Welsh Ambulance Services NHS Trust Has

2018/19 – 20/21

Welsh Ambulance Services NHS

Trust

Integrated Medium Term Plan

Contents

1 MESSAGE FROM THE CHAIR AND CHIEF EXECUTIVE ...... 5

2 INTRODUCTION AND HOW TO READ THIS PLAN ...... 7

2.1 Our Plan at a Glance...... 7

2.2 How to Read Our Plan ...... 8

3 A REVIEW OF 2017/18 ...... 11

3.1 Our Performance in 2017/18 – A Review ...... 11

3.1.1 The Demand and Capacity Review ...... 14

3.2 Our 48 Strategic Actions: A Review ...... 15

3.3 Our 2017/18 Performance Ambitions ...... 15

3.4 Our Other Significant Achievements ...... 15

4 STRATEGIC OVERVIEW ...... 17

4.1 National Policy Context ...... 17

4.2 Emergency Ambulance Services Committee (EASC) and the Commissioning Quality and Delivery Framework ...... 18

4.2.1 Emergency Ambulance Services ...... 18

4.2.2 Non-Emergency Patient Transport Services ...... 19

4.2.3 EASC Ambulance Commissioning Intentions ...... 19

4.3 NHS Wales Strategic Change Agenda ...... 21

4.3.1 Regional Planning Committee Service Change ...... 21

4.3.2 Health Board Service Change ...... 23

4.3.3 Supra-Regional Change ...... 23

4.4 NHS Wales Strategic Change Agenda – WAST’s Priorities for 2018/19 ...... 24

4.5 Ensuring Integration with Our Health Board Partners’ Three Year Plans ...... 25

4.6 External Impacts on Our Services ...... 25

4.7 Service Change in Collaboration with Blue Light Partners ...... 26

4.8 Developing a Long Term Strategic Framework ...... 30

4.9 Our Aims and Priorities ...... 34

5 CHALLENGES AND OPPORTUNITIES IN 2018 - 2021 ...... 37

5.1 Challenges ...... 37

5.1.1 Demand and Capacity Review...... 37

5.1.2 Amber Performance ...... 38

5.1.3 Clinical Risk Assurance Review ...... 40

5.2 Opportunities ...... 41

5.2.1 The New Computer Aided Dispatch (CAD) and Other Technologies ...... 41

5.2.2 The Clinical Response Model ...... 42

5.2.3 Working with Primary Care Clusters and Colleagues ...... 43

5.2.4 Workforce Modernisation ...... 46

5.2.5 Health Care Professional Calls ...... 47

5.2.6 Other Opportunities ...... 48

6 QUALITY, SAFETY AND PRUDENT HEALTHCARE ...... 49

6.1 Strategic Context ...... 49

6.2 Strengthening Quality Assurance and Improvement Across the Trust ...... 52

6.3 Processes to Strengthen Quality Across the Trust ...... 53

6.4 Outcomes (Assurance, Improvement and Learning) – Strengthening Quality Across the Trust 55

6.5 Prudent Healthcare ...... 58

6.6 Patient Experience and Community Involvement (PECI) Team ...... 59

6.7 Clinical Structure and Clinical Supervision ...... 59

7 OUR SIGNIFICANT SERVICE CHANGES ...... 61

7.1 OUR EMS SERVICE DEVELOPMENTS ...... 61

7.1.1 STEP 1: Help Me Choose ...... 61

7.1.2 STEP 2: Answer My Call ...... 65

7.1.3 STEP 3: Come to See Me ...... 69

7.1.4 STEP 4: Give Me Treatment ...... 71

7.1.5 STEP 5: Take me to…...... 74

7.2 OUR NON-EMERGENCY PATIENT TRANSPORT SERVICE DEVELOPMENTS ...... 76

7.2.1 The NEPTS Business Case ...... 76

7.2.2 Commissioning of NEPTS ...... 77

7.2.3 The NEPTS Five Step Model ...... 78

7.3 SPECIFIC PATIENT GROUP SERVICE DEVELOPMENTS ...... 84

7.3.1 Amber Calls - Responding to the Challenge ...... 84

7.3.2 Welsh Government Together for Health National Delivery Plans ...... 87

7.3.3 Responding to Elderly People Who Have Fallen ...... 88

8 OUR ENABLERS ...... 91

8.1 Our People ...... 91

8.2 Our Finances ...... 106

8.3 Our Estate ...... 125

8.4 Our Discretionary Capital ...... 128

8.5 Our Fleet ...... 129

8.6 Research and Development ...... 132

8.7 Improvement and Innovation ...... 134

8.8 Health Informatics and Business Intelligence ...... 135

8.9 Information Communication & Technology (ICT) ...... 137

8.10 Partnerships and Engagement ...... 143

8.10.1 The Well Being of Future Generations (Wales) Act 2015 (WBFGA) ...... 143

8.10.2 Patient Experience and Community Involvement (PECI) Team ...... 145

8.11 Corporate Governance and Risk Management ...... 146

8.11.1 Corporate Governance ...... 146

8.11.2 Risk Management ...... 148

8.11.3 Meeting our Statutory Obligations ...... 149

8.11.4 Business Continuity ...... 150

8.11.5 Welsh Language ...... 150

9 PLAN DELIVERY AND OUR PERFORMANCE AMBITIONS FOR 2018/19 ...... 153

9.1 Plan Delivery ...... 153

9.2 Risks to Plan Delivery ...... 154

9.3 Our Performance Ambitions 2018/19 ...... 155 Annexes (Separate Document) Annex 1: 2018/19 draft Plans on a Page Annex 2: Detailed overview of progress on the 48 2017 – 18 strategic actions Annex 3: Overview of our 44 2018 – 19 strategic actions Annex 4: Detailed report on 2017 – 18 performance Annex 5: EASC mandated templates Annex 6: Embedding the Prudent Healthcare principles across the organisation Annex 7: Work programme across National Delivery Plans Annex 8: Performance ambitions for 2018/19

1 MESSAGE FROM THE CHAIR AND CHIEF EXECUTIVE

Welcome to our Integrated Medium Term Plan for 2018/19 – 2020/21, which continues our programme of reviewing and updating our plan on a rolling three-year cycle, tracking progress against our organisational ambition and ensuring our thinking, and our practice, remain current.

It’s an exciting but challenging time for the Welsh Ambulance Service as we transition from a traditional model of ambulance services to one which is at the forefront of ambulance services worldwide.

We have already established ourselves as a global leader with our clinical model, which was introduced in October 2015 and subsequently confirmed in early 2017, but we are now on the cusp of a much bigger cultural and system change which, we believe, has the potential to make a fundamental difference to the landscape of unscheduled and scheduled care services over the next 10 years.

So, while this IMTP represents the final year of our original plan approved in 2016, it also marks the preliminary year of our next phase of development, with an absolute focus on the needs of the people we serve, both now and in the future.

During 2017/18 we made significant strides in positioning ourselves as a system leader across NHS Wales, influencing policy through our contributions to a number of Welsh Government consultations and Assembly committees, while actively delivering change and improvement at the frontline of care delivery through developments like those in community paramedic schemes, hear and treat and multi-agency working.

We have also begun to understand more fully the impact of our clinical response model, recognising that, working with our commissioners, we need to keep its operation under regular review, especially given the pressures placed upon the unscheduled care system by consistently growing demand for services.

While our performance in meeting our target for Red calls has been consistently good, we recognise that our performance in the Amber category needs to be reviewed to understand what we can do, working within our organisation and across the wider unscheduled care system, to improve the experience for patients, some of whom currently wait longer than we would like.

With changes in our operational and clinical leadership structures in 2017/18, as well as the further development of our Non-Emergency Patient Transport Service (NEPTS), we have taken steps to structure our organisation in a way that is fit for the future and allows us to further develop our twin ambitions of being a clinically-led and operationally effective service.

However, we remain ambitious, as we hope is evident from this document, and have this year begun the process of articulating a long term strategy which sets out the role the Welsh Ambulance Service could play in the gamut of wider NHS services by 2030.

To-date, this work has involved both internal discussion with our Board, staff and senior leaders, as well as a programme of engagement with our stakeholders, to understand the art of the possible and where, by working very differently in future, the Welsh Ambulance Service can optimise its contribution to healthcare in Wales.

Our long term strategic framework work will be completed in 2018/19 and will set our organisational direction for the next decade. It is, therefore, critical, that we work closely with

5 staff, stakeholders and our commissioners over the next 12 months to fully sense check the ideas we have and to work towards their realisation in the next 10 years.

Our workforce will be crucial in helping us realise our potential. Fully unlocking their skills and abilities, whether that’s through the introduction of professional competency frameworks or through supporting colleagues to deliver change and improvement, whatever their field of expertise or role, will be at the heart of our future strategy.

We hope this IMTP gives you a flavour of our challenges and opportunities, coupled with our relentless commitment to quality and patient safety. We’ll be monitoring its progress throughout the year, with a focus on delivering our best for our patients.

Mick Giannasi, Chairman

Patsy Roseblade, Interim Chief Executive

2 INTRODUCTION AND HOW TO READ THIS PLAN

2.1 Our Plan at a Glance

As an organisation, we were really proud last year to produce, once again, an Integrated Medium Term Plan (IMTP) which was approved by the Trust Board, the Chief Ambulance Services Commissioner (CASC) and the Cabinet Secretary for Health, Wellbeing and Sport.

Despite this plan representing year 3 of our originally approved plan and us wanting to show that we have delivered on our original commitments, this plan should not be seen as ‘conservative’ in its approach. Alongside consolidating our achievements we remain a highly ambitious organisation and we have tried to demonstrate this in our plan whilst recognising the significant challenges that still remain in the ‘here and now’ which we must address.

In the immediate we are ambitious in our plans to;

 Realise benefits of investments into the organisation and servce such as CAD, Band 6  Address the continued challenges we face around our Amber cohort of patients (section 7.3.1)  The work we are going and want to do more of in regards to Paramedics working in the community (5.2.3)  Do further innovative work with patients who fall- another large cohort of patients we frequently help (section 7.3.3).

In the longer term the development of our longer term strategy and our response to the Parliamentary review and the emerging Long Term Plan for Health and Social Care (section 4.8) will demonstrate the level of ambition we have for strengthening our role in the unscheduled care system.

Our plan provides a detailed and comprehensive overview of progress and our commitment to actions over the next three years. To help give the reader perspective as they explore it further, we can describe our plan at a glance.

Our plan responds to a number of contexts:

We continue to frame our plan against our purpose, vision and behaviours:

We have reviewed and consolidated our priorities from 10 in our 2017/18-2019/20 plan to five in this updated plan. Our five priorities reflect our commitment to continuously improving the quality of the services we provide across the Trust. These are detailed further in Section 4 of the plan.

2.2 How to Read Our Plan

Our plan should be viewed through the lens of the following building blocks. You will see these referred to throughout our plan.

In our 2017/18 – 2019/20 plan, we listed 48 actions which we committed to progressing during the life of the plan. This enabled absolute clarity on what our commitments were and we have systematically tracked delivery against those actions. In terms of delivery, we provide a detailed overview of where we are with all these actions in Annex 2 in the supporting document. In addition we provide a snapshot of progress for each area throughout this plan. You will always find this snapshot in the green call-out boxes as shown below:

In 2017/18 we said we would

 This is a summary of how we have done



We will continue to be clear and transparent as to the strategic actions we are committing to.

In this 2018/19 – 2020/21 plan, we will detail;

 All residual actions from our 2017/18 plan which still remain outstanding/in progress which need taking through to completion and/or have been appropriately re-scoped given the environment the organisation is now operating within.

 All new Tier 1 actions we have identified as needing to take place and which we commit to commencing during the life of this current plan.

An overview of all the actions which we commit to in this plan can be found in Annex 3.

Our 44 strategic actions are easily identifiable through this plan, and are captured as below:

Strategic Action:

All of our medium term strategic actions have an associated plan on a page. These plans are designed to offer assurance that we are clear on what delivery of this actions means. We continue to refine and develop these 44 plans on a page and current draft versions can be found in Annex 1. They will ultimately go before the March 2018 meeting of our IMTP Delivery and Assurance Group for approval.

Details on how these plans on a page are subsequently monitored can be found in section 9.1

3 A REVIEW OF 2017/18

This section provides an overview of the last 12 months, our performance story, headlines against our actions and some key achievements.

3.1 Our Performance in 2017/18 – A Review

We have made good progress in improving key elements of our performance during 2017/18, in particular Red performance, improved hear and treat rates and performance against concerns responses. This is underpinned by improved management processes across all directorates, including a strengthening performance management approach. We are increasingly using the wealth of intelligence and information that we have from our Health Informatics function, the Commissioning Quality and Delivery Framework (CQDF), including Ambulance Quality Indicators (AQIs), the emerging NEPTS commissioning framework and learning from themes and trends from our concerns, incidents and patient engagement activities, as well as what we are hearing from our stakeholders and the wider public.

However, we recognise that we still have areas where performance is fragile, where there is variation or where focused attention is required to demonstrate improvements. A detailed look at our performance is available in Annex 4.

Key points from this analysis are:

 Incident demand is predicted to increase at 2.7% per annum or 14.4% cumulative over five years i.e. comparing year five with baseline position.  These predicted increases are smaller than the observed increase. Last winter incident demand increased by 4.09% year on year and 999 calls by 3.20%.  Verified demand increased by 5% Q3 2017/18 compared to Q3 2016/17 (125,992 compared to 119,960) and 7.9% in December 2017, compared to December 2016 (45,357 compared to 42,027);  Overall demand (verified incidents) decreased by 6% in January 2018, compared to December 2017, but was 6% higher than the same period last year.  Pan Wales Red performance had been consistently higher than 70% (the Welsh Government target is 65%) up to December 2017 but dropped just below it in January 2018;

 However, there is variation in Red performance at an LHB level, with Hywel Dda and Powys remaining challenging areas.

 Amber incidents account for approximately 65% of the Trust’s demand. Median and the 65th percentile Amber performance are good, but Amber 95th percentile performance is a challenge and spikes during periods of high system demand.

 There is clear evidence of emerging good practice for Step 1 – Help Me Choose, including the development of the 111 service and the reduction in calls from frequent callers  The Trust continues to operate its NHSDW service (in areas where 111 is not live) which has its own balanced scorecard of performance metrics. Key metrics include: the answer rate (less than 90 seconds) of 75.1% (April to December 2017) and call abandonment rate of 9.7% (April to December 2017).  2017/18 saw a significant focus on Step 2 – Answer My Call, with the go-live of the new CAD and enhanced hear and treat service.  Clinical indicator performance is quite static but is not currently achieving the 95% proposed commissioning intention (excluding ROSC) for the six existing clinical indicators. An exception to this is the percentage of ‘patients with suspected febrile convulsion (five years and under) documented as receiving appropriate care bundle’ which has exceeded target for the last two quarters.

 The conveyance following face to face assessment rate is stable at just under 70% and the level of activity remained stable through the winter, despite the significant increase in demand.  Handover delays remain a significant pressure on resources in periods of system pressure;  Patient safety remains an area of focus. The number of reported adverse incidents, near misses and hazards increases in times of system pressures.

 Whilst each patient safety incident, near miss or hazard is recorded and taken seriously by the Trust, as is the increasing trend, the actual number of patient safety incidents, near misses and hazards relative to the number of verified incidents remains very low. For the period April 2017 to November 2017 there were 1,219 patient safety incidents, near misses and hazards and 315,884 verified incidents i.e. 0.4%.  Similarly, patient experience is an area of focus. The Trust undertakes a wider range of engagement activity through its Patient Experience and Community Involvement (PECI) Team and this includes the use of patient experience surveys to support some of the Community Paramedic scheme pilots, which may offer a model for wider roll out during 2018/19. The Trust has achieved a significant improvement in its 30 working days concerns response performance, with a current year to date average of 79%;  Sickness absence is still higher that other areas of the NHS and we retain a focus on this through the sickness absence toolkit, review of the Occupational Health function and focused case management of long terms sickness incidents;  The NEPTS Commissioning Framework went live in shadow form on 1 November 2017, with the formal launch planned for 1 April 2018. Initially WAST only NEPTS provision will be reported across the NEPTS 5 Steps  For NEPTS, there has been positive progress: renal patient aborted journeys (7.7% December 2017), renal patients transported to their appointment +/- 30 minutes either side of their appointment (74%/target 70%), % of calls abandoned South East (7.3%) and an average speed of answer (1 minute and 38 seconds).

Last year, in order to translate our strategic aims into quantifiable ambition, we set out the levels of performance to which we would aspire. The ambitions are tangible in order that they can be measured and monitored and, where possible, the Ambulance Quality Indicators (AQIs) have been used to ensure that the ambitions are embedded in regular reporting and monitoring. We provide a full overview of these ambitions in section 9 where we explain how we will deliver on our plan.

Achievement against our performance ambitions is monitored through our Monthly Integrated Quality and Performance Report and through our Directorate Quarterly Performance Reviews. In addition to this, the Board and Welsh Government receive a quarterly report on performance against the delivery of the IMTP.

3.1.1 The Demand and Capacity Review

In last year’s plan we identified the initial findings of a detailed Demand and Capacity Review. Over the past 12 months we have begun to exploit these opportunities as follows:

 The Review identified that there was an opportunity to improve the alignment of our rosters to the incident demand pattern. The Review highlighted that the peak demand was earlier in the day, which was masked by when we were responding i.e. later in the day when resource became available. A Demand & Capacity Rota Review Project Team has been established in partnership with the Trade Unions and will be progressed with appropriate time for staff engagement.

 The Review identified an opportunity to expand the Clinical Desk, with an identified efficiency of an 8% hear & treat rate (and an IMTP performance ambition of 7%). This efficiency gain has been delivered in 2017/18 as a result of the enhanced hear & treat service and the additional 12 FTEs with a significant uplift in activity and a higher level of performance, for example, the Trust achieved a 8.5 % hear & treat rate for December 2017 and delivered a 25.3% uplift in activity i.e. ambulance not required outcome, comparing quarter 3 2017/18, with quarter 3 2016/17.

 The Review also modelled the impact of 20 Community Paramedic Schemes specifically how many Red/Amber 1 incidents these Schemes would respond to and how much capacity they would have available to support GP clusters. The Review identified that the number of Red/Amber 1 incidents would be low (the modelling work was on rural market towns). Subsequent to this work a Community Paramedicine Schemes Project Team has been established which will include access to forecasting, modelling and evaluation techniques.

 A key finding of the Review was the relief gap i.e. the gap between the lines in the rosters and the funded establishment. The Review identified a relief gap of circa 205 FTEs. This finding is not linked to future demand but is an analysis of current establishment. Work is train to realign internal resource to reduce this relief gap. Actions being taken include converting a proportion of overtime spend to funded establishment.

 The Review was a one off project, using an external provider. In addition to the various efficiencies and opportunities that the Review identified the Review also highlighted how powerful building modelling software and expertise is and the need for the Trust to build its capability to deliver this as a business as usual function. In 2017/19 the Trust started to explore how it could support the use of Optima Predict to deliver this in house capability. The Trust undertook some benchmarking work with South Central Ambulance Service (who use Optima) and Yorkshire Ambulance Service (who have developed a strong in-house capability) and there are now clear plans in our 2018/19 IMTP to test the ability of this software before making any longer term revenue decisions.

 In order to maintain performance for Red category of calls against the backdrop of predicted demand, the Review identified the need for additional staff (circa 60fte) by 2020/21. Through 2018/19 we will revisit the finding of the review, engaging with any wider unscheduled care system modelling, with the Commissioner and EASC to agree a way forward.

3.2 Our 48 Strategic Actions: A Review

Our 2017/18 plan detailed 48 actions which we committed to delivering over the life of the plan. We want to be absolutely transparent in the actions we committed to, where we have delivered and where there is more to do. At a headline we were due to complete 40 of these 48 actions by the end of 2017/18. As at Month 11, February:  18 have been completed  12 projected to complete by year end as scheduled  10 will be outstanding and have rolled over, reframed and are outlined in this plan or will be completed via business as usual and documented within the relevant directorates local delivery plan.

Annex 2 provides a detailed status of all 48 actions. It also outlines how we have reviewed, revised and adapted our actions from 2017/18 into 2018/21, to flex our actions according to the requirements of the next three year planning cycle.

This 18/19 plan outlines our new 44 strategic actions and Annex 3 provides a list of those in one place for ease of reference. We have developed plans on a page to support the specific actions for 2018/19 and ensure that the milestones for achieving the actions are clearly articulated.

3.3 Our 2017/18 Performance Ambitions

Our 2017/18 plan detailed a number of performance ambitions which we committed to track over the life of the plan. Annex 2b shows the current status of these ambitions as at February 2018. Annex 8 documents the reviewed performance ambitions.

3.4 Our Other Significant Achievements

We have made progress in many areas and more detail is found in the green boxes throughout the plan. Some headlines, however, include:

 Successful implementation of a new Computer Aided Dispatch (CAD) system  Successful development of a new Non-Emergency Patient Transport Delivery Framework  Agreement of the Band 6 paramedic role – held up as an exemplar of partnership working  In conjunction with both the Older People’s Commissioner and the Children’s Commissioner we developed ‘Promises for Older People’, a Dementia Plan and ‘Promises for Children and Young People’. These have been developed through stakeholder engagement, staff feedback and from concerns and compliments, and are being monitored.  The Trust continued to deliver against all the actions set out in the Trust Concerns Implementation Plan (2017-2019). We made significant improvements across all areas of the Putting Things Right guidance and regulation, particularly against the Welsh Government’s tier 1 targets for concerns, with an overall improvement of our

30 day response to concerns from 16% in March 2016 with sustained performance up to 93% November 2017.  Our Mental Health Improvement Plan (MHIP) was developed and approved by Trust Board, and we identified six key priority areas including education and training, developing local mental health patient pathways and supporting the mental wellbeing of our staff. The commissioners and Welsh Government have fully endorsed the plan.  We have strengthened our clinical leadership infrastructure with the appointment of regional and LHB area clinical leads to support operational teams in clinical practice, audit and pathway development;  We have rolled out Omnicell.  67 of our 225 team leaders have commenced the bespoke Team Leaders development programme  We became a dementia friendly organisation and launched our dementia plan  We were awarded the Gold Corporate Health Standard  160 WAST staff and volunteers trained over 9000 students in October 2017 as part of Restart a Heart Day and Shoctober  All three EMS Clinical Contact Centres achieved ACE Accreditation  We maintained IS014001 status.

4 STRATEGIC OVERVIEW

This section is intended to offer assurance that our updated plan is set in the context of both our own emerging longer term strategic framework and also the requirements of our commissioners, the wider strategic context of Welsh Government policy and priorities, partner Health Boards / Trusts / Blue Light partners and other relevant legislation.

4.1 National Policy Context

Our 2016/17 – 2018/19 plan outlined the national policy context within which we are operating and we remain cognisant of this wider environment. Where new policy has emerged or existing guidance updated we have ensured this plan is reflective of that. Key policy areas to emerge in 2017/18 include:

Prosperity for All

In September 2017 the Welsh Government published its national strategy Prosperity for All. The strategy is designed to drive integration and collaboration across the Welsh public sector and put people at the heart of improved service delivery.

The strategy sets out a vision and actions covering each of the key themes – Prosperous and Secure, Healthy and Active, Ambitious and Learning, and United and Connected.

It also identifies five priority areas – early years, housing, social care, mental health and skills, which have the potential to make the greatest contribution to long-term prosperity and well-being. A number of action plans or supporting strategies have been, or will be, developed to translate strategy into action.

Parliamentary Review

The Parliamentary Review of Health and Social Care in Wales final report was published on 16 January 2018. It was preceded by an interim report. The final report made 10 key recommendations around themes of a unified vision of seamless health and care services in Wales and a focus on maximising value of care through application of the quadruple aims of:  improving the health and wellbeing of the population;  improving the experience and quality of care for individuals and their families;  improving the wellbeing and engagement of the workforce;  Increasing the value achieved from the resources that are invested in services.

The report recommends bold new models of care with services organised around the individual and their family, as close to home as possible. It also emphasises that services need to be preventative, easy to access and of high quality. They also need to be seamless and delivered without artificial barriers.

A Long Term Plan for Health and Social Care

Welsh Government and the NHS and social care system in Wales have moved swiftly to translating the messages of Prosperity for All and the Parliamentary Review into a longer term vision and plan for health and care. We in WAST are proactively engaging in this work through membership of the workstreams below:

 Establish a single national vision for health and social care  Develop a comprehensive approach to public engagement to enable discussion of the issues facing health and social care  Develop design principles

 Develop a plan to transform access to health and social care information and services using digital technology  Develop a leadership strategy for health and social care  Develop a comprehensive workforce strategy for health and social care including the contribution of the third sector workforce  Develop proposals for an integrated governance model(s) at local and regional levels  Develop proposals for a sustainable funding model for health and social care that also considers how budgets could be tailored to support local and individual needs

This work is moving quickly and it is important that we embrace the opportunity to influence and shape the development of the national plan for Wales and then respond in an agile way through our emerging Longer Term Strategic Framework.

4.2 Emergency Ambulance Services Committee (EASC) and the Commissioning Quality and Delivery Framework

4.2.1 Emergency Ambulance Services

Emergency Ambulance Service (EMS) commissioning in Wales is a collaborative process underpinned by a national EMS Collaborative Commissioning Quality and Delivery Framework (CQDF). The framework introduces clear accountability for the provision of emergency ambulance services and sees the CASC and the Emergency Ambulance Services Committee (EASC) acting on behalf of health boards and holding WAST to account as the provider of emergency ambulance services. The framework went live on 1 April 2015.

Working with the CASC and his office on development and delivery of the CQDF continues to be critical and core business for WAST.

The framework’s overall strategic aim is to move towards steps 1 and 2 on the 5 Step Ambulance Care Pathway:

Designed with permission using the CAREMORE® 5 steps. Copyright, 2017 WAST

In April 2017, the Welsh Audit Office published an audit entitled: Review of Emergency Ambulance Services Commissioning Arrangements

The overall conclusion from the review is that the new collaborative commissioning arrangements have helped to drive some important changes for emergency ambulance services in Wales. However, these arrangements are not yet mature and will require greater commitment by partners to demonstrate their full impact.

In response to the review new structures have been put in place, including:

 The revised EMS collaborative commissioning structure  The roles and responsibilities for the Planning, Delivery & Evaluation group (PDEG) and the Joint Management & Assurance Group (JMAG)

We have identified that we need to supplement these arrangements with quarterly meetings between each LHB and WAST to provide a regular setting to collaborate on the 5 Steps, including strategic NHS changes and the IMTP. We will be seeking to establish these this directly with LHBs or as part of the EASC sub group arrangements.

4.2.2 Non-Emergency Patient Transport Services

The NEPTS commissioning framework went live (in shadow form) on 1 November 2017. Like the EMS framework there are five steps:

At this stage the NEPTS commissioning framework includes only WAST delivered services. Over the next three years, LHB NEPTS provision will transfer to WAST in a phased manner and is likely to require multiple providers to deliver the increased workload. As this non- WAST work transfers into the Trust, the commissioning framework will be enacted to cover these services also. Further detail on the process is included in section 7.2.

From 1 April 2018, a set of NEPTS Quality Indicators will be in place across these 5 Steps.

4.2.3 EASC Ambulance Commissioning Intentions

In December 2017, the CASC issued EASC’s EMS commissioning intentions. We welcome the introduction of commissioning intentions into our planning processes and the opportunity they offer in providing clarity of direction and expectation across the unscheduled care system for us and the LHBs. A summary of these commissioning intentions is shown in the table on the next page.

Whilst we have not received specific commissioning intentions relating to the NEPTS service, we continue to work towards satisfying the deliverables contained within the approved business case and the shadow NEPTS quality and delivery framework.

Part of ensuring we are appropriately responding to the EMS commissioning intentions has meant the population of a number of EASC mandated templates.

These templates include;  Confirming how WAST to update / develop the CDQF – Commissioning Intentions template 1a;  Confirming the required WAST performance improvement - Commissioning Intentions template 1b  Confirming joint Health Board and WAST service initiatives - Commissioning Intentions template 2

Copies of all these templates can be found in Annex 5 and these provide a significant level of detail on the joint initiatives we are progressing with our key partners in Local Health Boards.

Commissioning intentions highlighted in blue are documented as ‘joint’ expectations between WAST and Health Boards

How / what we are expected to record o Within step 2 - 999 call answer times by time band to be produced. o Within step 5 - Conveyance to all locations to be recorded. o Within step 4- . Call to door times for STEMI (pPCI door) and Stroke to be produced. . Cardiac Arrest data sets to be submitted to the Welsh and UK Registries. . Further 4 clinical indicators to be developed.

How we will manage our resources o Resource utilisation will improve: . sickness rates reduced for all direct staff across each of the steps . overtime use to reduce . use of external providers to be reduced . rosters aligned to demand for direct staff across each step . compliance with planned rosters to increase o Proportion of spend will shift from Steps 5 & 4 to Steps 3 & 2 o Reduced spend on operating expenses

How we must improve our performance

Activity to ‘shift’ left for WAST within each individual health board where safe to do so – such as conveyances, attendances at scene, incidents, and calls. o Step 1 – more calls to ‘111’ NHS Direct and less conversions to 999 from 111 and NHS Direct

Within Step 2 o Time to allocation for Red calls to reduce o The volume of calls assessed and closed by the clinical desk to increase o less 999 and HCP calls and more calls transferred to ‘111’ ‘NHS Direct’ o Proportion of patients referred to alternative pathways/services to increase following ‘hear and treat’ and ‘see and treat’

Within Step 3 o Multiple vehicle arrivals at scene to reduce for Amber and Green Incidents o The percentage of incidents where the first arriving vehicle is the ideal to increase o Red performance to be maintained and the 95th percentile to reduce o Amber 95th percentile times to reduce across each health board area o Step 3 – less incidents requiring attendances at scene and more incidents resolved by phone

Within Step 4 o 95th percentile call to door times (STEMI & Stroke) to reduce across each health board area o Clinical Indicator performance to improve, and be above 95% in all health board areas (except ROSC) o less attendances at scene

Within Step 5 o Handover to clear times to reduce across all health board areas o less conveyances and more conveyances to other locations i.e. non-Major EDs o Proportion of conveyance to locations other than major Emergency Departments to increase across each health board area o Notification to handover times to reduce across all health board areas o Compliance with HCP time requests to improve across each health board area

4.3 NHS Wales Strategic Change Agenda

We have recognised through our last two IMTPs that the ambulance service operates as part of a complex health and social care system which is progressing a number of significant service changes and developments both at health board level, and at regional level.

