Cynulliad Cenedlaethol Cymru

Good morning. I'll perhaps start with a general summary of our financial position, and perhaps Martin may want to comment from a board perspective in terms of scrutiny of our finances. The general position for us as a trust, I think, is good. We will balance financially this year, as we have in the last three—actually, in more years than the last three, but certainly the last three. We'll have a small surplus this year. And whilst we clearly are conscious of how we spend public funds and ensure that we do that in a prudent way, offering good value for money, our services are not necessarily constrained. We've received additional investment this year to develop new services across Wales, our falls service is a good example that we've received additional funding for. And we've reached a settlement with commissioners for next year, which sees further growth. So, our financial position, I think, is sound and in a positive position. I don't know, Martin, if you want to comment from a board perspective in terms of scrutiny of the finances.

From the board's perspective, the finances are scrutinised through the finance and performance committee. That's been operating for three to four years. We are much more assured this year than any of the more recent years about financial performance, because we've developed a good track record of delivering savings according to plan. Whereas in earlier years, I think the comment from auditors was that we were delivering one-off savings that couldn't be sustained. I've personally attended the finance and performance committee to witness that assurance process being undertaken. I think we have a high degree of confidence in our financial position, which I wouldn't have said four to five years ago.

Okay. Looking at some of the figures here in front of us, the cost pressures in particular—significant cost pressures, or a funding gap, perhaps, going back over the past few years—what do I learn from that in terms of a significant funding gap at the beginning of each financial year? 

Each organisation does need to make savings on an annual basis, and in the financial planning period—and we're in the financial planning period now for the 2020-21 financial year—we look to see what savings we can generate and how we can reinvest those moneys, essentially, in front-line services. Given that 80 per cent of our spend is fixed on people, on clinicians, on front-line patient-facing staff, we look to identify opportunities to direct as much of our income to those services as we can, and there is always a gap there. However, as Martin has just described, we've had a good track record of success in identifying those efficiencies and delivering them in the last few years. 

Okay. In his structured assessment report for 2019, the auditor general points to the fact that in-year funding arrives quite late in the day. How do you manage that?

That's true to say, and it would be right to say that it's only in the last couple of weeks we've settled the financial envelope for the 2020-21 period. We model through the year a range of assumptions and, as we get closer to settling the financial position with our commissioners, we can make adjustments to those. But the gap, as we go through the year, is not so significant that material elements of the plans need to shift.

Okay. Did you want to come in there at all?

It's worth adding that the in-year funding issue is particularly pertinent to capital spending. On that front, we are committed to moving to a three year capital programme, rather than one year, and having business cases prepared in anticipation that opportunities will arise, so we can get ahead of the curve, if you see what I mean. 

So, you would have, by now, a number of opportunities to make capital investments sitting on the shelf, whereas perhaps in the past you didn't have that strategic outlook. 

Absolutely right. There are a number of capital schemes that are developed through the year. Clearly, we have a capital plan and commitments against that, but we also have capital schemes ready for the next year, which we can adjust and bring forward if we need to, to account for any slippage in the plan. We do have other capital schemes that are ready, particularly for our main assets—fleet and equipment, and also estates provision across our stations throughout Wales—that are ready to go should we have capital moneys available. 

And given that criticism, that perhaps this hasn't been as sharp as it should have been with WAST in the past, do you have a new asset management programme or a refreshed asset management programme? How would you describe it?

Well, we certainly have a refreshed asset management programme and we have perhaps a longer horizon now than the organisation historically had on its capital planning. For our fleet replacement programme, which is the most obvious one for us—a fleet of 750-odd vehicles across our three service areas—we have a 10-year rolling plan for fleet replacement, and that's refreshed on an annual basis. So, our horizon is much longer than it historically has been. That's not to say there isn't room for improvement, because there is. We've committed, as Martin has said, to move from an annual to a three-yearly capital plan for the other capital spend. We are in a much stronger position than we have historically been.

Okay. Another element of criticism in the auditor general's report is concern that there are inconsistencies in the performance against individual savings plans, and the auditor notes the risk that this could create significant problems in future. Would you like to comment on that, and maybe comment on whether you think targets for individual savings plans are realistic? What actions has the trust taken in light of those criticisms and the auditor's report? 

We've accepted the recommendations that have been made by the Wales Audit Office and, indeed, by our internal auditors when they've looked at savings around saving plans and arrangements. This year, we've had some challenges in securing changes to some industrial arrangements and rules around particular savings—rules we needed to change internally to secure one of our savings plans. But I think it's right to say that we recognise the challenges of delivering savings in a stressed environment where activity, for us, is on the rise. So, we are sometimes distracted from the delivery of those savings plans, but we have a good track record of delivering the bottom line. So, if a particular scheme goes off for whatever reason, we understand that early and we are in control of that and we can make adjustments to that plan, or bring forward others to deliver the total savings that are necessary, and we've got a good track record of doing that. 

Okay. Diolch. 

Diolch, Chair. Good morning. Thank you very much for your evidence. I want to talk to you about service delivery. May I just start with trying to understand a comment in your—I just want to clarify something in your evidence. You talk about the Welsh ambulance service using the internationally recognised and globally used medical priority dispatch system, and you make much of that in your evidence. Can I clarify, is that dispatch system simply a methodology about how you handle the calls and how you process it, or is that dispatch system the one that also says, 'This condition should go into this category'? So, who makes the choice about what goes into red category, what goes into green, what goes into amber? 

If it assists the committee, I'll just step back a bit and explain the system, and I'll ask Brendan, our medical director, also to comment on this particular point. So, MPDS, as you say, we mention in the evidence pack, that's the medical priority dispatch system. It's used in over 30,000 pre-hospital emergency medical services globally and originates from the United States. All of the devolved administrations in the UK ambulance services use it, and half of the English ambulance services use it too. The only other product that is available is something called NHS Pathways, which could be used, but the majority of services use MPDS. That has something in the order of about 1,900 what we call determinants or codes that the questioning algorithm arrives at at the end of the 999 call. And it's those 1,900 determinants or codes that are then locally determined by us as to what response category they go into: red, amber or green. So, the priority dispatch system is the telephone triage mechanism—the algorithm, the series of questions, the structured questions that our medical emergency dispatchers use. We arrive at a code at the end of that. We then decide—through a committee that is heavily medically governed, and this is where I'll ask Brendan to comment further. We then locally decide what response category time or colour priority is assigned to that code. So, Brendan, do you just want to add to that?   

Yes, thanks. So, as Jason was saying, the MPDS is something that was developed internationally. We have a certain amount of freedom then around how we put the different responses in. So, this goes back to the way that we changed the ambulance response model. And of course, we were the first of the UK ambulance trusts to move to what we now see as the newer model. We don't make these decisions purely in isolation; the ambulance trusts across the UK share the information. We've recently undertaken a large exercise where we've compared our response codes to those across the English model and, in fact, they were very, very similar. We made one or two adjustments to our current position.

The difference, I suppose, with our model is that we allocate an ideal or suitable response to each of those codes, and this is where sometimes people get a little bit confused because of the red and amber. So, the big difference for us with the red is that we send multiple responses, because it's somebody who's in cardiac arrest, respiratory arrest and needs life-saving treatment as quickly as possible. So, to that sort of code, we would send not only an ambulance, but also a lone paramedic in a single response vehicle, also community first responders and possibly also a responder from the fire service, because we know that it's early cardiopulmonary resuscitation and the use of a defibrillator that will save a life in those cases.

But, of course, if we have something that is serious and potentially life-threatening, but actually requires conveyance to a hospital, there's no point in sending multiple responses. What we need to do is to get an ambulance there and that's the difference. So, the amber response—an ideal response would be an ambulance that can then assess, initially treat and then convey the patient to the hospital, but they are both blue-light responses.  

Okay, thank you. And is it this system that dictates that, for example, the 65 per cent of calls in the red category should be answered within eight minutes, or is that a choice that Wales has made? And, if so, why only 65 per cent, because actually that leaves 35 per cent who could die because, as you say, they are absolutely critical?  

