to ensure continuous learning & improvements in service delivery, outcomes & experiences. - Build on our application of Putting Things Right with our duty of Candour to be open & honest when things go wrong to focus on learning & improvements. - Strengthens the voice of our citizens by working with the new Citizens voice organisation. - Demonstrate compliance with the NHS Wales Health & Care Standards & Commissioning Core Requirements. - Review options & agree approach for the routine collection & analysis of patient experience data. 30. Implement the relevant learning from the recent Cwm Taf Morgannwg UHB Maternity services review. - Strengthening professional clinical supervision - Engage with service users to seek feedback Value & Efficiency in Everything We Do 31. Continue to work with the Bevan Commission, NHS Wales Finance Academy & ICHOM - Ensuring value for money - Value based healthcare drives quality by focusing on outcomes for patients & carers. - Ensure that optimum resource will be for front line services as WAST uses its resources as efficiently as possible - Collaborate on evaluation capability, methods & programme of work. - Known ‘Net Effect’ in terms of activity impact, resource impact & performance impact will be agreed, identified, monitored & reported for key initiatives. - Shift of front line spend from current levels to 75%

for 2020/21, remains on stabilising performance and expediting key aspects of our plans which will help achieve that e.g. recruitment, the development of alternative referral pathways etc.