Significant progress has been made in the last 24 months in engaging in this work in a more systematic way and in creating an internal infrastructure to manage effectively the challenge that the impact of these changes on the organisation could otherwise be.

We have now established an internal Strategic Planning and Partnership Forum which acts as the focal point of intelligence related to external service changes and assessing what work we need to undertake in order to robustly respond to these changes.

As our partners seek to deliver sustainable configurations of services both within their geographical footprint and across regions, the potential impact on our services takes a number of forms:

 Travel times (job cycle times) – when services move closer or further away from current status;  Associated impact of job cycle times – impact of changes in fuel consumption and crews having to travel out of area;  Secondary transfers – in models where patients are transferred to a fewer number specialist centres from local hospitals for short acute phases of care;  Repatriation – patients who have had their acute care in a specialist hospital setting are then transferred back to their local hospital to continue their rehabilitation and ongoing care closer to home;  Workforce implications – if our workforce conveys acutely ill patients over longer distances there may be additional training and/or equipment requirements;  Redesigning scheduled/planned services may impact on our non-emergency patient transport services.

In 2017/18 we said we would  Work with the CASC and our Health Board and Trust partners to agree a consistent approach to quantifying activity implications for major service change.

This is a summary of how we have done  We have prepared briefings and papers for the CASC and the Committee on the subject and in February 2018 an EASC development session was held to discuss strategic service change and the implications on the Ambulance service. It was agreed that a Once for Wales approach to quantifying service change should be established.

4.3.1 Regional Planning Committee Service Change

During the last twelve months the Cabinet Secretary has directed Health Boards to establish a number of regional planning committees as sub committees of the organisations’ Boards. The intention of this was to increase the pace and focus of regional service change and collaboration.

Whilst we are not full members of these fora we are ‘invited’ members in the majority of cases. The ambulance service has a key role in supporting the successful delivery of the priorities which have been identified by these planning fora.

We have worked closely with the regional planning fora to identify where we are a key stakeholder.

South East Wales

 Paediatric, Obstetric & Neonatal Services – impact on EMS services and those associated with repatriation

 Centralisation of Emergency ENT Services - impact on EMS services and those associated with repatriation

 Centralisation of Vascular Services - impact on EMS services and those associated with repatriation

 Diagnostic Hub at the Royal Glamorgan- Implication for the NEPTS service

South West Wales

 A new regional Stroke model (HASU) - impact on EMS services and those associated with repatriation

 Regional Vascular Service model - impact on EMS services and those associated with repatriation

Mid Wales Health Collaborative

 Respiratory - Develop an integrated community focused respiratory service across Mid Wales with co-ordinated services across primary care, community and hospital care services in order to ensure early diagnosis of respiratory conditions and improved provision of chronic disease management through enhanced support from specialists within the community to optimise treatment and support for patients.

 Workforce - Develop and extend new/enhanced workforce roles

In addition to those areas identified above, the Regional Planning Committees are also undertaking detailed work on key elements of planned care – Orthopaedics, Ophthalmology and Diagnostics. We remain “close” to this work through the formal structures and will assess any emerging impact on our NEPTS services.

4.3.2 Health Board Service Change

In addition to the work being progressed at a regional level by health boards there are also service changes being progressed by individual Health Boards within the own footprints and by bordering healthcare providers.

The map below provides an overview of the NHS Wales strategic change programmes in which we are engaged.

4.3.3 Supra-Regional Change

There are a range of programmes which are being managed on a supra-regional or national footprint. The main example of this work with an impact for WAST is the work that the NHS Wales Health Collaborative is leading on the development of a Major Trauma Network for South Wales and South Powys. There is already a Major Trauma Network in existence in North Wales, with three trauma units located in the region, and an MTC facility provided by the Royal Stoke Hospital. WAST continues to participate in the South Wales work via the Major Trauma Project Board, and will be a key member of the Network, once established.

It is anticipated that in late March 2018 a decision from Health Boards will be made regarding some elements of a Major Trauma Network, including the location of the Major Trauma Centre. It is recognised that the creation of the service will have some impact on WAST services and the early modelling done on this impact will be revisited once the decision on location made.

We continue to work with the Collaborative to identify impacts on WAST and to support the development of the Network.

In addition, there is a programme of work, in the early stages of development, led by the Welsh Health Specialised Services Committee (WHSSC) regarding the provision of thrombectomy treatment for stroke patients. WAST continues to be engaged in this work, and will look to consider the potential impacts at the appropriate time.

For both of these service areas, WHSCC are the commissioning body and it will be essential that WHSCC and EASC establish a process and agreement as to how the impact on WAST is commissioned. This has already been flagged at a recent EASC development session.

4.4 NHS Wales Strategic Change Agenda – WAST’s Priorities for 2018/19

As the previous sections demonstrate, we have worked hard to embed ourselves across the complex planning agenda unfolding across NHS Wales. As these arrangements continue to mature, we have now identified a number of specific priorities from an ambulance perspective which we need to address through to satisfactory conclusion with respective Health Board partners and the CASC.

These are summarised by region in the table below:

North Wales  Quantify and agree appropriate commissioning impact for the new model for stroke care across North Wales which BCU expect to agree in quarter 1 of 2018/19 South East Wales  Quantify and agree the appropriate commissioning impact for the following new services which will go live across the region during the life of this plan; o Paediatric, Obstetric and Neonatal (PON) regional service model (live across the region in March 2019) o The ‘interim’ PON solutions designed to sustain services through to March 2019 o ENT service (2018/19) o Diagnostic Hub o Vascular services (2018/19 starting and into 2020/21), Cwm Taf services to transfer to UHW by 2019 Mid Wales  Quantify and agree the appropriate commissioning allocation for the new model for stroke services for patients in Mid Wales affected by the redesign of services across Hereford & Worcester. Supra-regional  Agree a commissioning and delivery model for the emerging major trauma network across South Wales & South Powys.  Define the WAST support required to the national HASU model work  Quantify and agree a consistent commissioning model for Thrombectomy services.

Strategic Action: We will work with Health Boards and the Chief Ambulance Service Commissioner to agree business cases which detail required commissioning allocations for the following service changes which we expect to see happen in 2018/19; Paediatric, Neonatal, Obstetric services / ENT / Vascular (all SE Wales), stroke services across BCU and the provision of thrombectomy and major trauma services to Welsh patients.

In recognising the continued implication of the service changes documented above and the fact that there is no Once for Wales approach to managing these changes, we are taking the opportunity in this plan to reaffirm our commitment and desire to work the health boards and CASC on the following strategic action.

Strategic Action: We will work with our Commissioner and our Health Board and Trust partners to agree a consistent approach to quantifying activity implications for major service change.

4.5 Ensuring Integration with Our Health Board Partners’ Three Year Plans

It is critical that, as far as possible, our plan aligns with those of our LHB partners. Annex 5 provides further details about the joint work we have agreed with each health board to deliver improvements across the unscheduled care system in NHS Wales.

Joint planning across WAST and LHBs continues to strengthen through:

 Detail contained within our Local Delivery Plans (LDPs) at health board level and building on our key links between WAST Operations teams and health board operational teams.  Discussions held at the bi annual NHS Wales Planning events.  Direct Planning2Planning meetings with all health boards.  Winter planning processes (including the additional monies planning),  through the EASC infrastructure and sub groups of PDEG and JMAG

There is scope for further maturation of the process to ensure that:

 Risks are recognised and mitigated through joint approaches;  Proven initiatives are scaled up and rolled out;  Regional solutions can emerge

4.6 External Impacts on Our Services

In addition to service change ongoing across NHS Wales, there are a number of other projects which are being progressed across Wales which will impact on the provision of our services. These projects are wide ranging, but encompass large infrastructure projects and significant housing developments which could potentially increase the population we serve and/or increase the risks to our working environment. An example of such schemes is included below, and we are engaged in discussions with local authorities and the relevant organisations to ensure that we are able to plan our services appropriately.

 Wylfa Newydd Nuclear Power Station: this is a proposed nuclear power station which will be located on the northern tip of Anglesey. The project has an estimated development and construction period of 5 to 10 years and a working life-span of the power station will be 60 years. A further development is also being undertaken by National Grid to run overhead power lines, and to drill a tunnel under the Menai Strait to house power lines connecting up the power station with the mainland. We know that the increased workforce will have an impact on how we deliver services on Anglesey and in the wider North Wales area; we continue to work with the developer to assess the risk and agree mitigating arrangements in order to safeguard the service we provide.  Swansea Bay Tidal Lagoon: if approved, this development would see the construction of a six mile long harbour structure closing off a tidal sea area, and incorporating hydro turbines through which the sea moves to generate electricity. Up to 1,900 jobs could be created and sustained during the construction of the lagoon. WAST will seek to engage with local authorities and developers at the earliest opportunity, to assess any potential impact.  Major housing developments: as part of their local development plans, each local authority continues to consider its housing provision and we know that there will be large scale developments over the medium to long term. We will ensure that, as an organisation, we are appropriately engaged in any discussions with our health and wider public sector partners. 4.7 Service Change in Collaboration with Blue Light Partners

The police, fire and rescue and emergency ambulance services have a statutory duty (Policing and Crime Act 2017) to keep collaboration opportunities under review and to collaborate where it is in the interests of their efficiency or effectiveness. The main mechanism to encourage collaboration is through the Association of Ambulance Chief Executives and the Emergency Services Collaboration Working Group (ESCWG) which was formed in 2014 to improve collaboration between emergency services in England and Wales.

In Wales WAST is represented at the Operational, Tactical and Strategic level at the Joint Emergency Services Group (JESG) whose core activities are currently focused on adverse incident escalation and demand management through effective application and sharing of business intelligence.

To achieve our ambitions, our whole plan is predicated on effective working with our many partners, both in the NHS and more broadly local authorities, the voluntary and private sectors, the wider public and also, importantly, our blue light partners. We have continued to do some innovative work with our blue light partners.

Fire service collaboration

There are three Fire and Rescue services in Wales. The North Wales service is coterminous with the WAST BCU area and the UHB. The South Wales service covers the area of Aneurin Bevan, Cardiff and Vale and the Bridgend locality of ABMU. The Mid and West service covers the remainder of ABMU and all of Powys and Hywel Dda.

Across Wales we collaborate with all three FRS in delivering a range of services.

Co-responding

Between December 2016 and May 2017 data was collected for all verified incidents where a vehicle call sign from Fire and Rescue Services attended at scene of behalf of us. There were 1824 incidents- 89% (n=1625) of them by MWWFRS, SWFRS responded to 7% (n=118) and NWFRS responded to 4% (n=81).

Due to an ongoing industrial dispute between the employers and the Fire Brigades Union all co-responding activity by full time fire-fighters is on hold. The Retained Fire-Fighters Union in MAWWFRS area are continuing to respond outside of this dispute.

We remain committed to working with FRS services in regards to co-responding once this dispute is resolved.

Currently co-responders are sent to most RED codes and selected AMBER 1 codes. A clinical review has shown that it is the RED codes where co-responders can save lives. Over 2018 we will re-profile the use of co-responders to RED codes and to assist uninjured fallers as falls assistants in line with our falls strategy.

Co-located stations

We are currently co-located with FRS colleagues at 10 locations pan Wales and the Estates Strategic Outline Programme is clear on the importance of maximising existing freehold sites and exploring partnership opportunities (this is explored further in section 8.3). At present WAST are represented on various service boards with Mid & West Wales FRS, South Wales FRS, North Wales FRS, Dyfed Powys Police, South Wales Police, North Wales Police and Gwent Police, other forums include Carmarthenshire CC, Hywel Dda Health Board, Cardiff CC, Denbighshire CC, as well as Shared Services meetings with all Health Board Estate representatives.

Develop a WAST and FRS Strategic Outline Programme

In order to support a more informed discussion regarding the future opportunities for wider collaboration with FRS colleagues each Chief Officer in Wales has been asked to identify a lead officer who will in partnership with senior Trust managers develop a strategic outline programme for consideration during Q1 of 2018/19.

Police service collaboration

There are four territorial Police services in Wales. Initiatives currently underway include:

 Co-locations. A WAST led piece of work through the Emergency Services Collaboration Working Group and Joint Emergency Services Group (JESG) has resulted in co-locations in North ABHB area (2), Cardiff & Vale (3) with at least two other projects planned for 2018.

 Adverse Incident Reporting and reduction. We are currently evidencing a downward trend in adverse incidents (circa 32% reduction) relating to Patient Conveyed by Police, No Ambulance Available at Time of Call, Police Conveyed Patient and Failed to Notify WAST as a result of a piece of work being led by senior managers in our CCC.

 Demand reduction and intelligence sharing. A project is being scoped out to agree a method of approach to more robust intelligence protecting patients the wider public, and the WAST workforce.

 Gwent Police Joint Response Unit (JRU). A groundbreaking partnership between ourselves and Gwent Police which is helping to save lives and resources and has won a number of awards at the 2017 Gwent Police Awards.

The Gwent JRU sees a paramedic and a special constable attending incidents such as assaults and road traffic collisions together, to provide medical assistance and free up their colleagues to help others.

The team comprises five paramedics and 10 Special Constables. Since January 2017, the JRU has responded to over 800 incidents and has prevented over 500 conventional ambulance responses. Gwent Police colleagues are evidencing significant changes to weekend policing with reduced time at scene also.

Pilot JRU schemes have been put in place in other areas as part of winter planning and the model is being considered for further development in other areas for 2018:

 Dyfed Powys JRU – We and Dyfed-Powys Police worked collaboratively on a Christmas safety campaign. The theme of ‘presence not presents’ was launched as a key date 3 day trial on 22nd, 26th and 31st December. Under the scheme, a Paramedic and a Special Constable in a specially marked police vehicle, known as the Joint Response Unit (JRU), carried out shifts covering the Pembrokeshire area, self-selecting appropriate 999 incidents via remote access to calls coming into local control rooms. This meant that police officers at the scene were freed up to move on to other cases by not having to wait for an ambulance to be allocated and the ambulance Paramedic could assess the appropriate pathway for the patient. The JRU allowed us to provide an enhanced service to people in need, usually with mental health of the worse for wear due to alcohol that required some medical response and reduce the amount of calls that needed Emergency Ambulance or police officer attendance.

 Clinical Support Desk Presence in Police Control Rooms- The Clinical Support Desk is a pan-Wales operation which has extended into police control rooms throughout Wales (with the exception of Gwent Police) in order to ensure there is collaborative working to provide service users with the most appropriate advice and resource if required, based on clinical need.

Clinicians based in police control have a particular focus on police calls, providing advice and support to police officers on scene, CCC staff and operational staff.

During a typical month, approximately 350 ambulance responses are avoided as a result of having a clinician present and approximately 70 police officers are released from the scene of an incident who would have previously awaited an ambulance response.

We are continuing to work with the police, providing training to continually raise awareness of the instances in which a 999 call is appropriate. We also continue to work with Gwent Police to implement a Clinical Support Desk function in this force area, and are working through some of the technological barriers to implementation, in partnership.

 DPP Operation Darwin- Operation Darwin is DPPs bike safety scheme targeting both education and enforcement in Powys during the biking season between Easter and September each year.

Sadly there is a fatality almost every weekend in Powys over this period annually.

Op Darwin sees a paramedic crew a traffic police car with a PC. They spend the morning meeting bikers and explaining risks and then the afternoon enforcing speed limits and other offences and sadly attending any collisions that occur. Op Darwin provides “help me choose” activity under step 1 and “come to see me” rapid response under step 3.

The BCU ‘Collaborative’

In 2015 the three north Wales emergency services discussed areas in which we could build further on emergency service collaboration and following this the Tri-service Collaboration Programme Board was formed.

One of the projects commissioned from this Board involved looking at how we prevented and responded to incidents from a multi-agency perspective in order to identify a more streamlined and alternative response to calls received by us.

It was from this scoping activity that the concept of NWFRS, responding on behalf of the WAST, to non-injury falls, was developed and soon after, the Conwy and Denbighshire Community Assistance Team (CAT) was formed. The CAT team is currently due to run until March 2018 at which point a further evaluation on the scheme will be undertaken.

This collaboration board continues to build momentum and our Assistant Director of Resilience, Business Continuity and Operational Intelligence has assumed the Chair of this group to further drive progress of the collaborative in 2018.

Looking Forward to 2018/19 and Beyond

We know, however, that there is much more we can do. Consequently, over the period of this plan we plan to progress the following in particular:

Joint Police, Fire and WAST Intelligence Hub (Thinking Together)

From April 2018, we intend to embark on a pilot in South Wales of a joint intelligence hub to ‘Think Together’ with our South Wales Police and fire service colleagues.

The purpose of this initiative is to recognise and respond to demand by avoiding duplication or variation, and helping each other to reduce inappropriate demand.

The key intended outcomes will therefore be a reduction in demand across all three emergency service areas, maximising the 5 step clinical model through alternative pathways and minimising unnecessary conveyances and maximising the quality of patient experience.

The recent visit to WAST by the ‘UK NHS Improvement Team’ complimented WAST on embarking on an intelligence led idea that will be the first in the UK and something they would wish to share as best practice.

Strategic Action: We will progress with our plan to develop and implement a Joint Emergency Service Demand & Intelligence Hub (Phase 1 – WAST, South Wales Police, Gwent Police & South Wales Fire & Rescue).

Information Sharing

Our ambulance crews, especially our NEPTS crews visit hundreds of vulnerable patients in their homes every day. By sharing referrals with FRS safety teams then home assessments, fire/smoke alarms and other interventions can be made to keep our communities safe and reduce future demand.

Foot Intervention Teams (FIT)

During the 2018 RBS 6 Nations Rugby WAST have worked with the London Ambulance Service and South Wales Police to develop FIT for deployment in large crowds and pedestrianized areas during large events. A FIT is a team of ambulance staff responding on foot with a stretcher and equipment into an area where vehicular access id impossible or would endanger crowds. This tactic will be further refined during 18/19.

4.8 Developing a Long Term Strategic Framework

In 2017/18 we said we would  Develop a Long Term Strategy for Ambulance Services in Wales

This is a summary of how we have done  We have established a Long Term Strategy Steering Group to oversee and co- ordinate the development of the strategy.  We have identified the four pillars of our strategy – (i) Widening our Clinical Offer, (ii) Leadership and Workforce, (iii) Working Together, and (iv) Embracing Technology.  We have conducted a series of engagement events with our service users, staff and external stakeholders to explore these four themes in more detail.  We have set ourselves the ambition of distilling all this information, along with the other best practice and evidence which we have gathered, and finalise our strategic framework in the spring/summer of 2018

We are proud that we are in our third year of having an approved IMTP. Having such a status has not only contributed to stabilising the organisation, but also afforded us the thinking space to consider what the long-term term strategic plan for the future of ambulance services in Wales needs to be.

Our Board and Executive Team spent the early part of 2017 considering what the cornerstones of what our strategic framework should be. They identified four pillars: (i) Widening our Clinical Offer (ii) Leadership and Workforce (iii) Working Together (iv) Embracing Technology

Consequently, we have adopted a collaborative approach to developing what these mean in detail by engaging with a range of stakeholders – the public, partner organisations and our staff through a range of workshops (the table below offering further detail). An Executive Director took the lead on each strategic theme, undertaking a range of actions including a detailed deep dive into best practice and available evidence.

Engagement Number of Key Notes Work Stream Attendees

(i) Service 135 Our Patient Engagement & Community Involvement (PECI) team Users has attended / organised a range of service user events, including ‘Meet Your Ambulance Service’ events, public events and bespoke meetings with service user groups. (ii) Staff 160 We have engaged directly with over 160 staff at a range of different fora including staff meetings, development sessions & bespoke workshops held across the Trust. (iii) Health 145 We have also held 3 regional external stakeholder workshops Boards & including NHS Wales organisations, CHC, AACE, College of External Paramedics, blue light partners, Community, Third Sector and Stakeholders Voluntary Sector. The three workshops were held across Wales in Carmarthen, Llandudno & Nantgarw on the 12th, 15th and 29th September. Total 440 These exercises, which took place through the autumn of 2017, provided us with some rich and comprehensive information. Our Board considered all the available information at a Board Development Day in November 2017, and a further smaller workshop comprised of executive leaders and some Board members took place in January 2018.

Our Emerging Strategic Ambitions

As a result of this work, we are now able to use this opportunity to begin highlighting some of the emerging indicative strategic ambitions. These will require further internal testing over the coming months as well as a targeted engagement process with some external partners.

Whilst we have four strategic themes within our emerging strategy, they cannot be considered or developed in isolation. All our ambitions are intrinsically linked with dependencies.

The table overleaf demonstrates this.

Next Steps Work has already commenced on unpacking these themes into some more specific statements of ambition and some clear short, medium and long term priorities. This work has some further internal testing to and once we have tested these with Trust Board through 2018 we will look to undertake further targeted engagement both internally and externally. We will undertake this further engagement on a number of levels:

 The Long Term Plan for Health and Social Care is currently in development and will be published by the Spring, we will ensure our emerging strategic direction responds explicitly to this plan.  We will have both a new Chair and Chief Executive during 2018 and will want to test our findings with the ambitions of the new leadership team.  Many of the ambitions we are identifying cannot be delivered in isolation. They will require the support and collaboration of our partners in the unscheduled care system and beyond.  Our staff are our most important asset, and collectively it is they that will drive forward delivery of our strategy. We want to further test our views with them.

Throughout our journey to date we have worked closely with the CASC; it is important that as the Chief Ambulance Services Commissioner he is cognisant of our work to date and supportive of the strategic direction of travel. To date we have the CASC’s full support.

In addition, the CASC and EASC are developing a suite of strategic commissioning intentions by the end of the summer 2018. Both we and the commissioner are aware that neither strategic commissioning intentions nor a long term strategy for ambulance services can be developed in isolation, they are intrinsically linked. Consequently we have agreed that we will look to jointly progress both pieces of work together so that they are complementary.

Whilst we continue with this engagement there are still some fundamental work which we can progress. This will act as a foundation for whatever our form future framework takes. As such, you will see commitments throughout this plan in the form of our existing strategic actions that will contribute to putting the building blocks in place for a longer term strategic framework. For example:

 Develop and embed a clinical leadership culture to create sustainable clinical effectiveness across the Trust from the Trust Board to the operational frontline staff. This will fundamentally support our frontline staff in any widened clinical offer environment.

 Develop an overarching Education Strategy by the end of 2018/19 that will enable us to ensure all staff receive the highest quality education and training to deliver their roles effectively; expanding our apprenticeship opportunities will be a key deliverable of this strategy. This will provide the backdrop to any future role redesign.

 Work with NWIS and other partner organisations on the development of clinical information sharing arrangements. We know that whatever our final framework says that information sharing will be key so we can start progressing this now.

 Ensure that everyone with an interest in our work, including staff, stakeholders, patients and the wider public, understands what we do and our ambitions for the future, through a proactive programme of two-way engagement and communication that delivers tangible outcomes, supports delivery of our organisational priorities and informs future development.

Again, we know that whatever our final framework says that it will only be able to be delivered in partnership so we can start maturing our partnerships now.

Strategic Action: We will finalise our long term strategic framework for ambulance services in Wales.

4.9 Our Aims and Priorities

In 2016/17 we worked with our staff and Board to agree our strategic aims. The purpose of these is to guide our business and strategic development.

We will place quality at the heart of everything we do, whether that is supporting all our leaders to be vibrant and compassionate, ensuring our services are excellent, in developing strong partnerships or in striving for continued value, excellence and efficiency

• To deliver value, innovation and efficiency across the organisation. • To build even stronger partnerships with staff, patients, the wider public and our full range of stakeholders. • To ensure service delivery excellence and further improve the services we provide patients.

• Our staff are fantastic. We must ensure they are continually able to be their best.

• To ensure all our leaders are vibrant, compassionate leaders that help create a compassionate, caring culture.

We have subsequently been able to set our priorities for the coming three years against these strategic aims. These are shown in the table below.

1. We will progress our quality improvement journey - implementing all strands of our quality improvement strategy

2. We will sustain our Red performance whilst delivering further improvements and efficiencies in our clinical contact centres and our Amber performance

3. We will continue the transformation of our NEPTS service, placing a significant focus on the successful transfer of work from health boards and implementation of the Quality and Delivery Assurance Framework.

4. We will deliver patient and system benefits through effective partnerships with Health Boards, our blue light partners, the third sector and the people in Wales. There will be a specific focus on estate, fleet, joint training opportunities and the continued rollout of the 111 service.

5. We will continue to develop, re-shape and engage with our workforce. We will place a specific emphasis on the implementing and embedding of the Band 6 paramedic role

Over the page, we provide an overview of our how the organisation’s vision, purpose, strategic aims, priorities and anticipated outstanding strategic actions in the current IMTP continue to remain aligned.

5 CHALLENGES AND OPPORTUNITIES IN 2018 - 2021

This section outlines the key challenges facing the organisation in the coming three year period. More interestingly, it also draws out the big opportunities for the organisation and demonstrates the ambition to play a pivotal role in the unscheduled care system in the future.

In considering the wider landscape in which this plan will be delivered, we are mindful of the following:

 Political Landscape. The life of this plan will be against the backdrop of Brexit negotiations and both general and Welsh Assembly elections. The outcome of the Brexit negotiations may have a profound impact on Wales, while the periods in advance of elections can slow the pace of change.

 The wider unscheduled care system in NHS Wales and our role within it. We are a vital partner in the unscheduled care system within Wales and we must work closely with all other stakeholders to re-engineer the system. The system is under pressure and, at periodic points throughout the year, escalation levels are such that delivery of our plan will face some risks, as will delivery of LHB plans. This is both a challenge and an opportunity.

 Planning assumptions. In developing our plan, we have had to make some explicit assumptions. These assumptions have been in relation to our finances, performance targets, availability of capital, no significant changes to demand etc. Should these assumptions not prove to be accurate, we will have to revisit sections of the plan. The sensitivity of each assumption may vary.

 Leadership Challenge. Identifying, developing and encouraging a change in leadership style from the old “we know best’ to a more collaborative, empowering, courageous and vibrant style of leadership for the future, is seen to be essential in delivering sustainable culture change across the organisation. A further shift in behaviours is needed to transform and deliver our Trust vision.

5.1 Challenges

Our main challenges coalesce around our ability to respond (dispatch available resources) in a timely way to the demand which presents. Some of those key challenges are highlighted below:

5.1.1 Demand and Capacity Review

We undertook a Demand & Capacity Review in 2016/17, using an external company, ORH. The Review used the following assumptions:

 No mitigation of predicted demand increases  98% Unit Hour Production;  Time at hospital, handover and clear, capped at 30 minutes (15 + 15);  Red Activation times reduced by 30 seconds;  A Hear & Treat rate of 8%; and  The redeployment of existing resource, particularly UCS, to more closely match demand patterns.

Based on the above assumptions and population data, the review identified a number of strategic challenges:

 Demand Projection (verified incidents) - predicted to rise by 2.7% each year for the next five years (to 2020/21) totalling a cumulative rise of 14% over five years.  Existing Capacity - the review identified a current relief rate of 18% against an ambulance standard of 34% to cover abstractions from the rosters of 25%.  Performance Reduction – with no action or transformation, Red performance (and other categories) will gradually decline and fall below the 65% Welsh Government target  The impact of system wide pressures – in particular, the extra staff required to deliver an acceptable level of performance if handover lost hours remain at current levels.

As outlined in section 3.1.1, we are already using the outputs from the review to help us improve rotas to better match demand and improve hear and treat.

For 2018/19, we have identified reducing the relief gap as a next step priority. We are exploring a number of actions to make inroads this gap within current resources including converting a proportion of the overtime budget to substantive posts, reviewing all protected time from EMS rotas to maximise time spent on response to rotas and seeking additional savings to re-prioritise spend towards EMS operations.

There are other actions that we will pursue in 2018/19 in the context of the review. The Trust has invested in its own in-house forecasting and modelling capability through the purchase of Optima Predict. During 2018/19 the Trust will seek to develop its approach to forecasting and modelling through piloting Optima Predict. In addition, the work we will progress with the CASC and the National Unscheduled Care Programme Board to review and support evidence based development of the Trust’s Clinical Response Model and seek to recognise “missed opportunities” which will help inform future discussion on capacity to achieve improvements in Amber responsiveness. “Missed opportunities” are incidents that the Trust has responded to, but could have been responded to by the wider unscheduled care system.

For 2018/19 we will:

 Pilot the use of Optima Predict.  Review the rosters across all LHBs, with an initial focus on Aneurin Bevan and Cwm Taf, and 999 call taking using the rota key information provided by ORH, which offers the opportunity to align our resources more closely to demand patterns. These reviews are underway  Deliver the 30 second reduction in activation times via the new CAD (strategic action 15).  Develop the Clinical Response Model to identify “missed opportunities” (strategic action 6)

These developments should enable the Trust to have a strategic discussion with EASC during 2019/20 on predicted demand and a collaborative strategic response.

5.1.2 Amber Performance

Annex 4 provides a detailed review of the Trust’s performance during 2017/18 and identifies Amber response times as a particular challenge for the Trust. Although the Trust does not report response times for Amber calls, the time taken for an ambulance to arrive is a key part of the experience of a patient. For conditions such as stroke and heart attack there are overall optimum times for the patient to reach definitive care or receive definitive therapy or imaging. These are measured in hours and so an 8 minute ambulance response is not clinically appropriate. Amber calls account for approximately 65% of the Trust’s 999 workload and are made up a very large

cross section of conditions, which range from suspected strokes and breathing difficulties through to suspected broken ankles and elderly patients who have fallen and are injured.