So, the system doesn't determine that. Again, that's locally determined and for us here in Wales, the 65 per cent within eight minutes for the immediately life-threatening category—the red category—is locally determined by commissioners. 

And could you just explain perhaps to the committee your decision for that 65 per cent? I appreciate that you've had difficulty in the last few months in meeting 65 per cent, but I would hate to think that we're not setting ourselves the correct targets. Meeting them is a different discussion. So, I just wanted to understand why. Is it because, for example, of rurality, or why the decision that only 65 per cent need to be got at in eight minutes, especially if it's to do with CPR? 

Well, we would see it as a minimum standard to be met, particularly for the red category, and, of course, we work to exceed that where we can. Brendan may want to comment on the clinical evidence behind such a target, perhaps that would assist the committee more. 

Yes, to be perfectly honest, I don't think that there is a huge amount of clinical evidence—. The clinical evidence says that you get to the red calls as quickly as possible and, as Jason was saying, we regard this very much as a minimum, and when we review our missed reds, we look back to see what opportunities were there to get to people a little bit quicker. What we've actually found is that a lot of the calls that we don't get to within eight minutes, we do get there within nine minutes. 

Okay. So, it's the literally just over.

Yes, and we review all of those on a case-by-case basis. So, you're absolutely right in terms of some of the rurality. Before I joined Welsh ambulance, I was the medical director in Powys and it is extremely difficult to get to some of the more rural areas, depending on where the vehicles are based, within eight minutes. So, there's a very clever computerised system that says where you base your ambulances depending on the population and the prevalence of the calls, so that you hit the majority of the calls as quickly as possible. But we don't just sit back and say 'Right, okay, well, we've got our 65 per cent, we'll rest it there'. Every red call gets the absolute maximum response and, of course, the whole of our coding system was subject to an external academic review by Sheffield University that was published under the public and corporate economic consultants review. 

Yes, that's amazing. Sheffield University get everywhere—[Laughter.] They review absolutely everything. I do hope they know what they're doing, because we seem to rely inordinately on them in the NHS. 

There are just two further points that may assist as well. So, as Brendan mentioned, if we pick December as a good example here, where it was the second month we missed the target, we reached over 75 per cent of those patients categorised as immediately life-threatened in nine minutes, as Brendan indicated. So, it's not a million miles off. And it's also right to say that, whilst we missed the target, 200 more patients in December across Wales actually were attended to within eight minutes than there were in December the previous year, and that's simply a function of additional volume. So, whilst the target was missed, 200 patients—additional patients, extra patients—received an ambulance in eight minutes in December 2019 compared to December 2020. 

And that was despite an increase in the actual number of red incidents as well. 

Now, I want to talk about the deployment of ambulances in just a moment, but I'd just like to finish with categorisation. So, I'm sure that you will agree with me that, actually, it's not important just to save a life, but to save a life well, so that the person whose life you are saving can carry on and live as good a life as they can. So, can you explain to me, within the amber system, how you're call centre differentiates between, for example on a stroke victim, those who've had a haemorrhagic stroke and those who've had an ischemic stroke? Because, as we know, you have a little bit more time, perhaps, with an ischemic stroke than you do with haemorrhagic.

So, the difference, as you quite rightly point out, can be significant, clinically, and of course, it's the clinical symptoms that the relatives or the carers will ring up with. So, very often, with a haemorrhagic stroke, it can be absolutely catastrophic. So, patients can rapidly lose consciousness, and that would be the call. So, we would be basing the coding on a patient who has lost consciousness and maybe have ineffective breathing. In which case, we would be categorising that as a red call. So, it depends on the actual symptoms that people phone in with. So, if they phone in with classical stroke symptoms—weakness down one side, the face is a bit droopy—they're taken through the categorisations of the Face Arm Speech Time test, and we would then recognise that that was a stroke.

We know that there is a therapeutic window for thrombolysis or potentially thrombectomy, and we would classify that and send an ambulance on blue lights to get that patient and take them to the stroke unit. So, that is the main classification for strokes. Severe haemorrhagic strokes, as I said, they will present, very often, differently, and under those circumstances, they would often tip into the red category, and, of course, then, you would have to get them to a neurosurgical unit and ensure that they are scanned prior to treatment.

So, two questions I have from that are: first of all, one of the most successful public health campaigns of all time has been FAST, and we all know and have learned to recognise some of the issues with a stroke. And of course, again, that public health campaign talks about the one-hour window, as indeed do the clinicians I speak to, who have been really concerned by the fact that they have stroke patients coming to hospital hours after the stroke has occurred.

And of course, the second thing, and again, this is from clinicians, and I have talked to a lot of them, they've explained to me that if somebody has a haemorrhagic stroke—as indeed has happened to two of my constituents just this winter—the bleed started slowly, so when they phoned in, it was stroke. But then, of course, the blood builds up—. And there's no comeback from the ambulance service. There doesn't seem to be any sort of review of the symptoms. So, when the family kept phoning in and saying, 'Where's the ambulance? Where's the ambulance?'—in the end, after five hours, they put the person with a haemorrhagic stroke in the car and took them to Withybush hospital, totally paralysed. A terrible shame, one of your statistics, but it's a human life.

So, what I'm trying to understand is we're telling the public, 'You've got an hour to get somebody in with a stroke', but you guys are saying, 'We've got four hours', or the system is saying 'We've got four hours to get somebody from stroke into hospital because—'. And here's the kicker, and it's been explained to me on a number of occasions by the Minister for Health and Social Services, once they get to the hospital, they go straight through the stroke pathway to the right place that can deal with them immediately.

But secondly, if it's a haemorrhagic stroke, which starts off looking awfully like an ordinary stroke, then it can be quite catastrophic by the time they get there. So, I just wondered what plans you have in place to ensure that people are not disadvantaged because they're having a stroke and they're in the amber category.

Okay, there are just a couple of things I can, perhaps, respond to there. There are a couple of points there. Firstly, I want to say, I've gone on record and said this publicly—patients who have waited a long time, particularly this winter, there are a number of those. We are sorry about that. That's not the service that we aspire to deliver. And there are a number of patients who have waited a long time, who we have directly reached out to or who have contacted us about their circumstances. And I apologise on behalf of the organisation for that, because the service that they've received is not what we want to offer.

What I would go on to say is that, whilst the red category has a target, or an ideal response time, as we've discussed—65 per cent of patients within eight minutes—the clinical model we operate here in Wales doesn't have a response time standard directly associated with the amber or the green category as we know, and, indeed, that's now not different to the rest of the UK. However, what I would say is that the ideal response time for a patient in the amber 1 category is around 20 minutes and the ideal response time for a patient in the amber 2 category is around 30 or 40 minutes.

We would say—and, indeed, the 'Amber Review', which reported last year, confirmed this—that the prioritisation system and the response category within which we place such patients, including strokes, isn't incorrect. The challenge for us—. It isn't incorrect because the ideal response time is in the order of 20 minutes. The challenge for us is having the right amount of resources, in the right place at the right time to respond to those calls within that ideal response time.

There were just a couple of points. So, we do advise callers to call back if the condition deteriorates and the response can be altered depending on a change in the clinical condition. So, what you were saying about a haemorrhagic stroke initially presenting with relatively mild symptoms, if the symptoms deteriorated, that patient could be elevated to a different response level. And also, we don't apply the four-hour window to calls that come in that are suspicious of stroke. So, with a stroke, we send a rapid response ambulance on blue lights to get there as quickly as possible. We recognise that time is brain tissue in these cases. That's been part of the education that we've been undertaking with our staff and we have been working with health boards to see if we can have pathways that take the patient directly into a process by which they are scanned as quickly as possible, and then, obviously, the treatment undertaken from there, because, as you are aware, the treatment for a haemorrhagic or a thrombosis-originating stroke could be quite different.

