Cynulliad Cenedlaethol Cymru

If I start, my colleagues will offer some more detail, if I may. In terms of our preparedness for this winter coming, clearly we have reviewed performance from last winter, which you know was quite exceptional in terms of the flu and weather challenges that we faced. What we have done is looked at what worked well, both within our own health board but also elsewhere, and one of the things that did work very well was, when we were under really significant stresses, we had what we termed a gold command, which was that we worked in conjunction, partnership, with the police and with the Welsh ambulance service, as well as our clinical teams, to ensure that we were prioritising appropriately, and we are going to continue to do that.

We also, last year—and we have built on it this year, and we've seen an increase in attendances at our MIUs as a consequence; we try and ensure that people receive care in the best place for them. So, a minor injuries unit—or a minor illnesses unit, as we prefer to refer to them. Last year, Chris led a piece of work across north Wales to ensure that we had consistency with the Welsh ambulance service, so the Welsh ambulance service were able to make a decision to take patients to minor injuries units rather than to the overstretched EDs. That has continued. Chris, I don't know whether you want to add to that.

What we saw was, between the months of October to January, a 15 per cent increase in attendances at minor injuries departments, and a lot of those were actually people who walked in rather than the ambulance bringing them as well. So, the Choose Well campaign and all the comms around Choose Well, I think, started kicking in last year. Obviously, in the west area, we have a lot of tourists, whether it's summer or winter, so we were able to deal with the people coming in as well. That worked very well and we're increasing that piece of work going into this winter, because we've extended the hours of many of MIUs up until 10 o'clock and midnight, looking at the demand from last year as well.

Diolch, Cadeirydd. Good morning to you, bore da. Last winter, the escalation levels reported indicated hospitals were under tremendous pressure. Wales remained at high level risk 4, and some health boards were at a 5. My question to you is: were escalation levels in Betsi Cadwaladr health board higher than expected during the winter of 2017-18?

I'll pick that question up. Certainly, from an acute hospital perspective, all of our action points that we have linked to our escalation plans had been exhausted quite often. So, we were at the highest level of escalation, but, for us, most concerning was the risk profile that we ran. And those are two very different and separate indicators of the pressure in the system. We were seeing risk levels of 20 and 24—really at maximum—for quite protracted periods of time. A lot of it was due to the additional escalation spaces that we had to put in place. The demand on our critical care services is also a trigger for the level of risk that we carry on our hospital sites, but also the sheer volume of patients in the department and the delays that we were having outside of our front doors as well. So, in short, the answer was, 'yes, much higher', but not just much higher than we would have anticipated or what we'd ever seen before. But the protracted period and our ability to de-escalate that risk and that sitrep as well was a very challenging time.  

So, you talk about the planning and, obviously, our winters that we have in Wales and the UK as a whole are not something new. We know that they can be quite severe at times, so this is not a new concept that we have to plan well ahead. So, how much of the higher level escalation levels were the result of poor winter planning and/or a mismatch between demand projections and capacity modelling used to inform plans? 

Our capacity modelling certainly was telling us that, yes, demand would be higher. But what we didn't anticipate—and I think we weren't alone in this, we'd have seen the whole of the UK in the same position—was the acuity of the patients that were coming through our front doors. So, we were seeing sicker patients, again as a result of flu; flu was a huge demand on us, and even in the younger population. So, it wasn't just the older population with high acuity needs. We had younger patients who then resulted in our critical care units because of a flu that we really hadn't anticipated would be to the extent that it was. 

But the flu injections are readily available for everyone—so, when you say about the flu, how much of a precedent did the higher level set? 

I think there are a couple of things with the flu. We promote and we've done quite well with the vaccination programme and we're building on that this year in terms of pharmacists giving community immunisations. I think it was noted across the whole of the UK last year that perhaps the vaccines did not cover all the strains of flu, and so it was something that we weren't anticipating. I understand that there's been learning around the public health dimension on that. 

Just a little bit more, if I may—so, we've talked about the planning and everything, so how much have you learnt from what's happened last year that you're going to incorporate in your plans now?

We're continually learning every day; we try and review what's gone wrong on that day to see how we can improve, because it's what we owe our public. In terms of what we've—. In addition, from what we've learnt last year, just linking into the flu, one of the things that we are in conversation with Public Health Wales about—I think it's referred to in our report—is accessing timely turnaround times so that we can be confident around the diagnosis, because that does impact our ability to be able to isolate any patient. We have continued the things that work really well. So, 24-hour district nursing has had a big impact in keeping people where they need to be, because hospital is not a good place for people to be unless they really need it. So, we are continuing those initiatives. We are building on the work that we started last year in terms of the safety huddles and a term that we call Red2Green, and that is ensuring that, whilst a person is in our care, they are actively receiving treatment and they're just not in a bed for the day without any active treatment. We're also working with our partnership organisations, particularly with our local authorities around how we can improve delayed transfers of care performance, with our police partners, and we do have shared appointments now with mental health for that arena as well, because we know that, given the nature of mental health illness that can also cause distractions in ED. So, the principle should be that we try and manage those in the community. 

Thank you.

Angela.

Good morning. I wonder if you could tell me, in your health board, what workforce planning tool you use to predict your capacity for particular pinchpoints.

In terms of the tools that we use, what I would say is we look at the demand points, so, again, if you look at some of the analysis that we're doing within the health board, what we are trying to see is where the peaks and troughs are. So, if I can give you an example, if I may, we know that in the east ED department we see a higher incidence in the evening hours, and that's, we think, down to, as much as anything, the geography of where the hospital is. We don't see the same within centre and west. So, that's enabling us to analyse where we need to put our staff and at what times of the day. So, we're doing that according to the demand and the skills.  

But who puts the information into your—? What's your workforce planning tool? How do you know that this is an issue somewhere? How do you know you might have a shortage on a ward or a shortage in an A&E? Who puts that information in? Who does the rostering and the planning? 

Right. Sorry, apologies if I misunderstood what you were saying. So, in terms of the rosters that we have in secondary care, they have been signed off in line with the Nurse Staffing Levels (Wales) Act 2016, and we have a report, a template, that comes in to me when those do not meet the needs. Because we know we've got vacancies, we need to be real that workforce is one of our challenges. But what we also do is assess any harm as a consequence of any shortfall, because sometimes there is harm, sometimes there isn't, sometimes there's harm even when the staffing levels are as should be. So, we're looking at a number of different things. 

So, we use the audit results that we receive from the audits that we do across Wales for the nurse staffing. Within our ED department, we've done something a little bit different, looking at, again, where the trends are, where the times of activity lie. And we've looked at the shortfalls in terms of particular skillsets. So, this year, for example, learning from last year, there's an increase in advanced nurse practitioners or advanced practitioners in our ED departments and emergency nurse practitioners.  

The systems, in particular—we use e-roster for nursing. We've just added on to the e-roster a medical model as well, and the safe care system. And what we do do, our infomatics department every day looks at the heat map so we can actually overlay staffing to our heat maps of demand, particularly in ED. Our ED medical staffing are based on RCEM—the Royal College of Emergency Medicine—guidelines, best practice, and they're quota-ed then to the size of the department. But, as Gill has already said, we know that we have different trends—they're marginally different, but they are different—and what we've learnt from last year is that we would staff up based on, particularly in ED, when patients were arriving in the department when, in fact, we need to move that resource further in because that's—. We need to reflect it to when the activity happens, not when the patients arrive, and that's the work that's been ongoing for the last couple of months right across the health board.  

One of the analyses that I've seen says that one of the issues for last year was the fact that there were two four-day weekends, essentially, and that, whilst the front door was basically covered there was no-one behind to support, and that the health boards have not really looked clearly at the fact that social workers would be away for two times four days, that they wouldn't be able to move people through the hospital and back out the other door, that the MRI scanners wouldn't be working, the x-rays wouldn't be working, because everybody else was away on holiday except for the poor people at the front door. Is that true of Betsi Cadwaladr? Did you experience that kind of issue and, if you did, what would you do to mitigate that going forward? I don't think this year it falls on a four and a four, but it's still pretty tight over that period.    

I guess the principles for a four-day bank holiday weekend are the principles regardless of how often—. And what we do have is we do have specific bank holiday plans that we put into place. And you're absolutely right: there were pockets where patients were delayed through discharge as a result of maybe a social worker not being allocated in a timely way, or examples such as that. What we did do, and I think we need to do more of going into this year, is to put specialists into—. So, it wasn't just acute medicine that we had working over those bank holidays; we actually had specialist consultants, particularly respiratory and cardiology consultants. And what we did see was there was a much quicker turnaround of those simple discharges, if you like. So, those that didn't have the complex needs—those of our patients that didn't have complex needs or housing issues—we were  turning those patients around very quickly, and they were being discharged because they were having the specialist input. But it's the more complex, and that's the bit that we need to develop this year—how we do have that same turnover with the more complex of our patients? Because, of course, we know that every day the patient spends in a hospital bed unnecessarily compromises them.

I do appreciate that point, and later on this afternoon, we'll be talking to the Association of Directors of Social Services Cymru. Because, the NHS is 24/7, 365; county councils work on a different principle. Could you also, though, please tell me—? If you look at the winter in general, rather than just that fortnight, we always have this cry, don't we, every year, that elective surgeries get cancelled because of the pressures? Is there a way around it? Would we be better off saying that we need to completely divorce elective care from emergency and ad hoc people just coming in, in an effort to try to preserve that elective care? Because, I get letters from consultants saying, 'All our elective surgeries have been—'. I mean, I had a letter last winter from 19 orthopaedic consultants saying, 'We've got nothing to do for two months—this is ridiculous.' So, I have to say, I don't think any of them were from Betsi, but I just wanted to say that—. So, you have this extraordinary waste, where we've got a lot of very talented people with very little to do, because they haven't got the beds to put people in afterwards, because everything's being sort of gobbled up by the emergency care. What's your view on how we might split that to protect elective care and drop these waiting times?

If I start, and then—. I think there is always a risk. I think last year was an extraordinary risk, and we saw that. But what we do do is try and plan our elective care in those months, to do the highest levels of care in those months where we've got the least risk. So, in the summer months, for want of a better term—

Sorry, may I just stop you there? Because I'll tell you what, the evidence we heard last year when we looked at winter pressures was that the pressure is on all year around, so—.

It is. I'm not negating that, but what I'm saying is we need to—. In terms of trying to manage that, we need to try and plan so that we're doing as much of that as we can when the risk is lowest. So, I don't want to suggest that—. And they will be cancelled at all times of the year, if we've got emergency pressures. We do try in Betsi to do as much in the day surgery environment, and we obviously have the opportunities around one of our colder sites to do surgery through there, so we try and maximise the throughput through those months using those facilities. I don't think there's an easy answer, I'm sorry.

Can I just jump in there, though? I have constituents who tell me they've been told by staff at Betsi that all elective orthopaedic operations are put off for months between December and April. That's not just a particular pressure point.

If I may, I'll pick that question up. Obviously, the constituents will be from the west, and I think it's an example for you of learning, because not this winter gone but the winter before, we made the decision to convert our elective orthopaedic ward into an unscheduled care additional capacity ward to try and make sure the patients weren't compromised. What we did for those months was convert in-patient orthopaedic work, and we brought in a lot of day case work. As you know, we've got long orthopaedic lists, and there were lots of people. So, we actually delivered twice as many orthopaedic operations during that period than we would have ordinarily. But what we didn't deliver was arthroplasty, so it's hip replacements and knee replacements, and those patients that needed an in-patient stay.

What we reflected on in our learning from that winter was that, actually, it didn't maximise our efficiency, and given the pressures that we've had in the last year around our referral-to-treatment activity, we couldn't afford to do that this year again. In the west, certainly in Bangor, what we did find is we were in a position where we were so compounded that we had to convert our surgical day unit into an in-patient ward for surge capacity. So, that's where we compromised our elective care, and, again, for us in the west, the learning is: how do we create that surge capacity without surging into elective areas? So, you're right. We try very hard to separate them out, but at 3 o'clock in the morning, when we have five patients in ambulances outside the front door, there are really difficult decisions that we have to make for the greater good of our population, and sometimes it's very difficult to recover that surgical day unit. 

Just to add, our cancellation rate in this winter just gone, as a health board, was half of the cancellation rate that we had the previous year, and our RTT activity was significantly higher this year than it was last year. So, we have delivered: we have reduced our waiting lists and our waiting times. Orthopaedics, we accept, is still a problem and a challenge, as it is for the rest of Wales. But, certainly, Bangor suffered the worst. We lost 200 patients within the first quarter or within the last quarter of last year—so, between January and March—purely because our surgical day unit had to convert into an in-patient facility.

Diolch.

I've just got one last area that I want to touch on, which is governance and risk management. You mentioned safe staff nursing levels, which is a really positive step forward, but only last week, a north Wales coroner warned about the possibility of more lives being lost because of delayed transfers from ambulance into hospital. So, given that, I wanted to know whether or not you run any risk management analysis over what your greater risk is. I used to be on a risk and audit committee and we would always rank our risks. Sometimes you would say, 'Yes, this is a risk, but, actually, this risk is something we're prepared to take because the risk of not doing it is far greater.' So, my question to you would be: do you do any analysis about whether it is safer for that particular patient to be in the ambulance, on a trolley in a hospital corridor, or in the accident and emergency department, and in order to facilitate that bounce-through somebody in A&E has to go on a ward, which might make you a bed over your capacity levels? When we're under pressure and you're talking about life and death and major trauma, I just wanted to know if there's anybody that does this constant analysis all the time and says, 'Actually, this patient needs to be here, which means that patient has to move there, which actually increases my risk in my ward because I've now got 21 beds instead of 20, but it marginally lessens the risk to the life of that patient because they are now in a bed in A&E and they're not on a trolley in an ambulance.'

The answer to that is we regularly put additional beds on wards, so we are reviewing the risk on the wards, and we have done what we term—. It's a low level of boarding. So, I've made the decision personally that, if the risk is in the emergency department, and it is too high, then we need to consider how we 'board' a patient safely—and it has to be safely. And we have to acknowledge the dignity, in particular, of that individual—so we need to explain to that individual that they may not have the resource available to them that we would ordinarily expect them to have on a ward. But, no, those risk assessments do take place, and they take place on a regular basis.

In terms of the response to—. You're absolutely right to pick up the point the coroner's made. Our sympathies go to the individuals to whom we failed in our duty of care, but we are learning from that, and one of the key recommendations from that is that we should have more advanced nurse practitioners—so, advanced practitioners in our ED. We are currently recruiting to those, and we've also asked for additional places for training so that we can train our own in-house.

Sorry, can I very quickly ask you—are you also looking at physician associates?

Yes, we are. When I say 'advanced nurse practitioners', I should say 'advanced practitioners' because it may not be a nurse, so apologies there. We're also working with the ambulance service, particularly around some of our minor injuries because the numbers in the ED—they might be minor injuries, but nonetheless they are taking up time and space within the department, which potentially could be used more effectively elsewhere. And we're already in conversations with our ambulance colleagues to see how we can work collectively on that, perhaps using some ambulance personnel while we're under stress.

That's what we've done with the ambulance—. What the ambulance have done—they've put liaison officers in each of the three emergency departments, so when the ambulance comes in, they will actually review to see whether they felt it appropriate for that person to actually be redirected to minor injuries rather than, as you say, sitting outside an ED or coming in, taking the space of somebody that really needs to be in an emergency department. As I said, through the work that we're doing with the Welsh Ambulance Services NHS Trust, we have seen a significant increase in our minor injuries. The attendances in ED haven't significantly raised, so I think what we're doing is maintaining—. Rather than increasing in ED, we're increasing in minor injuries, which is the right place for that individual. The conversion from minor injuries to ED is very low—it's 1 or 2 per cent of the patients who actually then have to go on to an emergency department.