When the unscheduled care system comes under pressure, which is normally reflected in increased lost hours to handover delays, Red performance is protected by the Clinical Response Model, with Amber response times lengthening. The model has been proven to ensure that after Red calls the Amber 1 calls receive the next fastest response.

Through the AQIs, the Trust (and stakeholders) have placed increasing focus on the Amber 95th percentile, disaggregating the Amber 95th percentile into Amber 1 and Amber 2. The following graph demonstrates relationship between system pressures and responsiveness to Amber calls:

We have recently completed a rapid review of the first half of Winter 2017/18 i.e. October to December 2017. This review identified that:

 The Trust maintained Red performance above 70% in Q3 2017/18, but it is becoming more difficult to do so within the wider context of the system pressures;

 Verified demand increased by 5% Q3 2017/18 compared to Q3 2016/17 (125,992 compared to 119,960) and 7.9% in December 2017, compared to December 2016 (45,357 compared to 42,027);

 Amber response times were identified as a challenging area in the Trust’s Winter Plan and WAST LHB level plans. Amber has become particularly challenging this winter with the Amber 95th percentile being 29 minutes, 62 minutes and 87 minutes higher in October 2017, November 2017 and December 2017 respectively, compared to the same periods last year;

 Amber 95th percentile was 3 hours and 44 minutes in December 2017;

 Despite the increase in verified demand, the Trust conveyed less patients to hospital in Q3 2017/18 than Q3 2016/17 achieving 65,973 and 68,891 respectively, a reduction of 4.2%;

 This reduction of 4.2%, despite verified demand going up by 5%, is primarily attributable to the enhanced hear & treat capability; and

 Lost hours to handover delays increased by 38% in Q3 2017/18 compared to Q3 2016/17 with 19,554 and 14,199 hours being lost respectively.

Put simply, the length of response times to Amber incidents, is a result of insufficient capacity to meet the level of demand, i.e not enough ambulances available to respond in a given area.

The consequence of lengthening response times to Amber calls manifests on patient care and patient experience with a an increase in complaints, concerns, SAIs and near misses when available capacity is insufficient to meet demand. It also contributes to staff morale levels.

In order to mitigate these risks, the Trust (and the wider unscheduled care system) needs to:

 be more efficient, within the existing resource envelopes, in order to release more capacity; and/or

 increase resource into EMT and/or the wider unscheduled care system

Opportunities for efficiencies for include:

 Demand reduction work at step 1 that avoids the dispatch of ambulance resource, freeing up the existing resource to focus on higher acuity incidents;

 Maximising the use of hear and treat at step 2 to prevent patients attending hospital and the dispatch of an ambulance

 The more efficient use of ambulance resource in Step 3, which therefore increases capacity;

 Major ED avoidance work, for example, see & treat, pathways and use of non-major EDs, which mitigates the impact of handover lost hours at major EDs;

 Increasing the available resource to respond to incidents, in particular, lower acuity incidents that can be responded to by the wider unscheduled care system, freeing up emergency ambulance resource to response to higher acuity incidents; and

 Reduced handover delays

These types of efficiencies demonstrate that improving Amber response times is multi-factoral. There are a significant range of actions planned for 2018/19 which are contained within our plan (see section 7.3.1).

5.1.3 Clinical Risk Assurance Review

One of the Trust’s biggest clinical and patient safety risks occur when we are unable to respond to the demand in a timely way. There are a number of factors which influence our ability to do this,

including rota, availability of staff (annual leave, sickness and CPD), efficient use of resources (post production lost hours) and capacity lost through delays at hospital.

The recommendations from the Clinical Risk Assurance Review, undertaken by our commissioner was published in July 2017. All 24 recommendations were accepted by the Trust and, in response, a robust action plan has been developed identifying the actions required for each recommendation.

Each recommendation has been assigned to the appropriate executive director and each director has identified a named lead in their directorate to be responsible for leading the actions.

Progress against these actions is monitored quarterly by the Quality Steering Group (QSG) and reported in the quarterly Quality Assurance Reports. In addition, the Director for QSPE and the Medical Director provide regular progress reports to the CASC.

5.2 Opportunities

Whilst the context may be challenging at times, there are a number of opportunities for the organisation that we must grasp, explore and exploit over the next three years. Some of these relate to realising the benefits of investments made and others relate to strengthening our role in the unscheduled care system and being clearer on our “offer”.

There are many opportunities for WAST over the next three years, and into the longer term. Some of the key opportunities for us are outlined below, but there are themes which run throughout this plan, and we have included signposts to key parts of our document below:

 Further enhancements to our Computer Aided Dispatch (CAD) system (section 5.2.1)  Clinical Response Model (section 5.2.2)  Working with Primary Care (section 5.2.3)  Workforce modernisation (section 5.2.4)  HCP calls (section 5.2.5)  Collaboration with partners (section 5.2.6)  Services for injured and non-injured fallers (section 6.8)  Implementation of 111 (section 7.1.1)  Hear and Treat (section 7.1.2)  NEPTS commissioning and transfer of work (section 7.2)  Supporting our volunteers (section 8.1)

5.2.1 The New Computer Aided Dispatch (CAD) and Other Technologies

The new CAD was implemented in November 2017, significantly improving the resilience of this critical system. The new CAD has also enabled an element of enhanced functionality as listed below:

 Our CCC is now operating as a national resilient platform which enables us to track resources, make smart clinically based tasking decisions and keep accurate records

 Clinical Support Desk has access to a separate call queue enabling it to focus clinical support and secondary triage on patients who would benefit from their intervention. This allows Clinical Desk colleagues to accurately signpost patients and their families to appropriate services as well as escalating the response profile of those patients needing more urgent assistance.

 An auto-allocation application has been implemented for Red calls as part of the initial implementation which is overseen by dispatch teams within CCC to ensure correct

decisions are made. This process will continue to be monitored and developed as feedback is received.

During the next year we will be launching a “phase two CCC programme” (see section 7.1.2). We see this programme as offering us some significant opportunities as we start to realign our processes and where we will see real transformational change and benefits in service delivery.

Technology more broadly offers WAST, and the system, significant opportunities. Whilst we explore this in more detail in our long term strategic framework work, we commit in this plan to making progress with pilots and work on mobile staff devices, electronic Patient Care Record, and a replacement system for NHSDW/111. This is a key theme of the Parliamentary Review and we will ensure we continue to have a strong voice in the digital agenda.

5.2.2 The Clinical Response Model

Public and Corporate Economic Consultants (PACEC) and the Medical Care Research Unit at the University of Sheffield were appointed by the Emergency Ambulance Services Committee to undertake a review of the clinical model pilot. To accomplish this external evaluation, PACEC and the University of Sheffield undertook a comprehensive research programme to document the design and implementation of the clinical model pilot.

PACEC found that the new clinical model, introduced in October 2015, has substantially changed the way in which WAST provides a response to 999 calls requesting emergency and urgent health care. The intention was to provide a service which is more clinically focused by prioritising the small cohort of patients who could most benefit from a very rapid response, and allowing more discretion for other calls, so that not just the speed, but type of response was proportionate to patient need.

The evaluation reported a clear and universal acknowledgement from all stakeholders that moving to the new clinical model was appropriate, and the right thing to do. The increased time allowed for call categorisation has not introduced any new risk to patient safety, and it is likely that, without the new model there would have been significant risk for patients, particularly over winter, because of continuing increase in patient demand. The evidence presented demonstrated that, for the period of testing the model, there had been no serious safety concerns, with two key indicators serious adverse incidents reported and re-contact rates remaining stable or declining.

On the basis of PACEC’s evaluation presented to the Emergency Ambulance Services Committee, on 28 February 2017, the Cabinet Secretary for Health, Wellbeing and Sport, Vaughan Gething gave a statement in the Senedd, confirming that the new clinical response model would move from a pilot stage to full implementation with immediate effect.

In response to the Cabinet Secretary’s statement, we gave our full commitment to work with both the CASC and EASC to develop the continued way forward for the new CRM so that people in Wales continue to benefit.

Through 2017/18 we have completed PACEC’s recommendations, regarding successfully implementing new technology for our clinical contact centres, and undertaking a clinical review of the Amber category of codes as part of our continuous/ongoing internal governance system to determine what type of clinical response should be assigned to every Medical Priority Dispatch (MPDS) code (approx. 1800) in all categories (Red, Amber and Green).

Strategic Action: We will work with the CASC and National Unscheduled Care Programme to review and support evidence based development to the Trust’s Clinical Response Model and seek to recognise ‘missed opportunities’.

5.2.3 Working with Primary Care Clusters and Colleagues

We continue to fully recognise the importance of developing a working relationship with primary care. In 2015 -2016, an extensive analysis was undertaken to identify opportunities to develop future services in line with the needs of primary care. This involved engagement with key stakeholders such as the Directors of Primary Care & Mental Health Services, Primary Care Cluster Lead General Practitioners (GPs), and Public Health Wales (Cluster Regional Network events – Pacesetter Projects).

The Parliamentary Review (2018) also reaffirms the strategic commitment to putting primary care and networks of clusters at the heart of the health system in Wales. The intent is to provide integrated services capable of meeting current demand and future need, to deliver timely care and treatment to patients when they need it. As part of this commitment, there is recognition that Wales must develop plans to deliver a sustainable primary care service, which will improve access to community-based care.

Through the work and collaboration described above through the Pacesetter programmes the following key points have been identified to illustrate how WAST can work with clusters, and health boards, to support primary care in driving transformational change and ensuring patient needs are met through a prudent approach to healthcare:

 Creating a scheduled service for the admission of patients to hospital, who require transport within an agreed timeframe, but not necessarily a ‘blue light’ ambulance. Our service improvement team has illustrated that this call volume is very predictable and has previously developed a model with Cwm Taf Health Board, which has proved to be successful in terms of increasing patient satisfaction and increasing the efficiency in patient handover at hospital. In terms of benefits, this approach can be summarised as improving patient flow for the high, and predictable call volume for GP (and other Health Care Professional – HCP) requests for low acuity transport and hospital admission (within a stipulated time period of 1 to 4 hours).

 Education and training for Paramedics in the Community to develop their skills in primary care, and attach them to clusters to respond to appropriate calls for both the 999 and primary care service. Such an approach potentially increases GP capacity to see patients at primary care centres.

 Providing Advanced Paramedic Practitioners (APPs), educated to master’s degree level, to work as part of a multi-disciplinary team (MDT - pharmacist, district nurse etc.) to staff primary care hubs / support teams as part of enhanced services provided by clusters. Such an approach potentially increases GP capacity to assess the patients with more complex needs, and increases the capacity of clusters to provide more holistic care within communities.

 Introduce chronic disease plans that can be accessed / interpreted by paramedics for patients who are being treated and managed within the community. This will potentially avoid unnecessary conveyance of these patient groups to hospital, & enable paramedics to ‘link in’ with community teams.

 Future estate developments, where ambulances can be co-located with primary care centres. This would support enhanced services, create a working relationship for clinical leadership by GPs, and provide rapid responses to any critically ill / injured patients who require advanced life support (ALS) either within the community, or as a result of attending the centres.

These potential strategic options have given us an opportunity to engage more meaningfully with the transformation of primary care services in Wales. Such collaborative working will not only bring increased benefits to patients and people in Wales, but will also support us with the transformation of ambulance services.

For this reason, the key priority agreed between WAST and the primary care community lasts years IMTP was the development of the MDT approach. Our main objective was to focus on developing the MDT models that had been agreed and were initiated with clusters.

 Primary Care Support Team Model (Hywel Dda – in operation): Role development for five Advanced Paramedic Practitioners (APPs), who are part of a GP- led MDT, which works with identified practices to provide additional support and increase the capacity / efficiency of that particular primary care service.

 GP Out of Hours Service (OOHs) model (Aneurin Bevan – January 2017): Role development for two APPs undertaking home visits on behalf of the GP OOHs in AB Health Board area. The posts will be rotational, with APPs continuing to also undertake shifts for WAST.

 Primary Care Practice model (Cwm Taf – January 2017): Role development for four APPs (trainees) undertaking home visits during the day, on behalf of the Aberdare practice as a result of calls being triaged by a GP, and allocated accordingly to the scope of the APPs’ practice. In addition, the APPs will support Cwm Taf GP OOHs (as per the GP OOHs MDT model in Aneurin Bevan above) and WAST with any operational resilience plans, and will be required to undertake shifts for these services as and when required.

In addition to the MDT models, there has also been agreement to test new ways of community working between Clusters and WAST’s existing operational model:

 Community-based partnership model (Cardiff & Vale planned for end of January 2017)

Develop and test a new model and pathway linking the local rapid response vehicle (RRV) directly to the three local primary care practices within the Western Vale Primary Care Cluster Group. This will create collaborative working between the two unscheduled care services in that geographical area. The aim is to improve communications to avoid untimely responses and unnecessary patient admissions to hospital, create care packages for frequent service users, develop alternative care pathways and create chronic disease plans/anticipatory care plans for paramedics to utilise. This model is heavily dependent upon being clinically led by GPs, who will retain the duty of care for the patients, unless it is identified that the paramedics need to convey the patients to hospital.

 Community-based partnership model (Powys planned for April 2017)

A similar scheme to Western Vale Cluster, but enabling four paramedics to be part of an integrated team in the Llandrindod Wells Minor Injury Unit.

Working with our health board partners and primary care clusters to develop a clear, persuasive single narrative that develops the role of paramedics within a community multi-disciplinary team

(MDT), clearly forms part of the development of the longer term strategy work, as well as the next phase of the demand and capacity review.

In response, to the initiatives above and further engagement with cluster leads, we progressed to supporting two community paramedic scheme pilots:

Paramedic – home visits to assess, Advanced Paramedic – home visits to and report back to GP assess, treat, refer / resolve. • Current trial in Western Vale. • Current trial in St John’s Medical Practice.

Both of the above schemes have been successfully awarded Bevan Exemplar status.

Looking Forward to 2018/19

 Evaluation – In conjunction with the Bevan Academy we will evaluate the two community paramedic Exemplar schemes, which will provide learning and information.

 Develop an Operational Business Continuity Model – to support primary care in the short term, and the development of community paramedic schemes, the following approach will be followed:

o In areas where WAST historically has rapid response vehicles (RRVs) with lower call volumes, re-focus the work to link in with a cluster (Western Vale, Monmouth, Lampeter, Brecon) – this will be subject to agreement with the cluster, as these RRV paramedics will require direct contact with GPs.

o In Health Boards (HB) where there have been specific requests to test the model further, and the Welsh Ambulance Service does not have RRVs based nearby, agreement on funding and release of paramedic staff will need to be reached with PC leads (Afan Valley Cluster; Torfaen).

 Scale up - A joint programme of work has been established with Cwm Taf University Health Board to develop a business case which will seek monies from the recently announced Welsh Government Transformation Fund to establish how the community paramedic model could be ‘scaled up’.

The aim would be to reach more people and/or broaden the effectiveness of the intervention in one entire HB area. Our joint work with Cwm Taf University Health Board would enable staff to deliver high standards of care through a rotational model. This would aim to relieve the pressures on both General Practitioners (GPs) and ambulance services. It would involve specialist and/or advanced paramedics rotating through these sectors, sharing learning, enhancing every element of community-based patient care, and concentrating efforts on the majority workload.

An example of the rotational model that will be deployed in this partnership with Cwm Taf is shown below

Embedding such a community paramedic scheme, would enable NHS Wales to fully evaluate the model as a whole system of change. If successful, this would potentially form a national programme of change that could be implemented on the basis of a ‘once for Wales’ approach – providing an equitable service for the entire population.

Strategic Action: We will support the development of an effective and sustainable, rotational model to maximise the contribution of paramedics within Primary Care

5.2.4 Workforce Modernisation

The workforce modernisation opportunities are set out in further detail in section 8.1, but two important opportunities to note are the implementation of Band 6 and the development of Advanced Practice Paramedics.

Band 6

We have successfully negotiated and implemented a Band 6 role for paramedics, with the support of our Trade Union Partners. The prospective benefits to this development, as set out in the business case, are anticipated to be the development of paramedics as decision-makers in the community, and a reduction of conveyance in patients presenting to emergency departments through WAST conveyance (subject to health board pathways).

We are working with the Chief Ambulance Service Commissioner and team to develop a range of quality measures, similar to the format of the clinical indicators, designed to quantify some of the benefits, based upon four ‘priority areas’ (determined by the Commissioners) including Mental Health, Falls incorporating Fractured NOF, Chest pain and Difficulty Breathing. It is proposed to pilot these indicators in the first instance to establish a baseline data source (to be agreed), which may also give us a prospective stretch target for the measures going forward. When we are confident the framework is robust, we expect to roll this out across the rest of Wales on a phased basis through 2018/19. Advanced Practice

A novel pilot in the Betsi Cadwaladr University Health Board area has brought together a team to test the co-ordinated deployment of nine Advanced Paramedic Practitioners (APPs).

Our rotational model operates with two APPs responding in the community who are activated by another in the Clinical Contact Centre (CCC). The APPs are tasked to predetermined codes that best use their extended scope of practice to provide safe patient-centred care and prevent unnecessary hospital admissions.

Interim analysis indicates that 70% of the incidents attended by APPs did not result in hospital conveyance; of which half were closed by the APP at scene, with the remainder referred into community services for ongoing care. Of the 30% conveyed, only a third required an emergency ambulance, with the majority using non-emergency transport.

Patient feedback surveys indicate a high level of satisfaction with the care that the APPs have provided. Ongoing quality improvement and health informatics metrics allow the project team to monitor progress and make data-driven recommendations for future changes.

Coordinated deployment of APPs to a selected code-set has demonstrable value as patients are getting the right care from the right clinician at the right time which fits the Clinical response Model. Further opportunities to support the system in BCU include APPs working in primary care where providing a traditional service is challenged.

If scaled up across BCU and Wales, more emergency resources can be available for higher acuity incidents as more patients would receive high levels of appropriate, and safe, care from APPs.

In February 2017, a smaller team of four APPs was deployed in the Aneurin Bevan (AB) Health Board Area who are starting to demonstrate their value in a more urban environment.

Over the life of this plan we want to expand the benefit that the APP role can bring to the organisation and the wider NHS Wales health system

5.2.5 Health Care Professional Calls

Calls from Health Care Professionals (HCPs) account for up to 40% of the total call volume for WAST. These calls are split into admissions from the community and inter facility transfers. HCP calls should be made because the patient requires urgent treatment from an ambulance crew or has a mobility need that can only be met by an ambulance. The latter situation should be rare because often a wheelchair taxi is as effective.

Analysis of HCP calls continues to show cases where no clinical or other need is identified and the patient simply requires transport to hospital. The clinical desk often re-contacts waiting HCP patients and arranges taxis or relatives to convey patients to their admission. Many inter facility transfers that are booked via EMS or UCS are suitable for NEPTS but the requesting clinician does not give sufficient notice for NEPTS to be arranged.

Health boards and WAST should work together in an approach similar to frequent callers to identify poor use of the ambulance service by HCPs. HCP calls should be scheduled to take place when services are available to receive patients. HCP calls should not go to ED. Such patients should go straight to speciality or an admissions unit.

Reducing inappropriate HCP activity and/or evening out the curve of demand will free up emergency and urgent care ambulances for other calls, as well as allowing patients to get to hospital faster than waiting for an ambulance. Getting to hospital in normal business hours improves flow in the hospital as it matches patient and clinician availability.

5.2.6 Other Opportunities

Collaboration and Engagement

Collaboration and engagement brings a number of opportunities, in particular the Wellbeing of Future Generations Act, our strengthening agenda with our blue light partners and the growing interface we have with the local authority and private sectors in terms of care, residential and domiciliary homes. We are engaging in the Welsh Audit Office review into the Act and will ensure that recommendations inform our next phase of work. Throughout this plan you will see evidence of where we are working in partnership with other sectors.

Commissioning Arrangements

The revised infrastructure under the EMS commissioning arrangements provides an opportunity to bring WAST and health boards together, to enable the system to collectively identify risks, trends and themes and to progress areas of good practice and scale them up. Whilst we have made good progress in agreeing priorities with health boards, this mechanism will require a level of agility to ensure learning from effective initiatives is spread.

Similarly, the new NEPTS commissioning framework provides significant opportunities for service improvements through the availability of information and intelligence and clarity on expectations, working towards consistent services across Wales.

Children’s Commissioner and the Older People’s Commissioner for Wales

The work which we are doing in collaboration with the Children’s Commissioner and the Older People’s Commissioner for Wales also brings with it some real opportunities.

We will continue to work in collaboration with the Children’s Commissioner for Wales to embrace the Children and Young People’s National Participation Standards and we have included within this plan the shared priorities identified by the Commissioner to continuously improve the service we provide to children and young people.

We are also working in collaboration with the Older People’s Commissioner to improve patient experience and outcomes. We have been fully engaged in the Ageing Well in Wales Phase One and now Phase Two Action Plans, focusing on improving services for patients with frailty, vulnerable older people, those at risk of falls, patients with dementia, sensory loss and people experiencing loneliness and isolation.

6 QUALITY, SAFETY AND PRUDENT HEALTHCARE

This section examines how we intend to place quality at the heart of everything we do along with progressing the prudent healthcare agenda.

6.1 Strategic Context

During 2017/18 we have continued to demonstrate our commitment to putting quality at the heart (see our Strategic Aims) of our service as defined in our Quality Strategy (2016- 2019). Year two of this strategy focused on building on the foundations established in year one, developing and improving our indicators and measures, aligning to the requirements of our commissioners with the quality core requirements of the commissioning framework and with NHS Wales Health and Care Standards (2015). Year three (2018/19) of our Quality Strategy will focus on implementing, monitoring and reviewing, whilst making appropriate improvements and changes in the areas which matter the most, informed by patients, service users, stakeholders and through staff feedback.

Since 2015/16, the Trust has adopted the Health and Care Standards, NHS Outcomes Framework and the core requirements in the Commissioning Framework to monitor the quality of our services and to ensure current and future services meet all of the four prudent healthcare principles and to secure a quality service for the health and well-being of future generations. We have continued to embed the Health and Care Standards into our core business and an internal audit of the Trust implementation of the Health and Care Standards in March 2017 provided us with substantial assurance.

The Trust Risk Management Strategy and Framework (2016-19) to deliver improvements in patient safety and care, as well as the safety of staff, patients and visitors is being reviewed and updated to reflect our developing risk maturity and section 8.11.2 explores this in more detail. The development of our Trust Health and Safety Improvement plan is a key component which will inform the update of the strategy.

The Trust has embraced the Social Services and Wellbeing (Wales) Act 2014 with regard to developing the Trust’s safeguarding team structure to support the powers within the Act and to ensure that adults, children and staff are safeguarded. Our Safeguarding Annual Report (2016/17) provided the Trust Board with the necessary assurances that the statutory duties under the Children Act 2004, the Social Services and Well-being (Wales) Act 2014, the Violence Against Women Domestic Abuse and Sexual Violence (Wales) Act 2015 and the Welsh Government Adult and Child Protection guidance are being fulfilled. The Trust has representation on each of the Regional Safeguarding Boards across Wales.

Healthcare Inspectorate Wales undertook an unannounced Governance Review of the Trust between January – March 2017 which was published May 2017. This inspection provided key findings of the Inspectorate Team:

 recognition that strong leadership was helping to promote a culture of learning, which was previously underdeveloped within WAST;  the review identified an organisation where overall feedback from staff was positive in terms of the cultural and structural changes that have been made;  they found WAST to be an organisation with effective leadership in place in relation to concerns and incident management;

 there was evidence that WAST had re-engaged with its staff to change its direction towards a more open and supportive culture;  they recognised that improvements had been achieved in the management and ownership of concerns, however recognised that there was a challenge around sustaining such significant progress;  improvements had been made with the handling of Serious Adverse Incidents;  WAST demonstrated that it is promoting a learning culture through the work of the Patient Experience and Community Involvement Team. Engagement with patients and the community and feeding this into Quality, Patient Experience and Safety Committee, supports the ethos of shared learning and the adoption of the more open and supportive organisation that WAST is seeking to become.

HIW recognised 3 areas that required improvement:

1. Trust to inform HIW how action will be taken to ensure that staff are provided with mental health training, specifically to assist clinical contact centre staff in the handling of callers with mental health issues; 2. Trust to provide an update on action taken to improve the DATIX system that would provide a facility to close and save input prior to completion; and 3. Trust to inform HIW how action will be taken to ensure that staff who report an incident receive feedback outlining the outcome of their submission.

In response, an Improvement Plan was developed and monitored through the Trust’s Quality Steering Group.

The recommendations from the Clinical Risk Assurance Review undertaken by our commissioners were published in July 2017 and we reflected on this in Section 5.1.4.

Our aim is to continue to develop our focus on quality governance (assurance and improvement) within the Trust so that we may discharge our responsibilities for quality. This means that we will continue to develop our structures and processes at Board level, and across the organisation, to lead on Trust-wide continuous improvement including:  ensuring that standards are achieved and compliance with regulation and legislation  triangulating quality data, information and patient, carer, stakeholder and staff feedback  planning, driving and measuring continuous improvement  identifying, sharing and ensuring best practice across NHS Wales

During 2017/18 we made significant progress with developing and strengthening our structure and processes to enhance the quality of outcomes and experiences for our patients, carers and service users and for our staff and key stakeholders.

Our commitment to enhancing quality of care during 2017/18 is evidenced with our achievements of the actions presented in the table overleaf:

We have taken forward the following actions during 2017/18 to promote and enhance quality of care:

 Developed the structure for mental health across the Trust to be implemented via the Trust Mental Health Improvement Plan.  Developed our organisational dementia strategy, based on the Welsh Government Draft Dementia Strategy and AACE draft Dementia Strategy.  Designed and implemented the family support model for WAST to provide appropriate support and signposting for families at times of bereavement and distress  Incorporated training for Violence Against Women, Domestic Abuse and Sexual Violence (Wales) Act for groups 1, 2, 3 and 6 into our existing learning and development framework. Submitted a training plan in March 2017 to achieve compliance with the training requirements by 2020.  Built IQT capacity across the Trust with local teams via the leadership programme. We are developing quality trainers, coaches and assessors  Worked with the 1000 Lives Improvement team to deliver our improvements across unscheduled care, for patients with mental health needs, falls programme, reducing healthcare associated infections and development of the WAST improvement hub  Worked with the Bevan Commission to embrace advocates for the Trust and drive innovation and improvements  Worked with the Children’s Commissioner to embed the Children and Young People’s National Participation Standards  Undertook a review of health and safety and to review the Risk Management Strategy to incorporate the health and safety priorities .  Aligned our internal audit and clinical audit programmes to our quality assurance requirements  Developed quality reports for each of the seven Health Boards for 2016/17  Developed the quality dashboard to enhance monitoring and measurement of quality data and information  Developed WAST Quality Improvement Plan from triangulation of quality data, patient and staff feedback (monitored by Quality Steering Group)  Taken forward the next steps of the sustainable improvement plan for concerns management (complaints, SAIs, Incidents, Claims, inquests)  Tested the implementation of technology (tablets) for local teams to access clinical guidelines, reporting DATIX incidents, safeguarding, e-learning  Developed a quarterly health and safety assurance report  Implemented the Trust Infection Prevention and Control Improvement Plan, including the integrated approach to vehicle and station cleaning across Health Board areas  Promoted professional standards with our paramedic professionals and registered nurses, embrace learning and development from measuring quality standards to achieve a skilled workforce. We identified the priority actions for registered nurses to align with the Chief Nursing Officer for Wales’ priorities  Developed a guidance document for Executive and Non-Executive visits and report the findings to the Quality Steering Group to inform improvements  Published our Annual Quality Statement for 2016/17 in June 2017  Implemented the Trust’s Patient Experience and Community Involvement Annual Plan. We will continue to measure patient experience and seek service user feedback to inform our continuous improvement  Further developed alternative care pathways working with Health Boards and key stakeholders

Moving Forward to 2018/19 and Beyond

During 2018/19, the Trust will continue to strengthen the Board Assurance Framework to provide confidence that the organisation is delivering our aims and objectives with a high quality service and this will be monitored at the Quality, Patient Experience and Safety Committee (QuESt) and also reported through to Trust Board.

Quality assurance is provided through our improving compliance with the Health and Care Standards and commissioning quality core requirements and this assurance is provided by the:  Quarterly quality assurance report  Developing organisational capability and culture, with patients and quality of care at the centre of everything that we do

The Trust is committed to building a clinically-led and quality-driven organisation to deliver safe and effective care, achieve excellent patient, carer and staff experiences, building robust structures and processes as our foundation to achieve the best outcomes for our patients and staff. The development of the clinical structure across the Trust is a critical platform to take forward learning and improvement.

In addition we will continue to ensure the provision of high quality, safe and effective care dependent on good governance and leadership. We frequently receive a number of external ‘notifications’ as part of inclusion in a wider healthcare distribution list. It is imperative that the service is able to provide the Trust Board with firm and absolute assurance that the care provided by its’ staff is based on agreed best practice and guidelines by evidencing that notifications received have been fully reviewed in relation to the applicability to the work of the Trust and that we can evidence the actions which have been taken / or to ensure that non-compliance is recorded.

We have a formal process established which systematically reviews all NICE guidelines received. A senior clinical team will review the notification and a formal log is kept to record all notifications received and any specific actions required and by whom. These are reported monthly through to the Medical and Clinical Services Directorate with updates through to the Quality Steering Group.

6.2 Strengthening Quality Assurance and Improvement Across the Trust

During 2017/18 we embedded the changes made to our organisational structures that were established during 2016/17. We strengthened the governance arrangements strategically and operationally for Quality, Safety and Patient Experience across the Trust to support front line teams and worked with key stakeholders across the following functions:  Safeguarding adults and children  Patient safety, concerns & learning – (complaints, patient safety incidents, claims & inquests)  Patient experience & community involvement  Professional practice development (Nursing Career framework)  Quality assurance  Quality improvement  Risk management  Health and safety  Infection prevention and control  Mental health

The Quality, Experience & Safety Committee (QuESt) and the Quality Steering Group (QSG) structures have been embedded during 2017/18 to triangulate the quality measures to provide assurance, inform improvements and learning. The sub groups reporting to the Quality Steering

Group have continued to mature this year and a standardised template, focussed on the Health and Care Standards (2015) developed and implemented to assist each sub group to report progress to QSG.