I have to say, I'm not hugely reassured by your answers, because I just don't see it working that well on the ground. I have ambulance staff and A&E emergency staff and clinical decisions unit staff telling me that, actually, people with strokes end up in A&E rather than going straight to the stroke unit, especially if they are so inconvenient they have their stroke at night, and I have a lot of casework where people have had strokes and have waited. So, the case in point that I referred to earlier: that individual was in line for the next available ambulance. So, that was your blue light rushing to them. After four and a half hours, they popped the person in the car and took them into Withybush hospital. Now, if that's your next available ambulance, how can you possibly say with any degree of confidence that, actually, within 30 minutes, hopefully, you'll be getting it? Because I'm not the doctor here, but four hours or five and a half, almost five hours of waiting, and then, when they got that person into the A&E, the clinician was absolutely incandescent with rage that they had waited so long, because, as I say, the results were catastrophic for that person. And that's just one. I have a number of cases along those lines.

So, although the theory may work well in practice, if you simply do not have the resources in place to actually be able to go on and get that person, then the whole thing falls apart. So, I'd just like to talk now about the ambulances, where they are, what's holding them up, and also what I perceive to be a lack of intelligence in the system. And let me—. If I can explain for a second: every single ambulance issue that I've had in the last five months, I have done FOIs on immediately to you—and you have, fair play, answered absolutely right—asking exactly where every ambulance in Hywel Dda was at that time. And, of course, where were they? Piled up outside hospitals. So, there's obviously an issue with hospitals, and I'm sure you'll be able to explain that to us, but where I have a real concern is—. This is a completely different case, this is a 97-year-old man who waited on the floor of a dementia ward of a hospital, literally 300 yards from Withybush and he was on that floor for 11 hours before an ambulance came to pick him up. But when we looked at the stats of all of my cases, you have a disproportionate levy on hospitals. So, for example, on that case, there were 13 ambulances waiting outside Withybush, there were two outside Glangwili, there was one outside Bronglais, and I think there was one outside Prince Philip. And I'm very happy to share—. Well, you did the FOI. You've got the information.

So I just wanted to also understand, given the pressure on our hospitals, when people review, does anybody within the call centre go back and think, 'Hey, let's redeploy ambulances seven, eight, nine, 10, 11, 12 and 13 to Glangwili, because then at least we've got a more even balance, and therefore, there may be more chance that those ambulances will go through and unload quicker.'

Okay, so there's a number of issues in that which I'll try and unpack, to assist you with. Clearly, you won't expect me to comment on individual cases, and I can't, because I just haven't got the detail in front of me. You rightly point, in the end of your previous question, to the material issue here in responding within a reasonable time frame to patients across Wales, and that's resource, and that's the resource constraint that we see. I'll just talk about a number of things in that regard, which will hopefully provide you with some answers to the points you've raised.

So, I'll start with activity. So, the number of calls we receive has risen. It rises year on year, and we've seen that trend follow through in this year a couple of percentage points—two or three percentage points' increase in activity. Across the peak of winter—so the last three months particularly—it wouldn't be uncommon for us to be holding a number, a significant number, a large number of emergency calls awaiting a response, and that's why there are those delays that you describe, and your constituents experience, our patients experience, through the winter. And of course, the prioritisation system does ensure that we send the nearest available ambulance to the sickest patient first, so it's regrettable that those patients with less serious conditions do wait longer.

Emergency department handover delays have been a particular challenge for us this winter. That position has deteriorated by in order of 80 per cent compared to last year, this time last year, so we've seen a number of our ambulances—as you've described in your area and indeed across Wales—waiting at emergency departments to hand over their patients for extended periods of time. Those ambulances are then not available to respond to patients; those patients wait in the community for a response. And when an ambulance becomes available, it will go to the most serious, longest patient first, if that makes sense: the longest waiting, most serious patient first.

Resources are moved across geographical borders and boundaries to go to the most appropriate call when they do become available, and the point you make about—

Sorry, may I just interrupt you on that one little point? Because, actually, I do know that, because I've sat in the ambulance call centre in Llangunnor a couple of times, and one of them was a Saturday evening, and much to my horror, I found that all the ambulances from Pembrokeshire drifted into Carmarthenshire, and all the ones from Carmarthenshire went to Swansea. So, actually, if somebody has a catastrophic incident in Pembrokeshire, you are not 15 minutes or 30 minutes away from your nearest ambulance, because they all get redeployed eastwards. So, not only are our services all eastwards, all our ambulances are all eastwards as well. Is there no system in place that actually keeps at least a bare minimum in county?

So let me talk about what we're doing in response to the circumstances that we're in, and your patients—your constituents and our patients—have been experiencing too. So, in the last year and 18 months, we've been focusing on what more we can do to avoid conveyance to an emergency department where it's appropriate and safe to do that, so that means treating patients in the community where it's safe and appropriate. That's better for them in some circumstances, that individual patient; it's better for the emergency department, because we're not taking patients to them that don't need to be there; and it means that we have the ambulance resources that are available to us available to respond to a patient that needs them. So, we've grown our advanced paramedic practitioners, we're doing much more now by way of telephone advice. About 10 per cent of our work every day receives telephone advice from a paramedic or a nurse in one of our three control centres, similar to the one that you visited.

We've become the first ambulance service in the UK, late last year, to deploy independent paramedic prescribers. So, these are our paramedics who are now able to prescribe medications to patients in the community—again, avoiding unnecessary conveyance to the emergency department. So, we, as an organisation, have been focused on what we can do to support the rest of the health system to free up capacity in the emergency department, where it's safe and appropriate to do that, and Brendan and Claire may want to comment separately on both of those points.

The other thing we've been doing with commissioners—and this is important, collaboratively with commissioners this year—is developing a forward-looking plan for the next five years that says to us, 'These are the resources we need in each of our areas across Wales to respond to our patients within a reasonable time: eight minutes for red, around 20 minutes for amber 1, around 30 or 40 minutes for amber 2.' Essentially it's resetting the number of ambulances we have available to us across Wales to be able to respond to patients in a reasonable time frame.

The final report from that modelling work was considered by the emergency ambulance service committee at the end of January and, indeed, was endorsed and approved. There are a range of recommendations in that, essentially, that see us do two things over the next couple of years: invest and grow, and we've already secured investment for phase 1 of this from our commissioners, which will commence with the recruitment of 136 additional front-line staff now; and it sees us make some internal changes, in partnership with health boards, to generate efficiency, such as being able to take patients directly to other bits of the health system to avoid the emergency department. So, direct referral pathways for our clinicians to other bits of the health system to avoid the bottleneck, which is the emergency department.

Sorry. May I just interrupt you there and ask you are you confident that our hospitals have those pathways in place? Because I've gone searching for those pathways, and it's pretty hard to find in a lot of our hospitals.

Well, I think it would be fair to say it's a mixed bag. So, we recognise there is work, the system recognises there is work to do to improve our ability to access some of those pathways. We're not looking for access to everything and, indeed, we've called out five high-volume pathways that we would want to be able to provide access to all our clinicians to. First, they're around cardiac, respiratory, falls, frailty and mental health. But perhaps Brendan and Claire would want to comment in more detail on that. Perhaps, Claire, if I ask you to add some additional detail.

Yes. Thank you. So, in relation to the work that Jason has talked about in relation to falls, we've done quite a lot of work. We have developed a falls response model and a falls framework to specifically focus on falls. We recognised that through the concerns we were receiving and through the incidents that we were reviewing that we had a particular patient safety and patient experience concern with patients who have fallen, particularly elderly patients who fall. And the rationale behind the falls response model was about trying to get the appropriate response to the level of need required.

So, we've developed three levels of response; this is in its various degrees of stages in its development. There are essentially three levels of response to fall—level 1, level 2, level 3—and the first level is about a response to somebody who has fallen but has not necessarily injured themselves or, certainly, in our assessment of them over the telephone, they do not seem to have sustained an injury, but they have fallen and are unable to get up. And, actually, what those people need is a timely response to be able to get them up off the floor, because by not getting to them and getting them up off the floor in a timely manner, actually the fall, then, becomes not the problem; the fact that somebody has been on the floor for a long period of time is what then becomes an issue for the particular patient.