Sorry, just on this, one last, very quick question, which is—because you've talked about minor injuries—how successfully do you think it's working in north Wales for the ambulance to take the red calls? Are the care pathways working well, so that they're skipping ED completely and going straight into cardiology or wherever it is they need to go? Because there are supposed to be identified care pathways in place, aren't there?

Yes, we do have patients who go straight to orthopaedic, straight to medicine, straight to surgery. Paediatrics worked really well last winter. We set a pathway and we did a pilot in Ysbyty Gwynedd with our paediatrics wards and a pathway through WAST, so they were dialling in and they weren't going through ED—they were coming straight to the assessments unit in paediatrics. We supported that assessment unit to open for longer hours through the additional seasonal plan moneys that we were given from the Welsh Government. That was keeping that unit open until about midnight, because a busy emergency department is not the place for children and their families. So, they were actually coming straight through, and we saw a significant throughput of children straight to paediatrics. I think more wants to be done on pathways, but they're definitely there and growing for next winter.

And some of the technology the ambulances are now using is helping that.

Okay.

Rhun.

Yes, we did, but we'd also done quite a lot of work—. So, it's really difficult to get underneath and analyse, which we are doing. Because we're really encouraging our staff now to report. The other thing we are doing is checking all those incidents ourselves, to ensure that we've got the right level. So, where previously someone might have described it as a 'negligible' incident, when we're reviewing that incident we might regrade it higher. So, we've done quite a lot of work in the health board over the last 12 months. Moving forward, we now have our harm dashboard in place, so we can see where we're seeing an increased incidence, and we can wrap some support around that area or that ward. We've done a lot of work in the health board as well on the 'PJ paralysis' campaign, and the data that we're seeing behind that is that it is having an impact, particularly on falls and pressure areas, because we're seeing people get up and get mobilised in a way that they previously hadn't, and so they're not debilitating within our care. So, there's an awful lot of work going on, and particularly, as well, around the infections.

And are you able to quantify or measure the effect that these serious incidents have on patient flow through the hospital and—

Yes. We know that, if a person has a fall or has an infection, it will result in a longer length of stay. We'll know that while we treat the infection, while we treat the consequence of the fall, treat the consequence of the pressure ulcers. Also, it's a really poor experience and outcome for that individual. But yes, we do.

So, in seeing how Betsi did when we look back at the winter of 2018-19, we'll be able to ask you how did it go on limiting those incidents and you'll be able to tell us how that affected flow.

Yes. And what we're also doing across the health board—we've just started—is we have a weekly meeting to define the incidents that have gone on both within the areas, and mental health, and within secondary care. That is with what we would call the corporate team and the local teams, to see what support we can offer and what interventions. So, there's an awful lot of work going on, because our prime duty is to protect our patients.

Just a couple of quick questions if I may. You answered earlier to Caroline about flu, so I won't go into that, other than just to ask you a little bit about how you are encouraging your staff to take up the flu vaccine, particularly in high-risk areas. 

What we did last year—. It is challenging, because, obviously, it's not mandatory; it's a voluntary thing for staff. And we know that people think, 'It doesn't work' or 'I get sick if I get the flu'; there's all sorts of—. People think why they shouldn't have it. But what we've adopted in Betsi over the last couple of years is peer immunisation. So, I would jab Gill, for instance. So, on the ward, colleagues can immunise colleagues. Then, last year—I think it was the first health board in Wales—we actually encouraged therapists to immunise as well, so it's not just nursing staff. Because, obviously, with the recruitment problems and the nursing staff, we needed to open our pool.

So, it's not just about infection of other patients—it's actually about them getting flu and being off sick.

It is, and their families and the wider community. It's not just about work, but it's obviously outside of work, because they'll have children who'll come home from school—

But it causes problems for you in terms of staffing, if they're off, as well, doesn't it, with flu.

Yes. What we did find is that, last year, we were just above the Wales average for high-risk clinical staff being immunised, just over the 50 per cent. The target is 60 per cent, but we've given ourselves a stretch target of 62.5 in Betsi. So, we're sticking to that stretch target again this year. And I'm working on the things that we did last year. So, we've had our flu planning day, brought the plan together and we'll just work on where we—. Because we increased staff vaccinations last year and we will build on that to increase again this year.

Is there any particular reason why you don't make it mandatory, particularly in high-risk areas? 

It's difficult for us to make it mandatory, but what we are aware of, and what we have done, is that where staff are in high-risk areas, then we've considered how we redeploy those staff, so that they're not in an area where they're creating risks for themselves or others.

So, you're moving staff around based on whether they've had the jab.

If it's a very high risk, we would look at that as an option. Because it's a risk to the patients.

In the respiratory ward, intensive care and so on. 

Absolutely, it's a risk. I'm just wondering why not just Betsi but NHS Wales, really, hasn't moved towards saying this should now be mandatory, because I remember talking about this when I used to sit on the Wales partnership forum. 

It would help. As the lead nurse for the organisation, and looking at my colleagues in therapy and the medical director, we actively encourage our staff to take up the opportunity. As I say, we will risk assess; we definitely do do that. 

Just one final quick question. All health boards received additional moneys to help with winter pressures—that came through in January. How much of that now has just become what you rely on to get you through winter pressures—that additional money that's coming in at winter time?

Last year was extraordinary. We know we have responsibilities to live within our budget, so we plan within our budget.

Okay. So, the additional money is just that. It's helpful but it's not something you're relying on. 

Certainly when we're looking at opening additional resources that we don't have the core budget for, then we would be looking for support to do some of that work.

I think the challenge is that, while there is additional money, we know that there's not staff in the system. So, you might have a lot of money, but we know there's a shortage of registered nurses and doctors et cetera. So, where you would maybe want to invest that money in additional services in the winter, the staff aren't there to support it to its maximum.

Presumably, it would enable you to get in additional agency staff—

It does, and I think that's where the premium lies and that's what I was alluding to—core versus what we would be looking at on top of that. That is a continual challenge. I will say that having the—. I was at a graduation ceremony in Bangor yesterday for the new nurses and I think that the principle of the bursary being upheld is great and is going to help us moving forward, because we see those people taking up jobs within our organisation, which is fantastic. But we've got a gap, and it's still not closed.

All right. Thank you. Thank you, Chair.

I'm happy to go first, Chair. Thank you very much for the invite to come today. We've certainly improved our planning arrangements over the last few years. Particularly, last winter, as the committee will know, we've come through quite a challenging period for us within Hywel Dda. The previous winter, we coped reasonably well, whereas this last winter has been much more difficult a period, so we're certainly trying to learn from that carefully, working with all of the other health boards to look at the best practice that's going on across Wales, and also to learn from our own experiences and the evaluations that we've done across each of our four hospitals. We've already started a number of planning events internally. We're trying to refocus our winter plans to be—because, really, winter now is sort of happening all year round within our health board; we've certainly not come through a quiet period in April, May, or June, where we've seen continued and sustained pressure. So, we're working harder on our improvement plans across the whole of the unscheduled care system, across the whole of our population, to make sure that we have really good unscheduled care arrangements in place all year round. But, particularly for this winter period coming, we're trying to learn from last year and just focus on a smaller number of initiatives, but those that will have what we believe will be the biggest impact, trying to help us cope through the coming winter.

Thank you. Good morning. I think very similar to Joe, really, except I think that the lessons, from an individual health board's perspective, but, additionally, on a national perspective—so, through the national unscheduled care programme board lessons are shared more widely—and I think, as Joe said, us concentrating on a smaller number of initiatives that we know will have a bigger outcome. And, certainly, from a local perspective in Powys, our focus this year, and our planning, as with all the other health boards, has started already for the upcoming winter period. This focus is very much on discharge to assess, or prevention of admission in the first place. We've been talking about that for some time. What we've got are lots of different smaller initiatives in different pockets, different localities, and it's about how we upscale, and that's the focus for us this year.

Okay. Thank you. I think that this is a very complex area—it's something that, if it wasn't complex, one assumes that we wouldn't be in the situation and in some of the escalation that we've had, certainly the last winter. I'm not sure it's a result of poor winter planning. I think it's probably—. My own sense—I'll speak for Powys—is it's more about the demand and capacity modelling. But when you take into account the analysis that we've had of the past winter, you could question could we have predicted the flu, should we have been predicting the bad weather, should we have been predicting—

The winter.

For winter. Well, absolutely. Clearly, there's an intense planning process. Both Joe and I will know that through years of experience. I've been doing this for years and years and years. And my own sense, and certainly coming back in to the operational field, in the last five months, without a doubt it's sharpened—it's much crisper, it's much more multi-agency. So, I think that this is an evolving process. But definitely for us it's much more about demand and capacity. But, from a very local perspective in Powys, a lot of the delays are particularly for the Welsh Ambulance Service NHS Trust, and ambulance performance is geographical, and it's the challenge of very rural locations. So, a combination of both. I don't think it's about poor planning. I think the planning—the wider sharing across NHS Wales, we are learning from each other, but we have got different nuances, depending on the health board and the geography and the population.

I think, similarly to Rhiannon, demand and capacity issues are the key area for us, in that our demand forecasts weren't predicted to go up as high as we did, and also the number of elderly people who required our services increased on previous years. And that was coupled really with a health board where we're not easily able to turn on capacity, in that all of our hospitals pretty much operate at capacity on a daily basis, and, even if there were additional moneys to open additional capacity, we wouldn't have the nurses and doctors and therapy staff available to put that on. So, our focus has always been on trying to improve the system that we've got with the people that we have, and trying to focus on our improvement work all year round to try and enable us to cope better at times of extreme pressure. Also, with the flu challenges this year, and additional workforce challenges that we had within the health board, a number of things, I think, came together: fragility of out-of-hours services and day-time primary care as well, so that just a number of things came together this winter that made it particularly difficult. I would say, on the escalation side, that I think the NHS staff are amazing in periods of escalation—we ran four calls daily to manage escalation across all of our health board, and that involved mental health, all the community services and all the hospital services. We often diverted patients around as well to make sure that we could manage the pressures as best as we could within the capacity that we had. Certainly our staff travelled to other sites and other locations to work at times of pressure and were a real credit to all of us through that period.

It was just as a supplementary, thank you, but, as Joe said, I think the workings within the individual health boards—. But I'd also want to promote that, on a national level, the calls that we have daily—sometimes twice daily and even more than that, depending on escalation—there is a collaborative sense of integrated working across health boards to accept and acknowledge demand and to do what we can to help. That's easier to say than to do, when you think about rurality and geography, but I think the working with—certainly the Welsh Ambulance Service NHS Trust, but, additionally, the third sector and how important they are to the planning processes and the reaction process.

Good. Angela.

Thank you very much indeed, and thank you for your papers. You made the comment that you didn't think it was about poor planning, and I think, Joe, you said that it was about trying to improve the systems that you have already in place. So, I was just wondering for last year: what systems were put in place to deal with the fact that you had two four-day weekends almost back to back? Because the analysis I've seen from various organisations, but particularly the Royal College of Emergency Medicine, is that, although the EDs were staffed, there weren't the consultants to back up, so, if somebody had an issue with orthopaedics or paediatrics or whatever, they weren't necessarily there. And then, beyond that, you didn't have the radiologists to do the x-rays, the MRI scanners, and then, of course, you had the issue of people being in bed and not being able to be transferred back out into the community because the NHS is 24/7, but county councils don't operate on the same timings. What recognition was made of the difficulty you had of those two back-to-back weekends and how are you learning from that, going forward?

I'm happy to start, Chair. Firstly, for the two four-day weekends, we obviously have detailed weekend plans on for those areas where we put on extra capacity and extra staff to deal with that, in a way, on a more exceptional basis than we would over any normal weekend. One of the issues for us within Hywel Dda is that lots of that is often based on, always, additionality, on overtime and on goodwill of staff, to get people to work additional hours—we have lots of vacancies and therefore we use our existing staff groups to sometimes do that.

We also ran what we call 'perfect weeks' before the Christmas period: so, we reviewed every patient in all of our hospitals in that period and tried to identify packages and needs for them earlier on in their care pathway to make sure that we would go into that period having a clear set of clinical conditions by which we would be able to discharge patients from the hospital, working with social services colleagues.

There is always, I think, for us, a challenging period after the Christmas period, where often, and again this year, we've used a lot of the capacity available for domiciliary care and other capacity in the build-up to Christmas and soon after, and, therefore, the first two weeks of January were particularly challenging as everything else stepped back up. And so one of the areas for this year's plan—and we've already had agreement from the directors of social services through our unscheduled care programme—is that we would have a much more integrated winter plan and try and provide a joint document for the whole of the system this year, which is signed off by the regional partnership board. So, we really go into this winter—. We did some of that last year—we did get sign-off by local authorities, but not perhaps in the formal way and one where we could all put our logos on the front of a document and go into that in a truly integrated way. And so I feel that's good progress for us within Hywel Dda in that we'll have a document where we'll really stand together as we go into the busy period post Christmas.

I want to say 'ditto' really—[Laughter.] But that's not going to suffice, but really just to flag up the challenge of vacancies and particularly in hard-to-fill posts: so, radiology is particularly challenging for us—again, I keep promoting, just in case we didn't know, Powys is rural. But there is a challenge in terms of some of that. So, I think your attendees previously identified you can have all the money but if the posts are not there—. Even from an agency perspective—. So, our contingency plans can often be based on the use of agency to include off-contract agency. If they then don't fill, we're left with that gap, and it's how you manage that as part of your contingency.

I have every sympathy, because we can't magic staff out of nowhere, but it is about massaging the system and ensuring people are moved through appropriately and trying to take that pressure off of ED. I know that's not perhaps the effect that's felt within your health board. 

But it is about admission prevention, where that can be—. I think the focus for a lot of the—. Up until perhaps the last two years, the focus particularly in terms of unscheduled care did tend to gravitate towards the ED, when actually it needs to be in primary care and in the community—a personal view.

And when you've dealt with primary care and community, in terms of capacity planning and going forward, one of the big areas that was picked up is the increase in ambulance unloading—it's not unloading, it's transfers. In Hywel Dda, it tripled, I think. It was a massive increase. So, I'm assuming that those are ambulances all waiting outside of ED, trying to get through the system. Therefore, is that a reflection on whether or not the care pathways for particular areas are working? We've just listened to one health board where they were talking about that, in north Wales, they've got quite good care pathways to make sure that paediatrics go straight through to the paediatrics department and so on and so forth. Could you just give us an assessment of whether or not the care pathways are really working and does that take any pressure off of ED at all during those tough times?

Firstly, dealing with ambulance delays, we normally account for around 3 per cent of the whole of Wales's ambulance delays and generally are very good and have great relationships with the Welsh ambulance crews on the ground, and that's not really historically been a problem for us. As you've said, this year, we've seen, on days—I think on one day one of our hospitals accounted for 20 per cent of all of the Wales figures. We've been around 8 per cent, 9 per cent, of the all-Wales numbers, which for us is high as a health board.

We do offload ambulances into our emergency departments and into spaces on the basis of trying to consider system risk all the time around patients at home not receiving ambulance at times of acute pressure, and particularly we monitor the amber waits and some of the waits beyond the red eight-minute target to try and make sure that we're mindful of the whole-system risk when we look at that.

I think the honest answer in terms of pathways is we can always do better. We've got lots of good examples across our clusters and primary care and community services systems that we know can be effective alternatives to admission. The acute response teams, for example, can—. In Pembrokeshire, we'd have three teams on during the daytime and one overnight. We know that, at times of pressure, when we've expanded that, that's made a difference to give people alternative options to being brought to hospital—similarly, working with care homes on providing alternative options for those.

We also know that we've got lots of pathways in place that sometimes aren't used. That's one of the areas of learning for us—how do we really embed some of the services that we have across all of the agencies, and particularly across our own services as an integrated health board, to make sure alternative options are pursued before just dialling for an ambulance to bring to an ED department. I certainly would say we can do better with that and it'll be a key feature of one of our key areas of this year's planning for the seasonal demands.