The Improving Quality Together (IQT) forum to build capacity across the organisation with embedding the model for improvement has continued to support the Trust’s Team Leading Development programme to drive improvements forward with local teams. Quality Improvement coaches have been identified and trained in IQT methodology and these will support the Team Leaders with their silver IQT projects. Section 8.7 explores this in more detail as part of our improvement and innovation work.

The Trust has integrated the functions of concerns and patient safety as recommended by the review of concerns in NHS Wales – Using the Gift of Complaints (2014). The Trust’s Concerns Sustainable Implementation Plan (2016) has generated significant improvements which have continued to be sustained during 2017/18, with the management of concerns and approach to investigation, support and engagement, timeliness and quality of responses, informing learning and improvements.

2018/19 Next Steps

To continue strengthening our quality governance structures we will:  Implement the revised Risk Management Strategy, including the implementation of the Health and Safety Improvement Plan (a further update on risk management is covered in section 8.11.2)  Review our organisational Quality Strategy (2016-19)  Evaluate and mature the Quality, Safety & Patient Experience team business partnership model to support operational teams across the Trust  Establish a Mental Health Team to lead and implement the Trust Mental Health Improvement Plan.  Monitor changes to the Policing and Crime Act 2017 regards Section 136 via mental health steering group  Implement our Dementia Plan in collaboration with the Alzheimer’s Society and partners, aligning with the Dementia Friendly Wales plan.  Explore the organisation’s contribution to the public health agenda from Choose Well to making every contact count (see section 7.1.1)  Commence implementation of the WAST falls improvement plan  Implement our Violence Against Women, Domestic Abuse and Sexual Violence (Wales) Act for groups 1, 2, 3 and 6 training plan to achieve compliance with the training requirements by 2020.  Support the IQT capacity in the Trust Team Leading Programme, through our Quality Coaches and Quality Improvement Plan, aligning improvement projects to priorities identified via triangulation of quality data and information.

6.3 Processes to Strengthen Quality Across the Trust

During 2017/18 we continued to mature the quarterly Trust quality assurance report for the QuESt Committee with regard to quality assurance and monitoring of quality improvements across the Trust. This quarterly report is coordinated by the Quality Steering Group and supported by a revised technical document mapped to the Health and Care Standards and Quality Core Requirements within the Commissioning Framework. The technical document development is assisting the development of quality metrics that will inform the development of a Trust dashboard.

Our Board members actively visit staff and patients, listen and engage through visits and ride- outs, connecting the Executive Team members and Non-Executive Board members with frontline staff and patients to seek feedback and inform improvements.

We have produced Health Board Quality Reports for the second time to share the 2016/17 quality data and information for pre hospital care for each Health Board. These reports have been shared at Health Board committees, quality events and aim to inform the development of IMTPs.

The Serious Case Investigation Forum (SCIF) process has been embedded into core business to provide a framework for effective investigation for serious adverse events and learning. The Trust has developed guidance to support staff with writing statements and preparation for inquests.

We know that reducing the number of serious adverse incidents (SAIs) needs to be a particular area of focus for us. Over the last year that we have been working collaboratively with BCU and have established joint staff forums across BCU and WAST teams to inform priorities for improvements with identifying opportunities for pre hospital care pathways to be developed to reduce conveyance to hospitals and SAIs.

The Community work stream projects are reported into the BCU USC Transformational group and led by the Nurse Director with WAST teams supporting the following pathway developments- falls, chest pain, respiratory, mental health, district nursing and minor injuries. In our 2018/19 next steps section below you will see we continue to remain committed in addressing the number of SAIs which occur.

2018/19 Next Steps

To continue to strengthen our quality assurance and improvement processes we will:  Build on aligning our internal audit and clinical audit programmes to our quality assurance requirements  Develop an electronic solution for safeguarding referral processes across the Trust  Lead the implementation of an electronic audit tool to enhance organisational data capture to inform priorities for improvement (for example: Health & Safety, Infection Control, Safeguarding audits)  Work in partnership with our Planning and Performance colleagues to align our quality reporting mechanisms more closely with performance reporting  Mature the quality reports for each of the seven Health Boards for 2017/18  Contribute to the development of the Trust’s integrated dashboard to enhance monitoring and measurement of quality data and information  Establish the WAST Quality Improvement Plan from triangulation of quality data, information, patient and staff feedback (monitored by Quality Steering Group) as part of the Continuous Improvement Hub  Develop DATIX functional dashboards for key departments in WAST to support those departments with specific intelligence needs (e.g. Infection Prevention and Control)  Implement e-risk assessments and electronic Risk Registers  Maintain the progress with the sustainable improvement plan for concerns management (complaints, SAIs, Incidents, Claims, inquests) focusing on learning and improvements  Test the implementation of technology (tablets) for local teams to access clinical guidelines, reporting DATIX incidents, safeguarding, e-learning  Implement our Health and Safety Improvement plan  As part of our Trust Infection Prevention and Control Improvement Plan, support the implementation and roll out of the vehicle and station cleaning processes across Health Board areas  Progress the Nursing Career Framework in WAST and the Paramedicine Career Framework.

 Develop WAST non-medical prescribing framework for Nurses and Advanced Paramedics  Implement the guidance document for executive and non-executive visits and report the findings to the Quality Steering Group to inform improvements

6.4 Outcomes (Assurance, Improvement and Learning) – Strengthening Quality Across the Trust

We published our 2016/17 Annual Quality Statement in June 2017 to share our achievements, challenges and our priorities for the year ahead.

The Patient Experience and Community Involvement team has continued its work with the Commissioner for Older People. The Trust has engaged with older people to implement our WAST Promises to Older People., as well as engaging with people with specific needs including dementia, sensory loss, falls, continence care and learning disabilities. We held a learning disability awareness session for staff in Cardiff delivered by Cardiff People First. The session allowed staff to talk to people with a learning disability, ask questions and find out more about our Learning Disability Champion role.

Our work and focus on patients with learning disabilities is a key component of “Treating People Fairly”. Treating People Fairly is the Trust’s Equality, Diversity and Human Rights Strategy. The (refreshed) four year plan was launched in April 2016. It describes the Trust’s Strategic Equality Objectives and the Strategic Equality Plan for the period 2016 - 2020. We produce an Annual Report on progress against this strategy where there is significant amount of detail on our work with protected characteristic groups. Both documents are available on our website.

The Trust online engagement directory has been designed and launched to capture all engagement activities across the Trust.

Our patients and service users engaged with the development of our Quality Strategy and have defined “quality” as:

 Confidence to receive a prompt response  Providing a prompt response appropriate to the needs of the patient  Being able to get medical help as soon as possible and not wait  To arrive in good time, administer appropriate treatment  Being informed every step of the way, treated with courtesy and professional expertise  Help when you need it and the ability to make a patient feel safe when they are at their most vulnerable i.e. when they are ill  Meeting the patient’s needs  Assurance that treatment/help will not be compromised  Good communication with patient/family

2018/19 Next Steps

To ensure we maintain our focus on improving patient experiences and outcomes to achieve safe and effective care and achieve excellent patient, carer and staff experience we will:

 Publish our Annual Quality Statement for 2017/18 by July 2018  Work with the Older People’s Commissioner with the Ageing Well in Wales programme, evaluating the impact of our Promises for Older People  Implement our Trust`s Children’s Promises, continuing our work with the Children’s Commissioner to embed the Children and Young People’s National Participation Standards

 Enhance compliance with the All Wales Standards for Communication and Information for People with Sensory Loss and the All Wales Spiritual Care Standards  Work with the CASC applying the NHS Wales Framework for Assuring Service User Experience to monitor and evaluate patient experience aligned to the priorities in the IMTP through the Patient Experience and Community Involvement Annual Plan to inform continuous improvement and learning.  Through ongoing engagement by our Patient Experience and Community Involvement Team with different community and patient groups across Wales, such as those patients with learning disabilities, we will;

o Continue gather feedback, patient stories and experience to inform the delivery of and access to our all our services. o Promote the “ChooseWell” campaign and Public Access Defibrillators. o Our PECI team continue to work closely with our Learning Disability Champions. o Ensure our trained learning disability champions continue to go out deliver information to learning disability groups across Wales about the ambulance service, the different between a little and a big accident to support people in deciding which NHS service they need and what happens if they call 999.

What will success look like through a quality lens?

1 We will be a clinically-led, quality-driven organisation adopting the principles of prudent healthcare. 2 We will have effective leaders and our staff will be developed and supported to deliver high quality care, in a high performing organisation that staff are proud to be part of and feel valued.

3 We will have made and will continue to make demonstrable improvements for our service users across all of our services, with sustainable quality improvements aligned to key performance indicators, measures and targets supported by our research & innovation work.

4 There will be clear lines of reporting and escalation routes with the Board receiving the right quality assured information, in a timely manner in a format that allows the Board and Executive Team to make informed decisions about the quality of the services we provide.

5 We will have good governance and risk management foundations in place that provide confidence in our systems to support decision-making, identify priorities for improvement, planning and quality delivery. 6 Staff will be engaged and will shape our priorities and know why they are important. We will continue to work in partnership, fostering productive relationships. 7 Quality indicators at station, contact centre and health board level will be developed by staff locally, relevant to the local population / service needs. 8 Service users, our communities, partners and stakeholders will be engaged in shaping our goals and priorities on a continual basis.

9 Our commissioners and other stakeholders will have confidence in our services and we will be striving to drive quality improvement through the commissioning process.

10 We will be a credible ‘go to’ organisation.

Developing our Learning Organisation through Engagement and Continuous Feedback.

Our Quality Governance Framework ensures that we continue to implement, monitor and review our strategy, structure and processes, capabilities and culture to drive quality forward across the organisation and measure compliance and improvements.

Quality Governance Framework

Measurements

We recognise the need to develop quality measures to use our information more intelligently through triangulation, heat mapping and early warning systems, developing this over the life of this plan. During 2017/18, we have commenced undertaking “deep dives” into areas of concern highlighted through incident reporting and we present these at our QuESt committee to further inform learning and provide assurance.

Key questions are applied when triangulating the information from a variety of sources to consider the dimensions of quality to demonstrate that we are actively listening and learning.  How we will provide safe care?  How we will meet required standards of effective care?  How we will improve user experience?  How we will provide efficient services within our resources?  How we will engage with the workforce?  How we will provide accessible and equitable services?  Are we improving population health?

Our Strategic Actions

We have reviewed our strategic actions to ensure that we reflect progress made in 2017/18 and to re-frame the specific milestones and timescales associated with these for 2018/19, where necessary. These actions are reflected below:

Strategic Action: We will deliver on the agreed priorities identified in WAST’s Mental Health Improvement Plan

Whilst last year we had an action focused on developing our mental health improvement plan, this revised action places a focus on implementation.

Strategic Action: We will continue to evolve and implement our falls improvement plan

Again, whilst last year we had an action focused on developing our falls improvement plan, this revised action places a focus on implementation. We focus on the implementation of the falls improvement plan in section 7.3.3.

Strategic Action: We will implement our Infection Prevention and Control (IPC) Improvement Plan

Strategic Action: We will lead the improvements identified following the Clinical Risk Assurance review

These represent a continuation from last year.

Finally, in our 2016/17 plan we gave a commitment that in year two i.e. 2017/18 we would develop DATIX. We have mentioned this again in the section above but, to reiterate our commitment to this important action, we again, for clarity, document the action below.

Strategic Action: We will develop our electronic information systems to support our organisational risk maturity.

6.5 Prudent Healthcare

The Trust Board is resolute in its determination to ensure that the organisation delivers high quality services that are underpinned by a prudent approach to delivery. Consequently, we have ensured that the prudent principles are implicit throughout this plan and the service developments which we describe.

We are committed to the four principles of prudent healthcare and the organisation continues to make great strides in its ambition to move from a transport-based to a clinically-led, quality-driven service. The principles of prudent health reflect the journey on which we have embarked and are now on. They are also reflected in our shared behaviours.

The Trust submitted the Clinical Response Model to the NHS Wales Awards 2017 and won the award for the organisation’s “outstanding contribution to Prudent Healthcare”.

The tables in Annex 6 provide an overview of where the four principles are completely embedded across the organisation. Further details can be found throughout this plan.

6.6 Patient Experience and Community Involvement (PECI) Team

The WAST Patient Experience and Community Involvement Team (PECI) has, at its heart, a commitment to engaging with patients on their experiences of our services, helping us understand what it feels like to be a patient in our care and to use that learning to help improve our services and practice.

The PECI Team also has a distinctive role in educating the public in how to access and use our services sensibly and appropriately, from discrete demographic groups like children and older people, carers and those with protected characteristics, through to the mass of the population.

Using a continuous engagement model, the experiences, perceptions and feedback of the public are captured to improve Trust services. Patient reported measures have been identified as a means of reflecting the interests of the patient.

NHS Wales is required to establish a consistent evidence based approach across Wales in providing every patient with the opportunity to co-produce and evaluate their own care. The progress of Patient Reportable Experience Measure (PREM) captures the individual’s perception of their experience with healthcare or a service. We will continue to engage with the NHS Wales PREMS (and PROMS) Programme Board to ensure that we continue to capture experiences to measure how the Trust is doing in delivering quality services for people. We will continue to measure and report against the NHS Wales Health and Care Standards, National Service User Framework and Commissioning Quality Core Requirements.

We will continue to strengthen the integration of the work of the PECI team with our IMTP priorities and work with the Commissioning Team and colleagues across the organisation throughout 2018/19. This work will continue to be reported regularly to the Quality, Patient Experience and Safety (QuESt) committee and Trust Board, providing the organisation with evidence and quality assurance required.

This approach will ensure that the Trust’s engagement activities, in their broadest sense, are focused on the delivery of outcomes and that, cumulatively, they contribute to the organisation’s broader ambitions. As the partnership agenda is so integral to the PECI Team, we also include information on the team’s role in our Partnerships and Engagement section at 8.9.2.

Strategic Action: We will review and align our Patient Experience and Community Involvement programme of work with the Trust IMTP priorities and Commissioning Quality Core Requirements

6.7 Clinical Structure and Clinical Supervision

The clinical leadership structure within the Trust provides a clear direction for the organisation to be prepared for the changes that will impact on what it does in the medium to longer term. Clinical leaders will change the emphasis, inspiring clinicians to deliver optimum care for all our patients, shaping future delivery and flexing to meet the challenges the future health economy will undoubtedly present.

Clinical leadership is regarded as a process by which an individual influences others to set standards, accomplish objectives and directs the organisation to greater consistency. Leaders are generally identified by a number of key characteristics; knowledge, skills and attributes. Therefore clinical leadership that covers a range of areas will encourage clinicians to inform strategy, improve quality and drive service design and resource utilisation. The clinical structure will prove

critical support to Boards, Executives and Clinical Teams to ensure the organisation is developed and shaped appropriately with organisational learning and continuous improvement.

Clinical Leadership in the organisation will be designed to provide a framework that will support WAST for the longer term. Although good clinical leadership is vital for ‘today’, we must also ensure we look forward in the medium to longer term to engage with the workforce, develop succession plans and inspire talent to become future organisational leaders.

There is a need to establish a tiered system of clinical leadership, throughout the organisation and to create an aspirational career pathway within the paramedic profession. This need is further emphasised in many other related national policy documents.

There will be five strands to the WAST clinical leadership structure and clinical supervision initiatives:

o Embedding the newly developed clinical leadership structure across the three regions, supplemented by the Clinical Operations Team and supported by the Research, Audit and Improvement Team, to ensure that systems and processes are in place to support all ambulance clinicians in this ever increasingly challenged area of healthcare practice. o Developing and supporting the current and future workforce. Working with internal and external education and training teams to commission the programmes which will ensure our workforce has the skills and characteristics to more effectively manage the patients we see. o Work with clinicians, our commissioner and all clinical leaders across the health community to increase our decision making support capabilities to assist paramedics and ambulance clinicians in ensuring care is delivered in the most appropriate setting for their presenting condition. o Increasing and improving the level of clinical support available to the front line from within our Clinical Contact Centre. Developing the Clinical Support Desk to take a proactive role in managing service user’s needs by working directly with operational clinicians out in the field. o An emerging focus upon the role of Clinical Team Leader to ensure a continuation and development of the current support through appraisal of clinical indicators, PADR reviews and operational performance.

Strategic Action: We will develop and embed a clinical leadership culture to create sustainable and clinical effectiveness across the Trust from the Trust Board to the operational frontline staff

7 OUR SIGNIFICANT SERVICE CHANGES

This section represents our key service change commitments

This section focuses on the key service areas in which we will be investing our change capacity and resources. We have aligned these significant service changes to the five step ambulance care pathway and the five step non-emergency patient transport pathway.

This section of the plan is divided into three parts;

I. We describe the activities which we continue to progress to drive the EMS service which we provide. This is described through the lens of our 5 step EMS model. II. We describe the activities which we continue to progress to drive the NEPTS service which we provide. This is described through the lens of our 5 step NEPTS model. III. We place a focus on specific patient groups

We recognise that across the five steps of the EMS clinical model we should, where relevant, be drawing an alignment to the commissioning intentions with which we have been issued by EASC. In order to help demonstrate this alignment, we have included a summary box within each ‘step’ to clarify the commissioning intentions we should be addressing within the relevant step.

7.1 OUR EMS SERVICE DEVELOPMENTS

7.1.1 STEP 1: Help Me Choose

Working with the public to educate and inform on accessing the right support before escalation into an emergency Relevant Commissioning Intention(s):

- Step 1 – more calls to ‘111’ NHS Direct and less conversions to 999 from 111 and NHS Direct

This step focuses on helping the public choose and navigate the right part of the NHS, including the services provided by us and how/when they should access them appropriately.

Prevention

Whilst LHBs retain responsibility and accountability for population health, we recognise that we have a role to plan in the prevention agenda. As a front line service, we often see the opportunities to intervene in the lifestyle behaviours of our patients. Similarly our NHS Direct Wales website is a useful resource to support, educate and influence service users.

The Association of Ambulance Chief Executives (AACE) is undertaking some work on the role of ambulance trusts in the prevention and step 1 agenda and we will use our networks into this group to ensure learning and action is taken forward.

There is also the work on the National Unscheduled Care Programme and the 0-10 step model and Public Health Wales’s own strategic work on Step 1 that provides context for any future work. With this context in mind, we will provide seek to crystallise our approach to Step 1 in 2018/19.

In section 6.2 we committed to “exploring the organisation’s contribution to the public health agenda from Choose Well to making every contact count”. We have commenced engagement

with Public Health Wales and key stakeholders to inform the outline scope of the Trust’s Public Health Plan. Our staff working in hear and treat, our Community First Responders, Emergency Medical Services and Non-Emergency Patient Transport teams all have a part to play in identifying opportunities to redirect patients and service users to the correct service for support, primary/secondary prevention with a focus on those who are particularly vulnerable in our society.

Following a period of engagement and consultation we aim to have an approved Public Health Plan by the end of 2018 and this will include:

 Early years  Adverse Childhood Experiences  Prevention and secondary prevention (i.e. chronic conditions, provide information for stop smoking services)  Focus on Frailty and vulnerability (falls prevention, dementia, nutrition/hydration, housing/heating/shopping)  End of life care

Our Public Health Plan will align with our Mental Health Plan (2017) and embrace collaboration with our blue light partners, local authorities, voluntary sector and Health Boards.

Strategic Action: We will develop our Public Health Plan (Choose Well and Making Every Contact Count)

Frequent Callers

We have successfully introduced a national approach to individual frequent callers, which has produced significant reductions in the number of such calls. The following graph illustrates a frequent caller cohort over a four month period and reduction in activity.

We have also recently piloted a multi-disciplinary response to frequent caller care homes in Cardiff and the Vale, working with the LHB. As part of its 2018/19 plans, the Trust will expand this approach across Wales through the appointment of a national project manager (subject to LDP resource bid). There is frequent caller work reflected in the joint priorities with LHBs at Annex 5.

The 111 Service

The 111 Pathfinder launched on 4 October 2016 and up to the end of October 2017 received over 175,000 calls from patients living in ABMU and Carmarthenshire (where the service was launched on 2 May 2017). Typically there are between 350/400 calls per weekday, and around 900/1100 at

weekends into the service. A collaboration agreement is in place between the Trust and Abertawe Bro Morgannwg UHB & Hywel Dda UHB which sets out the respective roles and responsibilities of each organisation.

During 2017/18, an independent evaluation was undertaken by Public and Corporate Economic Consultants (PACEC) (latterly incorporated into the RSM network) working in conjunction with University of Sheffield. The key findings from the evaluation report are set out below:

 The 111 Pathfinder was successfully implemented in October/November 2016 and received over 71,000 calls in the first six months of operation, 94% of which were answered by call takers.  The 111 Pathfinder generally met the standards that were set for it (under the Interim Standards and Quality Measures), for example the average triage times for priority one calls was three minutes compared to a standard of 20 minutes. Also, only 2% of priority one calls were queued for more than 20 minutes against a quality standard that notes 95% of priority calls should be answered within 20 minutes.  There was a high level of service user satisfaction, with 95% of survey respondents stating that they were satisfied or very satisfied with the whole 111 process. Furthermore, the service has received a very small percentage of formal complaints, all of which were minor (0.07% of all calls).  There has been a very small reduction (1%) in the number of Emergency Department (ED) attendances during the first six months of operation compared to the same six months in the previous year. However, other Health Boards across Wales experienced a slight increase in ED attendances during the same period. Therefore, whilst this is not a statistically significant reduction it is an important one.  The number of non-urgent ambulance conveyances has decreased since the introduction of the service (29%) compared to the same time the previous year.  Key stakeholders involved in the development and the operation of the service are enthusiastic about the Pathfinder and believe that greater benefits and efficiencies could be achieved with careful roll-out across Wales.  Whilst it is difficult to disaggregate the impact of the 111 Pathfinder from other ongoing initiatives within urgent and emergency care services in the ABMU region, it is possible that the 111 Pathfinder contributed towards efficiencies particularly in ED and MIU attendances and Ambulance conveyances. For example, ED attendances in ABMU decreased slightly compared to increases in other LHBs. It must be stressed however that this cannot be directly attributed to the 111 service, and that these findings are based on the limited available data.  Feedback from operational staff and senior stakeholders suggests that the service requires more clinical staff and experienced call handlers to facilitate any further expansion  There have been no significant incidents/events or serious complaints since the launch of the service in October 2016.

The report also highlights a number of key considerations for future roll out including:  The challenges of recruiting sufficient experienced clinical staff such as experienced nurses and out of hours GPs  Issues of staff morale within the 111 service which were noted through the staff survey that was conducted  The design of the algorithms used within the prioritization and triage processes need to be reviewed as the perception of some professionals is that they are too risk averse which leads to too many calls being transferred to GPOOH services  The need to ensure that the future IT platform connects and that the future interoperability requirements of the new ICT system are properly considered

The organisation has continued to work closely with the 111 Programme Team and 111 Board and have contributed to the development of the 111 Strategic Plan for 2018/9 – 2019/20. As well as the preparations for service roll out, we will ensure we retain our focus in the short and longer term on the corporate and clinical governance arrangements and will work with the 111 team, our Board and Welsh Government to clarify and strengthen as required. This plan starts to paint a picture of a future service vision for 111 with much closer alignment between the clinical desk in the EMS service and the clinical support hub in 111. The plan seeks funding for a further two years of roll out, after which point further roll out would occur only once the new IT solution is successfully secured and implemented (see Section 8.8). High-level milestones are detailed overleaf.

Strategic Action: We will implement the next phases of the 111 Pathfinder in line with 111 Strategic Plan for 2018/19 - 2019/20

7.1.2 STEP 2: Answer My Call

Prompt call answering, advice and treatment and signposting to LHB services/alternatives Relevant Commissioning Intention(s): o Time to allocation for Red calls to reduce o The volume of calls assessed and closed by the clinical desk to increase o less 999 and HCP calls and more calls transferred to ‘111’ ‘NHS Direct’ o Proportion of patients referred to alternative pathways/services to increase following ‘hear and treat’ and ‘see and treat’ o 999 call answer times by time band to be produced o Proportion of spend to shift from Steps 5 & 4, to 3 & 2. o

Our Clinical Contact Centres (CCCs) are at the centre of the entire WAST operation. Our operational performance is dependent on the front end (CCCs) getting it right, and this requires appropriate systems to support staff to deliver the best outcomes for patients. Our CCCs deliver a call answering, assessment and triage service and a dispatch of vehicle service to a population of 3.3 million people. Demand to the service includes 1,880 “999” calls a day, 1270 incident responses and 400 routine and health care professional calls per day.

Two elements of clinical assessment, information and advice services are hosted within CCCs: NHS Direct Wales and Clinical Support Desk (CSD). The CSD reviews more than 2000 patients each month to ensure appropriate utilisation of emergency response vehicles; we sometime refer to this as our Hear and Treat service.

The NHS Direct Wales service receives around 27,000 telephone calls from the public each month in addition to triaging circa 2900 ‘green’ calls that originally present to 999. The service also has a strong online presence, with in excess of 300,000 visits to the website each month.

We have made some significant progress over the last twelve months in step 2 and these are outlined below:

In 2017/18 we said we would  Implement a new Computer Aided Dispatch (CAD) system  Work with the 111 project board to ensure successful implementation of the 111 Pathfinder project in association with ABMU  Increase Hear and Treat services through the Clinical Support Desk.  Implement a system where those calls appropriate for Clinical Triage are identified and dealt with  Review the service provision for non-injury falls.  Implement a clinical support desk in Police Control centres within Wales

This is a summary of how we have done  In November 2017 we successfully Implemented a new Computer Aided Dispatch (CAD) system  Across Hear and Treat in our Clinical Support Desk (CSD):  The CSD now employs 30 wte staff, including two Senior Clinicians.  Extended our responsiveness to fallers, advice given and links with other agencies to improve the level of resolve without the need for ambulance attendance.  CCC Clinicians are now operating out of police control rooms in North Wales Dyfed Powys and South Wales force areas most evenings.  The upgraded computer platform (CAD) has allowed the Clinical Support Desk to have its own selection of call codes, where we have evidenced that the assessment will improve the outcome for the patient, reduce the need for admission to hospital and empower patients to treat themselves at home.  We have achieved ACE Accreditation on the call answering element of the service. This means that there are clear quality and governance processes in place in the call answering element of the service and we deliver a high quality standard of audit in this area.

In addition, we reviewed all Standard Operating Procedures in line with the new CAD implementation and reviewed business continuity and resilience processes.

Despite the progress, we recognise that there is still much for us to focus on. To ensure we do not lose focus on the scale of the work ahead, we have identified a number of key areas of work we must progress.

The long-term success of the CRM is dependent in part upon the modernisation of the organisation’s CCCs. Consequently, we are clear that, over the early part of this plan, our focus must now be on the following three key areas.

CAD Implementation Phase Two and Wider CCC Modernisation

Stage one of our CAD project was completed once the system was implemented and stable in November 2017. The new CAD is currently running the same processes as were operated on the previous system but with the addition of auto dispatch for RED calls and the clinical desk queue for our clinicians. Following a consolidation period where staff have got used to operating the system we are now planning phase two of the project. Phase two will run over 2018/19 and include the switch on of new functionalities available with C3 (the new CAD) which were not available on the previous CAD. By the end of phase two (mid 2019/20) we will start to utilise functionality with revised processes in the CCC where we will see real transformational change and benefits in service delivery. This

process of change will require focussed engagement, training and communication with staff across the organisation, and a review of processes and procedures. Transformational change will be as a result of releasing enhanced functionality within the now established CAD system. Examples of enhanced functionality that Phase 2 will seek to exploit are:

 Increasing the functionality of the Clinical Support Desk Queue to further improve the impact of clinicians within our CCC both through increasing our hear and treat rate and also through highlighting high priority calls that are unlikely to receive the time based response required.

 Implementation of specialist desk queues will allow increased functionality for our HCP desks ensuring that UCS resources are used to the maximum capacity to ensure response standards for patients requiring urgent admission to hospital. Specialist desk functionality will also assist EMRTS allocation allowing them a dedicated queue for incidents identified as requiring their response.

 The Aeromedical module will allow improved management of EMRTS resources through a single incident where multiple pick up and destination points are required due to helipad restrictions.

 One of the key modules for Control Centres across the UK is Ambulance to Ambulance transfer of incidents using ITK functionality. This will allow WAST CCCs to electronically transfer incidents to neighbouring ambulance services as the call is taken. This allows improved dispatch for patients being managed by neighbouring services or where the call is taken in a neighbouring control centre for dispatch within Wales.

 This connectivity will also allow us to explore improved links with NEPTS systems and communications with other Emergency Services through DEIT/MAIT.

 Improving functionality of Major incident and event management through the introduction of Dynamically Controlled Access Zones will support CCC staff when dealing with high pressure scenarios. It will allow identification of clear boundaries for incident access and egress and will also communicate with resources approaching these boundaries ensuring the safety of our operational colleagues.

 WAST continue to work with our system provider MIS to further develop modules to improve integrated functionality for resourcing, fleet management and reporting.

 Further refinement of the auto dispatch functionality and an automation of our demand management and REAP escalation tools will be possible.

 Improvements in the deployment plans will allow ambulances and RRVs to be deployed more accurately to anticipate demand.

 Rest break scheduling in line with revised policies will allow for more efficient use of resources.