So, in developing that falls response model, we've developed in a number of ways. We've worked with St John Cymru, particularly in south Wales, but we are now rolling that out across the whole of Wales into every single health board. We have, with our community first responders in north Wales, worked with them to be able to respond to that level of need. And within south Wales, we now have a level 1 falls response service, where we work in partnership with St John Cymru in all of the south and west Wales health boards. They operate currently only within the 12 hours of the daytime, from either 7 a.m. until 7.30 p.m. or 8 a.m. until eight o'clock. We do have one area in south-east Wales, in Aneurin Bevan, where that is operating on a 24-hour basis because the health board there has invested in putting in that night-time service.

What we have identified in doing that is that, actually, for those people that we get to with the level 1, only about 40 per cent of those people then need to be conveyed to hospital. So, we are seeing that when we  can get to people in a timely way, we can pick them up off the floor quite quickly and then we can do an assessment, that, actually, not all of those people will require going to hospital. We have put some governance and safety around that, so, obviously, the people who are responding are our St John colleagues. The clinical decision as to whether or not those people have had the right response, the assessment and then whether any further assessment is required is undertaken by our clinicians on the clinical desk. So, we have a pathway in place where they telephone the clinician on the clinical desk when they get there, they do an assessment and, obviously, they relay that to the clinician.

So, that is one example of where we are trying to be able to get to people in a different way, being able to meet the need that they require, and being able to avoid that conveyance to hospital, recognising that, actually, particularly with somebody who is elderly or frail, we should do everything we can to not admit them to hospital, unless they medically need to go there.

Can I just pick up on the point you're making? You mentioned that sometimes the crews take the patients to ED and sometimes they take them directly to the scanner. Now, of course, that's a decision made by the health board, depending on the availability of staff at the time. That variation has been highlighted in a paper that will actually be coming to the national unscheduled care board this afternoon, and, obviously, we would like to be working with the health boards to ensure that we have a pathway that enables our crews to take the patients directly to the appropriate treatment.

In terms of leaving areas without ambulance cover, that's very much a dynamic situation. As ambulances are moved, and if we do have congestion of ambulances outside one ED, then a decision is made around where the ambulances are deployed. So, we do try to ensure that areas are not left without cover. It's not a static arrangement; that will take place on a regular review basis.

Also, the teams with Welsh ambulance, working with the local health boards, will dynamically review the situation on a day-by-day basis and make decisions around diverts between hospitals. So, within one health board, they may well organise diverts, for example, in Hywel Dda between Withybush, Carmarthen, Llanelli and Aberystwyth, depending on how busy one of those units is. If the situation is extremely busy, we will then arrange for diverts across health board boundaries. But, of course, some of the diverts also need to take into account the fact that there is more specialisation going on, and we don't take all patients to all hospitals. So, sometimes, you will find crews taking patients to a hospital that's further away because that is clinically appropriate.

Thank you. I've got so many questions for you, I'm going to distil them down to just two more. So, one is actually connected with what you've just said, Brendan, about the intelligent reanalysis on an ongoing basis. Who makes that decision? Because almost all of my FOIs that have come back have shown at least one hospital to have huge numbers of ambulances outside it, and the other hospitals with minimal numbers. So, when I just look on the balance of the FOIs I've had back, I have to tell you it doesn't seem to be happening. So, is that a decision that your guys will sit down and review, or is it that you're waiting for the health board to say, 'Oh, we've got too many at Withybush, send them to Glangwili', or whatever it is?

I think it has to be a joint decision. As soon as we pick up that we have ambulances queueing outside one ED, and also, of course, the intelligence that we will have as we will know how many patients that we've got on the stack in that area, we will communicate with the people on call for the local health board and say, 'Look, the situation is you've got six ambulances queueing up, the longest wait is four, five hours. We've got calls on the stack. We think that we now need to put something in place.' We would move up escalation levels that are already written into the process, but when it comes to the situation then when we start diverting ambulances, that would be a joint decision between us and the teams at the health boards.

Okay. It would be great if you could let us know who those teams are, and at what level, because I'd like to go and basically talk to them, because they're not making those decisions, it would seem to me, timely enough, and I'd like to understand that.

So my second question, then, is simply: according to your evidence, things go swimmingly well when it comes to handovers at Cwm Taf, so what are Cwm Taf doing right that all our other health boards are not? Because, again, I'm going to give you just one case to elucidate the point: one woman was in the ambulance, she waited five hours outside one of my hospitals—not mine, but Hywel Dda's—and she was taken out of the ambulance to go and have an x-ray, and then she was put back in the ambulance for another two hours. What a waste of your resources and your highly trained staff. So, what are Cwm Taf doing right that everybody else seems to be serially failing on?

I think it would be fair to say that not everyone would agree that the approach that's been taken in that particular hospital in the past is necessarily right. It's different, and it does—

This is Cwm Taf, is it? Because it's in your evidence as well.

Yes. It has resulted historically in much lower ambulance handover delays, but it does create other challenges locally, which Brendan is probably much better to comment on because they are essentially clinical challenges. What I would say is that notwithstanding the fact that the delay position has deteriorated significantly during 2019, we have now seen new arrangements put in place at the majority of our most challenged hospitals, and we are starting to see a reduction in handover delays, which is resulting in improved ambulance response performance, because we've got more capacity available to respond.

The other thing I'd just say—and it connects to diverts—before I hand over to Brendan to talk about that particular department is that, at the end of January, new arrangements went live for what, essentially, we call regional escalation, where we are now at the centre of daily huddles, patient safety huddles, with all of the health boards. We're chairing those, we're facilitating those. We've got clearer arrangements for escalation in place now, so where a divert across a health board boundary is necessary, or becomes necessary, they can be triggered much earlier than they were before. So there's learning that's gone on through the winter, through last year, and we've reached agreement with health boards that we've taken over those arrangements now, because we can see it live, it's in our control rooms, we're feeling it, it's dynamic, it's happening in a live environment. We're able now to work in a much clearer way to trigger those conversations at an earlier point to get those diverts in should we need them, across the health board boundary, at a much earlier stage. Brendan, do you just want to comment on cohorting and handover?

Yes, so, I think basically Cwm Taf took the decision that they would not keep ambulances waiting outside ED if at all possible, and they would move patients and cohort them in areas within the hospital, which causes some difficulty with nursing, but obviously it's a question of managing the risk across the whole of the system.

Sorry. Can you just explain 'cohorting'? I don't know that term.

It's basically taking the patients off the ambulance and putting them into an area where they will be waiting for clinicians to assess them. So, they could end up with people on trolleys in corridors waiting to be clinically assessed before they can find a space in the emergency department. What I would say is that the Cwm Taf position does follow the recent advice that came from Keith Willett, who is the national unscheduled care lead in England, who was very clear that people who are most at risk in the emergency and unscheduled care system are those who are still waiting for an ambulance and haven't had any clinical assessment, and therefore he was saying that the responsibility really needed to be emphasised for hospitals to release ambulances as quickly as possible, because the other patients have already had some sort of risk assessment.

I agree. I don't see why patients are taken off ambulances, have investigations and then are put back on ambulances when we have calls waiting that those ambulances should be sent to. I think that that has been part of the recent work to try to review cohorting areas when a number of ambulances are waiting. We've seen examples, for example, at the Royal Gwent Hospital, where they've expanded a patient assessment area for cohorting, and that does actually seem to have had an impact.

The other piece of work that we have undertaken is in sending information to the emergency departments to release ambulances immediately when we have red and amber 1 calls in the community. That message is regularly conveyed to the EDs so that they can sense the urgency within the system. It is a problem. Some hospitals, such as Cwm Taf, seem to be able to take the patients in, accepting, perhaps, a bit more risk within the hospital but at least releasing an ambulance for the next call in the community; with some hospitals, they seem to have more difficulty in making those arrangements. 