You mentioned system risk. That was another question I wanted to just explore a little bit. Do you have a constant evaluation throughout the day as to whether or not there is more or less risk in opening up an extra bed or two beds on a ward, which would then put that ward marginally over capacity, compared to a patient being left on an ambulance or on a trolley in a corridor?

Yes, for us, we have four times a day site calls involving all of our sites. During this winter, we did use less than ideal areas to move patients into, so we would have used procedure rooms within our wards; we regularly use the bay in Glangwili hospital to offload patients into. In some of our hospitals, we're not able to do that because of the physical environments. So, in Prince Philip Hospital, for example, in the medical assessment unit, it's difficult to take patients out of an ambulance there. But we've got constant delay information about ambulances at the hospital, which I see on a live basis, and we will have four calls a day, so we're constantly monitoring system risk. We'll divert ambulances across our four sites. We're able to do that as we've got four general hospital sites. We will often take ambulances from—sometimes, help on the borders with ABMU, and, vice versa, take an ambulance to Prince Philip if that helps the overall system. 

And also, really, part of my job around hearts and minds of our staff in our hospitals, particularly, is that there are patients waiting for an ambulance sometimes for unacceptably long delays, and so ambulance—. I don't like to use the word 'offload' because there's a patient, but bringing a patient out of an ambulance into a healthcare setting is a real priority for all of us, given we know the long delays that patients have experienced, particularly over the last winter, waiting at home through ambulance response times.  

You talked about hearts and minds; it was actually just on hearts. Of course, you also had huge delayed transfers of care between Hywel Dda and Morriston in cardiology, and the more rural health boards do rely very much on their neighbours to pick up all this kind of slack. What kind of capacity planning is done between the health boards so that you know where Morriston are going? We know the stories of our babies ending up in Rhyl because there isn't the capacity in Morriston, et cetera, et cetera, so I just wondered what systems you have in place to ensure that you both have a really good handle on your neighbouring health boards, and the help that you might require from them during periods of enormous capacity pressure.  

I'll pick up on some of that; I'm giving Joe a rest, really. I recognise that we haven't got those facilities in Powys, but it is about our residents, of course. 

Of course, you lean on everybody else much more, actually, in—. 

And support everybody a lot more. We try to, anyway. I think, without a doubt, those issues are picked up on in the national call where all health boards and Welsh Government are involved on a daily basis. If escalation is required in terms of that, the network will pick that up. So, there are inter-health board discussions about delays. I think the good thing about the national call is you're aware of everybody's position; it's on the national dashboard, anyway, which is electronic so you can see that. But you can understand everybody's pressures and I think, based on that, and the risk factors that are being presented in those calls, it does feel very collaborative in terms of understanding how you prioritise, particularly in that situation. Notwithstanding that Abertawe Bro Morgannwg will be under significant pressure with a lot of ambulance delays, if there are patients there that are awaiting repatriation, everybody works to ensure that that repatriation happens. So, in terms of planning through the network, it's escalated through the network if that's required, both for ICU capacity, whatever it is—special care, as you've identified. My own experience of that, even though Powys is not in it, is that that works reasonably well, and with outside partners. So, where we do need to rely on English partners, that happens as well.  

On the very specifics of cardiology, we do have some joint work going on with Chris White and his team now at ABMU, a group being chaired by Dr Mark Ramsey from Morriston, looking at the cardiology pathway, and particularly our patients that require transfer to Morriston. There was a day, I think, over this winter where the whole of our ward at Withybush cardiology ward was full of patients waiting to go to Morriston. I'm pleased to say that, following Chris's intervention with that, that's improved a lot over the last few months, and we've got some joint work going on planning regional capacity now for cardiac, and, similarly, a vascular board, which I chair for the network for south-west Wales. We've got joint work in ophthalmology, orthopaedics, dermatology. So, I think we're really starting to develop, through the regional planning arrangements that Dr Goodall has established, a much better interface between the two health boards in terms of longer term planning, as well as the day-to-day management of repatriations and transfers. We do work closely together because we're quite close to each other, so we've got each other's numbers. You often get a call to see if there could be some help to bring a repatriated patient back to Withybush or Prince Philip, and we'd always try and prioritise those first.   

The last set of questions, because I know we're tight on time, which is actually, I guess, aimed particularly at Hywel Dda: we know—because I'm not quite sure of the numbers in Powys, but we know that in Hywel Dda we have an above the Wales average older population. Therefore, it goes to follow that we're going to have above average frailty cases coming through all the year round, but particularly in the winter. What recognition is there between the board and social services on that issue? 

We're piloting the integrated pathway for older people work with the national programme, both in Pembrokeshire and Carmarthenshire, in which, again, the directors of social services are actively engaged. We're also the first hospital in Wales—at Withybush—taking part in the acute frailty network. We've got some excellent geriatricians at Withybush who are working on looking at comprehensive geriatric assessment at the front door, providing elderly care clinics out in community services. So, I feel that it's an area that we're actively planning and working on and have good progress in those areas. 

Rhiannon. 

Yes, can I just come in? Thank you. So, an ageing population is a significant factor for Powys as well. What I want to flag is the importance of virtual wards. It absolutely is about the front door, but it's about the role of primary care, the third sector, social services and clinicians in preventing admission and actually holding patients safely in the community with a wraparound of the multi-agency team. That's something that we've been working on for some time in Powys and have had national awards for those pieces of work to minimise admission. 

Again, I'm happy to go first, Chair, with your permission. We run five GP out-of-hours centres, two in Ceredigion, two in Carmarthenshire and one in Pembrokeshire. We're working with a GP advisory group, but we have GP representatives from each of those areas to try and work out what we are going to do about GP out-of-hours, in that the models that we have aren't sustainable. I think daytime practice is becoming more challenged. There are fewer GPs who want to work in the evenings and out of hours on GP shifts. I think some of the taxation rules and other changes have made that also less attractive for some of those to do that. 

We're trying to create perhaps a different—. We've piloted 111 in Carmarthenshire, and, whilst that's had its ups and downs, we see that still as a long-term good model, because there's more triage, and through the clinical hub there's more central triage of patients, which enables fewer needing to be dealt with on a face-to-face basis. That certainly has been our experience in Carmarthenshire to date. 

We're also looking at new roles, looking at how we can—. Advanced paramedics particularly are extremely effective in out-of-hours, and some advanced nurse practitioners as well, who can provide alternatives to having GPs. So, we're trying to look at the skill mix within our out-of-hours services and use the GPs for the areas where we need a higher level of skill base, and then use other extremely capable practitioners to supplement the service.

We will need I think to look as well at the number of centres that we run and how we roll out 111 to try and create a more sustainable model, as well as looking at opportunities to work with ABMU and on a more national level as 111 rolls out across Wales.  

From a Powys perspective, we're probably in a bit of a unique position compared to the rest of Wales, because our out-of-hours service provider is Shropdoc, and we're partners with some of the clinical commissioning groups in England. That's had a really good rating from the Care Quality Commission in terms of the quality of provision. We daily monitor the response rates for patients out of hours and they provide an excellent service. Our challenge over the past few months has been about the sustainability of that service for, not quality issues, but other issues, and we've gone through a re-tendering process.  

So, for us, we're about to embark on the 111 journey as well, which we're planning for, but a very different position—it's part of our planning process, particularly features within our winter plan, but it's not so much of an issue for us, at the moment.  

And do you have—? Just briefly, do you have step-up plans within those general plans to make GP out-of-hours services more sustainable—step-up plans for those busy periods in winter? 

Yes. I think that that includes what Joe was referring to there in terms of alternative models and blended roles for staff, particularly the advanced paramedics and how their involvement is really key. 

And are they adaptable fairly quickly to particular peaks or do you have to plan for these well in advance? 

You have to plan. 

Is that a problem? If we look at the whole of winter being busy, within that busy winter period you will have particularly difficult times. Is there anything that you're able to ramp up and escalate during those periods, in terms of out of hours? 

For us, that's extremely difficult. We ask GPs to, effectively, travel across counties, so, rather than run five bases, we might need to close bases at certain times and then ask GPs to cover other areas. Some feel confident to do that and are fantastic and will do that and others feel less able and feel it's more stressful to cover more than one base. We need to be mindful of the well-being of our GPs as well and try and really create an environment that makes working out of hours an attractive place to work, not one where they'll feel perhaps isolated. So, our area of focus is really on listening to our GP colleagues to try and make sure that we can create the best possible climate within which for them to work and provide the best care to patients that need them. 

But, where there are gaps, that will be managed through rota management. We'd be looking at agencies again or rationalising the service, as Joe has indicated, and closing down centres in order that you can centralise—so, to ensure cover—but there will naturally be delays. 

The second one is about serious adverse incidents: patient falls, sepsis and so on. Was there an increase last winter compared with the year before? I'd welcome your reflections on how that affects patient flow and how you're looking ahead to next winter to try to limit those incidents. 

As a health board we've worked really hard on our governance systems. We've got clinical leaders in each of our hospitals that have monthly governance meetings, so we track every individual incident. One of the things that's, in some ways, remarkable about last winter, given the pressure that we were under, is that, though we've seen some more falls, as you'll see from our own briefing—I think four to 10 in-patient falls were the numbers in our brief—we've generally coped okay and we've actually seen fewer complaints over this period from patients, and generally we haven't seen a significant increase in serious incidents reported.  

That applies to Powys. Our numbers are so small, but there is constant monitoring, and, if it's identified as a serious incident, it's managed as such. I think there's something really important about clinical leadership, as Joe's identified. 

Okay. The other issue, rather a big one, is delayed transfers of care and the high number of medically fit patients that are occupying hospital beds. Looking forward to next winter, how confident are you that fewer patients will experience delays waiting for packages of care and how confident are you that that relationship with local authorities is strong enough for you to work together to deal with that? 

Shall I go? Thank you. The planning—we've got daily numbers of delayed transfers of care and they're obviously monitored and reported on a monthly basis through the census. Certainly, for Powys, the majority of the delays are non-health related; they are associated with social care delays, whether that's assessment, placement or package of care. We've got an escalation process with Powys County Council. I will say that there have been some challenges for us because of the position of the council at the moment in terms of improvement programmes for adult social care and children. There's been quite a change of staff at a very senior level, so it has created some continuity issues. However, we have now got a substantive director of social services. She's very responsive; she's recently taken up post. The plans are being developed collaboratively, and Joe referenced earlier—but it's the same, I think, probably for all the health boards—that the plans for the winter, but also management of delayed transfers of care, are all reported with oversight through the regional partnership boards. Additionally, the allocation of the integrated care fund funding actually targets where we think there are issues, and, certainly, the winter pressures money that was allocated in February to the health boards and to social services targeted domiciliary care, which is a particular issue in terms of capacity.

I was just going to add that although DToC is the target that we monitor actively through Welsh Government, probably the bigger issue for us is what we would call our clinically optimised list of patients. And whilst we might be bobbing around 50 delayed transfers of care, we might have up to 200 patients in our hospital clinically optimised, which are discharged from a medic but still need further care or interventions before they're safe to transfer. So, we work, as part of our unscheduled care programme, through the integrated pathways for older people work, with our three directors of social services and their teams to really focus on the whole cohort, not just the delayed transfers of care element, which may be the joint health or social care reasons, but actually trying to bring the assessment of patients much quicker, further into their pathways. So, it's early assessment or discharge to assess in an ideal scenario, to make sure that we're identifying patients' needs much, much sooner and therefore minimising the delays in hospital for clinically optimised patients. 

I probably just want to add as well that the number on a given day or on census is such a crude measure. I think there's something really important about the length of those delays as well. 

Okay. We're nearly out of time—I think your question has been dealt with.

Mine has been done.

Good. Dawn, you've got three minutes left.

Just very briefly on—. You touched, Joe, on flu earlier on as being one of the factors that caused pressures this winter. How is that figuring in your plans for this year in terms of priority promotion of flu vaccinations, and not just amongst the general population but amongst your staff?

We as a health board did much better last year. Our staff vaccinations went from, I think, mid 40 per cent to 60 per cent, and we actually achieved the target that we set ourselves for our staff. We've had a new director of public health and we're really proud of what we've achieved. We work with our operational teams. We came together each month, so we created a bit of competition as well around flu champions within each area and really actively promoted across all of our health board to do that. So, we'll try and build on that again this year. We all got jabbed at the board at the beginning of the campaign and then we really worked hard on that and that's been shown with our results.

One of our challenges, as you look then to the wider population is, although we improved again and there were more people vaccinated across Hywel Dda, we still have some specific work to do with certain age groups, particularly high risk. And if you looked at the six months to 64 years high-risk group of patients, we haven't improved enough in those areas, and that's the sort of targeted area of campaign this year, looking at some specific chronic conditions, working with pharmacy and others to see how we can make further improvements on that this year. 

Okay, thank you.

From a Powys perspective, certainly in terms of the staff group, we were the best in Wales in terms of our percentage of staff, and that included clinical staff and prioritisation. There's always more work to do, because, actually, the target still remains quite low. So, actually, you'd want all clinical staff to have engaged in the vaccination—

Would your—? Sorry, Rhiannon, go on.

Sorry—I was just going to add there, again, that Powys won an award for their communication around flu with public health and occupational health, which was great. So, I think that demonstrates the effort that goes in.

I heard the conversations earlier in terms of mandating flu vaccination—I'm not sure if I pre-empted any of your questions—

Yes, that was—I was just going to ask you what your thoughts were on that.

I think that's a very difficult area to tread. This is a choice, it's about informed decision making and it's about us understanding why people are not having the flu vaccination. I don't think mandating it is appropriate, personally. I think it's more about further education.

We didn't meet the target for over 65-year-olds in terms of the population, but we're on an improvement trajectory. And, again, I think it's about trying to understand why people don't want to have the vaccination, when the evidence base for it is so clear. So, there's more work to do, but, without a doubt, I think the other thing is to assure you that the flu is an element in the national checklist of what you're putting in to your planning process. That's got a very high profile, for sure.

Okay. I think the mandatory element was just about staff; it wasn't about the general population.

No, I agree.

Okay. Just a very brief question on the additional moneys that you receive from the Welsh Government for winter pressures. How much are you now relying on that additional money coming in, or is it something that you have not planned for, and it's just a bonus if it comes?

It was absolutely a bonus this year, and we were able to use it for the areas of work that we know we would like to do but we haven't got the funding for, even though it's been identified in our integrated medium-term plan. I think the key here is other funding sources—so, the integrated care fund money. All of these works are part of the live well or age well work streams as part of the Social Services and Well-being (Wales) Act 2014 and the regional partnership boards. This is how we're targeting and utilising that money. I think, again, that process is evolving. Initially, hundreds and hundreds of projects that were being supported through ICF funding—the approach now is much more narrowed down to focus on what the four areas that we want to focus on are. I think the clinical pathways work is an area that we've targeted.

So, those areas that have got the greatest impact, basically, which you've talked about.

Yes, so we've narrowed down the spend to key areas that are evidence-based that we know are going to have a higher impact. But additional money is always welcomed. One of the areas from the additional money this winter that we had in February—we were able to bring in agencies and a locum therapist to ensure that we had seven days' services in the wards. So, it is really helpful for that.

And that was the same for Hywel Dda—

I think, similarly, it made a significant difference to us. Again, in our briefing, we've set out how we utilised that funding, and it enabled, really, the weekend capacity in the main to really be put on, and also some additional medical cover, and I think the learning for that—if there was an opportunity again this year, we would do more jointly with our local authority partners. I think they felt that, because it came relatively late and we had a quick turnaround of establishing plans, perhaps, as a health board—this is Hywel Dda, not a national picture—we could have involved them better. We're certainly planning better this year to make sure that, if the same opportunities arise, we'll have, again, a fewer, smaller number of high-impact actions to be able to turn on.

And following on very briefly, Dawn, our lesson was probably more about the engagement and communications in primary care and GPs, particularly. So, that's been a lesson for us.

Sure. Okay, thank you, both. Thanks very much.