 The use of modules allowing for dynamic creation of new sector areas for events or incidents, separating these areas from core resources, will also come on line with phase 2. We will look to exploit these opportunities which the new CAD is presenting by establishing a CAD Phase two Project Board. This project board will also capture all the outstanding benefits and

risks from the now closed CAD implementation programme board which still need to be robustly managed. Phase two will provide the following benefits:

 Improved ability to pass calls to the clinical support desk,  Improved support for multi-leg journeys and managing aeromedical journeys,  Telephony interfaces to make it easier to record and playback 999 calls and to re-contact callers and connections to NEPTS and our emergency service colleagues to pass calls electronically between agencies.  Better management of calls which can be managed by the Hear and Treat specialists on the clinical support desk reducing the numbers of unnecessary ambulance journeys,  Reduction in time taken to clarify information given by the caller where there is any doubt through instant playback,  Increased speed of transfer and reduction in potential for error by passing calls between ambulance services and other emergency services electronically instead of by phone call at present.  Improved rest break management  Improved deployment and standby regimes  Transfer of incidents via MAIT  Improved escalation processes  Improved event planning and deployment during large events such as marathons and cycle races, six nations etc.

Strategic Action: We will establish a CAD phase 2 project board and look to make significant progress in realising the benefits of the new CAD.

Further Improve Our Hear and Treat Rates

Over the previous years, we have received Welsh Government funding that has supported an initiative to place additional “hear and treat” staff in both our CCCs and in Police Control Centres. This has meant an increase in the amount of ambulance conveyances stopped following clinician assessment of over 2,000 per month.

The hear & treat rate year to date is 6.7%, which we expect to increase in 2018/19 to our performance ambition of 8% through efficiencies from the new CAD and other efficiencies in the CCC.

Learning from Winter 17/18 and some benchmarking with the NHS England Ambulance Response Programme (ARP) has established that “best in class” UK ambulance H&T performance is around 12%. Following the introduction of additional staff and the new CAD, we have improved our performance in this area to the 8% initial target of our previous IMTP. The new CAD has allowed for a queue of calls for clinical desk attention to be formed releasing the time that the clinicians previously spent searching for incidents to triage. At times of pressure our clinicians are also involved in “safety netting” of callers who are waiting. Whilst not showing in our H&T performance this is a vital contribution to patient safety but could be required less often if system pressures affecting ambulance availability such as handover were improved. During 2017/18 our H&T teams are regularly preventing the need for circa 2000 ambulance dispatches per month and releasing police and other agencies from scenes where ambulances are not required. We will develop a bid to the Transformation fund to increase our H&T teams in CCC to achieve the 12% best in class level.

7.1.3 STEP 3: Come to See Me

Prudent Dispatch and Divert to LHB Services and Alternatives – Alternatives to an EA that are better placed to respond to people with particular urgent needs Relevant Commissioning Intention(s): o Multiple vehicle arrivals at scene to reduce for Amber and Green Incidents o The percentage of incidents where the first arriving vehicle is the ideal to increase o Red performance to be maintained and the 95th percentile to reduce o Amber 95th percentile times to reduce across each health board area o Compliance with HCP time requests to improve across each health board area. o Less incidents requiring attendance at scene and more incidents resolved by phone. o Proportion of spend to shift from Steps 5 & 4, to 3 & 2.

As part of Step 3 we will continue to focus on ensuring the correct clinical response is provided to match the need of the person contacting the Welsh Ambulance Service. To ensure we make decisions about which clinical resources to allocate to calls in a timely manner, we will continue to adhere to the best practice guidelines set out by the International Academy of Emergency Dispatch (IAEMD).

In accordance with these conditions, the Welsh Ambulance Service has an internal governance system in place to determine what type of clinical response should be assigned to each of the 1800 (approx.) medical prioritisation dispatch (MPDS) codes. This process is clinically led, and is based upon the IAEMD’s requirement to have regular reviews of the MPDS codes.

Work has already been undertaken during 2017 as part of this continuous quality assurance mechanism:  Review of proposals from all other UK ambulance services as part of the adoption of an updated MPDS code set (version 13). This included a quality check of the Red category alongside those of the other services (completed and WAST is now using the most up to date version of MPDS).  Specific review of WAST’s Amber codes to meet the recommendation by PACEC during their external and independent review (published for the Emergency Ambulance Services Committee, January 2017).  In recognition that quality assurance, risk management, and clinical leadership are an absolute necessity for the ongoing use of the MPDS code set, WAST will continue with a cycle of clinical reviews annually to provide assurance that the clinical response model remains safe and fit for purpose. These reviews will be undertaken by a group of clinicians, a member from the commissioning team, and operational leads, chaired by the Assistant Medical Director. To meet the future intentions agreed with the commissioners of our service, we will ensure that a representative from the CASC Team is involved in the ongoing reviews of the MPDS code set.

As part of future reviews, it is recognised that further consideration will need to be incorporated relating to the recent implementation of new technology (‘Computer Aided dispatch’ – CAD system) within the Clinical Contact Centres. For example, the development of the capabilities within the new CAD system, will enable us to explore potential new ways of dealing with: o Health Care Professional (HCP) calls; o inter-hospital transfer requests; o auto-dispatch systems; o increasing the number of MPDS codes for telephone triage; and, o allocating appropriate 999 calls to community health care teams for a response, as an alternative to emergency ambulances.

The new CAD and efficiencies in the CCC should enable the Trust to reduce multiple vehicle arrivals at scene for Amber and Green Incidents, which should free up resources to respond to other incidents. The Trust measures this through AQI14 “number of incidents that received at least 1 resource allocation” (excluding incidents where multiple dispatches are appropriate) which for the last published month (December 2017) showed that we dispatched more than one resource in 32.4% incidents.

The Trust will also review AQI18, using information from the ORH Demand & Capacity Review, to improve how we measure the dispatch of the “Ideal/Suitable” response, with a revised indicator expected in 2019/20.

Red performance will be maintained within the performance ambition of 65% to 75% of Red incidents being responded to within eight minutes with continued monitoring of the 95th Red percentile, which may reduce as a result of benefits realisation from the new CAD, but may be offset by increasing demand and lost hours.

The Trust recognises the challenge of Amber performance and the desire to reduce Amber 95th percentile times and we will improve our understanding of Amber performance by increased used of percentiles and consideration of clinical risk and patient safety. Section 7.3.1 gives more detail of our approach to amber responsiveness.

Development of an Electronic Patient Clinical Record (ePCR)

The Trust currently uses ‘digi-pen’ technology to compile clinical records for the patients that we attend. This system has delivered considerable benefits compared to the historical paper based

process, however this was implemented as a short term interim solution. Looking to the future, and in line with the emerging ideas from developing our Long Term Strategic Framework, we want to develop a more innovative and effective electronic solution to capture and record clinical information that will improve the quality of care we provide to our patients.

This project is in its formative stage and, moving forward, we will establish a Project Board chaired by our Medical Director, to oversee the development of a business case to secure the investment required to implement a solution. We will involve key stakeholders from across the Trust, including Operations, Health Informatics, Fleet and ICT and will also engage closely with other health partners (including NWIS and Welsh Government) and wider organisation to support the project. This will ensure that we identify a ‘preferred’ solution that is fit for purpose, user friendly, delivers value for money and aligns with the strategic direction set out in the Digital Health Strategy and associated work streams.

Whilst a clear specification has yet to be developed, early discussions have identified a number opportunities and potential functionality of the solution (these are listed below):

. Linking the ePCR to the vehicle dispatch system to pull through data from the in-built vehicle data terminal; . Ensuring there is a simple and intuitive completion methodology, to minimise time completing records, thus maximising time spent caring for patients; . Providing clear prompts to the clinician to complete specific fields aligned to the patients presenting complaint; . Ensuring compliance with clinical indicator metrics by having mandatory fields . Ensuring that the e-PCR solution links all data (CAD records, vehicle telematics data, ePCR and other sources such as body-cam footage if introduced in the future) relating to an incident into one data file per incident

Whilst we undertake this work we continue to utilise and enhance the ‘digi-pen’ technology. Further information about the ePCR is outlined in the Health Informatics and IT sections of this plan (see sections 8.8 & 8.9).

Strategic Action: We will develop a business case for investment in an electronic patient clinical record solution

7.1.4 STEP 4: Give Me Treatment

Refer to LHB services and alternatives and see and treat – a wider range of care, treatment and follow up options available for people on scene Relevant Commissioning Intention(s): o 95th percentile call to door times (STEMI & Stroke) to reduce across each health board area o Clinical Indicator performance to improve, and be above 95% in all health board areas (except ROSC) o less attendances at scene

This step focuses on the development and delivery of a range of clinical care services offering a variety of treatment options. The treatment provided to patients by ambulance clinicians in the pre-hospital emergency setting is a major factor in patients’ chances of survival and recovery. Ambulance clinicians use care packages, specific assessments and treatments for certain conditions. Care bundles are a series of assessments, treatments and actions that are clinically recognised to improve a patient’s outcome and experience. This information is gained from the clinical patient records completed by staff. A clear programme of Clinical audit then supports the improvement in processes, practice and skills.

We have developed and report against seven key clinical indicators for cardiac arrests, strokes, heart attacks (called STEMI), fractured hips (known as neck of femur injuries), febrile convulsion, sepsis and hypoglycaemia. Through effective monitoring and the opportunity for clinical managers to have access clinical data, we will be able to demonstrate improvements in the delivery of clinically effective care.

In 2017/18 we said we would  Commission standardised stroke focused online training to all WAST emergency medical services (EMS) staff.  Ensure roll out and development of clinical indicators.  Implement Digi-pen phase two  Develop and modernise the Trust’s existing medicines management arrangements, by supporting the introduction of the Omnicell automated medicines management system.

This is a summary of how we have done  Access to the ASLS learning resource was opened to WAST staff on 18 April 2016. The course providers are supplying end of month reports on staff uptake and completion. The course providers continue to report very high levels of satisfaction (98%), amongst those who have completed  We have developed seven clinical indicators and a management system for CTLs to allow them to see their teams and individuals compliance against optimal patient care.  We have procured 20 medicine cabinets and appointed a project manager to support the implementation of a medicine management solution.

Some of the clinical initiatives which we will subsequently look to progress in the lifetime of this plan include:

Telemetry Project

This is a three year Efficiency through Technology funded project to enable clinicians at receiving hospitals to receive ECGs for patient’s en-route to hospital via telemetry from ambulance vehicles.

The aim of the project is to increase the accuracy of diagnosis of patients suffering a heart attack to ensure that they receive the right intervention, at the right time, in the right place.

Benefits are planned to include a reduction in the number of secondary transfers of patients to enable them to have faster PCI treatment to increase their chance of survival, reductions in hospital length of stay times, reduction in expensive complex interventions and reduction in risk of further health complications as a consequence of delayed treatments.

We will also explore opportunities to identify patients with previously undiagnosed ECG abnormalities and refer these patients to primary care for early intervention.

Omnicell Project

We have commissioned 20 Omnicell Automated Medicines Supply Cabinets across Wales. Five of the cabinets are located on ambulance stations and fifteen cabinets are located in Emergency Departments on hospital sites. This is an Efficiency Through Technology Fund Project which has modernised our medicines supply arrangements for Prescription Only Medicines (POMs) and Controlled Drugs (CDs). The Project has vastly improved governance, audit and monitoring capability on the supply and use of medicines by the Trust.

The system has replaced medicines cupboards that were reliant upon paper documentation for the withdrawal of drugs. The new cabinets use biometrics to record all drugs transactions. The Trust has received positive feedback from Users of the cabinets who are realising benefits of efficiency and time saved to restock medicines at hospitals.

The final three cabinets are planned to go live in April 2018. An evaluation of the project including a review of the benefits achieved will be undertaken in April.

Out of Hospital Cardiac Arrest Survival

We are working with our NHS partners to support the WG Heart Conditions Delivery Plan. This involves our contribution to the development of a multiagency strategy to provide patients suffering from a heart condition, timely access to high quality pathways of care. The Trust’s figures show that between January 2016 and December 2017 there were 7,411 patients who were victim to out of hospital sudden cardiac arrests, (3,700 annually in Wales). Survival rates are low and there is the potential for many more lives to be saved if CPR and early defibrillation were undertaken more often, and if the pathway from resuscitation to rehabilitation was improved. We worked with Public Health Wales, British Heart Foundation and various other partners to deliver the ‘Restart a Heart’ Day on 16 October 2017, when we helped to train a further 10,032 pupils in the life-saving skill of CPR (an increase on the 9285 children trained in 2016) . The initiative is to encourage an increase in the rates of bystander CPR before the arrival of an ambulance, which can double the rate of survival. Other areas of work undertaken include the establishment of pathways to enable paramedics to take patients suffering with cardiac conditions directly to specialist care centres for fast intervention to improve their outcomes. This upcoming year will see further work on developing our response to cardiac arrest with work being undertaken to standardise our response to cardiac arrest, ensuring that all clinical leaders and training and education staff receive the most up to date training in cardiac arrest management, with the intention that this can then be disseminated down to all frontline clinicians. Further to this, exploring the role of our Clinicians and optimising their contribution to cardiac arrest management, to aim to have a senior clinician on scene at each cardiac arrest to assist with leadership, decision-making and incident debriefing. Additionally, the development of the Trust’s Out of Hospital Cardiac Arrest Plan will ensure the organisation continues to push forward with improvements to all aspects of cardiac arrest care. Clinical Indicator Improvement Plan

We have developed seven clinical indicators from which we can measure our patient outcomes. These currently include STEMI, stroke, neck of femur fractures, return of spontaneous circulation, sepsis, hypoglycemia and febrile convulsion.

Clinical Team Leaders now have online access to team reports for all seven clinical indicators, and compliance reports for PCR condition code and pain scoring. Members of the Medical and

Clinical Services Directorate continue to meet with Locality Managers and Clinical Team Leaders within each Health Board area to support their understanding and how to best use the Clinical Indicator Reporting System. Three clinical presentations, neck of femur fractures, STEMI, and hypoglycemia, have been the main focus of the discussions with the goal of improving clinical performance in these three areas and generating a stepwise approach to focusing in on short term gains by monitoring Patient Clinical Records.

This previous year has seen the development of a country wide clinical leadership structure, with the appointment of Regional Clinical Leads and Health Board Clinical Leads. These individuals will take up direct responsibility for the Clinical Indicator Improvement Plan, by ensuring each area is focused upon directly. Ensuring that these local discussions and review of the care will improve how these care bundles and pathways are provided to ensure optimum care and improved patient outcome and patient experience.

The Clinical Audit and Effectiveness Programme is now more easily monitored, realistic and achievable, keeping in mind clinical audits that relate to the clinical response model and are not duplicated as clinical indicators. Updates on this programme continue to be presented to various committees and are still included in the Quarterly Assurance Report. The work we describe under our enabling people section supports all steps but in particular Step 4. Our work on advanced practice, our review of our training and education function and our work on a career pathway can support clinical decision making, foster innovation and motivate our staff.

Our developing model for clinical leadership (see Step 5 below and our people section) will provide the overarching leadership and structure to drive the improvements that will ultimately improve clinical outcomes.

Strategic Action: We will create opportunities to continually improve and report on the clinical effectiveness of the care we provide.

This section of our plan should also be read in connection with:

 Section 7.3.2 which outlines how as an organisation we are responding to a number of Welsh Governments Major Condition National delivery plans. A number of the priorities we have identified here also form part of our offer towards progressing step 4 of our clinical model.  Our plans to realise benefits from workforce modernisation including the move to Band 6 and the development of career frameworks in nursing and paramedicine (section 8)

7.1.5 STEP 5: Take me to…..

Handover to LHB services and Alternatives - Alternatives to ED to take patients directly for further treatment as part of a defined pathway Relevant Commissioning Intention(s): o Handover to clear times to reduce across all health board areas o less conveyances and more conveyances to other locations i.e. non-Major EDs o Proportion of conveyance to locations other than major Emergency Departments to increase across each health board area o Notification to handover times to reduce across all health board areas o Compliance with HCP time requests to improve across each health board area

This step refers to patients who are not appropriate for hear and treat or, following see and treat services, require hospitalisation. Our aim is to support those patients who trigger this part of the 5 Step Care Pathway. By definition these should be the patients who need a further level of care and our ambition is to convey these patients to the most appropriate setting and place of definitive treatment. This may be an Emergency Department, but equally it may be a specialist centre, or direct admission into a specialist service (e.g. trauma, cardiac units or gynaecology) or to another setting. The Trust recognises that it can improve against this step only by improving the diagnostic skills of our staff and working with health board colleagues. We will need to support our staff with appropriate training and technology.

In 2017/18 we said we would  Introduce eight dedicated clinical leads for trauma/PHEM, cardiac arrest, stroke/TIA, mental health, end of life care, sepsis and elderly fallers.  Implement a range of alternative care pathways  Introduce an All Wales End of Life Care Pathway  Develop a decision support tool for our clinical staff to use

This is a summary of how we have done  We have started to appoint clinical leads to support these key clinical areas and will complete these appointments through the clinical leadership restructure.  We have implemented a non-injury faller’s pathway approved through our Clinical Pathways Approval Group.  We have developed in partnership Mental Health Pathways in four LHB areas  We have secured access to the Cancer Network Informations System Cymru (CaNISC) which will eliminate the need for the paramedic to ask the patient or the relative the preferred place of care at a difficult time. Specialist support has been developed for paramedics on scene; this is a 24/7 phone line to an on-call palliative care doctor to assist with decision making and advise on patient management. This is available throughout Wales with three regional phone numbers accessible via clinical desk.

We have already outlined in section 4.5.3 our joint priorities with LHBs, all of which are relevant in this section (as previously outlined, Annex 5 provides further detail). In addition we have a strategic focus on the following:

 We have previously stated that the Paramedic Pathfinder triage tool will not be progressed until the outcome of the evaluation of the Manchester Triage System Tool has been completed. This remains the case but additional consideration to this evaluation is our recent progress in the Paramedic Band 6 competencies. The added skill set and capabilities that this three year programme will provide adds to our abilities to manage more of our patients closer to home and as such is a key consideration as to how either of these triage tools, be it Paramedic Pathfinder or the Manchester Triage System, becomes our core triage tool.

 Further embedding the All Wales End of Life Care Pathway which has been implemented across all health boards.

 Further embedding the Mental Health Pathway which has been implemented across all health boards.

 The CASC has requested from LHBs up to date pathways and directories of service to help provide clarity on the pathways and options available to our staff. We will fully support the adoption of these directories of service. Ultimately we would want these to be available on an electronic platform

 Timely handover at Emergency Departments. We will continue to work with LHBs on improving the flow in this part of the system, with a focus on sites where there remain a number of challenges. This will include working with LHBs on fit to sit protocols, identifying suitable holding areas in times of pressure and agreeing the underpinning governance, operational and workforce models. Central to this will be collaborative working on the findings, recommendations and response to the Internal Audit on Handover (December 2017).

 We will learn from the Hospital Ambulance Liaison Officer (HALO) role, put in place with winter pressure monies, to see if there is learning that could determine whether HALOs become part of a sustainable arrangement or as part of escalation plans

 We will work with LHBs to pilot and implement direct admission pathways, avoiding the need to take patients through Emergency Departments.

 We will continue to exploit the opportunities which alternative treatment options such as the alcohol treatment centre in Cardiff can provide in relation to substance misuse and, particularly, excessive consumption of alcohol in our night-time economies.

 We will continue to work closely with our Emergency Medical Retrieval and Transfer Service (EMRTS) colleagues. With the development of the South Wales Major Trauma Network this will be essential to ensure patients in West Wales have access specialist care. Priority areas for strengthened working with EMRTS are:

 Improving the safety of critical care transfers across Wales;  Training for WAST staff in the use of trauma triage tools and other trauma skills;  The switch on of the CAD Aeromedical Module (planned for CAD phase 2 by Q4 2018/19). The Aeromedical module will allow improved management of EMRTS resources;  Ensuring the most appropriate care and treatment and mode of conveyance to or between hospitals are provided for patients.

We are part of the EASC EMRTS Delivery Assurance Group (DAG) and this provides the formal interface for our services.

Strategic Action: We will deliver the LHB and WAST joint priorities as identified in the commissioning templates.

7.2 OUR NON-EMERGENCY PATIENT TRANSPORT SERVICE DEVELOPMENTS

The Non-Emergency Patient Transport Service (or NEPTS) is one of three operational directorates of WAST, alongside the Emergency Medical Service (EMS) and 111/NHS Direct. It is an important part of the Welsh Ambulance Service and is increasingly having the focus, attention and support of the leadership team.

7.2.1 The NEPTS Business Case

NEPTS, previously referred to as PCS, has gone through a significant period of change, firstly as a result of the Griffiths Review in 2008-2012 and then the McClelland Review in 2013. As a result of the McClelland review, a project was undertaken on behalf of the then Minister for Health and Social Care to identify options and make a recommendation as to the future of model of providing

NEPTS within Wales. The final recommendation made and accepted by the Minister (as part of a NEPTS business case) was that NEPTS would be commissioned on an all-Wales basis with WAST being responsible for delivery through a mixed economy approach.

The business case also recommended a number of service improvement initiatives which included:  Establishing a dedicated management structure  Enhanced service for renal, oncology and end of life care  Single point of contact  Longer operating hours  Increased use of 3rd sector providers  New ‘brand’  Integration project between health and social care

These were also reinforced by the current Cabinet Secretary, who highlighted specifically the clinical risk associated with individual renal patients arriving late on regular occasions. This clinical risk was eliminated in January 2016 and has continued to be a ‘never event’ since that time.

In 2017/18 we said we would o Engage with key internal and external stakeholders around the development and implementation of innovative ways of delivering NEPTS to users. o Work with Health Boards and Local Authorities to develop an integrated transport model. o Work with the CASC and Health Board partners to identify alternative ways of providing access to healthcare, including non-eligible patient journeys.

This is a summary of how we have done  Developed a Co-ordination Centre Apprenticeship scheme for NEPTS.  Increased our mix of part time workers to support the male/female mix of our teams and also add flexibility.  Provided stepdown opportunities for front line EMS staff.  Based upon feedback from our staff we have updated our Continuous Professional Development programmes to reflect the specific role of NEPTS.  Supported our team leaders to undertake the WAST Team Leader Development Programme.  Created four Communications Hubs at key hospital sites for our patients and staff.  Implemented mobile devices for our volunteer car drivers and partner providers to improve utilisation and quality of service.  Through working with NESTA and Cardiff University successfully secured R&D funding to assess feasibility of integrated health and social care transport in North Wales.  Developed our call taking functions to provide options for callers to access alternative ways of getting to and from their appointments.  Implemented an innovative scheme that allows oncology patients to stay local to hospital rather than travelling daily on long journeys across West Wales.

7.2.2 Commissioning of NEPTS

An additional recommendation of the NEPTS Business Case was the implementation of a new national commissioning model for NEPTS. Prior to April 2018 NEPTS has been commissioned independently by the seven Health Boards and Velindre NHS Trust to different quality and service standards. The new commissioning model provides a national approach to NEPTS provision across NHS Wales and assures a safe and high quality service through the adoption of a national set of care standards defined through the NEPTS Quality and Delivery Assurance Framework that

has been operating in shadow form since 1 November 2017. Through the development of the framework, it has been possible to capture, in a more robust way, a detailed suite of information on current health board provision. In addition to this, the framework sets out the process for transferring work from health boards in a structured way, and also provides a mechanism through which all future outcome measures can be captured.

A key enabler of the framework is the transfer of Health Board commissioned NEPTS services from non-WAST resources. This will create better value for money for NHS Wales and allow better coordination of services across Wales and provide efficiency savings that will be re- invested to improve the service further, especially around discharge provision to support unscheduled care. The transfer of work will also improve the quality of service by ensuring that both WAST and non-WAST providers deliver services in line with the new framework. A detailed plan exists for the transfer of work from LHBs to WAST, the first contract transferring from April 2018 and others following over the next 2 years.

Strategic Action: We will ensure the successful implementation of the Quality and Delivery Assurance Framework for NEPTS

7.2.3 The NEPTS Five Step Model

The NEPTS Quality and Delivery Assurance Framework is based around a five step model of service delivery.

The aim of the five step model is to focus on patient flow and to provide a clear framework for the delivery of the service in line with patient need. We will use various service improvement methodologies to improve the patient experience over all five steps

7.2.3.1 STEP 1: Help Me to Choose

This step focuses on public and health care professional education regarding the services provided by NEPTS. We recognise that we need to increase our engagement with both existing and future users of NEPTS and health care professionals to ensure that accessing the NEPTS service is simple and eligibility easily understood.

We understand the importance of working closely with Health Boards around their service change and the impact it may have on NEPTS service across Wales.

In support of this step we will work with the Health Boards and other organisations to increase the awareness of alternative methods of transport to care, improving our ability to signpost appropriately.

The valuable NEPTS resource should be focussed on patients who have no other means of accessing appropriate transport to care. Over the term of this plan we will continually work with other transport providers to increase the alternatives to NEPTS for non-eligible patients, as well as reviewing with our commissioners, Welsh Government and other stakeholders the existing eligibility criteria.

7.2.3.2 STEP 2: Answer My Request

Call Taking

During 2017/18, NEPTS introduced a national call taking model with a single 0300 number to simplify access for patients and HCPs. This national model is in place across the three WAST managed journey booking centres. The WAST booking centres take calls directly from patients and HCPs across all areas of Wales. However, there are currently two Health Board managed booking centres taking patients calls from the Ceredigion and South East Wales areas. This currently creates confusion for users and it will be a priority for 2018 to simplify this by full integration of all centres across Wales.

Putting this in place will require changes to the call taking infrastructure across all sites.

We also want to reduce risk associated with HCP bookings by stopping fax bookings from HCPs and extending the provision of on line and telephone capability. We expect that improvements in other parts of the NEPTS system will also reduce the ‘failure demand’ calls currently experienced as a result of uncertainty from users.

Eligibility

Our Patient Needs Assessment (PNA) tool will be continually developed to ensure that our patients get the most appropriate service to meet their needs. We will develop our service to meet specific user needs such as a complex handling service, end of life transport and a planned paramedic service that will help reduce EMS pressures.

We recognise that person to person conversations are the most effective way of gathering valuable information from our patients about their individual need.

7.2.3.3 STEP 3: Coordinate My Journey

Our NEPTS Journey Coordination Centres (JCCs) are key to ensuring we provide a responsive and prompt service to meet their needs. Improvements in the JCCs will provide some of the biggest returns in regard to efficiency and effectiveness of NEPTS. Effective service performance is dependent on our journey planners and on day coordinators getting it right, and this requires appropriate systems to be in place to support staff to deliver the best outcomes for patients.

Use of Technology

We believe that integrating our staff skills and experience with proven technology will significantly improve the way we provide our services. To achieve this we will review the functionality of our existing systems, specifically our Computer Aided Despatch (CAD) system and assess its suitability and flexibility to support our changing needs. If necessary, we will then explore options to bridge the gap including total re-procurement of a CAD or the development and/or procurement of needed functionality. One example of this would be the development of interfaces with the EMS CAD and the Welsh Patient Administration System (WPAS).

Plan Efficiently

During 2017 we undertook significant work to gain a better understanding of the NEPTS demand to help us identify the true need of the service we provide. During 2018 we will continue to focus on developing an effective forecasting model to accurately identify demand to help secure resource.

Using technology, we will shift the balance from user to system planning to reduce workload and reduce variation in approach. We have introduced auto-planning and will be moving to auto- allocation during 2018. This will free our journey coordinators to focus on the more complex journeys and ensure overall achievement of a timely and efficient service. To support, this we have increased the availability and flexibility of our resource base through increasing our use of alternative providers, increasing the numbers of our part time staff and rota changes.

We recognise that increasing the use of alternative transport providers without the ability to improve the way we use the resource will lead to increased cost of delivery. Therefore, during 2018 we will continue to introduce our new Journey Coordination Model.

The new model will increase the use of tried and tested technology such as mobile devices that allow our journey coordinators to know the location of all our resources at all times across Wales. To improve the utilisation of resources, we will also improve working processes and the working environment in the Journey Coordination Centres. This will lead to improved staff retention and reduced training costs.

To increase the resource base in a cost effective way, we have demonstrated that sharing of resources by health and social care can improve quality and reduce cost. The Welsh Government ‘Innovate to Save’ supported R&D project has demonstrated real opportunities in North Wales to reduce operating costs by maximising sharing of resources. During 2018 we will further develop the model and consider applying for Welsh Government funding to roll out the model to other local authorities.

Transfer of NEPTS Work from Health Boards

From 1st April 2018, in line with the business case recommendations and subsequent Commissioning Quality and Delivery Framework, WAST will start to become responsible for the provision of all NEPTS provision within NHS Wales. The transfer of NEPTS work currently commissioned directly by health boards with external providers will transfer into WAST management arrangements using a phased approach, on a health board by health board basis. Current indications are that this will not be fully completed, and all health board work transferred, until April 2019. This would see the enactment of a plurality model, or mixed economy of providers, overseen by WAST to ensure high quality, consistent and fit-for-purpose services are provided to all our non-emergency patients. Through 2017/18, we have played an active role in the development of the Framework, and a key component of this is clarity regarding current health board activity and expenditure. We continue to work closely with the health boards to ensure that accurate information is available to support the transfer of work, and to minimise the risks to both WAST and the wider health system.

After reviewing the agreed plan around transferring work from the health boards to WAST during 2018/19 we anticipate that there is likely to be a requirement for using the Transfer of Undertakings (protection of employment) Regulations (TUPE). TUPE is used where a formal contact ends with one provider and another provider takes on the same or similar work. WAST will ensure that robust legal advice is taken early to ensure that all parties, especially employees, are fully engaged.

This process offers significant opportunities around improving efficiency, maintaining quality and offering better value. However, it will also create risks for WAST that we will continue to mitigate through the development and delivery of the Transfer of Work plan. This will be needed to ensure that the existing arrangements and contracts are transferred in a planned and controlled way that does not increase the risk or cost to WAST and the wider NHS.

All identified risks are contained within the NEPTS departmental risk register. Some examples of the risks include the scope of the service to be commissioned and the management of future increases in demand.

During late 2017 we introduced our brokerage service that is used to identify and create a market place, to identify the most cost effective method of conveying patients whilst meeting the requirements of the Quality & Delivery Assurance Framework. During 2018 this will be further refined and be supported by the introduction of three procurement frameworks that will be used to secure community and voluntary ambulance service provision in a cost effective way. This will provide complete transparency to our commissioner and the health boards around the use of alternative providers and value for money.