So, risk management is an absolute key, and I do get that. I just wanted to clarify that, when you cohort, the idea would be that, if somebody's got a broken leg, you'd probably cohort them around orthopaedics. If it's an older person, you'd cohort them around— 

No.

No? You just stick them anywhere.

No. We have differentiated cohorting before a clinical assessment, before the patient is taken into the emergency department.

So they could just languish in a corridor for ages. 

They would be in a corridor.

Languishing in a corridor for ages, because if they haven't got the doctors in A&E, then they haven't got the doctors.

I think, just to clarify the point, it's not routinely corridors that these patients are waiting in. If we use the more recent examples at the Gwent, a new facility has been provided there where trained staff are providing care to patients whilst they're waiting to enter the full ED system. So, essentially, it's a holding area, if I could describe it like that. It's a proper facility—it's not the car park and it's not a corridor. It's a proper facility that has been designed, which has trained clinicians to work in that environment. It's an equipped area, where care can be provided to those patients and, instead of being in the back of the ambulance waiting, which stops us being able to respond to patients in the community, these patients are cohorted in a facility at the emergency department. 

And they are still being clinically monitored. 

Yes.

So people are taking their observations on a regular basis to monitor for any deterioration. 

We've got to move on in terms of time, otherwise we could be here all day, enjoyable as it is. You foolishly mentioned the Royal Gwent Hospital, so we've got the local Assembly Member for the Royal Gwent now. [Laughter.] Jayne. 

Thank you, Chair. Just on that, I actually visited the pod at the Royal Gwent last Thursday, I think, and it was quite impressive, actually, the structure outside, and the morale of staff had actually gone up at the Royal Gwent as well because of these extra beds, which I think they're determined won't become a ward. It hadn't last Thursday, and they'd seen some real improvements at the start of the week until Thursday, but they were waiting for the weekend. I don't know if you've got any up-to-date statistics with you or anything to show how that went on the weekend. Also, if it is working, what is the time assessment for that and when could it be rolled out to other places, perhaps, if it is something positive?

Okay. Yes, we have got some up-to-date data, and I would agree with you. Indeed, I'm visiting it this afternoon. A number of our team have already been there. You've visited, haven't you, Claire, already, and I'm going to pop in this afternoon. We're supporting that with 12 of our staff, in addition to health board staff as well, who have been, as I said, trained to work in there. The early indications are—and, of course, it's only been running for a week, but the early indications are we've seen something in the order of a 70 or 75 per cent reduction in lost ambulance hours at the Gwent as a result of the introduction of the pod. So whilst there are still some residual delays occurring, it is materially better—albeit that it's early days—than it was before the pod went live. And of course, as I've described, those patients who would have historically been waiting in an ambulance in the car park are now waiting in a proper facility that's properly equipped, with properly trained staff around them to begin to provide care to them. Our early intelligence and information is the same as yours. It's been good for our people. We've had some very positive feedback from our people about the provision of the pod, and equally, as I understand from my colleague in Aneurin Bevan, similar feedback from health board staff, too. 

And I'd also say patients on that point as well, because that's what—. The thing that came back was that patients were actually satisfied with—. There was nobody waiting when we were there. 

Can I bring Rhun in at this point? 

What additional resource had to be found to deal with that, because one problem—not the correct word to use—but one issue that arises is that you're able then to go out and get more patients that need to be brought into the Royal Gwent? And it's happening elsewhere as well, isn't it?

Yes. It does create a resource requirement because it's an additional service, for want of a better line, or an additional service line that was being provided. As I say, we're supporting that with 12 people at the moment, and we're essentially able to backfill those staff in the short term with the use of overtime, but it's not a sustainable solution for us with the current staffing model that's there. So, it's a short-term solution that we see at the moment through to the end of March, and we need to agree with our health board colleagues how we put that on a sustainable footing going forward. 

But you also, potentially, bring more patients into the hospital. 

Well, I wouldn't say we bring more patients in. I'd say we bring the same number of patients in in a more timely way. So, it's not new activity we're bringing into hospital because they would have been waiting in the community for three, four, five, six hours before. They're now coming in in a more timely way because the ambulance is freed up quicker. 

Okay. Time to move on, really. Lynne, some of the issues have already been covered, but I think you've got others.

Yes. I wanted to go back to the Cwm Taf thing, actually, because it's like groundhog day, really, isn't it? I mean, we've been having these discussions the whole time I've been an Assembly Member, which is 20 years now, so it is very frustrating that we seem not to be able to get on top of these problems. You said, Mr Lloyd, that there was expert advice supporting the Cwm Taf model. Can I just ask you a direct question? Do you think the Cwm Taf model is the right model?  

I think the correct model of care—and it was the Keith Willett advice that I was quoting—the correct model of care is that the ambulances are offloaded and freed up as quickly as possible. Now, the way in which different hospitals will do that will depend on their circumstances. The crucial factor is the flow of patients going from the front door right through the hospital, so even right up to what is sometimes referred to as 'the exit problem', about getting patients who may be medically fit for discharge, getting them out into social care and taking up beds that creates some of this flow problem.

Hospitals will have different ways of addressing that problem. Some of them will have capacity in different areas. Some of them will have these specially designed cohorting areas. So, how the individual hospital manages is a decision for the hospital. The principle of offloading the patients as quickly as possible and freeing up the resource for the ambulance, that is the crucial area. And, of course, we've also now recently got the new patient safety group, Improvement Cymru, and one of the first pieces of work that they have been asked to look at, through Dr John Boulton, is patient flow within some of those hospitals that have been experiencing difficulty with ED handover.

Okay. If I can move on to talk about the handling of concerns and patient safety incidents, what assurances can you provide that your internal governance and reporting arrangements in relation to complaints and patient safety are robust? 

Okay. I'll ask perhaps Claire to talk about the processes we have in place with the Putting Things Right team, and the work we've done more recently across winter to shine a stronger light on patient safety incidents, particularly long waits. And then Martin, you might want to comment on board governance around patient safety and the steps that the board's taken to assure ourselves of that.  

Okay. Thank you. So, obviously we have a patient safety team, a concerns team within the organisation. That team is an all-Wales team. We have got a team both in north Wales, in south-east Wales and central and west. We have got a number of roles that are dedicated to be able to undertake robust investigations into any concerns. We obviously follow the regulations. We look very closely to be able to address people's concerns in a real timely manner and, certainly, the change in the regulations to looking at local resolution and being able to respond to people in the way that is best for them, I think, is a step forward in terms of us being able to respond to their needs appropriately. And not everybody wants a very long letter with a very detailed investigation, but what people do want to know is that their concern has been taken seriously.

In terms of governance, on a weekly basis throughout the winter, I have been presenting to the executive team the volumes of complaints that are coming through and what the trends and themes of those complaints are. We have a patient safety learning and monitoring group that was established last November that consists of senior clinicians within the organisation, our operational teams and our patient safety teams to be able to make sure that we are bringing together immediate learning from those incidents and being able to look at how we address that.

We also, last year, developed a joint investigation framework particularly for serious adverse incidents. We developed that in conjunction with our health board colleagues, and that was formally signed off at the all-Wales nurse directors at the end of last summer, and subsequently went through our committee. And we are using that framework to be able to ensure that patients' journeys don't just—they're not just in the community or part of our service—obviously, it cuts across whole services. And where we need to undertake a joint investigation into a concern, we do that in conjunction with our health board colleagues. We are going to be, in the spring, evaluating that process, because it is a very new protocol, and we will be doing that evaluation with our health board teams.

But we're also linking with communities and with our patients and seek to get their feedback, not only through the concerns process and by being able to link with people directly, but also through our general community involvement work and being able to speak to people who may not even have yet used our service but perhaps have a view. So, I think in terms of the learning, we need to move to a place where it's not about volumes and numbers of complaints, we clearly need to respond to those complaints in a timely manner. But we need to respond to those complaints, getting to the real root of what people are concerned about, wherever possible. And in the main, we do this, we can have direct conversations with the persons who are raising concerns, but we want to move to a position where that is something that we do as business as usual. And I am, actually, at the moment, reviewing our processes to be able to ensure that we can improve them even further.