Diolch. Bore da. I wanted to ask you a general question to start with: how well prepared and equipped are ABMU and Cardiff and Vale to cope with the winter and any likely pressures?

Thank you. Shall I start?

Yes, by all means.

Thank you, Chair. Cardiff and Vale health board has started plans early this year. We took some information through April after a very difficult winter. On 4 May, we had a meeting with our system partners to discuss the challenges that we had last winter and to discuss plans for the coming winter. That was formalised into a debrief, which was sent to our board in June. The learning from that is feeding into the first cut of our plans, which we have now in place, but we're just refining those plans and working through them with system partners over the next few months. They will be collated, brought to our executive and back to our board eventually, but over the summer period, there is a period when we will work with Welsh Government colleagues and the delivery unit colleagues to challenge and support those plans, to refine them and to peer review them in advance of the winter to come. Those plans will be published on our website, then, in September, and there is a formal submission to the Welsh Government, as required, in September.

In terms of preparedness, there is some key learning from last year, already, for us. The normal things of winter that you would expect to see in terms of higher activity in terms of flu rates and in terms of adverse weather—it was a case of magnitude for us last year in terms of the degree to which they varied and came together in sequence to give us a prolonged period of difficulty last year.

So, there's some specific learning around that, which we have incorporated into the plans going forward, and then there is some general planning that we have played into that as well, and the key elements of that for us are improving resilience and sustainability in primary care—that is one element that we are focused on very heavily this year—improving working with our local authority and social services colleagues to improve discharge, and we're looking specifically at a model of domiciliary discharge to assess that we would like to work through and put into our plans for this year. We have some good learning from previous years in terms of putting senior clinical decision makers at the front of the unscheduled care pathways to get early decisions to stream patients to the right place in the pathways in the system. So, there's been some good learning from that and we will do that throughout our services this year, both in secondary and in primary care. We want to further improve seven-day working over this period as well, particularly around our community resource teams, our acute physicians' availability at weekends and in our GP out-of-hours services. And we have revised capacity plans in terms of bed and bed-equivalent plans going through to this year as well.

All of this is underpinned by a series of work that we're putting in place throughout the summer to try and underpin some of those actions. And that's around improving length of stay for patients in hospital, which would ensure that more beds are available to patients and would hopefully reduce length of stay over the summer period. So, that's the general approach from Cardiff and the Vale.

There will be more—[Inaudible.]

If I could just add, Chair, that's a similar pathway that ABMU are taking. The broad philosophy is exactly the same—the timelines are dictated to us by Welsh Government on how we get our reviews in. The only thing I'd add is that we're doing specific work around a review of our flu plan and whether we got as much out of our flu plan as we perhaps could have. I think that's important for us to reflect on, but also the escalation levels, and not only just the escalation levels but the risk within that context and what we were doing around that. So, we did specific—

Questions on escalation levels next—Julie.

In terms of the escalation levels, is that, do you think, a result of poor planning—you know, the higher escalation levels that we've had—or a mismatch between demand projections and capacity modelling? What would you say it was? Shall we start with ABMU?

Yes, by all means. I think that what we saw through last winter was that we stayed at higher escalation levels for longer and we didn't get the de-escalation that we would have hoped for earlier in the system. I think there's nothing wrong with escalation. On occasion, when people talk about going into an escalation level, that's good as long as you've got the pathways making sure that you can de-escalate as well. It's around what we're doing managing the risk in that arena for our patients in getting them into the appropriate accommodation, facility, bed—if necessary; it shouldn't all be about beds. So, I think there is something in understanding when you are going into escalation, and I think that's at a number of levels, both internally to the organisation in how you manage the risk across the organisation and secondly how you manage that risk in the system. We worked quite closely with colleagues in Cwm Taf—that's my previous organisation—and with colleagues in Hywel Dda around managing the escalation pressures around the boundaries there so that we can actually get flows of patients moving into different systems that help the patients that are in ours. 

Thank you.

Similar, really. On escalation, we have an all-year system where we have four points in the day where we judge escalation and judge risk across the system. There's a lot more we can do to improve that. We've been working with the delivery unit as part of the Welsh Government body to improve and review our escalation levels as we're going forward.

In terms of the link to planning, I think it's an important link in terms of understanding how we plan for that. So, for example, we use six-week rolling averages to inform our daily and weekly planning and escalation in terms of that, and then, in winter, we use a three-year rolling average to understand what that might bring in winter. Just to elaborate on that a little bit, this winter was exceptional in terms of our escalation levels, which, as Chris has said, stayed higher for longer, and there were three things that happened in sequence that influenced that for us in Cardiff and Vale. There was an extraordinary increase in demand between Christmas and new year. If you take Christmas eve, we saw a 22 per cent increase in presentations to our A&E department, and if you look at new year's eve, we saw a 26 per cent increase in presentations. In that week, we received 46 more medical admissions than the high level we already would get, which ate into our winter capacity already early in the period.

We'd expect to recover in January, but then the peak intensity of flu came in January, which meant that February was difficult, and in our submissions I showed some quite extreme variations in the pressures in February, which was a result of that flu. And then, once again, as we were trying to recover in February, we had the first of two periods of severe weather in March—at the start and end of March—which compromised our ability to get people out of hospital and home safely and compromised the ability of our local authority colleagues to care for them when they were at home. And that came with an inevitable surge of activity when the snow had receded—of people coming to hospital. So, it came together as a sequence of pressures, which was not only—. All of those things are winter related, but it was the magnitude and the sequence that meant that we stayed in a higher level of escalation for longer.

Okay. Angela.

I just wanted to talk more about capacity planning. I wonder whether you could indicate to us what systems you have in place to plot your heat maps where you're going to have not enough staff to cover, and how did you plan last year—what plans did you put in place to cope with the two four-day weekends that you basically were faced with, and what lessons are learnt from that going forward for this coming year? Because although you may have people at the front door, you don't necessarily have everybody behind.

From a day-to-day perspective, we use things like e-rostering. In ABMU, e-rostering hasn't been rolled out as much as in some other organisations across Wales, so I think there's a piece of work that the organisation can do in rolling that out. In particular, with weekend planning, we have weekend briefs. We work it through the week, culminating at the end of Thursday, when we should know what our weekend plan is looking like for that specific weekend.

When you talk about the big four-dayers around Christmas and new year, there's a balance for us to get around. It isn't all about ED; you're absolutely right. ABM does have additional staff in diagnostics, for example—in radiology and in pathology. They run Saturday services in radiology to try and improve the flow, and I think that does give us advantages. For those big events, we also then get additional therapists, where appropriate and where possible, because staffing levels are difficult, and sometimes people don't want to do extra shifts because they're doing some additionality through the year. But, most of the time, I would say our staff are fantastic in the NHS, and they come to the table at times of crisis, and it shows the real value of what we're about as a system. In saying that, they need to be given enough time away from the coalface so that they can actually enjoy themselves and then come back with a vigour the following week.

So, we do, in ABM, work up different types of plans. It's the winter ones, but also for all our bank holidays. On the bank holidays we've just been through, we went supernumerary with an ED consultant on the Morriston site, for example, but we're also short-staffed of ED consultants, so we've taken a view around how better staffing could be an additional surgeon in Morriston. So, we've put in an additional senior decision maker with a surgical background, so at least there are two senior decision makers on the floor making front-line calls, then that feeds into how your patients are coming out of ambulances and into your system. There are a number of ways that we take different patients through different pathways into wards, so that they're not hung up in the ED per se.

Do you want to add anything? 

Just that those bank holiday periods are landmarks in our planning. So, if you take the winter period, in planning for the winter period, we know that we get a surge in the post-Christmas period. We know that we often get a period, in the pre-Christmas period, where we get a lot of discharge activity coming up to that. So, there are patterns that we do see in this. Planning for those two points at new year and Christmas are the landmarks in terms of where we have to plan for them most.

On your point, though, as well, about how it's not all about the front door of the hospital, if you take the four-day period that we had last Christmas in Cardiff and Vale, in our GP out-of-hours service for year on year on year, we will see a build-up, from Christmas Eve to day 4, of activity that gradually gets more intense. As it happens, we saw the exact opposite this year. We saw the most busy period on Christmas Eve and a quieter day on the fourth day. So, after years of learning from our planning, and profiling our staffing to that, it actually changed completely in that one year. So, a challenge for us is: do we plan for the norm or do we plan for the exception?

Do you know why it did that flip?

We really don't. We think that there may have been—. And that will be the same thing that had driven the activity in the A&E department as well. But whether there was an early indication of the flu coming throughout that stage—. We do know that the intensity, which was the most intense since 2010-11, peaked in our GMS services in January, but there may well have been a build-up before that that contributed to it.

Can I ask about how you can protect, throughout the whole of the winter, the elective surgery element? Do you find that the pressures on emergency care do impact on elective surgery greatly, and do you think that if there was a divorce between elective surgery and emergency care that, actually, that could improve? I get representations from consultants saying, 'All the elective surgery has now been cancelled for x weeks', and it's such a waste of talent and capacity, but I can understand that it all boils down to the beds, doesn't it?

Again, a multilayered question there with a multilayered answer, really. I'll try and be specific. We didn't actually stop operating in ABM for large periods of time last year. From an orthopaedic perspective, we took our orthopaedic ward down for two spells, one for a two-day period, one for a four-day period. That's probably our last area, when we're right up against it, where we actually opened for medical admissions, because you've got to then deep clean the ward, the patients going in there are MRSA tested, et cetera, et cetera. So, you wouldn't want to do that. We try and map our capacity around day-case capacity, 12-hour capacity, 23:59 capacity and in-patient capacity. On the Morriston site, we brought in a little unit—the company is Vanguard; it's a small unit, it's got eight trolley areas on it—to give us some contingency to ensure that our elective capacity could be maintained. Likewise, on the Princess of Wales site, we have a short-stay surgical unit. So, we're trying to use different types of capacity to keep the flow of patients. There will inevitably be times when you have medical outliers in surgical beds. The fact of the matter is you need to try and minimise that to the best of your ability, and this year, the learning for us in ABM, coming out of winter, has been to front-load our system earlier in the year, using health board funding to make sure that we can actually drive our referral-to-treatment figures in the first quarter or half of the year, and we've done that so far. Quarter 2 is a big quarter for us around delivery in elective care, but at the moment we're on a trajectory to deliver what we've said in the organisation. 

I've got one more question to ask, particularly of you, about delayed transfers of care, but Caroline, did you say you wanted to come in on that? 

Thank you, Angela. It was just a question to ABMU, really. Hywel Dda health board has raised concerns about an increase in the number of delays of cardiac patients awaiting transfer to Morriston. And as this is my area, I'd like to ask this. So, how confident are you that the capacity will meet demand this winter, and that joint work between health boards can deliver the solutions to manage the ongoing growth for cardiology services within Morriston Hospital?

I think it's difficult to sit here and give you absolute guarantees that I would be comfortable with the capacity that we have available. What I can tell you is the way we work through it is on a national basis. We see, on a daily basis, what the cardiac issues are. Some of those would be escalated by a cardiac network solution, but that's taking it away from the coalface, so part of the work that I'm doing with Joe Teape from Hywel Dda is about, actually, what could we do on a regional basis.

So, over the last few months, we've set up a working party led by a senior clinician on the Morriston site, who happens to be a cardiologist, to do three things, really. First is to do an immediate review of those patients that are on the list in Hywel Dda on a daily basis, and what are we doing with them. That has seen a noticeable decrease in the numbers waiting on a list to come in to the Morriston site. Secondly, Hywel Dda themselves have done some work in cardiac angiography, in coronary angiography, by having a mobile unit on the Prince Philip site. We then have coronary angiography labs on the Morriston site, so it's dovetailing what that capacity looks like and then understanding who needs to go forward into a more interventional procedure, like an angioplasty. Then, thirdly, it's about how that links in to the cardiac surgery pathway. So, that group is clinically led. What we're seeing is good traction at the moment and improvements for patients in Hywel Dda at the moment, but I think we need to do further work to ensure that that system is balanced going into next winter.

For any patient that is—and Dr Lloyd will understand this, but I don't want to get technical. For anybody that's in an infarct state—the technical term is a STEMI or an NSTEMI patient—those patients are immediately brought into Morriston and are accessed into our laboratories. They don't form part of a wait at the front door. The wait at our front door is measured on a risk basis, and we do that on an hourly, minute-by-minute basis. Our teams at the front door are doing that. That's again clinically led by the consultant of the day in the ED who would have a look at that. There would be patients who we would risk assess, sometimes in the back of an ambulance, which is not where we would want to be in ABM, but at least they're getting a clinical view that then risk stratifies that patient as to where they need to go. Unfortunately, that sometimes affects people—a crude term is 'queue jumping'—so that we get the most needy in to the hospital. That's not to say that the other patients left in the ambulance are less needy, but from a clinical risk perspective, that's the way we try and manage that high level of risk escalation. 

Angela, do you want to carry on?

Yes. I just wanted to talk about, in terms of capacity planning, how integration works, particularly between social services or social care and the ambulance trust. So, I guess I've got two questions. The first is: how well do you think the alternative care pathways are working, so that we're getting people straight to paediatrics or orthopaedics, or whatever it may be, so that they avoid ED altogether during the winter in particular?

And secondly, how well, particularly over those pinch points that we talked about earlier, does that integration work? Because I know that, for example, in the Heath hospital last winter, you had almost two whole wards full of people—because I met with you senior ED clinicians—literally just waiting to be transferred out of the hospital. So, of course, that has that concomitant pressure at the front door. So, if those people were in the appropriate place for their care—wow, you'd have suddenly had enough capacity to deal with an awful lot of the pressures that you felt at that front door.

On the pathway work, yes, it's really important, the pathway work, because it's about getting the right skills to the person who needs them at the right time; it's not about traditional pathways that have been there. We've been working very closely, particularly with Welsh ambulance colleagues, on that over a period of time and we continue to work with them. So, there are two ways that we can do that: one is about conveyance avoidance—about avoiding people coming to hospital in the first place, and the other is, as you rightly say, about expediting access to the hospital to the right place, rather than going through the A&E department, as would be traditional.

So, for some examples of the work that we're doing there, we have some particular work in mental health, around mental health patients in crisis, who no longer need to be brought to the emergency department. It's not the best place for somebody who is having an event to be; it's much better that they're in an appropriate place. So, there's some direct access for a cohort of patients that's appropriate to our mental health services crisis team in that. That seems to be working well between ourselves and the Welsh ambulance service. Some other examples that we reviewed last year and brought through, both in terms of efficiency, if you like, and in terms of dignity, was patients with gynaecological problems having some direct access to the gynaecological wards, and that’s working particularly well. There are other pathways that we still pursue to improve, so we have a trauma neck-of-femur pathway, which is wholly dependent on us keeping empty beds all the time. Not all the time are we able to do that, but, when we do do it, it works particularly well and we try to do it as much as possible.

On the delayed transfers of care, there is a category of delayed transfers of care, and there are other patients who don't fit that category and that would probably refer to the 200 patients that my clinical colleague may have had discussion on with you—so, both actions on both. I believe we're working from a point of progress. I think we've got really good progress with our local authority partners, social service partners, on this. Our DToC number last year reduced by 25 per cent over the entire year and we had some really good success on the joint appointments of heads of integrated care, who are working, both to ourselves in health and to social services, to come up with ways forward in terms of placing patients that are safe and appropriate. And the conversation we're having with them at the moment is whether we can take that further now and have a discussion about domiciliary discharge to assess, particularly over this next winter and going forward, where we can support people in their homes whilst choice or ongoing care is being worked through, rather than waiting in hospital for that. But it would require the appropriate home support and our local authority colleagues have been very helpful in engaging those discussions to find a way through that.

Do you need the GPs to be involved in that as well?

Absolutely—a key part of it. Just finally, you've got to remember that these patients don't necessarily have a medical need—they are medically fit to leave hospital—but they may well have one after they leave, so involving GPs, local medical committee cluster groups, is really important.