Strategic Action: We will progress the transfer of existing non-WAST delivered NEPTS work from health boards into WAST, in line with the commitment of the Business Case

7.2.3.4 STEP 4: Pick Me Up

Service Improvements

Our ambition is to be the leading provider of NEPTS within the UK and, to do this, we need to constantly look at innovative ways of improving our service whilst at the same time becoming more efficient. We will consider the whole end to end system as this will require working closely with our Health Board colleagues. We will use the NEPTS commissioning arrangements to support this on a national basis whilst we look at improvements on a local basis, reflecting local needs where necessary. Our NEPTS management team will be trained in lean service improvement techniques and will constantly be looking for opportunities to implement lean methodology.

In 2017 we continued to deliver improvements to our call taking processes and the promptness of our enhanced service. We also recognised the need to develop our teams to equip them with the skills to meet our future developments such as team leaders’ development, service improvement training and specialised Metastatic Spinal Cord Compression (MSCC) with Velindre NHS Trust.

This was in addition to introducing the ‘End of Life’ service, a specialist patient moving service and other services. During 2018 we will continue to focus on improvements in the Journey Coordination Centre and supporting discharge services.

We will develop a continuous improvement methodology during the life of this plan that will identify, plan, test, check and implement initiatives that will resolve inefficiencies and quality issues as they are identified.

We will continue to work with our commissioner and our partners to ensure that the service meets the current and future requirements of NHS Wales.

Improving the information we provide to our patients will be a priority for us and we will be building on our trials of vehicle based and hospital based information screens to ensure our patients know the best ways of using our services.

3rd Sector Providers

A key aspect of the NEPTS business case was the need for the service to be delivered through a plurality of providers. To achieve this WAST will develop partnerships with the 3rd sector, especially Community Transport Schemes and Voluntary Ambulance Services across Wales. WAST will ensure that all potential providers are supported to meet the new NEPTS care standards contained within the Quality and Delivery Assurance Framework.

Enhanced Services

The NEPTS Business Case clearly identified the need to invest in and improve the transport service provided to renal dialysis, oncology and end of life patients. This was achieved during 2016 and maintained during 2017, with WAST significantly investing in the service both financially and in focus. We are proud of what has been achieved and the subsequent improvements in patient safety have been significant.

Although there is no clear evidence that return home after treatment has a clinical impact for dialysis and oncology patients it is clear that it plays a major part in patient experience. Our focus is to ensure that as many patients as possible are picked up for transport home within 30 minutes of them becoming ready for their return journey after treatment.

We have also significantly improved our response to patients at end of life and who need transport to their chosen place of death. We are now able to provide such transport as a priority with specially trained crews. This service will be made more widely available during 2018.

It is vital that we can convey our most vulnerable patients to hospital during inclement weather such as snow and ice. We have invested in an increased number of all-wheel drive (AWD) vehicles based in strategic locations across Wales to be used by specially trained staff in these situations.

Discharge

Patient flow is a critical part of the delivery of healthcare within Wales. NEPTS can play a key role in improving flow through the effective discharge of patients from hospital in a timely and effective way.

As identified above, NEPTS has already focused on improving discharge transport availability during 2016-2017 as part of the implementation of the recommendations of the NEPTS Business Case. However, there are areas where further improvements can be made through better coordination and responsiveness. NEPTS will focus on this as a priority during the period of this plan and will work alongside the Health Boards to improve the flow out of hospital.

We recognise the focus and effort that is needed to continue this improvement into 2018 and beyond.

Support for Patients Waiting

During late 2018 we will be changing the focus of our hospital liaison roles away from being a desk based role to a front of house, concierge type role. This will improve the patient experience while patients wait, and improve the turnaround times of NEPTS crews at hospital.

We will also be putting in processes to improve the level of information our patients receive to make them aware of how long they will have to wait and other information they will find helpful.

7.2.3.4 STEP 5: Take Me to My Destination

Collection of Information

Until mid-2017 we were unable to capture live arrival and departure times from our volunteer car drivers and community transport providers. We have now rolled out a system of capturing this data in real time. As we increase the number of providers working as part of NEPTS, we will ensure we are able to capture high quality reliable data around timeliness.

Patient Feedback

NEPTS has the opportunity to learn significantly more from feedback from its service users. During 2018 we will continue to develop innovative ideas to capture this feedback and learn from it.

ESMCP

NEPTS will work with the ESMCP programme team to define how NEPTS is best served by the new radio replacement programme. NEPTS is a valuable part of the NHS Wales civil contingency response process.

Aborted Journeys

Up to 10% of all NEPTS journeys are aborted (i.e. cancelled after allocated to a vehicle). This is an expensive waste of resource, both in terms of money and in capacity that could be re-allocated to provide a more timely service for patients.

We understand that nearly 70% of all our aborted journeys are down to just five causes. These are highlighted below.

Four of the five causes can be significantly reduced through pre-calling patients prior to setting off or by developing IT links between Welsh Patients Administration System (WPAS) and the NEPTS dispatch system (Cleric – currently). During 2018/19 we will be working closely with Health Boards to put in place an effective link between both systems.

Appointment Times

Prudency is a key part of delivering NHS services and we see scheduled appointment times as an area where better use of valuable resource could be better used. For example, we use multiple vehicles that are not at capacity to get patients to arrive at their hospital appointment on time. Often the patient then sits in a waiting room, as their appointment time was just an arbitrary time provided to the patient. We believe that through working closely with each health board; these clinics where this practice takes place can be identified and the arrival window widened without any detriment to the patient’s speed of treatment.

Strategic Action: We will deliver actions that ensure NEPTS delivers a safe, high quality and efficient service to our patients.

Strategic Action: We will transform NEPTS by introducing new systems of working, embedding technology and exploring opportunities to innovate through working closely with our workforce and other partners

7.3 SPECIFIC PATIENT GROUP SERVICE DEVELOPMENTS

7.3.1 Amber Calls - Responding to the Challenge

Earlier in the plan we described the challenges which we face in regard to our Amber cohort of calls. Our data shows us that in time of significant pressure our clinical model, as intended, maintains our responses to Red calls within eight minutes, but in doing so the response times for lower acuity calls, including some Amber, lengthens.

Improving our response times for Amber calls is extremely important for the Trust due the direct links with patient experience and patient safety. We have a detailed Amber improvement plan in place which is summarised in the following driver diagram:

The clinical and patient safety risks that materialise when we have insufficient available response to match demand is mainly felt in the community where patients wait. We try to mitigate this risk through use of the Clinical Desk to assess and “safety net”. Whilst this and our actions identified in the improvement plan will help mitigate those risks, a system wide response is required to achieve a more reasonable balance of risk working with the Local Health Boards both as our commissioners with responsibility for population health and as part of the unscheduled care system in their provider roles.

In addition to our targeted Amber Improvement Plan, this IMTP commits us to a number of enables and supporting Strategic Actions that will further improve our efficiency, resource availability and ultimately the service the public of Wales receives:

Demand Reduction Work

 We will review and align our Patient Experience and Community Involvement programme of work with the Trust IMTP priorities and Commissioning Quality Core Requirements (strategic action 7).

 We will commence the implementation of our Mental Health improvement plan (strategic action 8).

 We will implement the next phases of the 111 Pathfinder in line with 111 Strategic Plan for 2018/19 - 2019/20 (strategic action 16).

 We will successfully deliver a primary care programme of work (strategic action 17).

 We will develop our public health plan (Choose Well and Make Every Contact Count (strategic action 44).

 The volume of calls assessed and closed by the clinical desk to increase (sub-action of strategic action 29).

More Efficient Use of Ambulance Resource in Step 3

 We will establish a CAD phase 2 project board and look to make significant progress in realising the benefits of the new CAD (strategic action 15)

 Fleet and staff mix to be reviewed for each health board area tailoring the delivery of the 5 Step Ambulance Patient Pathway to local population needs (sub-action of strategic action 29)

 Rosters aligned to demand for direct staff across each step (sub-action of strategic action 29)

 Sickness rates reduction (sub-action of strategic action 29)

 Compliance with planned rosters to increase (sub-action of strategic action 29)

 Multiple vehicle arrivals at scene to reduce for Amber and Green Incidents (sub-action of strategic action 29)

 The percentage of incidents where the first arriving vehicle is the ideal to increase (sub- action of strategic action 29)

 The actions associated with the Demand & Capacity Review (see 5.1.1 above)

Increasing the Available Resource

 Further develop the “Response Logic” for the Clinical Response Model (strategic action 6).

 We will continue to evolve and implement our falls improvement plan (strategic action 9)

 The percentage of incidents where the first arriving vehicle is the ideal to increase (sub- action of strategic action 29).

Major ED Avoidance Work

 We will agree with our Commissioners a clear and measurable benefits realisation plan for the Band 6 paramedic role and investment, linked to the Ambulance Care Pathway and AQIs (strategic action 23)

 We will develop and embed a clinical leadership culture to create sustainable clinical effectiveness across the Trust from the Trust Board to the operational frontline staff (strategic action 27).

 Conveyance rates will be available at health board, locality, station, staff group and individual level (sub-action of strategic action 29)

 The development of more pathways and the more systematic roll out of pathways that have been evaluated as effective (sub-action of strategic action 29.

Reduced Handover Lost Hours

This is a LHB responsibility, but the Trust can support work in this agree through:

 Hospital Ambulance Liaison Officers (HALOs)  NEPTS work that assists with discharge and bed availability (strategic actions 20 and 21)  Collaborative response to the Internal Audit on Hospital Handover.

The Trust has a significant programme of work which will impact on the Amber tail; however, the Amber tail will remain challenging and the IMTP is predicated on further discussions with EASC, particularly during 2019/20 as the Trust identifies the “missed opportunities”.

7.3.2 Welsh Government Together for Health National Delivery Plans

In 2017/18 we said we would

As part of action 23, “deliver a series of actions to support implementation of the national delivery plans working collaboratively with implementation boards to ensure WAST are integral in influencing change within the wider health system”.

This is a summary of how we have done  We have established an internal national delivery plan forum jointly driven by the Planning & Performance and Medical Directorates.  Reviewed all national plans and determined which are organisational priorities for WAST.  Established a work programme for 18/19 and beyond which aligns to the priorities within the respective national plans.  Reviewed our membership on the national boards to ensure we have the right representation, maximising our input from both an organisational and NHS Wales perspective.

The newly formed National Delivery Plan Forum has reviewed all existing major condition national delivery plans and proposed where it considers the organisation needs to focus its attention.

The following five major condition areas have been identified;

 End of Life  Respiratory  Diabetes  Stroke  Cardiac

To take this forward detailed work programmes continue to be developed to clearly articulate how we will respond and support the implementation of the National Delivery Plans for each of the five major conditions. Draft versions of the work programmes are included in Annex 7 for information.

Once finalised we will focus upon implementing each of the major condition specific work programmes during 2018/19 and beyond.

It is important to recognise that, whilst we have prioritised these five major conditions, we will maintain a close watching brief of the other National Delivery Plans through existing NHS Wales structures such as the All Wales Medical Director and All Wales Planning Director groups. This will ensure that we are able to recognise any changes in priority, allowing the Trust to respond quickly and effectively.

We remain particularly cognisant of, for example, the role we have to play within action 28 of the critically ill national delivery plan which states “Health Boards to work with WAST to monitor and ensure timely inter-hospital transfers with agreed standard operating procedures”

Our Health Board Head(s) of Operations maintain close thinks with their Health Board counterparts to manage inter-hospital transfers whilst as part of strategic planning work in regards to the change agenda taking place across NHS Wales we also ensure pathways, plans and commissioning arrangements are put in place for hospital transfers and repatriations.

7.3.3 Responding to Elderly People Who Have Fallen

Older patients who have fallen are the most common reason for a 999 call in the UK. Approximately 30% of home-dwelling people aged 65 years or older fall every year, and about half of those who fall do so repeatedly.

999 calls to the ambulance service for patients who have fallen divide into two groups – those who are injured and need treatment and those who have fallen, are uninjured but need assistance to get up. This second group of uninjured fallers are categorised as a low priority response through our MPDS system as whilst vulnerable and often frail these patients have no medical need for an ambulance. There have been a number of reported patient safety incidents and concerns because of patients waiting for excessive periods on the floor as a result of a delay in the traditional ambulance response for assistance. Once a patient has been on the floor for some hours medical needs associated with tissue viability, nutritional and hydration needs as well as basic dignity around toileting mean that such patents need for assistance become more urgent but not more clinically significant.

We have developed a range of services to manage older people who fall and provide a faster, clinically appropriate support, which include alternative responses such as Community First Responders, The North Wales Fire and Rescue Service Community Assistance Team (CAT), urgent care service and local authority. WAST has also been one of three ambulance service sites for the SAFER 2 trial involving patients aged 65 years or older after an emergency call for a fall.

Following a workshop on the 27 February 2017, focussing on falls, facilitated by our Pre Hospital Emergency Research Unit (PERU) Team, it was recommended that the Trust develop a principled approach in line with prudent healthcare. This approach should avoid variation, be equitable, safe and effective, financially sustainable in the long term and involve patients as partners in this process.

A Falls Improvement Plan has been developed and focuses on the following key areas:

 Prevention of falls.  Avoidance of inappropriate demand on WAST (in particular from residential and nursing homes).  Responding to people who have fallen but are uninjured.  Responding to people who have fallen and are injured.

The focus has initially been on avoidance of inappropriate demand on WAST and responding to people who have fallen but are uninjured. Nursing home demand analysis to target and support homes with high call volumes for falls related 999 calls has been undertaken and targeted training and procurement of lifting devices has supported nursing homes to lift people who have fallen and are uninjured without the need for an ambulance to attend. This work-stream will continue to scale up across Wales.

A prudent approach is being taken to respond to people who have fallen and are uninjured. Following a clinical assessment, a non-medical response will be dispatched to patients where an injury is not suspected. We are addressing this through a number of work-streams:

 Scaling up our Community First Responder (CFR) Teams through training and procurement of specialist lifting aids.  Plans to scale up our Urgent Care Service (UCS) to respond to people who have fallen but are uninjured

 Working with St John Ambulance to start providing falls assistants. These staff will respond to non- injured people who have fallen after secondary triage by the clinical desk. A pilot of this model commences on the 1st February 2018.

2017/18 and the established of a strategic falls group has also allowed us to develop and consider a Falls Framework. Our thinking to date is represented in the diagram below but this should be considered draft at this stage and is subject to further testing and refinement through 2018/19:

During 2018/19 we will continue to evolve and implement our Falls Improvement Plan (Strategic Action 9) building on the work-streams we have already initiated and developing new initiatives where required.

In particular, we will be exploring scaling up our Falls Response Model currently on-going in Aneurin Bevan UHB. This model involves the deployment of a paramedic and a physiotherapist and is particularly appropriate for people who have fallen, require a more in-depth assessment at home or may have other co-existing morbidities/complex needs. Between October 2016 and October 2017, only 11.34% of patients required further assessment and/or treatment at the Emergency Department following a fall and 76.4% of patients remained in their home or were cared for closer to scene. Further scale up of this model across Wales will require collaboration with other health boards.

We have developed our Falls algorithm for managing our attendance to falls calls:

In Q4 of 2018 we have used Winter Pressures monies to fund falls assistant support from St John Cymru Wales. The St John support has been deployed in line with the non-injury side of the algorithm and has demonstrated around a 40% need for onward conveyance to hospital or face to face assessment by an ambulance clinician. Subject to ongoing evaluation, we may bid to the Transformation Fund to expand this service in 2018/19.

8 OUR ENABLERS

This section describes how we will enable and facilitate change.

The transformation we continue to seek in our service can be achieved only through the effective delivery of our enabling plans. Without a doubt, our most important enabler is our staff, but ensuring we have appropriate estate and fleet is also critical, alongside a timely, sophisticated and relevant businesses intelligence function (health informatics), an appetite for learning and improvement (service improvement, innovation and R&D) and robust and clear governance arrangements.

This section covers the plan for our “building blocks for change”.

 Our People  Our Finances (revenue and capital)  Our Estate  Our Fleet  Our Partners, Patients and Stakeholders - engagement  Service Improvement and Innovation  Health Informatics/Business Intelligence  Information Management and Technology  Research and Development  Our Governance  Welsh Language

For each of these areas, we have also continued to be explicit in the actions that we will take. 8.1 Our People

Note further detail to some of the plans and actions, as well as the operating and strategic context can be found in last year’s Integrated Medium Term Plan 2017/18 – 19/20, and earlier sections of this document.

Our People strategy 'Being our Best', introduced in 2016, continues to be the focus for our workforce, organisational development and education plans and actions. Underpinning our People strategy and action plans sit the principles of prudent healthcare and a prudent workforce.

Four-Step Model – Our People Strategy

There is much to celebrate in terms of progress made, some of which is highlighted in the call out table overleaf, and the Welsh Ambulance Service feels a very different place to work from that of

three years ago. As a result (we have seen an increase in our Staff Engagement Index score from 43% (2013) to 53% (2016). Our clinical response model and the development of the clinical desk in our clinical contact centres are excellent examples of prudent healthcare in action, which, alongside the successful implementation of a new Band 6 paramedic role, scope of practice and competencies, are already driving changes to the shape and skill-set of our existing and future workforce.

In 2017/18 we said we would • Develop a workforce plan informed by the output from the ORH demand and capacity work and fill all EMS vacancies.  Implement the Band 6 role for paramedics, and use this as an opportunity to review the skill mix of emergency ambulance crews at station level.  Collaborate on expanded roles for paramedics across NHS Wales unscheduled care services, GP out of hours services  Commence our review of the Clinical Team Leader role as part of our future workforce planning and skill mix  Reduce abstractions and reliance upon overtime and private ambulances through improved recruitment and reduced sickness and vacancy rates among staff, including a 1% reduction in absence across the Trust

This is summary of how we have done • Further refined the ORH projections and used this to inform our workforce planning and recruitment decisions, and discussions with commissioners. Our current vacancy rates run at less than 4% for the EMS workforce.  Successfully negotiated and implemented a Band 6 role for paramedics living and working in Wales, with the support of our trade union partners; introduced a new EMT3 expanded scope of practice role.  Introduced a pilot for community paramedics in Cwm Taf and Cardiff and Vale, with interest from other Health Board areas, as part of the career pathway  Commenced review of the CTL role looking at role, function and time required.  Demonstrated an increase in the number of staff and production hours available to our Health Board operational teams and a consequent reduction in the need for overtime as a result of better workforce planning and timely recruitment.

There is, however, still much for us to do to be the leading ambulance service we aspire to be.

Key Workforce Assumptions

Our enabling plans and priorities for the next three years focus on the following key workforce assumptions:

 Pay cost inflation of £2.413m in 2018/19 and further cost beyond (see Finance Section);  Identifying the EMS workforce required to deliver safe and high quality, effective services with an assumed level of turnover (at 5.5%), taking action to close the (modelled) relief capacity gap (described earlier in this document) thereby reducing the overtime bill;  Robust forward workforce planning and education commissioning of future paramedics and advanced paramedic practitioners (including funding sources), taking account of degree entry;  The starting position and baseline establishment within the Workforce and Financial Plan is based upon our funded, commissioned workforce establishment and assumes no unfunded changes or increase to workforce numbers across the period to 2020/21;

 Delivering the benefits of Band 6 via education of the paramedic workforce through the course of this plan, to our patients and the wider system, taking account of the £3.577m ring-fenced allocation in 2018/19 and further funding beyond;  Delivery of the benefits of the Clinical Desk, taking account of the £0.622m ring-fenced allocation in 2018/19;  Actions required to deliver our Tier 1 workforce targets (i.e. sickness, PADR , Statutory and Mandatory Training, CPD and Staff Engagement index);  A continued focus on equality, diversity and treating people fairly (i.e. ensuring actions to improve diversity and inclusion in line with our 5% BAME target);  Continued action to ensure timely and safe recruitment plans are in place and processes are efficient to ensure the right calibre of staff with the appropriate qualifications, skills, experience, competencies and personal qualities to meet present and future requirements;  Improving the employee experience and wellbeing, with a focus on mental health and reducing musculo skeletal disorders, with a corresponding reduction in sickness absence rates;  Re-invigorating our Go Together Go Far Trade Union Partnership working and developing a programme of work to achieve this;  Improving our Flu vaccine uptake to meet and exceed the Welsh Government target of 60%.

Workforce Plan

We continue to strive to ensure robust workforce planning across the Trust, building on past improvements to establishment control, confirmed budgeted and actual establishments and aligning recruitment, training plans and education commissioning plans.

Having completed our work to understand current and future demand and capacity in 2017/18, we consider action to close the ‘relief capacity’ gap (identified through this work) to be a key priority for this coming financial year. Whilst positive progress has been made, the efficiency opportunities previously identified have not delivered a substantial, tangible benefit in terms of financial return or WTE available to close the gap, and so we will continue to focus on those efficiencies that are within our gift to control, and seek to accelerate plans to deliver where possible. This includes actions to further improve attendance and reduce variable pay expenditure through timely recruitment, effective deployment and taking opportunities to maximise further rostering efficiencies. We will also review all existing vacant posts across the organisation, re-visit our proposals to introduce an operational shift of reflective practice as part of CPD time, and accelerate our review of the clinical team leader role, among other plans.

Funded Establishment

The starting position and baseline establishment within the Workforce and Financial Plan is based upon our funded, commissioned workforce establishment and assumes no unfunded changes or increase to workforce numbers across the period to 2020/21. The plan outlines some of the opportunities to be explored and potential workforce implications which would be subject to further discussion and agreement with commissioners.

The Trust employs approximately 3,200 members of staff (3,064.60WTE) (as at 31/12/17). The majority are employed within our Operations Directorate, which includes our Clinical Contact Centres (NHS Direct Wales and 111 service), and Emergency Medical Service (EMS), Urgent Care Staff (UCS). We also have our Non-Emergency Patient Care Services (NEPTS) teams.

Funded Establishment and Staff in Post (31 Dec 2017)

Actual Actual Workforce @ Workforce @ 31/12/2016 31/12/2017 WTE WTE Core Workforce:- Board Members 16.00 16.00 Medical & Dental 2.00 2.80 Nursing & Midwifery Registered 111.62 134.57 Additional Professional, Scientific and Technical Healthcare Scientists Allied Health Professionals 984.44 959.45 Additional Clinical Services 1382.66 1450.90 Administrative and Clerical (inc Senior Managers) 447.05 455.16 Estates and Ancillary 48.95 45.72 Students Sub total 2992.72 3064.60

The positive shift in our funded establishment takes account of the impact of a number of investments and developments over the past 12 months, including investments into clinical desk and hear and treat capacity, implementation of a Band 6 for paramedics and creation of a new Band 5 EMT3 ‘step across role, and the further roll out of the 111 Pathfinder.

Our Emergency Medical Service Workforce

Our EMS workforce continues to account for our biggest workforce resource and, therefore, continues to remain a significant focus for our workforce planning activities, particularly the balance of resources and need to maximise developments within Step 2 and Step 4.

STEP 2 (Answer my Call) (Hear and Treat)) NHS Direct Wales/111 Pathfinder

We continue to work with the 111 Programme Team to review baseline demand and capacity calculations and resulting projected workforce numbers for the remainder of 2017/18 and the planning for future roll-out across Wales.

We will work in collaboration with Health Board partners to ensure the successful roll out of 111 across Wales. This will be supported by the introduction of new rotational posts to ensure that nurses gain new skills and experiences, while maintaining existing skills and competencies. This could see, for example, nurses working in both WAST and Primary Care, supporting a ‘hear and treat’ and ‘see and treat’ model of care. To enhance our ability to recruit and to retain our nursing workforce, we are also looking to see how we can use technology to support a flexible approach to working and work life balance, this will include strengthening the Hub and Spoke model by offering opportunities at a local level, to eventually having the ability for homeworking, supported by a centralised clinical leader for advice and support.

Clinical Contact Centre Modernisation

Further detail on the scale of opportunities relating to the CCC is contained in Section 7.1.2. We note the continued positive impact that substantive investment in hear and treat clinicians in 2017/18 has had on ambulance dispatch in this period.

(STEP 4 (Give Me Treatment) (See and Treat)) Urgent Care Services, Emergency Medical Technicians and Paramedics

In 2017/18 we also planned to rebalance the skill mix of UCS, paramedics and EMTs by splitting, where appropriate, double paramedic crews on an emergency ambulance and crewing with an EMT. We anticipated that around 20 paramedic posts each year could be converted to EMT as we move from double paramedic to mixed crews. This was reflected in our financial efficiencies. This exercise was complicated by the introduction of the Band 6 paramedic role and creation of a new EMT3 role for those who did not wish to operate at the higher scope of practice. The impact of this development will be clear by 31 March 2018, enabling us to revisit this skill mix work in a structured and planned way in 2018/19.

A number of prospective benefits to the Band 6 development were identified as part of the business case process, including the development of paramedics as decision-makers within the community, and a reduction of conveyance of patients presenting to the ambulance service to the Emergency Department (a key enabler will be access to health board pathways). We are working with the CASC and his team to develop a range of quality measures, similar to the format of the clinical indicators, designed to quantify some of the benefits. These will be based upon four ‘priority areas’ (determined by the commissioners) including mental health, falls incorporating fractured NOF, chest pain and difficulty breathing. When we are confident the framework is robust, we expect to roll this out across the rest of Wales on a phased basis through 2018/19.

Strategic Action: We will agree with our Commissioners a clear and measurable benefits realisation plan for the Band 6 paramedic role and investment, linked to the Ambulance Care Pathway and AQIs.

Our Non-Emergency Patient Transport Service Workforce

As we continue to implement the recommendations of the Welsh Government approved NEPTS Business Case, the workforce requirements are expected to change significantly. As non-WAST NEPTS demand is identified as part of the transfer process, the TUPE implications of which will become clear over the coming months, we will need to identify the most appropriate and efficient way of delivering the demand in the future.

This is likely to be a mix of Community Transport Schemes, the Voluntary Sector and directly employed staff.

At this moment in time it is not expected that the WTE of NEPTS will increase. However this may happen if the capacity of Community Transport and the Voluntary Sector does not meet the new identified demand (much of the Health Board demand is undertaken by Private Providers) or additional demand is exposed as part of the transfer of work process.

We continue to work with health boards to understand their activity, and to identify the potential NEPTS workforce requirements. Further detail on our NEPTS service is provided at Section 7.2 of this plan.

Corporate Directorates and Support Services Workforce

In 2017/18, the restructure of the Operations Directorate was completed, which sought to strengthen strategic and operational management across all ambulance response and CCC operations teams through the introduction of a regional based management structure. Alongside this, we have also developed our new Clinical and Medical Directorate with the aim of improving clinical leadership across the Trust through the creation of clinical leads within each health board area, and alignment of senior clinical leaders at the regional level to work closely with the proposed Ambulance Response Operations Area Managers. We expect minor headcount changes to establishment in 2018/19 to reflect improved support for mental health across the Trust, including specifically supporting the Trust’s Mental Health Plan and also proposals to enhance occupational health services for staff.

Initial benchmarking of corporate services was commenced in late 2017/18 to understand how the Trust’s corporate and administrative teams compare to those of other similar sized ambulance services and opportunities for further efficiency gains that could be made in 2018/19 and beyond. This work will now be taken forward in early 2018.

Strategic Action: We will benchmark and review our corporate and support service structure and operating model for the future.

General Workforce Efficiency and Productivity Opportunities

As we plan and develop our future workforce, we recognise the need to ensure we maintain focus on opportunities to increase workforce efficiency and productivity. Our main areas of opportunity to reduce variable pay spend and spend on private ambulance providers and improve performance include:  Effective resource planning and efficient rostering of resources, with a drive to tackle variability in abstractions and performance;  Improving attendance at work, reducing cumulative sickness absence rates over the next three years;  Improving the working lives of staff by reducing overruns and improving rest break compliance, providing local solutions to ensure staff are given opportunity to take breaks during their shifts;  Maximising the benefits of a technology enabled workforce;  Streamlining recruitment and reducing time to hire.

As part of our approach to savings in 2017/18, we have, once again, maximised the short term benefits of holding and delaying filling appropriate vacancies, particularly within corporate functions, non-frontline roles. Through continued careful management, we have achieved short- term non-recurrent savings and will continue to maximise these opportunities in 2018/19 as they arise.

Improving Attendance at Work

WAST considers reducing improving attendance at work as a key priority and we refresh our sickness action plans on an annual basis. Our plans remain ambitious and holistic, with a focus on improving the conditions for wellbeing and attendance, rather than just a focus on the process of absence management. In December 2017 we were awarded the Gold Corporate Health Standard for our commitment to improving the health and wellbeing of our staff, described later in this document. However, a lack of any significant improvement in 2017/18 has highlighted the need for investment in services around our most prevalent reasons for sickness, both preventive and reactive. We are aware that, since the improvements delivered in 2015/16, we have

sustained but not significantly improved attendance levels. We will roll forward our targets into 2018/19 – 2020/21 and explore options to enhance services for staff; creating more robust arrangements for managing long-term absence and developing line manager capability.

We have identified several further actions we will progress and focus on over the coming 12 months (and beyond) including:-  A regular, robust case review of the Long Term Sickness cases (our sickness is 70-80% LTS);  Exploration of a business case for physiotherapy services, including preventative;  Exploration of fast-track pathway for mental health cases;  Expediting internal SLA for OH to ensure performance metrics (appointment times; report production etc.)

It is also our intention to work closely with academic partners to track the impact of our sickness interventions to ensure that we are focusing our attention on areas which we are able to evidence have impacted our sickness rates.