You're nowhere near meeting your 30-day target, though, for responding, according to the Putting Things Right process, are you? Indeed, I've had constituents where people have died, and we've literally waited months. I mean, probably more than a year. Any comments on that?

Yes. Our most recent position was around 73 per cent, and, obviously, that's just off our 75 per cent target. But again, I would reiterate that, actually, our ambition is not just to meet the 75 per cent target, it is really important for us as an organisation that we are responding to people in a timely manner, and we want to exceed that target. So, our desire and our intention is to improve those processes and to be getting back to people as soon as we possibly can. Where we have missed that target, where we have not responded to people in a timely manner and those investigations have taken a long time, then, absolutely, we apologise and we seek to improve that.

Mr Woodford, did you want to say something?

Thank you. Safety has to be the top priority of the board, and I think I'm right in saying that we give it that priority. And these have been difficult times with some of the things that we've been talking about. On the subject of serious adverse incidents, those are reported to the board. A year or so ago, I set up a non-executive director-led forum to review serious adverse incidents to ensure that they were thoroughly investigated and lessons learnt, and probably more importantly, to understand causal factors, because it's easy just to attribute cause, for example, to ambulance delay. And that work has been reported through to board, in fact, there are a number of actions around SAIs that followed. And we've had some very honest discussions, cards on the table, about the threats to patient safety when the service is under pressure, which has led to the board, and the chair and CEO specifically, being charged with escalating concerns within NHS Wales to seek greater collaboration, to improve things. Because it's one thing to report things, but the other hard thing is to do something about it.

So, Jason and I have held top-level discussions with our counterparts in three of the health boards where we've experienced the most significant pressure, and I think that's led to some of the actions we've talked around, for example, the point of delivery facilities in the acute hospitals, and a number of our other actions as well that have emanated. We've also had discussions with Andrew Goodall as the director general, and, indeed, in January we're meeting with the Minister as well. I think that's all fed into some of the activity around the taskforce that now presents. So I think we've done our bit in terms of saying that we cannot see patients suffering on our watch. We have to act. That's played through to board, we've escalated appropriately and I think we understand the issues.

On the theme of complaints, I am passionate about this. Jason, you probably see and signed 90-plus per cent of complaints responses and are as determined as I am that we respond as promptly and as meaningfully as possible. I see complaints that are addressed to me via an Assembly Member or an MP, perhaps, and espouse the same principles, and Claire, as the incoming director, you and I have had a conversation about how we turn around responses more quickly and cut to the chase in terms of what we are saying, and demonstrate rapid action. But I don't think there's a single complaint in the organisation that's put in writing that escapes the notice of you or I. So I can give you an assurance on behalf of the board that we are determined to improve this, and the 30-day response measure is very much in the framework of things we are reporting at board. With all these things, what we're looking for is improvement. It's got to be an upward trend.

Right. Agility is required.

I'll be very agile. I just wanted to ask about the culture within the organisation and whether staff feel supported to raise concerns. Over the years, I've had regular meetings, confidential meetings, with paramedics who've come to see me with concerns that they haven't felt that they could raise within the organisation. Indeed, I had a paramedic come and see me on Friday complaining about bullying, and I'm going to be writing to you about that. But what assurances can you give that the culture is really changing, and that those relationships are there to enable people to raise the concerns that they want to?

It's a really good question. I'm not going to sit here and say to you that everything inside the organisation is perfect, because it's not. What I would say—and this pre-dates me joining the organisation 18 months ago—is that there's been a lot of work done on culture and behaviours and values, and I would say, I think, that we are in a strong position with a set of values and behaviours for our people that resonate and that people connect with and understand. They're meaningful to them.

About a year ago, about nine or 12 months ago, I undertook a series of roadshows where we saw about 600 staff face to face and talked to them about a range of issues. What I got from that, as indeed any other ambulance service that I've worked in, is that our people aren't backwards in coming forwards, so generally they are quite clear and quite vocal when there are concerns to be raised. That said, there are those who don't feel comfortable, for whatever reason, to do that, and we have a range of mechanisms in place to support them. That can be through their line managers, through peer support staff that exist, or they can, as many of our people often do, write directly to me, or get in touch with me, or indeed another director if they don't feel they can raise the concern they have with their line manager or their line manager's line manager, for whatever reason.

I think morale has been particularly difficult as a result of the handover delays that we've been talking about this morning. We talk about the concept of moral injury with our people through this, because our people do not come to work to sit in the back of an ambulance with a single patient for 12 hours. They come to work to help people, and as many people as they can, and when, regrettably, they've been delayed for long periods of time, as has been the case through the latter part of last year, they can hear calls on the radio being broadcast for a patient in the community that needs a response, and they can't go. That is difficult for our people, so I think it would be right to say that, not only for our front-line staff, but also for our control room staff, who, arguably, have the got the most difficult job in this because they are in continual contact with the patient or the caller who's with the patient saying, rightly, 'Where's the ambulance? Where's the ambulance? Where's the ambulance?' And of course, they haven't got one to send. So there are also stresses for our control room staff, too. 

So, I think morale has been affected as a result of that. But, again, staff have been very clear and vocal in expressing those concerns and we are doing everything we can to not only support them with their own welfare in the workplace, but also to keep our staff, our organisation, up to date with what we're doing and what steps are being taken, not only by the board and those things that Martin has recently mentioned, but more locally by the management team at a local level, to support our people and free up our resources to respond to patients. So, has morale taken a bit of a hit? Probably, as a result of the pressure that we've seen. But in the main, my sense is that things are healthy and that staff can, in the main, raise concerns that they have about things that are happening inside the organisation. 

Okay. We really have to be agile now. Luckily, our agility lead is asking the next few short questions, with some short answers, otherwise we will be here all day. Jayne. 

Okay. Recent reports from the Wales Audit Office highlighted the need for an updated performance management framework. It was due in 2017; when is it likely to be delivered? 

That work is under way now and we'll see that brought forward through the board in the early part of 2020-21. 

Okay, great. Better summary performance and benchmarking information were called for in those same reports. Has that been actioned?

It has. The demand and capacity review—I'm being very brief—that we undertook collaboratively with commissioners, benchmarked us, particularly the emergency medical service, so the 999 service, across the rest of the UK and, indeed, internationally. So we now have a suite of measures where we can see how we perform. It's good, actually, from that, that we are pretty much in the top quartile in most of them. There is some work to do in some areas and they'll be some of the efficiencies we look to put in in the next 12 to 24 months. 

Okay, thank you. Mr Woodford, I think you touched on the ministerial taskforce that has been set up in one of your answers. It was talked about in that, and it's not just about ambulance availability, but also service responsiveness and improvement. How is WAST going to engage with the taskforce? 

We'll be represented on the taskforce—

That was a question put to me. 

Okay. Go on, Martin. 

I'll answer it and then Jason can correct me. 

We'll be right in there—that's the long and the short of it—because we cannot not be involved. Our approach is a collaborative one. We have a very healthy relationship with our commissioner, Stephen Harry, who is leading that taskforce. When we fall out, it's constructively, and we put things back together. There's an issue about terms of reference and membership of the taskforce, which we're in discussion with Stephen Harry on at this very moment. We will be very close to it. I envisage that he will be invited to come along to our board to report progress. There will be working groups that we'll be playing into, which Jason can talk about. My vice-chair, as a non-executive, will be a member of the taskforce group, so we have that assurance link as well. We're looking for shared conclusions and, ideally, conclusions that we reach jointly with the whole of the NHS, so that what we sign up to is deliverable across the whole system, because there are big system changes in this. It's not simply about the ambulance service in isolation. But we're up for it, basically. 

Great, okay. Just finally from me on this point, in the ministerial statement, there were proposals to develop a system of incentives to support improvement. Have you had any discussions with Welsh Government on what the system of incentives might look like?