Just to add to that, I think a number of the interventions that Steve spoke about there for Cardiff and Vale are replicated in ABMU. I think I mentioned earlier on some of the pathway work. It is interesting though, the closer—and we should always work closely with our Welsh ambulance service colleagues, but the successes of some of the interventions in the Welsh ambulance service just changes—you mentioned the question around demand and capacity planning—some of the demand that comes to our front doors, and their 'Hear and Treat' example actually is taking a number of the patients. So, their conveyance rates into ABMU, and I think across Wales, are going down. But, if you're taking more of the green calls out of the system and you're taking some of the amber 2s out of the system, by definition, what's coming to your front door are amber 1s and reds. We've seen an increase through the period that we're talking about here of 24 per cent in red calls, and, particularly in February and March respectively, a 10 per cent and 8 per cent increase in those. Now, they are difficult patients, more complex patients, with a different type of needs, so, therefore, through that period, we've got to remap our capacity, I think, as a system to get us ready for what the new type of demand is coming down the line, and that will be more rehabilitation, different relationships with our primary care practitioner GPs and other primary care practitioners in admission avoidance. And as important is what we do in that space with our local authority colleagues about understanding speedier transfer, packages of care available for longer periods of time, and I think that balance is going to be important for us in mapping as we see, hopefully, more success stories about stopping people coming to our front door.

I can—. Sorry, Chair, can I just add? I think one of the things that we are finding across Wales is how do we learn off each other. Some of the work that was done in Cwm Taf around a system called 'stay well at home'—there are those systems in ABM; there are those systems in Cardiff and Vale—and one of the things that we need to do is understand what works well, how do we replicate it and how do we get it to accelerate the change in Wales. I think there are opportunities for us, particularly in intermediate care, where we could interact more with patients, perhaps on the deterioration pathway, to make them stay in their own bed, maintain their own independence, and therefore it should help them in actually living a full and fulsome life.

Thank you. We have similar issues in the out-of-hours service in the AMB region, from a staffing perspective. We're doing that on a number of bases. How do we actually get a more multi-disciplinary environment, a multi-professional environment, in out-of-hours? So, we use pharmacists and we're using paramedic practitioners to give them a little bit more depth of service. Can we make the deal more attractive for our GP colleagues? Because some of our GP colleagues in ABM have decided not to do out-of-hours work, and our primary care medical director has done some work with colleagues who've just left that for a number of reasons, probably not for here, to try and get them back on to the rota, and we've had a little bit of success there.

I've brought in some of the bundling issues that we did in Cwm Taf to see whether we can bundle a deal up so that if somebody comes with us for a longer period of time then you can manipulate—not manipulate; wrong word, sorry, manage—those rates over a longer period and therefore give yourself more assurance that you're going to get more out-of-hours cover. So, I think there are three there. We have to make out-of-hours an attractive proposition, and we have to see out-of-hours sitting alongside 111. ABM hosts 111 and we are seeing successes in the way 111 is again stopping people coming to our front door.

All that could be applicable any time of year of course. Do you—both of you, actually—have escalation plans for the winter period in out-of-hours GP cover?

Yes, we do. In our daily calls—I host a daily call, or the executive on call would host a daily call—we would have a picture on our four units, from a hospital base. We'd also have an update on what's happening in mental health, because there are a number of issues around mental health patients coming to our front door, and liaison with psychiatry and using those types of skills to better place mental health patients. Primary and community services would also be on that call to give us an outline of what's happening in out-of-hours itself, 111 and what our community hospital capacity is like, to enable the pull into that system to get patients out of our main ED hospitals.

I'd agree. We have escalation, and contingency plans are really important as well. As you'll appreciate, these aren't plans that we prefer to do, but we would deploy if we got into difficulty. So, we absolutely staff up periods like, for example, the bank holidays that we were talking about, and try to over staff if we can. If there is a problem with GP support in particular we will increase the support around them in terms of nurse practitioners and use multi-disciplinary teams to provide a wider resilience. If necessary, we will provide a back up.

So, for example, one of the areas that will spill over in GP out-of-hours, if it doesn't cope, is paediatrics, is children coming into hospital. So, if we got very worried, we would ask our paediatric emergency consultants to staff up as well so that there would be a divert there if that was necessary. We try not to go to that. We very rarely do. But, just in case, we do have that available.

Did you have to last winter, for example?

Yes, we did. On two occasions last winter, we did. 

That's a responsive system that can respond to particular peaks, not just the winter period.

Yes.

Yes. Internal escalation levels are 52 weeks now. One only has to look at the current pressure on the system and the yellow thing that's in the sky and one would imagine that chests would be drying up and we wouldn't be having the respiratory problems that we are. But because it's a heightened summer that we're having, with higher temperatures, there's a different exacerbation of chests that's going on at the moment, which is giving us different types of pressure at our front door. It's not the flu respiratory end of the spectrum; it's more the breathlessness end of the spectrum. But, again, it does increase numbers coming to our front door. 

If I could add, Chair, if it's okay, I would also link that to the sustainability of the in-hours general medical service, which is absolutely key, because what happens after hours is directly related to the ability of the in-hours service to cope. So, what we've been doing is not just looking at that but looking at our GP services' sustainability in the round. We're doing a piece of work at the moment where we have identified a number of very, very successful pilots. GP colleagues are telling us anecdotally that up to 30 per cent of their workload is made up of patients with a mental health or a musculoskeletal need. We see those as two high-volume, high-impact areas. They're two areas where we can bring a multi-disciplinary team approach to them. In Cardiff and the Vale, we are now embarking this year on a programme, which will not be complete by winter but will have started before winter, to roll out those successful services at scale to ensure that there is a scale of benefit across the system that brings an overall improvement in sustainability and resilience for our primary care services. 

I am aware of time being tight, Chair, but, if I could have your thoughts on serious adverse incidents, maybe you can tell us if those, in particular patient falls, went up in number last winter and what your thoughts are on preparing to limit them and to stop them adversely affecting patient flow through your systems over the next winter. 

We track those in detail; they're reported openly to our open board as they come though. Our executive nurse director leads a weekly meeting on concerns and incidents on that and the executive team are briefed at their executive team meeting once a week on that. So, it is very, very clearly in our line of sight. We haven't seen a variation in winter versus the other periods significantly. There is a blip we saw during the snow period that we're trying to analyse at the moment, but we haven't seen that in particular.

Over last winter, 40 per cent of our beds were occupied by people who were over the age of 85 and we have to recognise that that older age group is a key stream for us to design our services around and wrap our services around. So, a lot of work that we've been doing around making our areas more dementia friendly, work that we've been doing on a scheme to avoid deterioration called pyjama paralysis, is all about enabling people to become more independent, keep them in hospital for the least amount of time and support them into their own homes in the least amount of time as well.

Then, finally, we have what's now called a FOPAL service—a frail older persons advice and liaison service—which used to work in wards helping older people get to their appropriate place of care. We've moved that, or extended that service now, to work right at the front end of our hospital so that, when patients come in with not always a medical need—there may be a social need or something around that—there is an expert team with a care-of-the-elderly physician, expert nurses, social workers and therapists, who really do know how to work across the health system to support those individuals independently back into their own homes. So, I agree that the incidence is really important but I think linked to that is the age profile of the patient groups we're seeing, which we need to wrap our services around.  

Similar position from a governance perspective around that—. I notice Steve's is called a FOPAL, we've got a TOCAL. So, it's normal for Wales; we do something slightly different from Cardiff into Swansea and we have—

I'm surprised to have you in the same room.

And this close. [Laughter.] But we've also got an integrated care for the older persons team around frailty at Singleton, so many of the same interventions are going on. Understanding, however, the impact of those interventions, that was learning out of last winter, and, as Steve mentioned earlier, part of our review coming out of this winter prepping for next winter is to not wait. What we've been very keen to do is learn the lessons and get them into what we would call normal practice, because if it's the right thing to do, it's the right thing to do. That does give you issues, on occasions, with the funding streams, but there are many opportunities—the integrated care fund, transformation fund, winter moneys funding—where we can actually better use what is coming into the organisation to ensure that the patient is at the centre of our thinking and then we wrap the right things around. We've got very linear pathways with patients at the moment, and they interact with the system as and when. We need to try and wrap that more holistically around the patient. They shouldn't worry where in the system they arrive—they should be getting that service wherever.

And that includes social care as well. This is a strange one to try to squeeze into a minute or two, because it's a big issue—delayed transfers of care. How confident, briefly, are you that issues of capacity, at local authority level, are being addressed and that you have a relationship with local authorities that is improving quickly enough to try to limit those delays next winter?

I'll go first. From a relationship perspective, I think the relationships are getting better and better. There are forums like the western bay forum. Local authority colleagues also sit on my unscheduled care board, so we have interaction around what the back door—to use the terminology—looks like. There are issues in social care because, coming out of last winter, one provider in Swansea just folded. So, all of a sudden, there was a number of packages that just went down. That's difficult to map, back to your earlier questions around have we got our demand and capacity in the correct place. But I think the relationships are building. There's a better understanding of how we're going to use some of this funding in developing the back door and rehabilitation and doing a lot more of that with the staff working in either sector, because there's a boundary there: is it artificial, is it not, and should we be doing something about closing that boundary?  

To sum it up, I suppose, are you confident that, because things are happening, we'll see fewer long delayed transfers of care next winter?

Yes. We're in a position, as I say, of progress. It's progressed, certainly, over the last two years, quite well. We would want to keep that going and accelerate it. We've got some new ideas and have had great engagement with local authorities to take that forward. So, we think that we've got the right forum to do that, including the regional partnership board, to take those discussions forward to work together to do that. I think we can build on what we've already got.

Okay. Thank you. 

Okay. We're on the last five minutes now. Your issues, mostly, have been covered, Caroline, I think. Have you got a question?

It was on the acuity—

I think it's mostly been covered.

Has it?

Yes, I think so. We'll finish off with Dawn. 

Just a quick question to ABMU, actually, about the boundary changes with Cwm Taf and how that's impacting on your winter planning. Is it?

At the moment, because of the timeline of actually getting the decision—the decision's only been out in the public arena over the last two to three weeks—there has been work going on behind the scenes to start mapping what services would look like in that space between the Princess of Wales Hospital—. And it's not just Princess of Wales Hospital; it's the community services and other mental health services in that area. So, we're starting to map what that looks like. There's a transformation board that's already in place, a transformation group on which operational colleagues will be sitting. So, I think we're starting to see that in the round. And the key criteria for that is that the patient remains in the centre of our thinking and they shouldn't be unfairly disadvantaged, wherever they go. 

So, this transition shouldn't be impacting on the service that's going to be provided over the winter.

It shouldn't impact on the quality of service that patients receive in the Princess of Wales end, or the Bridgend end, of ABM. It's challenging, and I think the timelines will be challenging for both organisations, but it's about understanding, I think, that there's also some opportunities for learning out there across that boundary and making sure that there are more robust pathways. We can learn from Cwm Taf and Cwm Taf can learn from AMB. There's a balancing there. 

Okay. And just on the issue around the additional funding that the Welsh Government put in this year, I think in your paper for ABM—and I'll ask you the same question in a moment—but in the ABM paper, you were saying that it actually came a little bit late to factor into your planning. Are you waiting for that money to plan around winter pressures, or are you saying that it just would have been helpful to have known earlier how much you were getting?

I think we're always grateful to receive additional funding. I think timing is important. We did get it the other side of Christmas this year, which only allows you to extend some of the developments that you've already got in place. But in ABMU, ABM committed £1.2 million into winter pressure moneys, so then when the additional £1.7 million came in, we could then extend it or get supernumerary in some areas, get therapists over the weekend—part of the question on what the multiprofessional response is.

So, you used it to bring additional staff in. 

Where appropriate. There are some of our specialties where we can't get additional staff. That's one of the big impingements to delivery on a day-to-day basis, let alone the winter.

Sure, I understand that. And then Cardiff and Vale: again, from your point of view, was that additional money something that you factor into your planning, or do you plan for not having it and then it becomes the bonus?

There is provision within the health board's allocation for winter. We provide and we plan on that basis. If there is more money available, we will then increase the planning and factor that in. In the paper I submitted to the committee it set out what we spent our £1.3 million of the £10 million on last year, but it certainly does help. It isn't the only constraint. Workforce is a real constraint, and some other things, but we make a provision for it and plan on the basis of what we know.

Okay. That's helpful. Thank you.

Bore da. The first question is a general question to ask how well prepared you are for the forthcoming winter pressures, and where do you think you'll see the pressure points. 

Do you want me to kick off, Paul? I hope that we're relatively well prepared, and I think hopefully you'll see in our papers that we've already taken a review through our organisation, very early in the year, and actually we took our winter plan for the coming year through our board yesterday. There wasn't any special timing about that, it's just that we do like to get on with these things very early in the year. We also took our evaluation of the immunisation plans for the coming year as well, and took those through our board for assessment, recommendation and agreement. So, we came out with both of those approved yesterday and just in terms of the process that we've run to get there, I feel very comfortable about that.

Off the back of winter, we did three potted reviews, if you like, because I think everybody understands that we had a fairly exceptional period, certainly from February onwards. So, we did a gold command review, because we had to go into a gold command period where I took the lead across the partnership bodies to make sure we were driving daily processes. So, we reviewed that in detail to make sure that we can do it better next time. We did a snow review, because that was a potted feature of our gold command—that suddenly we were living in a couple of hospitals for four or five days, some of us not going home for that entire period. So, that needed a good review and understanding. And then, of course, we did a whole winter review, and that forms the body of the paper that we submitted.

So, that's the process we've been through, but of course, plans don't mean anything unless they're enacted, and I think what I'd like to think is that we've taken the learning from a very intensive winter period and thought about not just what it means for winter activities, but actually what it means for the entire year, because we run in seasons. We can predict some of that seasonality. Dr Buss will probably tell you later that when it comes to rotavirus and respiratory syncytial disease there are obvious spikes during the course of the year that we can predict on a regular basis. It's about making sure that our operational plans respond to those predictable themes during the course of the year.

I'm sure that in the rest of the conversation we'll go into the absolute detail of some of the operational things that we're doing. The final point I'd just make in opening is that I can't see how we can deliver as an organisation and as a health board on winter planning, or any period of intensive activity, without full engagement from primary care and community care, and without full engagement of partners. I think the successes that we've had in Cwm Taf over the last couple of years particularly have been utterly built on that kind of foundation. So, I think those are my preparatory comments, if that's helpful.

Dr Buss—anything in addition?

Well, I think, from a clinical perspective, there's been an enormous amount of learning in Aneurin Bevan health board. I think last winter was a winter that really focused our minds on the future about how we take things forward, particularly with our futures project facing us. The clinical messages that we took from the winter period I presented to the board in May. We've, since then, had me taking on, as a clinician, our urgent care board. As a result of that, we're starting to look at really what kind of clinical issues there are facing health systems.

The big question that we're asking ourselves is that—. There are two facets to this. The immediate current pressures absolutely are about how we respond much more adeptly to pressures such as flu, respiratory syncytial virus and adenovirus—the kind of winter viruses that might hit us at any particular time in the winter—and also the cold and the impact that cold has on our system. There's no doubt we saw a 25 per cent increase in strokes, for example, in February as a result of the very cold winter period.

On top of that, there's a fundamental underlying issue for all of our health systems, including ours, which is the impact of multicomorbid frail patients and how we deal with that more effectively going forward in terms of preventing an adverse impact on quality and an adverse impact, possibly, on safety. Those kinds of things are really focusing the way we think proactively for next winter. I'm very happy to give you some examples of the kind of things we're thinking of, but it's not just doing last year's plan. We thought we had a good plan, but it's not enough—we need to do the good plan plus, and the good plan plus is about recognising what the data is telling us and what the clinical nature of the presenting problem is telling us about how we craft our services going forward.