Whilst we have made improvements to our Flu Vaccine uptake, from 27% in 2016/17 to 41% in 2017/18 (total staff), we are not content with the level of improvement made. We have, however, learned significantly from this year’s campaign in terms of what has driven improvements in uptake, and what has not been successful. Having considered this, and with support provided via Public Health Wales in terms of the best available evidence, a fresh approach to the campaign will be designed in early 2018/19, collaboratively between the Workforce & OD and Medical Directorates, maximising the benefits of the new clinical leadership structure, along with Peer Vaccinators. We will also build on the successes of this year’s campaign, most notably the tailored communications messages, and sharing of myth-busting evidence, while also focusing on soft persuasion and greater story-telling alongside messages to reinforce responsibilities to protect patients, and professional responsibilities.

Benefits of a Technology Enabled Workforce

We will continue work needed to standardise and streamline workforce processes, maximise the potential benefits of the whole ESR system and enhance the quality of workforce information available to managers. This will significantly enhance individuals’ and line managers’ ability to ‘live report’ and provide intelligent data to drive managerial decisions. Our ability to maximise the true benefits of this depends on accessibility for our staff, and this is one of our ICT priorities over the next three years, including plans to increase access to mobile electronic devices for all staff.

Our Volunteer Workforce

It is important we do not overlook the huge contribution to supporting our frontline teams and services made by our fantastic volunteers, including our Community First Responders (CFRs) and circa 360 volunteer car drivers. We will seek to conduct a full review of the recruitment and use of volunteers across the service, and develop a volunteer strategy that will look creatively at solving the difficulties experienced in attracting new volunteers, ensuring we maximise and demonstrate we value their contribution to our work.

Strategic Action: We will develop a Volunteering Strategy that will ensure we understand, value and maximise the important contribution that volunteers can and will make to our services in future.

Making the Future Look Different

Following our Career Pathway Stakeholder Event in summer 2016, we kicked off a programme of work to shape future roles and a career pathway for frontline staff, and have been working collaboratively across clinical, professional, operational and workforce colleagues to progress a number of developments, including a visualisation of a career pathway with clear educational requirements.

The Band 6 / EMT3 development has further enabled us to create a much needed career structure for EMTs with progression through EMT1 (Trainee); EMT2 (Qualified EMT); with potential to get to EMT3 (To include current Advanced AEMT workforce; Step-Across paramedics from Band 6 process; and option to create a further number of EMT3 posts within establishment). In addition, this will support direction of travel in terms of any potential scale-up of Advanced Practice; as well as potentially creating a pipeline of EMTs to progress to paramedic conversion for future workforce requirements.

We are developing an agreed Nursing Career Framework which will continue to value and support our current nursing workforce, while also developing new and exciting roles and opportunities. To take this forward we will support the introduction of Student Nurse placements (and other healthcare professional placements) to ensure that students have an understanding of what WAST has to offer and the scope of practice that nurses in WAST work to. It will see the development of a new Band 5 to Band 6 nursing role, supported through a professional competency framework.

Our workforce modernisation developments and opportunities have included development of apprenticeship opportunities, including a new NEPTS Control apprenticeship, and addressing opportunities for the deployment and scope of practice for EMT and UCS scope of practice. We have also explored specialist or extended roles that we believe could have a positive impact on our ability to better respond to demand from our Amber category patients in future. These include, but are not limited to:

 Community-based paramedics in rural areas – more and more paramedics will be working with GP clusters in a geographical area in RRVs on behalf of either WAST or GPs directly  Expanding the expert knowledge base of staff working on the CCC clinical desk by collaborating with health boards to extend opportunities to midwives and mental health nurses  Creation of a nursing workforce modernisation forum, and introduction of rotational posts for nursing staff between ABMU Health Board and the 111 Pathfinder service  Introduction of formal clinical leadership roles (clinical lead / consultant paramedic), working at a strategic level developing new care pathways whilst liaising with central heath policy makers.  Using clinical information via the Digipen system to allow clinical team leaders to discuss alternatives to conveyance with colleagues;  Developing a decision making support app which staff can use to support their clinical decision making.

We also remain committed to exploring opportunities to expand our impact and influence across the wider health system; to modernise and redesign clinical roles and clinical practice. A key example of this is the development of the vision and role of advanced practice within the service.

The Nurse Staffing Level (Wales) Act 2016

We also recognise that The Nurse Staffing Level (Wales) Act 2016 which became law in Wales in March 2016 also has an impact on how we make the future look different.

The Act requires health service bodies to make provision for an appropriate nurse staffing level wherever nursing services are provided, and to ensure that they are providing sufficient nurses to allow them time to care for patients sensitively. This requirement extends to anywhere NHS Wales provides or commission’s a third party to provide nurses.

The Act consists of the 5 sections, however, section 25A refers to the health boards’/trusts’ overarching responsibility to have regard to providing sufficient nurses in all settings; whilst the other sections of the Act set requirements specifically for Health Boards for each adult acute medical and surgical ward.

With regard to section 25A, the Welsh Ambulance Services NHS Trust has:

 Embraced the Nurse Staffing (Wales) Act 2016 through the focused development of the WAST Nursing Career Framework (2018). The aim of this framework is to present the nursing career opportunities within WAST to attract, recruit, train and retain nurses in the pre hospital care setting, whilst working in collaboration with Health Boards and Trusts to establish nurse rotational posts across services over the next 12 months and beyond.

 Established the WAST workforce group for the 111 project (NHSDW &GPOOHS) during 2017 to review, plan and monitor the nursing workforce plan to support the roll out of the 111 service and to embrace a collaborative approach with Health Boards to achieve the appropriate nurse staffing levels for this service.

 Provided evidence of the nursing staffing levels to support the first expansion phase and implementation of the clinical desk in the clinical contact centres and will continue to work with commissioners to maximise the future expansion of this service.

 Commenced working with the Health Boards to undertake joint investigation across patient pathways to inform the measurement and reporting of the metrics required by Health Boards to be reported to their Boards (for example joint investigation for health care acquired pressure ulcers).

The Future of Advanced Practice

Subject to securing necessary funding availability, we will believe there is a strong a case to expand the provision of advanced practitioners in each health board area. The likely introduction of prescribing for advanced paramedics within the next year or two, offers a further, significant opportunity for advanced practitioners to treat and discharge patients.

Working as a clinical team in each area will ensure only the patients who really need to be transported to the emergency department are conveyed and, where possible, patients are managed within a community based setting. We are also seeking to maximise our existing APs’ opportunity to contribute and add value to the appropriate category of patients, whilst also ensuring they are able to maintain the four pillars of advanced practice through the development of a rotational model which would see APs being based in the Clinical Contact Centre, as a WAST response and also supporting other areas of the health community, for example primary care. This also has potential to support the developments in paramedic banding and the creation of a Band 5 newly qualified paramedic who will require access to clinical advice and support.

As we develop our advanced paramedic vision, we will be informed by current trials in North Wales, Aberdare and the Vale of Glamorgan as to the role of AP staff in the community. Should these evaluate positively we will consider bidding against the Transformational Fun for additional APP resources. We will commence development of a programme to recruit, train and supervise APPs in the future. This will be developed by our clinical leadership structures in discussion with

the primary care workforce and Health Board partners to ensure the contribution of AP staff is maximised, as described earlier in the plan.

Education Commissioning

Our position in terms of diploma qualified paramedics has also evolved positively over recent years, from a position in which we had too few paramedics to fill our vacancies in 2014/15, to a position in which we are now able to fill our vacancies. In 2017/18 we were also able to over- recruit to a limited extent (to replace overtime spend). We do, however, continue to keep diploma commissioning numbers under review, to ensure we do not return to the position of previous years.

In preparation for potential development to degree level education, we have worked closely with Swansea University to develop a three- year undergraduate degree. This means we have the option to either commission places on both diploma and degree programmes simultaneously for one year, or to commission places on the degree programme, supplemented by an internal supply of qualified paramedics via the EMT conversion programme. It has been agreed that the EMT Conversion programme will continue until 2020 at diploma level giving current EMTs the ability to work within the timescale to progress to paramedic roles.

We will ensure our paramedic educational commissioning numbers to 2020 meet our demand for newly qualified paramedics - subject to our attrition rates, our ability to secure student outtake and assumed no growth in the workforce. However, this will be dynamically reviewed in the context of suggested increased paramedic and advanced paramedic workforce requirements across the system (identified in Health Board plans), any agreed action to bridge the relief capacity gap and the final EMT3 step-across numbers.

In terms of the Advanced Paramedic Practitioner (APP) workforce, commissioned education at Masters Level, our proposed numbers reflect our ambition and preferred direction of travel to upscale the successful APP pilots in Cwm Taf and Betsi Cadwaladr Health Board areas to maximise benefits across the wider system.

Timely Recruitment

Promoting the Trust as an employer of choice is a key objective of this plan, with an emphasis placed on the kind of employment experience the Trust can offer potential candidates and a clear understanding of why people stay within the organisation and are prepared to go the extra mile. We will ensure we link our work to that being undertaken on an all-Wales basis, led by the NHS Wales Directors of Workforce and OD, specifically in relation to developing an ‘NHS Wales Recruitment Brand’.

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In 2017/18 we said we would • Progress the Trust’s corporate recruitment branding and development of new promotional boards and materials. • Reduce time to hire and streamline our recruitment activity. • Develop targeted recruitment events and a positive action recruitment plan to increase applications from members of ethnic groups currently under-represented in the workforce.

This is a summary of how we have done • Refreshed our recruitment re-branding and produced applicant information packs for use at open days • Significantly improved the average time to recruit from January 2015 (169 days) to January 2018 (68 days) • Successfully repeated our award winning 'Big Bang' recruitment event for qualified paramedics and successfully recruited a further 50. The majority of these became operational prior to Christmas 2017. More events are planned for 2018 with a focus on EMTs and increasing our intake from BME communities.

In terms of supply of paramedics, which remains a shortage profession UK wide, our workforce planning has demonstrated that, over the course of the three years, we have commissioned more than sufficient student placements to meet demand for paramedic staff within our current staffing model. It does not necessarily follow that all paramedic students who train in Wales will seek employment with our service – indeed three years ago a high proportion of students sought work outside Wales. However, we have been increasingly successful in our recruitment, as a result of positive changes within the organisation, leading to a position in 2016 where the Trust was able to over recruit to get ahead of the recruitment and turnover curve advance of the winter months – this has been an important part of our winter planning process, and will continue to be so.

Our focus for this programme of work will be:  continued drive to deliver targets set by the ‘Hire to Retire’ Streamlining Programme for NHS Wales;’ a look at our current approach and process of recruitment to ensure we attract and recruit the right person, with the right behaviours and an understanding of the demands of the job to improve retention of new starters  Ensuring timely recruitment and training plans in line with operational needs.  Increasing our presence in schools and at careers fairs, ensuring we are visible and increasing opportunities for work experience (as appropriate), and completion of the Welsh Baccalaureate modules development with the WJEC.  Building on the success of events such as the Loudoun Square Cardiff Career Event in January 2017 to increase awareness and access to careers in WAST for individuals coming from the BME community, increasing applications from members of ethnic groups currently under-represented in the workforce.

Education, Training and Development of Our People

2017/18 has been another very successful year in terms of the transition to regulated, accredited education and the creation of a vision for the future of education in WAST, and we also have delivered a number of developments and improvements, over and above our expectations.

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In 2017/18 we said we would:  Design a vision for a flagship NATC and trial delivery of CPD via Local Learning Cells  Review the Education & Training Team staffing model and build a training plan aligned to demand and core priorities  Develop and expand technology enabled learning opportunities  Review the existing model of delivery for paramedic education and propose alternatives  Develop accredited, regulated education programmes for NEPTS and UCS  Increase the availability of apprenticeships across the Trust

This is a summary of how we have done:  We have developed and begun to engage on a vision for the future of NATC, as part of the Trust’s Long Term Strategic Framework development and we have trialled a Local Learning Cell in Aneurin Bevan as part of this development.  Our Immersive Learning Environment (ILE) is now being installed permanently at the National Ambulance Training College for daily use  Established positive, collaborative meetings with Swansea University colleagues, to explore potential alternative models of delivery, including the transition to degree level education and delivery of the EMT Conversion programme in both North and South Wales  Continued our development work on apprenticeships, with the introduction of fleetcare apprenticeships and creation of a new NEPTS Control Apprenticeship

Education Strategy

The creation of a single Strategic Education Steering Group in 2017 has created an opportunity for a more strategic dialogue on future educational requirements across the whole Trust. In 2018/19 we plan to review and evaluate the existing paramedic education delivery model in collaboration with Swansea University, with a view to ensuring an appropriate balance between the provision of quality teaching and research with opportunity to gain practical training, skills and experience in a range of settings. The Education and Training Team will also lead development of a new Strategy to support the ambition of becoming the leading ambulance service. This strategy will include the infrastructure, estate and staffing model required to deliver access to a high quality, transformational education for all. It will also consider options for the provision of a virtual learning environment for staff and a fully functional and effective eLearning platform that will provide students and tutors with state of the art, innovative learning and reference materials and tools. We will look to collaborate with the wider health, social care, education and emergency service partners to maximise opportunities and turn our vision and aspirations into reality.

Strategic Action: We will develop an overarching Education Strategy by the end of 2018/19, that will enable us to ensure all staff receive the highest quality education and training to deliver their roles effectively; expanding our apprenticeship opportunities will be a key deliverable of this strategy.

Vision and Future Capacity

In 2016/17 we set ourselves the challenge of designing a vision for a flagship National Ambulance Training Centre (NATC) of the future, and we are currently developing that vision and sharing it with key stakeholders for their view and support. In 2017 we undertook a benefits appraisal exercise to identify a preferred model. Our vision is to create a hub and spoke model centred on the development of two or three equitable ambulance academies, supported by local learning

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cells, with agreement for training facilities to be included in all future operational estates developments.

In 2018/19 we will develop this work to include the views of colleagues across the Trust and to explore exciting opportunities for collaboration through co-location with strategic partners. The idea of creating local learning cells for the local delivery of nationally designed CPD programmes has been well received so far, and we plan to further test some of our assumptions by launching a second pilot of this model to commence in April 2018 in the Hywel Dda LHB area. We continue to work closely with colleagues in the Medical, Operations and Estates Directorates to seek solutions to potential future capacity constraints and ensure our education, training and development facilities and programmes are fit for future purpose.

Strategic Action: We will continue to develop and engage on our vision for 3 equitable Ambulance Academies and develop a clear business plan in early 2018 for consultation and implementation, subject to identified funding.

CPD/Statutory & Mandatory Training Compliance

In response to constructive feedback received from all levels of staff, 2017 saw the review of statutory and mandatory training. The Trust’s target for S&M compliance is 100% and over the last year we have developed two targeted campaigns in order to directly and positively impact on compliance rates. Compliance at end of December 2017 was 85.96%, compared to 65% in April 2017, showing significant improvement.

Widening Access

Good progress has been made, and in 2017/18 we developed a Level 3 Award and Certificate in Non-Emergency Patient Transport Services (NEPTS); we will work to introduce this programme in 2018/19 and provide regulated and accredited education for all operational grades of staff. This development supports the Welsh Government’s health care support worker agenda, and the team will also be leading the scoping and development work to establish a number of apprenticeship roles within the operational arena, starting with NEPTS roles as a trial.

Our Organisational Development Plan

We continue on our transformational OD journey described in more detail in our 2016-19 Plan. In 2017/18 we further embedded our overarching principles/approaches to help the normalisation and living of our shared behaviours. This helped support and deliver increased understanding and ownership of our approaches to equality (Treating People Fairly), wellbeing (#WASTWellbeing), leadership development and engagement delivering transformation for communities, partners and colleagues.

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In 2017/18 we said we would  Regularly monitor and improve Engagement Index levels;  Increase the quality and levels of 1:1 and PADRs including achieving a PADR target of 85% by 31st March 2018.  Review and expand our celebration and awards programme  Start the delivery of our bespoke Team Leader programme  Develop leadership opportunities for middle and senior managers (with a programme to be scoped by April 2018)  Increase the health and wellbeing support available to colleagues (especially mental health), specifically by delivering TRIM and achieve Corporate Health Standard Gold  Deliver Treating People Fairly with an enhanced and supporting WRES Action Plan; Use every opportunity to promote understanding and valuing of difference such as highlighting and marketing specific Wales and UK campaigns

This is a summary of how we have done  Delivery of Treating People Fairly which was enhanced by Trust Board approval of our Workforce Race Equality Standards action plan. We were also the first Welsh NHS organisation to be accepted on to the NHS Employers Diversity & Inclusion Partners Programme 2017/18  Delivered regular pulse surveys results for local teams; with local ownership of engagement levels as evidenced within team/directorate plans.  Programmes of development for specific teams to improve their effectiveness – this has included Board and EMT Development Plans, Directorate Senior Teams, and specific groups/teams. This has included the QPSE Directorate, CCC teams and the NEPTs Senior Team  Delivered the first six cohorts of the Team Leader Programme; developed a proposal for middle and senior management leadership development, with better co-ordination of current approaches and opportunities (implementation subject to funding)  Staff Awards Programme delivered a highly successful Learning and Celebration Day in June 2017 and Awards Evening in October 2017. The programme attracted significant sponsorship.  Increased the quality and amount of the wellbeing support specifically mental wellbeing; this has included roll out of TRIM, launch of Wellbeing Advocates Network, creation of Strategic HWB Steering group leading to achievement of the Corporate Health Standard Gold in December 2017

We will continue to focus on improving the employee experience, increasing access to leadership development opportunities, and taking action to encourage the right conditions for health and happiness across the organisation. We welcome the inclusion of a fourth ‘aim’ of workforce wellbeing as part of the recommendations of the recent Parliamentary Review. This aligns with our own focus on improving the wellbeing of our workforce.

We use regular feedback from our quarterly Engagement Index Pulse Surveys to improve our services and shape our plans to make our Trust a great place to work. More work is planned to ensure that all colleagues can easily give feedback in order to increase participation rates, and we have an ambition to achieve 60%+ in the proposed 2018 Staff Survey (initial results of local quarterly pulse surveys through 2017 (59% in Q2 2017-18) indicate that this is achievable).

The priorities identified collaboratively, both corporately and within local teams, will continue to be implemented through the lifecycle of this plan. Specifically, these include:

 Maintaining continued visible, vibrant and compassionate leadership at executive and senior management

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 Delivering Treating People Fairly through the reinvigoration of our LGBT and BAME networks; collaborative research with Swansea University on barriers to BAME students and why they often don’t think/ choose paramedicine as a career.  Delivery of our bespoke Team Leader programme in 13 cohorts and then on an ongoing basis. This will be supplemented by a leadership development programme for middle and senior managers and a proposal for delivery during 2018/19 and beyond, subject to funding support.  Continued development and implementation of the Staff Awards and Recognition programme  Developing a programme of work to move our Go Together Go Far Trade Union Partnership working forward to a next phase  A continued focus on maintaining good mental health and wellbeing, through increased support for self-care, improved resilience and roll out of the Trauma Risk Incident Management (TRiM) support function  A focus on the importance of maintaining good physical health, including action needed to reduce the incidence of violence and aggression faced by our staff, (including a reduction in the number of staff who report being bullied, harassed or abused by members of the public and / or their colleagues) and action needed to reduce the incidence of manual handling injuries, and creating safer work practices and environments.  Implementation of sustainable regular immediate colleague feedback to enhance the PADR experience and improve opportunity for clinical reflection and practice development  Implementation of a robust flu immunisation programme for 2018/19  Overall planning for achievement of the Corporate Health Standard Platinum by 2020/21

Delivery of these actions will be key to achieving some of our Fantastic People and Vibrant Leadership performance ambitions.

Strategic Action: We will enhance and strengthen our Occupational Health and Wellbeing Services; with a focus on further improving access to mental health and musculo-skeletal services for staff.

Strategic Action: We will deliver the commitments within our WRES (Workforce Race Equality Standards) action plan, specifically designed to address reported inequalities and measure and improve the experience of under-represented BAME staff.

Developing Our Long Term People Strategy #FutureofWork

It is also our intention to refresh our People Strategy in 2018/19, aligned to the developing longer term People Vision and Strategy (see page 30) that will respond to the challenges we think the #FutureofWork in Welsh Ambulance Service will bring, and what that means for the Workforce and OD Directorate.

There is a large volume of literature and many ‘expert views’ around the subject of “the future of work”, but it is, of course, difficult to make accurate predictions about the future. We are currently exploring how we prepare ourselves to be able to deal with the challenges that may face us, as well as ensuring we are sufficiently agile to respond.

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All of the above is likely to impact hugely on HR, OD and people practice more generally. There will need to be a shift from traditional modes of HR delivery, away from transactions and employee relations, and much more towards a focus on enhancing manager capability, coaching, and enhancing the employee experience in a variety of ways. We will consider whether we are currently set up to meet these challenges, or whether we need to reconfigure the way we provide services to prepare the organisation for what might be ahead of it.

8.2 Our Finances

2017/18 has seen the continued implementation of significant service developments that are focused on delivering the best outcomes for patients and improving performance. Developments have been introduced on a pilot basis with the full service, activity, performance and subsequent financial impact of these significant developments continuing to be assessed and refined in line with emerging evidence and evaluation and, where appropriate, factored into the financial plan.

Specifically these have included:

 The formalisation of the Clinical Response Model.

 Successful implementation of a new Computer Aided Despatch (CAD) system.

 Continued roll out of the 111 service.

 The implementation of the Non-Emergency Patient Transport Service (NEPTS) with the introduction of the commissioning framework.

 Agreement and implementation of the band 6 paramedic role.

WAST remains committed to developing services over the immediate and medium term that will increase productivity and efficiency and promote sustainable system wide change. These include driving through innovative and collaborative service delivery. A key example of this are pilots to explore the development of the role of the community paramedic. These pilots have provided evidence to demonstrate how we can engage with partners across the wider care sector to develop holistic and patient centred approaches to help to manage the pressure of increasing demands in both primary, secondary and potentially social care. Determining how this can be sustainably resourced to secure these roles in the longer term will require a similarly collaborative approach, including consideration of funding streams including primary care and transformation funding announced as part of the Welsh Government Final Budget. Specifically there is an emerging proposal in relation to the introduction of Community Paramedics within primary Care Clusters across Cwm Taf which will be more fully developed over the next few months.

We have taken a strategic approach to the development of a Medium Term Financial Plan which has enabled the organisation to address both immediate financial requirements but reflects our commitment and flexibility to adapt to service change. It is evident that the effects of service change and the resultant financial impacts must be considered at a system wide level and that as part of this our resource and investment plans reflect the principles which underpin prudent healthcare. This includes in conjunction with the Trust’s commissioners. Similarly there will continue to be a drive to further increase efficiency, to ensure value for money and to maximise the benefits of the resources available. This remains a key focus in the refreshed IMTP with the scrutiny of costs and financial governance central to the delivery of our vision for a caring and responsive ambulance service for people in Wales.

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To achieve this we will work both internally within the organisation to ensure that there is cohesion between financial, workforce and service planning to support decision making and to optimise service delivery and also with our partners including the Chief Ambulance Services Commissioner (CASC) and the Emergency Ambulance Services Committee (EASC). This will include exploring opportunities for further collaborative working including estates.

The current revenue financial position – 2017/18

The table below presents a summary of the Trust’s financial position for the year to date at 28 February and the forecast year end outturn for 2017/18.

Mth 9 Annual Financial position Actual Forecast £000s £000s INCOME Total Income 162,006 178,298 EXPENDITURE Pay - Sub Total 113,552 125,755 Non Pay - sub total 31,786 34,665 Total Expenditure 145,338 160,420 Profit / Loss on asset disposal - 200 - 200 Total Depreciation, Accelerated 16,786 17,972 Depreciation & Impairments Total Interest Receivable - 28 - 29 Total Interest Payable 125 135 Net Surplus / (Deficit) 15 -

Our plan has included a challenging savings target of £4.9m (4%) for 2017-18. The table below presents a profile of savings delivery for the year to date.

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We said we would:

 Achieve break-even in accordance with our Statutory Financial Duty.

 Prepare a financial plan to support the IMTP and to have the plan approved.

 Meet the Welsh Government Public Sector Payment target. This is a summary of how we have done:

 We are forecasting a break-even position for 2017/18.

 We are on track to deliver our savings plans of £4.9m, of which £4.7m relates to recurring schemes.

 We have enhanced our arrangements to monitor and scrutinise progress against our approved financial plan which is regularly reported to our formal Finance and Resources Committee (FRC) and Trust Board.

 Public Sector Payment (PSPP) compliance for Month 9 (Non-NHS number & value) was above 98%.

Future year revenue financial planning assumptions

WAST receives the vast majority of its income through a commissioning arrangement, led by the Chief Ambulance Services Commissioner, who acts on behalf of all Welsh Health Boards on the commissioning of Emergency Ambulance Services. This arrangement is conducted through the Emergency Ambulance Services Joint Committee (EASC) which is responsible for developing collective commissioning intentions and plans. Funding for ambulance services is incorporated as part of the allocations made to NHS organisations by the Welsh Government. It is expected that national, NHS wide, planning assumptions, including funding uplifts, will be equally relevant to commissioning agreements and financial plans for WAST have been developed on this basis.

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There are some key financial assumptions within the Trust’s three year financial plan which include:

 National position The 2015 UK Government spending review announced an increase in NHS revenue expenditure over the next five years. The Welsh Government draft budget similarly provided for increases in 2016/17 and 2017/18 and has subsequently provided a further increase for 2018/19 of £230m for core NHS services.

WHC (2017) 053 Specifically highlighted that the additional investment of £230 million revenue funding is intended to recognise the cost and demand pressures facing the NHS in Wales which were outlined in the 2016 Health Foundation report – The Path to Sustainability.

The WHC provided details of Health Board allocations and identified how £92m of the additional funding has been allocated “to meet estimated pay and other inflationary cost pressures for 2018/19”. This equates to a 2% increase on the recurrent discretionary allocation, ring fenced and direct expenditure. In addition the WHC specified that “Health Boards and the Welsh Health Specialised Services Committee are expected to pass on appropriate levels of funding for relevant pay and non-pay inflationary cost increases in the Healthcare Agreements for services provided by other Boards and NHS Trusts.”

Further WHC (2017) 053 describes how contributions towards specific developments have been top sliced with funding transferred from discretionary to ring fenced allocations. For WAST the ring fenced allocations provide for:-

 Paramedic banding £3.577m  Clinical Desk enhancements £0.622m

In addition the allocation letter indicates that the level of funding to support depreciation is to be increased by £2.202m in 2018/19, to a total of £14.930m.

Each of these increases will be paid through EASC.

The table below presents our (current) assumptions in relation to how the expected uplifts will be applied in relation to the baseline income that WAST receives from Welsh Health Boards and Trusts.

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2018-19 Uplift @ Uplift assumptions Baseline 2 % Total Income Source £m £m £m EMS baseline 137.9 2.8 140.7 Increase in Depn - per WHC (2017) 053 2.2 2.2 Clinical Desk - per WHC (2017) 053 0.6 0.6 ESMCP 0.6 0.6 Band 6 paramedic - per WHC (2017) 053 3.6 3.6 ESMCP CRS 1.7 1.7 Total EMS 146.6 2.8 149.4 Renal Transport 1.1 0.0 1.1 NEPTs* 19.5 0.4 19.8 Income from Health boards & Trusts (including 111) 8.8 0.2 9.0 Total income from NHS Wales 176.0 3.3 179.3 * Includes £0.763k income from Cardiff & Vale transfer of work

In addition WAST receives funding of £4.5m from Welsh Government, to support the Hazardous Area Response Team (£2.3m), PIBS (£1.5m) and training and also a small level of income from English health organisations and non-health organisations.

 Inflation and unavoidable costs

Our financial plan has included the following increases attributed to inflation (pay and non-pay) and other unavoidable costs.

This exceeds the level of uplift by £0.4m

These figures have been based on a number of assumptions including:-

Pay

 That NHS pay awards remain capped at 1%.  That current pay terms and conditions, particularly in relation to the payment of enhancements on Sick Pay, remain in place beyond 31st March 2018.  That the impact of changes in the NHS employers pension discount rate due to be introduced in 2019/20 will be fully funded (£1.4m for WAST).

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Non-Pay

 That depreciation funding to support future capital investment will be made available as required.  That any future financial implications arising from Brexit negotiations will be reflected in future allocations.

2018/19 baseline position

 Emergency Medical Services (EMS)

In developing our financial plans the following assumptions have been made to provide a planning baseline for income for 2018/19, and future years.

 That baseline income for 2018/19 will remain constant in real terms with the values identified within the three year financial plan which supports the IMTP, and will be uplifted for inflationary costs by a minimum of 2%, in accordance with WHC (2017) 053, plus ring fenced allocations to support paramedic banding £3.577m, clinical desk enhancements £0.622m, and depreciation £2.202m. In addition funding of £1.7m has been agreed for ESMCP control room solution. This would increase the baseline to £149.4m for 2018/19 rising to a total of £150.5m when renal transport is included.

Our plans currently have assumed that additional funding, over and above this baseline, will either be required to support the following or that the costs will not be incurred.

 Community Paramedics. The full potential for the community paramedic role is being explored with the outcomes from existing pilots currently being evaluated as part of the work of the Bevan Commission, supported by Swansea University. The funding arrangements to support these developments are not included within the EMS baseline and their continuation will be dependent upon sustainable resources being made available. This role provides a unique opportunity to extend the role of paramedic across both primary and unscheduled care to respond to system wide demands and which is founded on improved patient outcomes rather than organisational boundaries. As part of our evaluation of this role we will explore how funding sources, including from Health Boards, primary care streams and potentially from the transformation funding announced as part of the 2018/19 budget, can be secured.  Local schemes to provide additional capacity (funded by Health Boards). In addition to the core EMS baseline there are in place a number of local initiatives, many of which are longstanding and some which are relatively recent. It is assumed that an uplift of 2% will be applied to these in line with WHC (2017) 053. For those schemes where funding has been provided on a short term basis it is assumed that activity and costs are similarly non-recurring.  Emergency Services Mobile Communications Programme (ESMCP). Any additional revenue costs falling to the Trust due to the ESMCP and associated business cases are assumed to be financially neutral, i.e. additional funding will be made available from Welsh Government to offset any additional costs.