Yes. We're in discussion and being consulted now on what that might look like. I think we would welcome anything that puts grit in the system and focuses on a particular challenge that we've had and the consequences of that challenge, as we've discussed this morning. Fines, incentives or sanctions aren't unusual. We use them in other bits of the health system here and they're widely used in other health systems, too. So we would welcome them. We would say they need to be smart and they need to be thought through so that we don't create any unintended consequences, but the intent of reinvestment of any fines into improvement has to be at the centre of what they are, or how they are constructed. 

Okay. So, as you say, the demand and capacity review that we undertook collaboratively with commissioners, and was endorsed last month at the Emergency Ambulance Services Committee, identifies a need for in excess of 500 additional staff over the next five years, and that essentially means that we'll be able to respond to the demand that we expect to see within a reasonable time, as I described earlier, for all categories of patients. It will mean a slight shift in the resource model. So, at the moment, we have more solo response cars than we will in the future. We'll have more double-staffed ambulances in the future than we have now, and fewer single responders. We will, in that 530-odd, see a growth in the number of advanced paramedic practitioners, as we touched on earlier, that are able to treat and discharge patients in the community. So, we'll have more of those. We'll have more double-staffed ambulances and fewer solo response cars—  

I'll just stop you there for a second. Why is that? Is it because more people will need to be transported to hospitals? 

It's essentially a function of how the modelling works. So, solo response cars become important for time management and the provision of care. If we've got more ambulances available across Wales, essentially we need fewer cars to be able to get to the eight-minute target. That's essentially how it works, and it's more efficient to do it that way. So, we'll have more ambulances, fewer cars, more advanced paramedic practitioners within those numbers, and the majority of that growth will be in emergency medical technicians. So, whilst there will be some paramedic growth, there'll be growth in the emergency medical technician numbers across Wales, enabling us to respond in a more timely way. 

The second part of your question is: is it affordable? Well, commissioners have already committed to phase 1. I mentioned earlier about a growth this year of 136 additional staff that we're about to commence recruitment for now, and we've got negotiations to run with commissioners about the remainder in phase 2 and phase 3. But we're confident, over the next five years, that we'll be able to grow and recruit the people that we need and, of course, that growth is contingent on delivery of efficiency as well. So, it's not just pouring more people into the system we already operate; it's changing the system we operate as we go forward.  

And related to that, you mentioned an increase in demand. What about increases in pressures on you due to changes in health service provision? For example, the Grange University Hospital and the increased number of intra-hospital transfers—?   

Some assumptions about some changes across the health system are within that 530. The Grange is a good example that's not. We're currently working with Aneurin Bevan health board at the moment on the additional volume of patients we expect to see that will need to transfer as a result of the clinical model there, and any staff that we need to service those patients will be in addition to those 530-odd that have already been identified. 

And, of course, things like the major trauma centre—[Inaudible.]—networks that have been personally involved with the changes—[Inaudible.].

Just one other point, because you mentioned the advanced paramedic practitioners, is the contribution that we've now been able to make to the wider health system, so that our advanced practitioners are now rotating in what we call 'the rotational model'. For example, in Hywel Dda, they're doing a significant amount of work within the GP out-of-hours and in other areas of work, working within general medical services.

How much of the increase in staffing that you predict you will need is due to the fact that you are understaffed now? The reason I ask that is, you report unacceptably high levels of sickness still, and quite often, understaffing leads to higher sickness levels among the staff that you do have. Is there a relationship there, and how are you dealing with unacceptable high levels of sickness?

Okay, so there are two issues in that, if I can. The demand and capacity review identified what we call a relief gap, or a deficit in staff at the moment, to the order of 226 full-time equivalents. So, part of that 530 is to reset the rosters that currently exist. And then further growth is to take account of additional activity in the next five years.

The second part of your question—. Just remind me of the second part, sorry.

How are you dealing with the unacceptably high levels of sickness?

Okay, sickness. So, sickness has been high, as you rightly identify. We have seen some quite good progress, actually, in a reduction in long-term sickness, which is the more entrenched, difficult area, often, to get into, where we've had, essentially, a case review system implemented about 12 months ago, where we are managing each individual case back to work or alternative duties. We've seen good progress there with the number of long-term cases essentially being halved, and the duration of those remaining long-term cases also coming down quite a lot as well.

Our challenge is in short-term sickness. If I'm honest, there's a range of factors that play into that. Some of which we've touched on earlier, and we've seen a growth in anxiety and stress-related absence in recent months within our short-term sickness. So, we are reasonably confident that, as we work through the recommendations from the capacity review, we see improvements in our welfare arrangements. We're growing our occupational health team as we speak, and as we see improvements in hospital handover delays, we'll see that short-term sickness come down as well.

One more question, briefly: how are things going with preparations for the next stages of roll-out of 111? And how does that work affect your plans moving forward and taking pressure off you, or adding pressure to you?

So, as the committee will be aware, we're the national operator or provider of what is currently NHS Direct transitioning to 111. Plans for the ongoing roll-out are good, and we successfully rolled out the last health board to go live at the back end of last year. We are in discussions with the national programme team now about the remaining health board areas to go live, and also what will happen once they've all gone live in terms of enhancing, developing and growing the service, as we go forward. So, we're in a positive position, a strong position, I think, there, with good discussions with the programme team and with our 111 internal team too.

Whilst it doesn't add work to us necessarily—the staff are already in place, we're essentially transitioning the 0845 facility into 111—it does give us additional flexibility in the future, as we go live, to deal with some of the lower acuity 999 calls, and how we manage those safely across the system.

Okay, thank you.

Okay. Lynne Neagle.

I wanted to ask about the ambulance fleet and capital funding. The Wales Audit Office has identified very high levels of maintenance required. How are you going to manage that? 

Well, our fleet, compared to some other services across the UK, is actually quite new. So, we've, for many years now, had good, strong support from Government with the capital plan for our fleet replacement programme. The exact number escapes me, but we have a multimillion pound annual fleet replacement programme which sees the average age of our front-line emergency medical services fleet at about five years, and we've got a commitment from Government, going forward, to have that on a rolling a basis in the years to come.

On fleet workshops or 'maintenance' as you describe, we operate workshops across Wales; our vehicles are on a regular, rolling servicing programme. And whilst there are clearly breakdowns that occur with vehicles that are on the road 24-hours a day, I'm not aware of us seeing anything outwith other fleets, certainly other ambulance services across the UK, but I'm happy to go and look at that.

Jayne.

Thank you, Chair. Non-emergency patient transport services are a really important part of the work that you do. It's gone up just slightly this year. Do you see that as a changing role in the ambulance service?

Well, I mean, there are three service lines, essentially, that we operate. We've discussed a lot this morning the EMS 999 service. You rightly identify the non-emergency patient transport service, and, of course, that provides critical transport for patients in communities, often those who are isolated or socially isolated as well. Our NEPTS teams do undertake journeys for patients who are reliant on regular timely transport, such as dialysis patients, and activity has gone up across the NEPTS fleet.

There's been some good work done, actually, in the last 12 months with NEPTS as we've continued to modernise how we operate there. Just one example I'd share with the committee: we used to operate, essentially, a regional call handling arrangement for NEPTS, so a patient would ring a number for their local area and their booking would be made. We've now nationalised that and we've seen a significant reduction in the waiting time for those patients and a significant improvement in patient satisfaction as a result of that work that we've done within the same resources we've had; we've just changed the model.

So, I think it would be fair to say—and Martin might want to comment here from a board perspective—that there's been a lot of good development in the NEPTS service in the last 12 months. Credit to the team there that have been leading that. But we do recognise that there are some stress points within NEPTS that we need to settle, such as activity that we are currently undertaking that is not necessarily clinically necessary. So, there is more work for us to do, but good progress, I think, it would be fair to say, has been made.

I think they've come a long way in the last five years—almost unrecognisable. The reporting we're getting to board is really good and positive. I think Jason's point about patients who don't have any clinical need for transport is the issue of the moment, and as a board, we are aware that that is emotive and needs to be handled very sensitively. It may be about seeking alternative forms of transport for people rather than the standard offering from our service.