I suppose those points you make are relevant to the whole of the planning of the health service, not just the winter preparedness, aren't they?

This is true. A really fundamental issue, for me, is that evidence has to underpin all of the things that we do, going forward, as a health service. The pattern of presentations that came into our service last winter told us some key messages about the nature of illness and how it's presenting in this modern society, but also it tells us about the focus being in the right place in order to manage our service sustainably going forward.

So, most importantly for me and our clinical teams is that we're starting to get the message very clearly that focusing our efforts on exacerbations of chronic disease in the community—dealing with those in the patient's home quickly and adeptly—is the way forward. So, the medium-to-long-term plan must be about a remodelling of our healthcare system. Meanwhile, the good lessons we've learnt from this winter need to be firmly embedded, but added to. 

The escalation levels reported last winter indicate how much pressure hospitals were under. Is that the result of the difficulties—? Is that the result of poor winter planning or a mismatch between demand and capacity that's been used to inform plans?

I think that's a really good question. I think the rough story of winter was that for the last quarter of 2017, we were seeing, probably, about five or six more people a day on average than we might have anticipated to, and then within that, we were—which doesn't sound like big numbers, but it accrues over time in terms of additional pressure. And then what we were also seeing was a sort of gradual climb in terms of the people who then became in-patient stays with us, resulting from original attendance. So, our attendance-to-admission conversion rate was just climbing gently, and there was a sense of building pressure in the system, if you like, but not ridiculously outside the plans that we had created for winter. When we got to 1 February—and this was a universal experience in Wales—that demand started to go up very steeply indeed, so largely we went to 32 extra presentations in A&E and, again, with a continuing creep in terms of conversions into admissions. So, I think, in general terms, on average, we had, in terms of demand and capacity, accounted for that initial increase, but I don't think we had anticipated in its fullest sense that additional increase thereafter. 

I can speak for Cwm Taf. I feel that we had some flex in the system that had been created by proper planning around surge capacity. We have about £0.5 million to £600,000 in our IMTP put aside every year to cope with surge. So, it didn't blow our plans in that sense, but I think what's important to say is that, probably, our stay well at home team, which Chris referred to earlier in his evidence—I think that did have a beneficial impact. What that's essentially doing is it's drawing down the length of stay episodes. So, whilst we might have that high conversion, actually the people who are staying with us—particularly in elderly, frail groups—are staying with us for a lesser length of stay. Again, detail matters and that's really important. The underlying model there is novel. It's been developed through the integrated care fund, working with our partners. It's actually led by the Rhondda Cynon Taf local authority, and then applied to Merthyr Tydfil as well, and works across the whole of the health board, with the voluntary sector involved too. And, essentially, what we're trying to do there is identify people at a very early stage, when they enter into the organisation through A&E: do they have high potential for discharge? So, we assess, we look to discharge quickly, and then the major innovation, I think, is then having all partners on hand with a four-hour call that will provide wraparound for a fortnight for that individual. What we're finding is that that stabilises the individual at home, makes the link to at-home services, and avoids readmission. So, that has been an absolutely critical part of the change that we've made in preparation for winter, and I think that gave us better returns than we were expecting.

Okay. Is it something similar in Aneurin Bevan? 

I really enjoyed listening to that, because for me—

So did we.

I really did, as a clinician, and I'd simply say that what it is that we have to understand is, one, the role of the multidisciplinary team across the sectors, and I think the other thing is that we have to recognise the impact that traditional behaviours have in relation to keeping our system very much the same. So, again, there's a real need for us to be driving through new models of care, and there's a real importance that we need to attach to understanding the clinical messages that are coming through from the system loud and clear, and that is that the focus that we see on ED belies the fact that the problems lie deeply within our chronic disease management.

One of the new things that we're looking at is understanding how we stream patients, for example. The traditional mechanism of screening patients is that you screen them at the point of contact with the ED, according to whether they're minors or majors, or whether they've been a GP referral, or they could be co-located with a local GP service. What we're looking at is identifying, using embedded safety scores that we have—early warning scores—and marrying them up to things called CURB scores, which are assessments of respiratory disease, for example in elderly patients, to identify those patients who could more rapidly be seen somewhere else in the system. If you look far and wide across our system, we have a number of mechanisms for evaluating patients that we hitherto haven't used as adeptly as we previously could have. And there is a message again about how the system, how the new multidisciplinary team, works and uses that common clinical parlance to direct patients more effectively to the right place.

Angela, some of your questions, I think, have been—

They have indeed—

—answered brilliantly so far, but doubtless you have more in the wings.

I do want to make a couple of comments. One is that it sounds great; however, we still had a problem last winter and we had a problem the winter before and the winter before that. And the reports all say the same. We know where the blockages are. We know where the issues are, and that's to get somebody well enough to be able to leave hospital in a safe and sustainable way so they don't enter a revolving door situation, and yet we still had the pressures last year.

So, you've both talked very eloquently and rightfully about the systems we need to put into place, but we have been talking about that year after year after year, and really we're looking at how well prepared—. Because those systems are still obviously not bedded in enough in enough health boards throughout the whole of Wales—and I know you're particularly talking about your two health boards—so we're going to have the same issues again this year. So, my questions to you revolve around the capacity planning in terms of: what workforce management systems do you use so that you can plot where your heat maps are, where your gaps are going to be? How do you take into account the way that Christmases and new years, the big pinch points, fall in relation to bank holiday working, people not being available, from the radiographers all the way back through the entire system? And of course there's the integration in part with how it works with these multidisciplinary teams, because a lot of them come from organisations that are not as 24/7 as the national health service is. So, that's one sort of area.

My other area is about how you actually define and update your risk modelling throughout your pressure point, because at some point I'm guessing that you're going to have to decide whether opening three extra beds on a ward, which may actually push that ward over its capacity—is that a greater or lesser risk than having three people lying on hospital trolleys in corridors or stuck in ambulances unable to come into the ED because of the pressures there? 

If I may, the assessment of risk is a daily—twice or three times daily—occurrence in our health boards. It happens every day; it's just escalated in terms of the number of times these events take place—maybe two or three times an hour throughout the days in the winter months. In terms of proactive workforce planning, months ahead, we have a drive in our organisation to make sure that the known pinch points from previous data analysis around when we're likely to be feeling the heat—. We ensure that our divisions and our directorates are clearly sighted on those risks and we try to ensure that gaps are filled if they are there in our ED teams, in our out of hours, proactively.

Nevertheless, even with those kinds of safeguards, the reality is that, on a day-to-day basis, we might well still be, through the winter months, seeing how we can get an extra pair of hands to help during a night to process patients in terms of being able to see patients earlier in our ED to make sure we retain a safe and high-quality service. And that's been the nature of the everyday practice that takes place.

To move away from that, however, requires us to understand the very basics of the way the system is operating at the moment. It is not as productive or efficient as it could be, clinically, because of the number of issues that arise in complex healthcare systems. So, when you have, for example, clinical pressures that have an impact—say a sudden surge of patients coming to an ED, it's very important that they get to the right place at the right time. If they don't, then what happens is that you start to get more freezing in a system, it starts to become more blocked, it starts to get difficulties with flow. So, we are starting to concentrate our efforts on asking ourselves: how do we get the patients to the right expert at the right time, and how do we bring the expertise as close to the front door as possible to enable them to turn around, if necessary, as quickly as possible and get back home with the support that they require?

To that end, some of the work that we've been doing with social care has been working tremendously well. I think one of the things we mustn't lose is that some of the work that has been undertaken in the last three or four years, clinically, trigger towards the sepsis NEWS—national early warning scores. They take time for big systems to embed and then to perform. Some of the working arrangements for social care are now working at a new level, and we expect them in the forthcoming year, and the following years, to be working at a completely different level to what they were in years before.

John.

I was going to say, in response to your comments, that I wondered whether I'd been too bullish in my first answers, but I don't think I was in that I think, in Cwm Taf, we were able to show that, by year end, we had been resilient and we had returned to very good performance, despite what was historically a difficult period of time. And during that, we were able to maintain, I think, at the very least, acceptable levels of performance around four hour and 12 hour, and we were able to get back to sort of tier 1 delivery very quickly thereafter, and May showed a really good rebound. One of the judgments of the system is how resilient your system is. Having said that, I'm not going to sit here and tell you that everything was rosy and perfect. During that period of intense pressure, we did have one night—and I think you all know what our reputation is for hospital ambulance handover. We operate in the high 90s, in general terms, in support of WAST. We have an excellent relationship with WAST, and we drive those pathways hard. We had one night when we did have three ambulances waiting outside for a period of time. That wasn't good enough. We treated that as a serious incident. We reviewed, we talked through with the senior nurses who were on that night exactly what our expectations were about escalation processes, and we made a change to our escalation processes in real time during the course of that week. So, I wouldn't pretend that that performance isn't hard won.

If we talk about risk, I think the risk in the system goes back to some of the things that the Cabinet Secretary has been saying recently in the context of transformation. So, for me, I think the risk is that very good ideas that are in the system do not get scaled up quickly enough 'at scale and pace'. I think we've been fortunate—we have had an additional amount of resources through the integrated care fund to allow us to get the stay well at home on a good footing over the course of the last 18 months to two years, and we've had great engagement and partnership to help us do it, and it's paying off. It is exactly that sort of thing that we need to do.

To take Paul's points and triangulate them, stay well at home is still a reactive model. What it does is that it allows us to respond to the patient as they present within the hospital, and then get co-ordination, integration, wraparound in the community thereafter. Stay well at home 2, which is the proposition we have at the moment and we will be bringing into transformation and any other fund that we think might be a place where we can get it funded, is going to be that step in the community first—a single point of access, multiprofessionally, so that our GPs, our GP out-of-hours and our district nurses can access the service that triggers that wraparound at a much earlier stage. I think it's that kind of activity that is really, really important for the next few winters.

To take it one step further, the other major initiative that we've been working on over the last 18 months—and it starts with a very small pilot in St John's Aberdare—is a virtual ward. Now, a virtual ward isn't necessarily the most mind-blowing concept that you'll ever come across. Powys have been running virtual wards for a long time, as have other health boards. We'd adopted some of that practice, and 18 months ago we had a fairly underperforming virtual ward in St John's Aberdare. The GPs came to us, through the cluster initiatives that we'd been running, and had a really good conversation with us about how they wanted to use that virtual ward to really stratify demand. So, what they did—they worked through all their medical records and they came up with 150 people who were the most frail in the population and most likely to have an acute exacerbation during the winter, and during those other spikes in the year that we've talked about. What they did was, they put occupational therapists and advanced paramedic practitioners into the skill mix. So, we did that, working with WAST and other colleagues, and some other therapies went in as well—a bit of physiotherapy. So, we kind of souped up the existing virtual ward and the existing multidisciplinary team. 

So, at the end of the year, Dr Owen Thomas, who is the lead partner in the practice, came to see me, and he said, 'John, I've got some interesting data for you.' He took me through it. So, in that cohort of 150 patients, we've managed to drop hospital admission by 80 per cent, we've managed to drop out-of-hours usage by 90 per cent, and we've dropped GP appointments by 60 per cent, because those OTs and those community paramedics were able to get out upstream, be proactive and work with those people to help them be stable and healthy at home. So, that is an obvious model for us to think about in our scaling up and investing and that's what's in our IMTP and where we want to go next.

So, really, I think we see the stay well at home basis, plus stay well at home 2, plus a virtual ward, as our future model. And, again, just to finally say, on Paul's points, it's that investment in primary and community infrastructure, linked into the secondary acute sector, that I think is going to bring the success of the future.

One of the other great casualties, of course, of winter pressures is elective surgery. So, could I ask you briefly—because I know that the Chair's giving me eyes because we're running out of time—to tell us how your health boards held up in terms of being able to maintain elective surgery during last year's winter pressures? And what will you do to maintain the rate of elective surgery you need to have this coming winter, throughout the whole of that winter season, so that we can try and improve on our waiting times and ensure that people get the preventative care that they need, which is really what elective surgery is often about?

We struggled towards the end of the last financial year to satisfy referral-to-treatment times, having had really very good performance up until December. The decisions either to cancel some of the more routine electives were not taken lightly; they were taken in light of the kind of risks that we were dealing with and the pressures that we were dealing with, which, after 33 years as a paediatrician, were unprecedented in my experience. So, we made decisions at that time that were based on what we saw as expedient, safe decisions to cancel a few routine electives.

The learning points, however, for us were that we needed to front-load our activity this year. So, to maintain our position on track, as it currently is, we needed to ensure that, when the sun is shining, we're making hay. And I think that is really—again, it's a lesson not just for Aneurin Bevan health board, it's for our whole system, that looking at productivity and efficiency in planned care has to be an aggregate activity, aggregated over the year. So, that's where we're moving to. I think it will give us some leeway in the winter period in terms of how we manage electives. And, of course, one of the things about our clinicians—the Aneurin Bevan board surgeons are anxious to do this work upfront this year, so I think we've got the impetus, we've got the clinical expectation that that's what we're doing and that's going to be the prime source, I think, for trying to ameliorate any pressure this winter.

The other thing, however, is about what we do with unscheduled care, because, for me, it is about planning for the worst. Last year, we thought we had the best plan we ever had, really; it was a really very good, well-thought-through plan. What we weren't aware of was that flu admissions would be the highest in Wales since 1998. What we weren't planning for was, really, the extreme winter, particularly in February and March, that we had. So, we need, now, to be planning with that in mind. So, I think if we plan our unscheduled care systems at that level and we make hay while the sun shines, we'll be in a better place next year.

Okay. John.

Very briefly, demand and capacity is probably the key to making sure that you can deliver on your elective capacity, and, at the same time, it's making sure that your unscheduled care system delivers as it needs to. So, in broad terms, we were able to say at year end that we were within spitting distance of delivering our tier 1. We had four breaches at year end. So, that was very good performance and it speaks to a well-managed system. However, we did make a recommendation into our internal audit processes this year that we'd like our demand and capacity planning to be reviewed, and that came back with limited assurance, actually, to the board. So, we've been doing a lot of work on demand and capacity for this year. 

I think one of the things that happened for us last year was that we were always out of kilter with our planned trajectory, and so we saw a classic kind of U-curve for the year, where we chased in our performance at year end. We committed ourselves to a much more balanced demand and capacity plan for this year, based on all the findings that came out from the internal audit work that we did. So, after the first quarter, we're able to say that we're well inside our trajectory currently. So, we're under 200 at the moment, which is better than we planned to be, and so now all the effort will be throughout the rest of the year to make the right investment decisions to keep that trajectory coming, and to stay balanced throughout the year rather than building up a challenging problem for us that then we have to solve during the most fraught period of the year operationally.

An audit office report last week raised serious questions about the sustainability of out-of-hours GP services. What are your thoughts on your positions in relation to that as we look forward to next winter, and how you might want to respond to make yourselves slightly more prepared?

Okay. Out-of-hours is undoubtedly a very challenging position. There's no getting away from it, and that report lays it out. We've had our own reports, bespoke for each organisation as well, and they are challenging. I can say on average through the winter period for out-of-hours we continued to have about an 80 per cent shift fill throughout. During the three big winter weekends we saw about 4,500 patients through out-of-hours, or contacts through out-of-hours, and we had about a 3.5 per cent conversion from those contacts into A&E. So, back to the original points I was making—you can't run a successful system without a successful out-of-hours service and a primary care service. That is the cushion that allows you to deliver in-hospital services.

We've gone through a major redesign in out-of-hours over the last three years in Cwm Taf. We've made some very difficult decisions. We brought our sites together on the two hospital sites, whereas previously we had four face-to-face sites for delivery. We found actually that worked quite well, and it did mean that we secured more doctors to work with us, because they like, actually, in general terms, being close enough to A&E, but far enough away from A&E as well. So, we've found our goldilocks zone, I think. Then we started on a programme of changing our multidisciplinary team. So, we've brought more advanced nurse practitioners into the skill mix to work with GPs. It's still a GP-led model, but we're trying to blend the approach, and, indeed, community paramedics are the other option that we're bringing into the space.