I think there's something for the future—. I don't think we can nail this today, but our NEPTS crews are a point of contact and a source of intelligence for us in the community. They see people repeatedly and often have almost an holistic understanding of patient need. There's got to be a way of tapping into that in terms of finding alternative sources of treatment and so on, and pathways for patients rather than coming automatically into the hospital system. So, that's probably something for the future that we'll begin to focus on.

Okay, thank you.

And just picking up on that point to explain about the public health plan. We recognise that there is a role for our staff, just as Martin says, in terms of the interactions and the visibility that those staff have with patients and being able to signpost them to all different sorts of organisations, whether that be housing support or referrals and signposting to social services. So, that is a key part of our public health plan and opportunity for the future.

Jayne.

Thank you. Last year, this committee published a report on mental health in policing and police custody and we heard evidence about the reliance of the police to transport people to hospital, largely because of delays in ambulance times. How are you tackling that?

Claire will comment in much more detail on the work we're doing around mental health, both in partnership with police and across the health system. On the waiting times for ambulance transport, that would be something that we see being resolved, and, indeed, is planned to be resolved through the work we've already discussed this morning with the growth in the ambulance fleet: reduction in the general waiting time for patients. So, we see that progressively improving as we recruit and deliver efficiencies over the next couple of years. But, Claire, do you want to talk about the detail of the work that's under way?

Yes. Certainly in relation to what you were talking about there in terms of the mental health concordat, we've been part of that and party to those discussions and continue to work through that and are very much at that table with the police and other organisations. In terms of our mental health improvement plan, that's been very much been based around three real pillars, which are around pathways, our people, and—I've just forgotten the third one. It's just gone straight out of my head.

But a particular focus of our mental health improvement plan in the last year has very much been around our staff, and in terms of thinking about the high levels of sickness, a lot of that in relation to stress and anxiety, and what support we are putting there for staff. We've had a number of various different schemes that we've operated. We've operated a peer-to-peer support in the aftermath of anybody having a particularly traumatic experience. We've got a head of mental health that is now leading that work and growing that team and looking at how we strengthen that further. We are working with our commissioners as part of the mental health access review, and, obviously, the outcome of that access review is very much going to inform the next steps of what we need to do with mental health, but recognising that that is an opportunity, particularly, where we can be offering different opportunities for both the community and particularly within our hear and treat services, in relation to looking at having mental health practitioners within our control centres. But that is dependent at the moment on us waiting for the outcome of the mental health access review, of which we are working with our commissioners on.

Okay. The last part is on sepsis. This committee's doing a review into sepsis. Angela, you've got a particular interest in this.

Yes. Just really quickly, how does your call centre identify if somebody is calling in with potential sepsis?

Okay. So, Brendan is clearly best placed to talk about this, as it's a clinical matter, but perhaps just by way of introduction there, of course, when someone presents with sepsis, they don't call us, saying, 'I've got sepsis.' It will often be someone who is generally unwell, or who has rung us because they've got breathing difficulties, or some other presentation.

There are usually a clear set of indicators.

Indeed. So, they often ring us with a different presentation, but Brendan is much closer to this work and able to speak to it, certainly from a clinical perspective.

Sure, thanks. I think there are two different categories. There is one where we have health professionals, commonly GPs, that would ring up and say, 'I think this patient has sepsis', and that would be prioritised. But the most common calls, of course, come from the public, and the difficulty here is because of the way sepsis can develop from very mild symptoms as to where it is picked up within the clinical condition. I think that Public Health Wales also submitted evidence around the common signs or symptoms. So, the common signs or symptoms tend to be around slurred speech, confusion, shivering, muscle pain, poor urine output, breathlessness, discolouration of skin, or just feeling very unwell. And very often, the key would be that there's a pre-diagnosed source of infection that now seems to have deteriorated.

So, all of the clinical conditions would be covered in the supplementary questions that would be asked by the call handlers, and so, depending on the severity of the breathlessness or the speech or confusion, that would give us the appropriate coding. So, we've undertaken a considerable amount of work within the organisation. So, for the front-line crews, we've been pushing the sepsis education, and particularly the national early warning scoring, which we run routinely across the ambulance service. And, in fact, we have a clinical indicator that measures our compliance with the NEWS score with suspected sepsis, and we always score very highly on that; we're over 95 per cent on that. We've also produced an e-learning package and made that available for all crews, and we've undertaken more work also, in accordance with the ambulance guidelines, the Joint Royal Colleges Ambulance Liaison Committee—JRCALC—guidelines, both around NEWS, but also a paediatric warning system.

So, we've undertaken a significant amount of work. We review all of the cases. The problem with sepsis is the way that it presents. And while we know that—. I think the latest figures were something like 2,200 deaths per year in Wales associated with sepsis, and that might be patients dying from sepsis, or patients dying with sepsis, which is an important differentiation. We have increased the awareness, we've participated in some research around the early use of blood cultures and antibiotics, but the evidence still doesn't support that on a wholescale measure, and we've also changed the pre-alert system to notify hospitals when crews are bringing in patients with suspected sepsis so that they have the necessary clinicians to implement the early sepsis model as quickly as possible.

The pre-alert news is excellent. However, you still don't have a sepsis protocol card. I understand some of the difficulties of identifying sepsis, but, of course, there are key areas where sepsis is a possibility, like, for example, urinary tract infections. So, do you have a system where if somebody phones in and says they're dizzy, they're confused, they haven't been able to wee—all the classic symptoms, but it could be something else—do you have a system in place where your call handlers will say, 'Okay, this looks like this. However, it could also be with that'? And do they then check, say, an hour later, or do they tell that patient, 'You might have to wait a while for an ambulance, but keep telling us if you progressively feel worse.' Because if you can prevent, obviously, someone from going into sepsis shock, then you've got a better chance of rescuing them.

So, yes, the patient would routinely be told, if there's any deterioration, to call back. But in those cases, what we would try to do is make use of the clinicians on the clinical desk, where, okay, the presentation appears to be a urinary tract infection, but there may be something more serious going on, and having a clinician then taking the history might give us a better indication if that patient is in serious risk of developing sepsis, and particularly septic shock, which, as you say, has got a very high mortality.

And you mention GPs—my last question, Chair. You mention GPs—I cannot not bring to you the concerns of the British Medical Association and the royal college over the fact that they believe that if they phoned for an ambulance for somebody who's in a GP surgery, whether it's sepsis or anything else, because they're already in a GP surgery, they feel that there is a slow response time because the ambulance call centre will take the view that they're already in a relative place of safety. And this, of course, gives an enormous amount of concern to GPs because they say that they are not equipped. They don't have all the correct gear to provide emergency medicine that you would find, for example, on an ambulance. I just wondered if you could answer that, because the British Medical Association have raised this on a number of occasions that people—and, Chair, you're obviously a GP yourself—are left. I wondered if you have a record of the number of incidents that GPs call in with, calling for you, and do you keep a separate record of the times it takes to respond to somebody who's already in a GP setting? And, in fact, you could probably also look at mental health facilities, because, again, they're seen as places of safety.

So, my background is also in general practice; I'm acutely aware of the anxiety and stress produced and the risk to the patient's safety of delays to ambulances when GPs have assessed either in the patient's home or in the GP practice. And I have undertaken a series of roadshows with the local medical committees to explain how the model works.

There is no coding to say that the patient is in a place of safety. So, they are not given a lower priority simply because they're in a GP's surgery or there is a clinician with them. We always ask that question, because, obviously, if the patient then deteriorates, it can be fairly critical as to know what sort of level of care is there, particularly if they go into cardiac arrest. And sometimes I think the asking of that question does tend to give the assumption—they know that I'm here with the patient and, therefore, the patient is going to be downgraded. That doesn't occur. The grading and the classification is based purely on the clinical presentation. We very rarely have codes dependent on the environment. The one that we did introduce was for fallers when they might be outside in particularly adverse weather conditions. So, there is no way that we would code that would reduce the priority simply because the patient is in a GP surgery.

Thank you.

Yes.