All of that has helped us over the last three years to be initially about a 90 per cent shift fill, and then we've come down now to, I would say, between 70 and 80 per cent on a regular basis. We worked hard over Christmas to get up to that 80 per cent. I think that reform, if you like, has started to run out of legs, and I think the reason for that is we've had significant tax changes to the out-of-hours GPs' earning potential, and we've had IR35, which has changed their classification. That has had an enormous impact, and, if I'm very blunt about it, I think it's also meant that health boards have generally been more competitive about chasing for GPs to work in the out-of-hours services, and we've seen a bit of salary inflation that hasn't always been helpful to us as a whole system. There are proper conversations going on about that through workforce and organisational development colleagues and through chief executives. So, it's an issue we've clocked and we know we need to manage it.

For the future, I think we've got to think really seriously about whether we can continue with the kind of model we have. I think we're going to have to be much braver and bolder about skill mix, and I think we're going to have be much braver and bolder about the use of technology. So, we have just made a decision as a board that we do want to try out some of the Babylon technology that's running in London at the moment. It's an artificial intelligence model, smartphone—it allows you to do some self-triage as a patient, and that probably is going to give us a yield in terms of triaging patients away from the core service whilst they get the appropriate treatment and service that they need. It will also probably come in at a lower cost per case, which is really important as well, because our out-of-hours costs have steepled over recent years.

And what about dealing with peaks within the winter peak, because there'll be spikes? How adaptive, responsive, can your system be?

I won't pretend that it's not difficult, but we absolutely plan, and I think I can say this universally, that health boards universally plan, for the peaks that will come through the Christmas period. There are conversations that get triggered around September point where we do talk about regional resilience and we do have plans to fall into regional arrangements if we need to. Aneurin Bevan, ourselves and Cardiff and Vale are working together during the winter period on night-time joint arrangements, and we certainly join up our nursing support as well. So, it is common that we pull together in that sort of way, and it is common for us to plan for the hot periods, and that goes for Christmas, it goes for bank holidays—that's when the mettle of the out-of-hours service is tested.

Okay. And in Aneurin Bevan?

I think we're pressured—less pressured, I think, than Cwm Taf, in terms of fill rates and shifts, but we still do have times where it's very difficult indeed. The fundamental issue for us, I think, is about the design of the model. We introduced senior nurses into our out-of-hours hubs last year—took 500 calls a month off the stack, essentially. It enabled fewer patients to be directly related to the GP; it eased the pressure on the GPs that we had in our service. We've set up a clinical reference group for our GP out-of-hours clinicians, and that's led by a senior clinician and that's been a very useful thing to do. It's enabled us to have some very deep clinical conversations about, really, how good out-of-hours services should operate in future in a multidisciplinary way. As a result, we've got more GPs interested in joining the out-of-hours system. 

But I'm mindful also of what the evidence is telling me as a medical director. I think it's not only a no-brainer that we need to be rethinking what the model looks like in our primary care out-of-hours systems, but a great paper in the British Journal of General Practice in January of this year indicated precisely what I was saying earlier about how connected these systems are. It wasn't necessarily the number of GPs who are available in a region that predicated the number, or predicted the number, of assessments you would have in your ED. It was the number of comorbidities you had as an individual patient. So, any patient with four or more comorbidities had a sixfold increased chance of being admitted when being referred to an ED. And, for that reason, it comes back down to my original point about our model. Our model needs to learn from this data, learn from the data it has in terms of the big data that's coming to us from our EDs, and recognise that bolstering the same old model with more GPs is not the answer. Developing a new model that is about chronic disease management and bringing expertise into the home earlier when you have a deterioration of a chronic disease is the way forward. 

So, that's how out-of-hours needs to dovetail with all the other things that we as a health board are doing in terms of our future project. Looking at where it's preventing, making sure that we have the population view of health, but recognising that the old disparate models of a GP out-of-hours, a GP in-hours, community systems, social systems and secondary care systems—those boundaries need to be seriously blurred. 

Okay. Just quickly, just high-level thoughts, really, on delayed transfers of care, and your confidence, looking ahead to next winter, that there will be a reduction in delayed transfers because of new work going on in local authorities, capacity building in local authorities and so on.

Very quickly—I understand the time pressure. I think, actually, performance on DToC generally has been good across health boards and local authorities over the last year, and we've had some historically good periods of achievement, and, in the early phase of winter, I think, in Cwm Taf, we achieved 17 DToCs in one month. That was our best performance ever. Over the last couple of months, it's important to say that demand pressure is actually very high at the moment, and, actually, it's continued to increase over the last three months. So, we see our DToC levels at about 29—28 last month, 28 the month previous, and 29 this month. 

Every single one of those cases is man-marked, if you like. And, back to some of the points I was making earlier, I think process resilience, and shared process resilience, is really, really important. So, of course, it is important, in regional partnership boards, and in public services boards, and in transformational leadership groups—all these shared spaces between local government and health boards—that we have a general sense of purpose and collective action, but, at the end of the day, operationally, you have to have the shared processes that make the difference. So, every Tuesday and Thursday, in the Royal Glamorgan Hospital, all of our partners meet and we drill every complex care package that we have in the system, we talk about any other associated issues, and we make sure that, as far as humanly possible, we're avoiding delayed transfers of care. 

The other important thing at a more strategic level is that we have taken advantage of having more opportunity to pool budgets now. So, we've created a pooled budget that allows us to make immediate decisions on complex care packages rather than worry about the money in the 24 hours, when actually we need to be worrying about the patient. So, that gives us a fund that allows us to sort out the here and now and then come back to brokering the financial relationship later on. Because in the past, we know that we've had slow escalation on dispute and then dispute leads to a delay. So, I think, broadly, we are in a good position. I have to say that Merthyr Tydfil County Borough Council and Rhondda Cynon Taf County Borough Council have both been excellent throughout, as we've gone through the past couple of years, trying to get hold of this issue, and I think our improvement continues. If we go on and develop another phase of stay well at home, I think that only continues to bring better performance on that front.

I think our working arrangements are on an upward trajectory. We've had really good relationships with social services and local authorities this last year, helping us get our numbers down. We've had a discharge-to-assess model in Nevill Hall Hospital, which has, I think, been remarkable in keeping Nevill Hall one of the highest performers in Wales. One of the developments there has actually led to, I think, 52 discharges within eight hours of referral between January and March. I think we need to build on that model, and that's what we currently aim to do. 

I think there's a fundamental issue for our whole system here and that is that the social care/healthcare divide is indivisible from my perspective as a medical director. The housing and the education budgets are really in danger of being seriously impacted upon by this kind of old model that we have of health. Whereas, actually, if we have a very, very whole-system view of health, then we'd start to be looking at how we train for domiciliary care and incentivise young people to come into the caring professions and social care professions to enable us to start to work more adeptly between the hard edge of the secondary care institution and the softer, but much more important, underbelly, which is really about how we care for patients well at home, with dignity, and they're not mutually exclusive. So, as a health board, that's where we need to go.

Thank you.

Some questions of detail from Caroline, or have most of these have been covered?

It's been covered, yes.

It's been covered. Dawn, to polish things off.

Just very briefly, Chair, if I might: just to pick up on the point you made earlier, John, about the viruses being a major issue in winter pressures—flu in particular is a major issue for everybody, as we know. Is that featuring specifically in your winter planning in terms of promoting the use of the vaccine, and not just for the general population, but amongst your staff as well?

Yes, absolutely. So, briefly again, our plan that we went through yesterday—we managed in the winter period to improve our performance on staff uptake, but we got up to 53 per cent on an average basis. But we're not yet at 60 per cent for healthcare support workers, and that's what we're really aiming for in the next period. So, we're committing to a peer-to-peer buddying system and a lot of communications activity to help support that. We've taken some learning from both Aneurin Bevan and from Cardiff and Vale, who have done well in recent years on that front. So, we're looking to apply that.

On the patient front, I think you probably know that we've got some excellent performance in terms of school programmes, and, indeed, we've received several national awards over the last year for some of the district nursing interventions that we've made, particularly in the very young cohorts of three to five-year-olds, and we've seen a 30 per cent increase in uptake in that grouping, so that's really important for us. It is a fundamental part of the winter plan, as I'm sure it is for Paul's organisation as well—it's right up there in the first five or six things that we lay out that are important.

Thank you. Paul.

I couldn't agree more. There's a major push this year for clinical leaders across Wales to ensure that they're fully behind flu vaccination of staff. I'd say that's right across the board—that needs to be right across the board in Wales. There's no doubt the message that comes from clinical staff in relation to flu vaccination has an impact on the wider community, and the messages that we send out then, therefore, are really, really important.

We have done reasonably well in relation to flu vaccination. I would say one problem for me as a medical director was that last year during the winter months, there were some adverse reports that came out in the medical literature about the cover of the vaccine, which I thought were untimely, unwarranted and not really helpful.

In relation to the broader community aspects, in terms of extracting maximum value from our system so that we can invest in social care, so we can move money around the system, this is one of those very low-cost, high-impact kind of interventions that we really should be going for. So, that's the kind of message I'd like to send—it's about making sure that we are highly productive, we're clinically efficient, but also that we extract as much value as we can from our clinical pathways to redirect finance and redirect resource into communities to enable the transformation that's going under way and scale up with pace.  

Just in terms of staff, have you given any thought to, particularly in high-risk areas, actually making the flu jab a mandatory requirement?

I think that's something that needs to come from an office probably even above mine. In our own system, we're very mindful to point out to individuals in unscheduled care, in critical care, in children's care, patients working with pregnant women, the importance of flu vaccination. I think it would be helpful if we had some messages from the chief medical officer et cetera that this is a mandatory exercise. The difficulty is that making it mandatory itself is not an easy thing to police. 

Sure. I absolutely understand that.

I think it's fair to say we haven't had that conversation as a board. We've thought about every possible way that we can to encourage, in a very positive way, colleagues to take it up, and we've tried I think more and more over the last couple of years to give very strong messages about the clinical reasons for doing that, and then trying to relate that through to what that means in terms of operational delivery so that everybody understands that, actually, if we get this right, it's going to make our jobs easier to deliver, and morally it's the right thing to do for our population. So, we'll continue to play that out.  

I'm very conscious of time, Chair—can I ask John specifically a question about the Princess of Wales Hospital, which is now coming into the Cwm Taf area, and how that is figuring in your winter planning at the moment?

I think it's fair to say it's not a huge area that we're focusing on in terms of winter planning. We do lay it out in our paper that it's one of the considerations as part of our planning for the boundary change, but also we've just got to be conscious that we don't actually take on that responsibility until 1 April. However, we've just initiated our first transition board and so we've had meetings between the chairs and chiefs and other officials to start scoping out the areas for major focus right now. We've just initiated the first set of formal clinical work streams and one of those work streams is picking up winter planning. So, it's in hand. 

And, of course, it is about developing a relationship with another local authority that you haven't worked with before. 

Absolutely. And, of course, they're around the transition board table with us as well. 

Okay. My final question is just about the additional financial support that you have from Welsh Government for winter pressures and whether you've actually got to the point where you're relying on that, or are you planning for not having it and, if it comes, well, yip-a-dee-doo-dah?

I'll answer and I'm sure Paul will have views as well. I think we plan as a basic that we have a £500,000 to £600,000 investment laid out in our integrated medium-term plan for winter planning. So, that's there as a base budget. That allows us to do a lot of important things straight off the bat. What it doesn't allow us to do is the really brave and bold service redesigns that we would like to do. I think it's important to say that we're very grateful for the financial support that did come in last year, so the core £50 million fund and then the following two sets of £10 million—one that came into health services and one that came into local authorities, and I think was actually well blended between the two sectors. That was very gratefully received. I think my only observation would be that it would be much better, especially if you're an IMTP signed-off organisation, to be able to have access to some of that funding earlier in the year to enable some of the plans that you've already made.

So, back to the theme of the questions, really—for us, we've got two major service redesigns that we can choose to do at a certain scale or we can choose to do at the entire scale at population level. Ideally, we want to plan to deliver at population level, so we'd rather have that conversation earlier in the year about potential funds. 

Well, the scalability issue is the thing for us. Within our community, we have a number of really encouraging pieces of work that are bearing fruit and move services in reach to care homes, the community pathway for eight common conditions is having a real impact on readmissions, the Newport older persons pathway—all these are having an impact. The question is whether some of them are having more impact than others that we'd want to scale up. I think that we have to ask ourselves again as a health board that has its IMTP signed off: what are the mechanisms that we can access to ensure that the things that really are likely to bear fruit, that we think all the indicators are saying are things we must go for, that fit with our futures planning, fit with the remodelling discussion that we've had earlier on—how can we endeavour to scale them up and show results at scale? That is a big problem, I think, going forward for us as a health board. 

We do plan with a similar amount—£600,000 within our IMTP for next year's contingencies around winter planning. But I think that the remodelling that is underpinning the medium to long-term plans that are required to get us on a more sustainable footing requires some adept movement of moneys. And so, some of that will be internal, some of it will be about value-based systems and trying to replicate what we did with respiratory care, getting pulmonary rehabilitation and changes in prescribing practices, but we need more adept at getting money earlier in the system to enable us to get things upfront before the winter rather than reacting to another winter crisis. 

Good afternoon. Could you tell us how well prepared and equipped the Welsh ambulance service is for the winter?

For next winter or for—? For winter 2018-19?

Yes.

Okay. So, if I start off, and then I'm going to hand you over to Richard as director of operations. We started planning for winter 2018-19 in April that has just passed, because, as you'll know, it was such a difficult winter period—an exceptionally difficult winter period. So, we recognised the need to start planning as soon as possible. So, if I pass you over to Richard to give you the operational detail and then I'll give you some high-level information.

Thanks. So, winter planning from an ambulance service point of view is slightly different to a health board as we have two challenges to overcome. We have challenges around the demands—the seasonal demands that we see at various points across the year—and we also have the challenge about the weather and actually just getting around at certain periods of the year. So, increasingly, over the last couple of years, we've tried to move away from very fixed things like winter plans and move into a range of escalation measures that we can apply, depending on the situation that we either find ourselves in or the situation that we plan to be in. So, we have a range of escalation measures about reducing demand, about providing more effective services, and then some bespoke plans for things like bad weather and actually getting to patients during bad weather, which of course is slightly different to the health boards' point of view.

So, some of our plan is around continuing initiatives that we have to reduce the number of patients that we attend to in the first place. So, you'll be aware that we are commissioned against a five-step ambulance model, and step 1 of that is about public education and management of frequent callers. We know now that our frequent caller work is managing around 600 patients a month and helping them find alternatives to calling for ambulances. And then you'll also know that, last time I was here, we talked about the 'hear and treat' services that, as an ambulance trust, we've developed over the last couple of years with funding. We're now closing about 35,000 emergency calls a year over the telephone. So, these are people who dialled 999, and we were able to provide a better service over the telephone. And part of our seasonal arrangements for any period of escalation, but winter being one of them, is to increasingly work with the health boards to make sure that it's not just our staff who are providing care over the telephone and that health board services come into play as well at times of escalation over the telephone—so, community nursing teams and that sort of thing.

And then, of course, we have a raft of arrangements in our operational plans and tactics aimed at reducing the number of people we take to hospital. We've heard from the health boards this morning about the effects of more people turning up at hospital, so we have a whole raft of operational tactics that are starting now in the third year of our plan to really bear fruit in terms of what we're delivering. So, last year, as an ambulance service, we dealt with about 16,500 more emergency calls than we dealt with the year before, but we took about 11,000 fewer people to hospital. So, even with a 16,500 call increase in demand, we took 11,000 fewer patients to hospital. So, we are getting much better at referring people to the right part of the NHS, either over the telephone or once we are on scene following an assessment, and that probably is the biggest contribution—if we take winter as the time of year we're talking about—the ambulance service can make to the overall system performance.

If I can just add one further thing to that, another thing that we're doing to prepare for next winter is meeting with each of the health boards individually. We have, obviously, regular meetings with our commissioner, but we have felt that it is really important to have face-to-face meetings with chief executives, the medical director, the director of operations and the nurse director for each individual hospital health board within Wales. We have done two of those meetings, they were both very productive, and the chief executive in both cases at the end of the meeting said, 'We need to do much more of this' and we will do follow-up meetings, so that will also help towards our winter preparedness.

Right. And following last winter, when you were at the highest level of escalation, have you reviewed that and seen what you'll be doing differently or extra in order to deal with that?

It's actually that, and that particularly difficult period, that led us to these individual meetings with individual health boards to see what more we can do to help them, whether that's in reduced conveyance or helping with their primary care need. But it is also what they can do to help, to help with our resource availability.

Angela. 

Hello. Thank you for your paper. I just wanted to ask some questions around performance, performance metrics and how you manage performance of the service. We did see over winter the pressure that you talked about—the queues outside of A&Es and so on—although I do appreciate the changes in working and the practices that you've been implementing. Could you tell us, though, if we were to look at the red call category to start with, how many of those red calls that were not met within time waited—? Do you have any metrics for how long they waited over time? For example, how many of them waited more than half an hour, an hour, two hours et cetera.

We only had one instance in the winter where somebody waited more than one hour for a red emergency call, and that was the first time ever since the model changed in 2016 that that happened. That was during the first period of snow that we had. And of course, as I said in the beginning, one of the differences between us and health boards is that we physically have to go and see our patients, and on that night in question, it was just impossible to get to where that patient lived more quickly than we did.

We publish our red performance at eight minutes. There's a minimum, and we don't see it as a target; we see it as a minimum within eight minutes, 65 per cent of the time in each health board area. We also produce data on eight minutes, nine minutes, 10 minutes, 11 minutes. Our 10-minute performance is around 85 per cent consistently, and it is unusual for us to have a tail for red calls of more than half an hour. Every red call that we don't attend to within eight minutes is reviewed every morning. So, one of the advantages of the way we're organised now is we deal with about 70 red incidents a day out of the 1,300 calls that we receive, and every call that we didn't get to in eight minutes is reviewed every morning, line by line, to make sure that nothing different could have been done.

Our performance for any category of call is, of course, based on us having an ambulance available to respond, and the spikes that you saw over the winter in our responsiveness to some categories of patients are always as a consequence of resource availability to respond to emergency calls. Our red calls are the sickest patients, they're people in cardiac arrest, they're people who aren't breathing, they're people who are choking, they're people who will die if we do not get to them as quickly as we can. So, the red calls always get priority and you will have seen throughout the winter, across Wales, that we maintained our red performance in some quite challenging scenarios.

Of all your patients you transport, what percentage end up being red calls?

Well, up until December time, our red category had not breached 5 per cent of our monthly call volume, so it was unusual for us to have more than 2,000 red calls a month. Since December, we have had an increase, month on month, on the number of emergencies we receive that are falling into the red category. It was interesting listening to evidence this morning from some of our health board colleagues, and the descriptions given to you this morning about respiratory disease being on the increase. It is the red calls for people with ineffective breathing that have increased—that's where the spike has come from. And it is only now, last month and this month, that the total number of red calls each month has gone back to what we would expect—you know, under 2,000 a month out of our call volume.

Which means that all the rest of your calls are obviously amber. Are you satisfied that the way we measure amber calls is appropriate?

Not all the rest of our calls are amber; we have red calls, amber calls and green calls—

And some green calls, but the bulk is amber, isn't it?

About 25 per cent are green calls, between 5 and 7 per cent are red calls and the rest are amber calls. Amber calls are measured on the quality of the care we give the patient, and they're also measured through the ambulance quality indicators on our ability to send the right thing. This committee has heard me talk before about the perils of managing amber by time, which drives sending any response to achieve a time-based target rather than sending the response that the patient actually requires. So, for example, somebody who is having a stroke needs an ambulance crew to come to take them to the stroke hospital. Sending a paramedic on their own in a car to somebody who is having a stroke is of no benefit.

On that point, I've got Lynne and then Rhun.

I wanted to ask about the amber calls, because what you've just outlined is that a great bulk of the calls are actually amber, and I've continued to have a specific concern about stroke patients. We had a death in Pontypool recently where the ambulance didn't get to a stroke patient in time. What kind of monitoring takes place of the response particularly to stroke patients and of any adverse incidents like that? You obviously review the red calls, but not all amber calls are as urgent, are they? 

Our amber calls are a wide range of conditions and stroke and heart attack are the two most clinically urgent calls within the amber category. So, an amber call is a blue light emergency and the only difference between our response to a red call and our response to an amber call for a stroke or a heart attack is that we will try and send one resource to somebody who's having a stroke. So, if somebody is in cardiac arrest and they are a red category patient, we might send a fire engine, we might send the police, we might send an ambulance, we might send a community first responder and a paramedic in a car, all to get there to save that patient in cardiac arrest. For a stroke we will dispatch an ambulance on blue lights to that patient, because that's what that patient needs. They're not going to get any clinical benefit from a first responder or a paramedic on their own in a car. So, when you're out in your constituencies and an ambulance goes past on blue lights, it's far more likely to be going to an amber call than a red call, but it is a blue light response by the most appropriate vehicle. There is no difference. 

Now, the challenge is around vehicle availability. So our business of getting to emergency calls as quickly as possible, irrespective of the category of the call, is around the availability of an ambulance. So, if we have one ambulance available and a red call, it will go to that. If we have two ambulances available and we have a red call and an amber call, they will go to both calls. So, the waits in amber are not about our model and our categorisation. They're about whether we've got an ambulance available to go to a call. You'll have heard this morning that one of the effects of winter, at some point during the winter, was that the availability of our ambulances was affected by pressure right across the system.

But there is a time factor, isn't there, with both heart attack and stroke? You've got that time to administer appropriate drugs.

Five hours for stroke.

How can we be assured as a committee that—? Because I think the public would assume that a heart attack and a stroke are actually emergencies. How can we be sure, then, that you are getting those ambulances there quickly enough, and that there aren't people like the gentleman I just mentioned in Pontypool, who unfortunately died?

The important thing that the public need to know about both heart attack and stroke is that they are emergencies. For heart attack patients, when we arrive now, as one of the health boards said this morning, once we've diagnosed a heart attack caused by a blood clot, we won't take you to the nearest emergency department. We will take you to Swansea, Cardiff, or Glan Clwyd if you're in north Wales. Now, that's really important, and we will take you to that hospital as long as we can get you there within an hour of leaving the scene.

For stroke, the treatment window for stroke is within five hours. The clot-busting drug for stroke can be administered within five hours of onset. The main challenge we face is not getting an ambulance to these calls; the main challenge that we face is that people tolerate symptoms, don't they? So, if somebody develops some chest pain, or it looks like somebody's had a stroke, quite often people think they will get better, or they wait a little while, or they phone a friend to see, and this is why public campaigns that we see about heart attack from the British Heart Foundation and the FAST campaign from the Stroke Association, which we have on our vehicles, are really important. It's crucial that people for stroke and heart attack call for help when the symptoms start, not wait for a couple of hours to see.

Stroke is a particular problem because a significant number of the stroke patients that we encounter are early in the morning when somebody wakes up and the person next to them has clearly had a stroke in the night. That's a really challenging case mix because there is no onset time, we don't know how long that's been, and those patients don’t do very well. But early calls for help by the public is our biggest challenge, not the challenge in getting an ambulance. Outside of red, stroke and heart attack are our second-highest group of calls.

Can I just come in that particular bit? Because, having listened to your answers to Lynne, why are those two then not in red? I know we've had this again, but I think it's worth asking, because we're always told as the public not to abuse the ambulance service, not to call when it's something we think—. In one message we're saying, 'Hang on and make sure you're properly ill', and the next message is, 'Oh, but, just in case, by the way, that may not be indigestion; it could be a heart attack', or—. I know that in men and women stroke appears differently. So, that's a very mixed message to the public. So, wouldn't safety actually say it would be better to put both of those conditions into red? Because it's not just the five-hour window, but we have consistently heard of people who've waited much longer than five hours to be able to be picked up, and, again this morning from the health boards, we also heard that not all of those critical care pathways, which a lot of this is predicated on, are in place, are working effectively, are routinely used. They're used for things like paediatrics—very definable—or gynaecology—very definable—but this other stuff that is a little bit grey area-y, and no-one's quite sure—none of them said, 'Yes, it works every time. It's not a problem'.

For stroke and heart attack, I can categorically assure committee that we have 24/7 pathways in all seven health board areas that are never closed to us—stroke and heart attack pathways are universally provided 24-hours a day. The challenge around the red categorisation is that the reason calls that are categorised as red are so is because those patients need immediate intervention to save their life. So, we will send a paramedic on their own in a car to defibrillate somebody who's in cardiac arrest or clear an airway for somebody who's choking or provide haemorrhage control to somebody who is bleeding to death to save their life there and then.

For a stroke or a heart attack call, we need to send an ambulance crew who can assess the patient and take them to the right place, and, increasingly, especially for heart attack—. Stroke care is delivered more locally. Heat attack care, as I say, is delivered in Cardiff, Swansea and Glan Clwyd. So, arriving at a heart attack patient in seven minutes, fifty-nine seconds or in 15 minutes—there is no clinical evidence to support that a fast ambulance arrival makes the difference; what makes a difference is the time taken to undertake the assessment and then to take the patient to the right place. If we categorised stroke and heart attack as red calls, the danger would be that we would go back to sending cars to those calls, which are of no clinical benefit.

But they could administer a clot-busting drug.

No. We don't administer clot-busting drugs anymore. For stroke, you need a CT scan of your head because if your stroke is caused by a bleed and we were to give you the clot-busting drug it will kill you. So, for stroke patients, once an ambulance crew have decided you're having a stroke, the next meaningful thing that happens is you have a head CT. For a heart attack, we don't thrombolise patients anymore; we take you to the cath lab and, as I think my colleague from AMBU said this morning, Chris, you go straight into the catheter lab and you have the clot retrieved there and then. So, quite often with a heart attack patient, 20 minutes after we arrive at hospital, their heart attack is over—it's cured; the clot's been taken out. The clot-busting drug that we used to use, people were in hospital for weeks; they used to get terrible heart failure—it was a bad treatment.

But that's only if they recognise immediately that they're suffering from these symptoms and call you immediately, because, otherwise, they haven't got a hope.

I think to say they haven't got a hope is a bit—

Well, of meeting the five-hour window. And also, I would just say that I hear clinicians all the time saying about saving life, but we've got not just to save life, but save life well so that you don't end up with all of the, particularly with stroke, awful consequences, that, if you aren't treated quickly enough, you can end up with. Because it is about giving people the best quality of life as well, because there are lots of different ways measuring that.

And that's why taking all of our stroke patients to hospitals where, 24/7, they can have a head CT is the most important thing we can do, because, if we take you to a hospital where you cannot have a head CT, you won't get diagnosed and then you will have a long delay in treatment. So, our 24/7 arrangements for stroke are that we take patients to hospitals within each health board area, where, even at four in the morning, the patient can have a CT in the A&E department, and that's really important.

Okay, Lynne's got a brief one.

So, are you telling us, Richard, that anybody with a stroke who gets taken to one of these hospitals in Wales gets their CT scan and their treatment within that treatment window?

So, what I'm saying is that there are 24/7 arrangements with the health boards—

No, I understand that, but are—

Yes, that's not what we're asking.

—the patients—? Are you telling us that they never get there and there's no chance of them having a CT? I want to know if they're getting there and getting their CT scan and either the thrombolytic drugs or the other thing to sort out the bleed.

So, I can tell you that for—. What happens to the patient once they arrive in hospital, I can't tell you, but what I can tell you is that we take stroke patients only to the units that accept stroke patients, which are those with the 24/7 services and the ambulance quality indicators that are published quarterly tell us that our stroke care is in the 90 percentile for the appropriate treatment being provided consistently.

Okay. We need to move on. Rhun—the next batch of questions.

We're kind of segueing into what I wanted to talk about anyway. We talked a lot about the beginning of your contact with a patient, the speed of getting to the patient and then you have what I want to talk about, which is the end, and that's the hand-over. I think, last week, a second coroner in north Wales issued a warning over ambulance and hospital delays risking lives—did raise concerns about the delay in the ambulance getting there, but, on the issue of delays of transfer, are you and your partners in the health boards paying enough attention to that issue of patient safety in preparing for next winter?

Yes, I think we can absolutely say we are. I think the pressures across the whole system over the last winter period were very clear to see and the data is the data, the numbers are the numbers, and the coroner's hearings will come up with the kind of things that happened in north Wales last week.

There are multiple reasons why resources aren't available to us and there are multiple reasons why patients are sometimes held in a queue outside of hospital. We have to work with the health boards collaboratively. We have to maintain good relationships with health boards. There is absolutely no point at all in developing confrontational relationships with health boards. The only way we can resolve these issues as a system is working together as a system.

So, again, the purpose of the meetings with the very most senior people within health boards are to resolve these kinds of issues. They don't want ambulances outside of their A&E departments any more than we want our patients to be held outside of A&E departments. They don't queue in accumulative fashion, so they queue based on the acuity of the patients that are within the ambulances. It is not an ideal situation. It's not ideal for the patients, it's certainly not ideal for our crews, but most of all it's not ideal for the patients in the community who are waiting for the next resource. We have to work together to resolve these issues and that is what we are doing.

We know that there are big differences between performances in different health boards on that issue of delayed transfer from WAST to the health boards at the hospital door. Do you know, and are you willing to tell us, why you think there is that big difference? Because that could lead to tension, I suppose, between you and some health boards. And is there also a difference in preparedness for next winter for trying to speed up that transfer? 

I think there are differences. There are clear differences, because the data will tell you there are differences and that data's publicly available. But there are multiple different reasons for the differences in the delays that we sometimes face. Some of that will be structural; some of it, there is physically not enough space in the emergency departments for our patients to be taken into that department. So, the safest place for them—and I'm not condoning this, but the safest place for them is to be with a clinician who can continually monitor their performance. 

In an ambulance. 

In the ambulance. I am absolutely not saying that is the right answer, but if there is physically no space to preserve the patient's dignity then what choice do we have? We simply would not, could not, just leave them. So, there are sometimes staffing issues in emergency departments that will lead to differences in their ability to offload patients more quickly, and there are different processes and procedures in different health boards. So, you heard from John Palmer earlier, who was really disappointed with his own team that there were three ambulances waiting at one point. We do not experience delays in the Cwm Taf area; they have a totally different clinical model to other areas within Wales. But that is a decision for health boards to make. 

But given that you're in a unique position in that you work with all the different health boards and know from your own evidence and your own data what's working well—you seem to be praising what's happening in Cwm Taf—is there a formal procedure through which you then, as the ambulance trust, feed back to the NHS collectively: 'Listen, we can see what's going on here and they need to be doing this and they need to be doing that'? And do they listen to you when you do say? 

So, we do that every single week. I like to think they listen. We do that every single week. I do that on a Monday morning in a chief executive conference call and that call includes all of the chief execs across Wales with Welsh Government and that is either Andrew Goddall—so, the chief exec of the whole NHS—or his deputy. Every Monday morning, we will have those conversations. Every single day, there's an executive conference call where delays of ambulances are discussed, where estimated times of offloading those patients into the emergency departments are discussed, and solutions are looking to be found.

Going back to your first point, the NHS Confederation have recently done, as a result of the winter, an exercise on looking at best practice, and that was actually triggered from looking at the Cwm Taf model. In some health boards, that doesn't work, and wouldn't work. In Cwm Taf, it works, and it works, of course, really well for us and for the population of Cwm Taf. So, we absolutely would encourage that and encourage the dissemination of best practice across Wales.