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 Renal Transport funded through WHSSC

It is assumed that income for renal services will remain, as a minimum, constant in real terms with 2017/18 levels. On this basis at least £1.1m will continued to be funded, separate to EMS, through WHSSC.

 Non-Emergency Patient Transport Services (NEPTS)

The implementation of the Non-Emergency Patient Transport Services (NEPTS) business case was announced by the Deputy Minister for Health on 22 January 2016. The financial case included a commitment to fund service developments through increasing efficiency in this service and is predicated on an assumption that future funding streams will reflect current levels. This is in line with the assumptions included as part of the business case developed in partnership with all Health Boards and Trusts.

The Quality and Delivery Assurance Framework for NEPTS was introduced in 2017/18 and we will continue to work closely with our commissioners to build on this in 2018/19, particularly in respect of strengthening service line reporting and enhancing financial information to support the continued delivery of the NEPTS business case.

Similarly we will support the transfer of non-WAST NEPTS activity from each of the 9 organisations (7 health boards, Velindre and WRCN) into WAST in line with the expectations of the NEPTS business case ensuring that the financial risks to the organisation are managed accordingly. This will include the development of the procurement framework for the enactment of the plurality model, ensuring that any new process is embedded within existing financial requirements. Underpinning this is an expectation that any changes to future service delivery / contracts with 3rd parties will be supported by additional and full funding. The first of these agreements with Cardiff and Vale UHB will result in an increase in costs / income of £0.8m from 1st April.

Our plan has assumed that the baseline NEPTS income for 2018/19 will remain constant in real terms with 2017/18 values and that this will be uplifted for inflationary costs by a minimum of £0.4m, 2%, in accordance with WHC (2017) 053 providing a total quantum of funding from Health Boards of £19.8m.

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We said we would:

 Implement the NEPTS business case including the implementation of the Quality and Delivery Assurance Framework. We assumed:

 That funding would remain in real terms constant with 2016/17 levels.

 That the costs of service improvement would be met through efficiencies. Our assumptions are:

 That funding will remain, as a minimum constant, in real terms, at 2017/18 levels uplifted to reflect inflationary pressures.

 That the profile of service development vs cost releasing allocative efficiencies will require review to ensure that a balanced financial plan can be achieved.

 Additional (full) funding will be provided to support future service / contract changes.

 111 The direct financial impact of the 111 pathfinder is assumed to be cost neutral, with corresponding income (initially via ABUHB) and expenditure assumptions

111 Estimated profile of costs (minimum) 2016/17 2017/18 2018/19 2019/20 2020/21 £m £m £m £m £m Total project 2.819 3.92 7.37 6.97 6.22 change 1.101 3.45 -0.4 -0.75

WAST element Service 1.673 3.036 6.223 6.223 6.223 Project 0.102 0.102 0.102 0.102 0 Total Planned 1.775 3.138 6.325 6.325 6.223 Actual 16/17 1.618 Balance of 2016/17 0.157 WAST Increase / - decrease 1.520 3.187 0 -0.102

It is assumed within this IMTP and financial plan that the implementation of 111 will not see any direct increase in 999 calls as a result, and it is on this basis that both the operational and financial plans for the Trust have been constructed within this IMTP. At this stage both the income and expenditure assumptions should be taken as estimates with the assumption that any changes will be cost neutral to WAST.

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2019/20 and 2020/21

 Funding uplifts Whilst the Welsh Government draft budget provides only for 2018/19, the UK spending review provided indicative budgets for the next four financial years. These figures present plans for further increases for the NHS in England, and, consistent with other NHS Wales health organisations, it is on this basis that WAST financial plans have been developed, which assumes that additional funding will be provided for each of these years resulting in total further uplifts of a minimum of £4.7m (increase reflects NHS Pension discount rate change) and £3.4m respectively.  Band 6 Paramedic Role WHC (2017) 053 has provided for £3.577m of ring-fenced funding to be provided to support the implementation of paramedic re-banding, however the full impact of this development will require further funding to be made available over the next 5 years. The impact of this is profiled in the table below:-

Year 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22 2022/23 £000,s £000,s £000,s £000,s £000,s £000,s £000,s Annual funding requirement 274 1,771 3,577 5,150 6,730 7,904 9,465 Increase in ring fenced funding by year 1,573 1,580 1,174 1,561 Our financial plan has assumed that ringfenced funding will be increased in line with this profile.  Other developments

There are a significant range of further developments over the planning period that will be implemented that will see changes in the cost base of the Trust, and how this profiles both in terms of type of spend and across the 5 step Ambulance Care Pathway and the 4 step NEPTS pathway. It is also assumed within this financial plan that the costs of any such developments will either be separately funded, release spend elsewhere within the Trust to offset such costs (including across other steps of the pathway) or will only be implemented when further additional savings and efficiencies have been identified. Examples of these include: o Furthering the ICT strategy of the Trust to develop a technically enabled workforce, especially in relation to front line operational staff, which will provide for even more treatment at scene and resulting impact on hospital conveyances; o Working with Health Board colleagues and others to further develop the availability of alternative care pathways, ability to access direct to speciality, etc., releasing resources and further enabling the proportion of the Trust’s spend to move towards steps 1 and 2 of the ACP. o Pan Wales and system wide Major Service change programmes in which WAST participates and which will impact on how we deliver our services in the future. As part of this it will be vital that the full potential to maximise benefits from collaborative working are

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considered, particularly in the context of significant increases in demand. Specifically these include Major trauma network, Specialist and Critical Care Centre (SCCC), service reconfiguration. o Developments / extension to the NEPTS service including the novation of 3rd party contracts currently held by Health Boards and Trusts.

Summary of financial changes

The table below sets out a summary of the assumed in year key, material revenue cost changes described for each of the years 2018/19 to 2020/21 which has been revised to reflect our updated planning assumptions.

2018-19 2019-20 2020-21 Summary of assumed financial changes R NR Total R NR Total R NR Total £m £m £m £m £m £m £m £m £m Brought forward recurring deficit/-surplus 0.0 0.0 0.0 0.0 0.0 0.0 Income changes Future years inflation -3.3 -3.3 -4.7 -4.7 -3.4 -3.4 ESMCP CRS -1.7 -1.7 0.0 0.0 Cardiff and vale NEPTS transfer -0.8 -0.8 0.0 0.0 Band 6 -3.6 -3.6 -1.6 -1.6 -1.6 -1.6 Clinical Desk -0.6 -0.6 0.0 0.0 ESMCP -0.6 -0.6 0.0 0.0 Additional Depreciation funding -2.2 -2.2 0.0 0.0 Other income changes 1.7 1.7 0.0 0.0 Assumed increase in funding for 111 (via ABUHB) -2.8 -2.8 -1.9 -1.9 0.0 0.0 Total income changes -13.8 0.0 -13.8 -8.2 0.0 -8.2 -5.0 0.0 -5.0 Expenditure changes Unavoidable costs - Inflation, pension, statutory compliance etc 3.8 3.8 5.1 5.1 3.9 3.9 Non-recurring savings delivery / gains 0.2 0.2 0.0 0.0 0.0 0.0 Underlying cost pressures 1.8 1.8 1.0 1.0 1.0 1.0 Assumed increased 111 costs 2.8 2.8 1.9 1.9 0.0 0.0 Additional Depreciation funding 2.2 2.2 0.0 0.0 0.0 0.0 Cardiff and vale NEPTS transfer 0.8 0.8 0.0 0.0 ESMCP CRS 1.7 1.7 0.0 0.0 Band 6 3.6 3.6 1.5 1.5 1.6 1.6 Clinical Desk 0.6 0.6 0.0 0.0 ESMCP 0.6 0.6 0.0 0.0 Total expenditure changes 18.1 0.0 18.1 9.6 0.0 9.6 6.5 0.0 6.5

Sub total deficit / -surplus (inc bfwd) 4.2 0.0 4.2 1.4 0.0 1.4 1.5 0.0 1.5 Efficiencies / service re-design / gains Potential savings -4.2 -4.2 -1.4 -1.4 -1.5 -1.5 Non recurring savings 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Total efficiencies / service re-design / gain -4.2 0.0 -4.2 -1.4 0.0 -1.4 -1.5 0.0 -1.5

Total deficit / -surplus 0.0 0.0 0.0 Recurring deficit/-surplus carried forward 0.0 0.0 0.0 This plan recognises elements of underlying cost pressures that reflect, growing demand, increased revenue costs associated with capital constraints in relation to replacing our fleet, and the provision of a modest contingency.

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Savings and efficiency During 2017/18 we put in place a further significant and challenging programme of savings totalling £4.9m (3%). This built on recurring savings of £9.6m delivered over the past 2 financial years. As at 31st December a total of over £3.5m of savings had been achieved. Progress against specific schemes is presented within the graph below.

The graph below demonstrates the month by month profile of recurrent savings delivery. Savings are monitored closely both by the Executive Finance Group which has been established in 2016- 17 and formally through the Finance Resource Committee (FRC) with regular reports to the Trust Board.

It is recognised that non-recurring savings against corporate budgets have offset corresponding variances within both EMS and NEPTS. This presents an underlying cost pressure which is reflected within our financial plan.

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We said we would

 Achieve £4.9m of savings in 2017-18. This is summary of how we have done

 We have already delivered £4.4m of savings and are on track to deliver in full against our target.

 We have strengthened our monitoring arrangements in relation to savings delivery and identification.

 We are confident that our planned level of saving of £4.2m for 2018/19 is achievable. We have developed plans to deliver £4.2m of savings in 2018-19 through:

 A number of schemes against specific themes e.g. Estates, Fleet, Consumables and workforce efficiencies which are aligned with;

 Our strategic plans for service transformation and which recognises the need for a more focussed and targeted approach, which is founded on efficiency and sustainability.

 System wide thinking that seeks to optimise resources across the whole system and which maximises outcomes.

Sa vings requirement for 2018/19

The revised table of assumed financial changes above indicates that £4.2m (Circa 3 %) of savings and cost containment measures will be required to achieve financial balance in 2018/19. Our approach to Savings Delivery We have demonstrated our ability to deliver significant savings which has resulted in the achievement of financial balance over the last few financial years, without the need of any strategic support funding. Our approach to developing savings plans has reflected the need to deliver immediate, recurrent and sustainable cost reductions, with little or no reliance on non- recurring savings within our plans. We are committed to the transformation of our services to facilitate value for money and which optimising the use of resources, both within WAST and on an NHS Wales wide basis. We are actively engaged in work to effect service shift across the system, identifying opportunities and recognising the requirement to develop financial plans which release resources for re-investment. Similarly we will in future years review the benefits realised through recent investments in the Trust, including enhanced hear and treat and band 6 paramedics as well as capital and technology projects. Underpinning this is an approach that is based on established improvement methodologies including IQT and Lean. As part of this we are undertaking a series of rapid reviews which will provide a cross cutting approach that supports service transformation, this includes Fleet and Estates both of which are critical to facilitating change, as well as scoping opportunities in relation to direct service delivery.

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A more transformational approach

The following are example of specific areas where we are looking to be more ambitious and transformational in our approach to financial sustainability. This will be particularly relevant when we move more towards years 2 and 3 of this revised 3 year financial plan:-

• Estates:- • Submitted SOP • Accelerating areas of Estates rationalisation • Potential capital receipts / revenue savings • Fleet:- • A more modernised fleet • Fleet management and maintenance – in-house v. external • New fleet management system • IT / technology enablers:- • CAD Phase 2 • Enhanced BI – Qlik / Optima opportunities • System thinking:- • Lean • Value • Service shifts across the unscheduled care system:- • Community Paramedicine • APPs • Releasing resource from elsewhere • Previous FRC areas of focus:- • Benchmarking with other Ambulance services • Patient Level Costing • “Shift left” • System wide efficiency • Working group on plans for financial sustainability • Workforce modernisation:- • Skill mix opportunities • Band 6 paramedic benefits realisation • Demand / capacity review / roster review opportunities • “Back office” functions:- • Procurement • NWSSP opportunities

To support this the Trust is also committed to a more focussed approach via its Executive Finance Group to enhance and accelerate the delivery of this. This will also include the development of a small team to prioritise:-

• getting a number of previous initiatives “over the line” • scoping and developing areas of main opportunity • a series of rapid reviews – similar to that recently undertaken in fleet / workshops

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Specific savings targets (2018/19) include  Workforce efficiency, modernisation & transformation. This includes a range of schemes which will improve efficiency, benefit staff and reduce spend, such as increasing job cycle efficiencies (including reducing the time from handover to clear), reductions in overruns, reviewing meal breaks, a proposed re-alignment of some operational CPD and further reducing the time to recruit operational staff. These will all reduce the variable costs associated with overtime hours. Similarly we will look to increase efficiency within our corporate departments. Our plan commits to reduce costs in 2018/19 by a further £1.5m.

 We will contain current cost pressures within NEPTS £0.2m

 Management of (non-operational) vacancies, through continued controls we will increase our savings by £0.3m.

 Estates and utilities, including energy - savings of at least £0.3m will be achieved through accelerating areas of Estates rationalisation in line with our Estates Strategy. Together with maintaining our focus on improved energy efficiency and rationalising estates costs

We will actively pursue the potential to maximise income generation to attract external sources of income £0.2m.

 Maximising Fleet efficiencies £0.2m – Our Fleet Strategy Outline Plans sets out how we will deliver best value through our fleet replacement programme and maintenance arrangements. In addition we will deliver fuel efficiencies both in terms of optimising price discounts but also through actively managing usage including through the analysis of telemetric information. We will also look to increase fuel economy as a key part of our fleet planning including the use of alternative fuel for non-emergency vehicles.

 Corporate savings of £0.2m including examining the potential to:-

 Extend the use of pool cars within the Trust with a view to creating a number of points around Wales where staff can access pool cars, thus reducing travelling expenses costs.  Increase the use of video / teleconferencing to reduce levels of travel across Wales.  Reviewing arrangements for the procurement of train travel & overnight accommodation.

 Consumables, Drugs and Medical Gases – through a combination of Trust wide and local schemes we will reduce non-pay costs by £1.1m. Our continued drive towards cost effective procurement, and working to maximise this with colleagues in NWSSP, will result in additional savings being delivered in 2018/19.

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 Other local schemes will deliver £0.2m of savings and efficiencies.

The graph below presents the cumulative levels of savings planned between 2015/16 and 2018/19. As well as indicating total baseline savings of over £16m during this period, it demonstrates a reducing reliance on non-recurring savings.

Sustainability, Value and Efficiency

The principles which underpin the national drive for NHS Efficiency, Healthcare Value and Improvement are consistent with the drive within WAST to deliver best value services, which promote efficiency and which recognise a whole system approach.

Within WAST we have worked closely across operational, clinical, and support functions to focus on how we can deliver our services cost effectively. This has included workforce planning to reduce variable pay costs as well as measures to rationalise non-pay costs.

In addition we are seeking to establish how, through working collaboratively with partners within the NHS, but also more broadly with other emergency services, we can work more efficiently providing both financial and operational benefits. We are already working closely with Health Boards to ensure that processes are developed (for example Mental Health) which support effective patient care based on system wide pathways.

We have worked in partnership to highlight how future investment in roles such as community paramedics might support primary care and potentially reduce demands on secondary care.

Similarly the NEPTS business case is premised upon introducing efficiencies to enable investment in service delivery resulting in improvements for patients. The current services provided by WAST are planned to be extended to include a number of additional contracts

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(together with corresponding funding) currently managed by Health Boards leading to a more streamline model.

Our governance models promote regular scrutiny of our financial plans including our performance against planned efficiencies. In addition we recognise the importance of learning through collaboration and have close connections through the Association of Ambulance Chief Executives (AACE) that ensure that we are able to compare ourselves operationally with other ambulance services across the UK.

Maintaining financial sustainability is a key priority for our Board and, whilst the statutory duty to break-even remains at organisational level, this is within a system wide context which contains a number of dependencies and influences. What is evident is that meeting both the financial and operational pressures will require a collaborative approach that optimises the role that ambulance services can play in primary, unscheduled and secondary care. This approach will benefit from a collective response to service improvement, which will also need to reflect an understanding of resource impact at a system wide rather than organisational level and which will span all areas of care (primary, community and secondary). Reflecting this, we are committed to the following strategic action:

STRATEGIC ACTION: We will develop a strategy for demonstrating value in an ambulance/pre hospital/emergency unscheduled care setting

National Value and Efficiency framework

Our savings and efficiency plans have been organised in accordance with the framework as presented in the extract below. Whilst elements of the framework lend themselves more towards the diversity of Health Boards there are common principles that are equally relevant to WAST. We are committed to developing services which are clinically appropriate and cost effective specifically:

 Improving service and workforce models to optimise resources  Improving value and reducing costs  Increasing controls to manage costs  Minimising cost pressures  Working with other ambulance services to identify opportunities and to promote comparison.

More broadly, the efficiency framework will continue to factor into our discussions with our commissioners facilitating a systems wide approach to service improvement and efficiency and which seek to minimise the resource impact of increasing demand and promote the most effective models of care.

However, it must be recognised that, whilst efficiencies will in some cases result in cash releasing savings, other actions will instead enable improvements in productivity and performance. A key example is the implementation of the NEPTS business case where efficiency savings have been reprioritised to fund agreed service developments. Whilst this is welcomed in terms of the improvement to patient care it presents limitations in relation to the potential to provide additional cash releasing savings.

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Benchmarking There remains a heavy emphasis both on the identification of immediate efficiencies either in terms of performance or cost but also exploring potential longer term opportunities, which will be further developed and enhanced throughout this planning period. Part of this approach includes the scrutiny and comparison of costs through internal and external benchmarking, including continuation of the work with the Commissioner led development of the benchmarking toolkit, in conjunction with the NHS Benchmarking Network. Similarly how we look to describe, quantify and evidence the likely shift in the Trust’s spend on EMS from Steps 4 and 5 more towards Steps 1 and 2 of the Ambulance Care Pathway will form an important part of our financial plans for the future. It is recognised that an important part of this will be to develop a fuller understanding of how these shifts influence costs across the whole system and the financial impacts both for the Trust and our partners.

During 2017/18 we have continued to work with both HFMA and other Ambulance Trusts to explore potential to develop costing information which is based upon best practice and which enables us to share and compare information. This information would potentially support internal decision making and help to identify areas of efficiency. This is in relation to both EMS and NEPTS.

Impact of Workforce

Co-ordination between financial and workforce plans is vital to both financial and service delivery. This alignment is a critical element of our future plans as WAST implements service developments and includes both immediate and longer term planning both in terms of existing workforce, and recruiting and training the workforce required for the future. As part of this our workforce plans reflect a commitment to:  Reduce sickness absence.  Streamline recruitment processes to reduce the reliance on more costly forms of cover for operational staff.  Minimise the costs of relief cover, whilst maintaining a level of flexibility that will enable the most efficient use of staff resources.

Over the past 3 years we have reduced the costs of overtime and external providers by over £4m. This is demonstrated in the graph below. This was a key element of the financial (savings) plan for previous years with a further reductions planned for 2018/19.

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Our plan assumes that our total workforce resources will remain relatively static, with the exception of the roll out of 111. However, our plan includes some assessment of the skill mix changes associated with reducing the number of double paramedic emergency ambulance crews towards a mix of a paramedic and an emergency technician (EMT). The pace at which this change can occur is reliant not only on turnover but also the capacity to train EMTs.

Summary of financial risks:

No financial plan is risk free. Financial risk management forms a key element of the project plans which underpin both our ambitions and savings targets. We have strengthened our financial capacity and corporate focus on finance, and as an organisation have structures in place to drive through the delivery of our financial plan.

A summary of the key risks to the delivery of the Medium Term Financial Plan includes:  Funding assumptions in relation to pay awards and the outcome of negotiations on the payment of enhancements on Sickness payments. To be clear therefore, the current costs within the financial plan do NOT assume that such enhanced sickness payments will be reinstated;  Non-pay inflation and any impact in relation to Brexit (particularly suppliers)  Full implementation of the NEPTS business case, specifically matching the profile of efficiency with service development;  Availability of capital funding to support the infrastructure investment required to implement service change;  Financial impact of EASC commissioning intentions, and confirmation of the EMS financial resource envelope as assumed within our financial plan;  Delivery of cash releasing savings and efficiencies. Transformational Fund We are exploring a number of areas for potential investment from the transformation funding announced as part of the 2018/19 budget including:  Further roll out of Community Paramedicine – including joint work being developed with Cwm Taf Health Board;

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 Expanding the role of the Advanced Paramedic Practitioner;  Additional falls teams. Whilst in itself any such funding would be financially neutral to the Trust, with the funding being matched by additional expenditure, any such approved schemes should provide system wide benefits within the wider unscheduled and emergency care system with Wales, and may in the longer term provide further opportunities for wider efficiencies. Each of these has the potential to drive forward the integration of health and care services, build on primary care services, provide care closer to home, and supports the transformation of hospital-based care.

In addition we will explore funding to support improvement through technology for schemes including:

 Digital Solutions / technology, including revising the current draft ICT SOP;  Electronic Patient Care Record (ePCR)o  Advances in testing / diagnosis devices / equipment. Capital

The capital programme has been developed in parallel with our service, estate and fleet plans. The Trust’s current Capital Plan includes schemes with a gross investment value of over £200m profiled over the next five years. This includes new estate developments, and the replacement of the CAD system as well as a rolling vehicle replacement programme.

For 2017/18 the Trust’s Capital Expenditure Limit (at 28th February) is £17.575m.

Discretionary Capital

The Welsh Ambulance Services NHS Trust Discretionary Capital Programme allocation is funded from the Welsh Government All Wales Capital Programme (AWCP). WAST was initially allocated a total of £3.884m discretionary capital for 2017/18, with a further £1.9m allocated on the approval of the IMTP. Funding from 2017/18 has recurrently included the additional £1.9m first made available in 2016/17. The organisation has an Internal Capital Planning Group which meets monthly and oversees all aspects of discretionary capital planning. The Trust’s Discretionary Capital Programme for 2018/19 will be taken to the Trust Board’s Finance and Resources (FRC) Committee, and Trust Board for approval.

Our revised assumptions include discretionary capital funding of £5.826m for 2018/19

Details of proposed expenditure can be seen in the capital section of this plan.

Costs of Capital

The costs of capital have been included as £14.930m in accordance with the allocation value presented within WHC (2017) 053 representing an increase of £2.202m from 2017/18 levels. Our initial calculations have indicated that depreciation charges will increase over the next five years and it is assumed that these costs of capital will be fully funded by Welsh Government.

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8.3 Our Estate

Our ambition to be a leading ambulance service requires an estate that is not only fit for purpose but supports the delivery of caring and responsive clinical services.

The overarching objective of the estates function within the Trust is to support operational services with the following areas:  Provision of modern facilities for operational and support functions to ensure the delivery of such services;  A working environment that maintains staff morale and ensures the productivity of the service is as efficient as is possible;  Provision of the right type of premises in the right location to allow for the effective and efficient management and deployment of resources;  Improved infection control outcomes through appropriate improvements of the estate to allow this to occur.  Ensuring value for money for the public purse by the redevelopment of existing freehold assets as well encouraging partnership working where possible;  Maintenance of a sustainable property portfolio fit for the 21st Century.

Through 2017/18, we have made progress in many areas:

In 2017/18 we said we would  Review and update the Trust’s National Estate Strategy 2013 to include all Trust estate, by submitting an approved Strategic Outline Programme (SOP) to the Welsh Government (WG) for consideration.  Commence the process of establishing the organisation’s next Ambulance Resource Centre (ARC) in Cardiff.  Relocate the organisation’s northern administrative centre from its current site at HM Stanley, St Asaph.

This is summary of how we have done  We produced a SOP which has been endorsed by Welsh Government, and started to consider the delivery arrangements and prioritisation of programmes of work  For Cardiff ARC, further site searches by Shared Service colleagues revealed up to 3 options. An element of due diligence works has been undertaken and a preferred site has been identified to accommodate a make ready solution, further searches will be undertaken for a workshop replacement. The original accommodation brief has been updated to include a NEPTS provision as well as multifunctional rooms for various uses. The updated NEPTS requirements for Cardiff have been included in this latest search as a minimum of two hubs are required to serve the city.  We have significantly progressed our move from HM Stanley to another site on the St Asaph Business Park. This continues to be a significant project for the Trust and forms a strategic action for next year (further detail is provided below).

In addition, we have also made progress with the following estates schemes:

Relocate the organisation’s northern administrative centre from its current site at St Asaph to another site in North Wales. An updated options appraisal process was completed early 2017 where unit 7, which is located on the St Asaph Business Park was identified as the preferred solution to accommodate the north Wales administrative function. Work continues at pace through 2017/18 with anticipated acquisition by the end of the financial year. The Trust supported the approach at its December meeting, and will look to progress the planned development in 2018/19. This action is key to delivering on our commitment and remains a strategic action for the Trust going forward.

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Strategic Action: We will significantly progress the move away from HM Stanley to Unit 7, St Asaph Business Park

Relocate the organisation’s regional Central and West administrative and training centre at Cefn Coed Hospital, Swansea. A land and property search has been undertaken to progress this piece of work; the Estates Department is working with NHS Wales Shared Services Partnership colleagues to evaluate options within the Swansea area, including an option to co- locate at the ABMU HQ facility on the Baglan energy park. This will be progressed during 2018/19 and forms a key strategic action for the Trust.

Strategic Action: We will rationalise the Swansea administrative accommodation.

Development of an Ambulance Resource Centre in Cardiff. The development of an outline business case (OBC) will be progressed in the first quarter of 2018. Once approved by Trust Board the business case will be presented to Welsh Government for further scrutiny and ultimately to access capital funding.

Strategic Action: We will deliver an OBC for the Cardiff ARC (subject to suitable site identification)

Estates Strategic Outline Programme

In 2017/18, we developed a Strategic Outline Programme (SOP) which was endorsed by the Welsh Government in December 2017. This document sets out the vision for the development of the WAST estate and a proposed 10 year plan of works commencing in 2017. This latest plan builds on the 2013 SOP and maintains the hub and spoke solution but promotes a more pragmatic approach based on the lessons learned from the North East Wales developments. The SOP aimed to ensure that the estates plan could be specifically tailored to support delivery of operational needs and future demand.

The SOP includes the entirety of the estates infrastructure across Wales, including operational sites, Clinical Contact Centres (CCCs), fleet workshops, training facilities and administrative centres. Whilst developing the SOP, progress has already been made to progress the plans that we committed to last year, ensuring that all projects align to the overall strategic direction of the Trust.

Through the remainder of 2017/18, the Trust will plan a delivery model for the implementation of the SOP, and will look to adopt a programme methodology to ensure that priorities for the Trust are identified quickly, and progressed at pace through the next three years.

Provision of Modern Facilities/Improved Working Environment

Many parts of the current estate are in a poor condition and there are clear indicators regarding the physical factors affecting the Trust’s ability to deliver services. The cost of improving the existing estate is significant as a result of the age profile and limited preventative and maintenance work undertaken over previous years. At present, the backlog maintenance liability is in the region of £12 million to attain a minimum category B standard; this investment alone would not enhance the estate and support operational service delivery, but merely maintain the status quo and not redevelop the estate as is required.

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The current location of some ambulance stations provides a barrier to the delivery of better quality care and improved performance. Issues may be the physical siting of the station or the location itself does not permit expansion. This has resulted in a more traditional model of service provision which puts greater emphasis on ambulance stations as a fixed base for vehicles and crews rather than deploying them at locations closer to the points of greatest demand.

Future of the Estate

The proposed approach is to continue with the hub and spoke model which would have a large central facility (which could include vehicle maintenance if required) with strategically placed social deployment points (SDPs) to ensure a timely and appropriate response to emergency incidents. This network of facilities will support efficient working and enhanced quality of care.

The development of the “Make Ready” concept to address issues of cost effective operational services and improved infection control practices through the use of ‘fleet assistants’ delivering an effective vehicle washing and stocking solution is considered the most efficient and effective way forward.

The SOP set out the investment aims and a key element of this is the provision of modern facilities which improve the working environment and support performance against operational targets and improved infection control outcomes.

Non-Emergency Patient Transport (NEPTS)

The emerging strategy for NEPTS is a move away from centralised facilities shared with EMS services. The identified requirements are for bases located within the community which, in many instances is an individual hub. This is because NEPTS crews generally start shifts in a central location and drive out to communities to collect patients; if facilities were located in communities the time saved both at the start and end of shifts could be significant. However, there is a need to consider a different mix of solutions to ensure the physical infrastructure is fit for purpose and cost effective.

Non-Operational Estate

The Board has approved the centralisation of the CCCs into three strategically located centres. There is an acceptance that administrative centres should also be rationalised and enhanced and that there are potential opportunities for co-location with CCCs where possible. Developing the non-operational estate is a priority, with work already underway on the configuration of the CCCs, regional administrative centres and training facilities in line with the development of an ambulance academy supported by locality learning cells.

Partnership Working

There is a strong driver for development of partnerships with blue light partners, primary care and other public sector organisations. The potential opportunities for co-locating administrative centres and SDPs is always thoroughly explored before a ‘go it alone’ approach is adopted.

Sustainability of the Building Stock

The economic climate and drive for improved sustainability is not in keeping with a vast and disparate estate. The defined standards for refurbishments to achieve a Building Research Establishment Environmental Assessment Method (BREEAM) rating of very good or above is challenging with the current estate configuration. The WAST estate can be rationalised and better use of freehold assets forms part of the updated SOP, reduction of revenue costs is key,

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improving the working environment and introducing a more sustainable infrastructure to improve the health and wellbeing of staff, whilst increasing the ability to provide an improved service.

Strategic Action: We will implement the Estates Strategic Outline Programme, starting with the areas in greatest need of attention.

In addition to the ambitious estates programme contained within the Strategic Outline Programme as described previously, the Trust will utilise an element of its discretionary capital funding to progress schemes that are internally deliverable. Recently completed works at Tredegar Ambulance Station to introduce make ready capability are being adopted by Operations to introduce more dynamic make ready solutions at freehold assets where possible. The current development at Barry fire station, due to be complete in February 2018, will provide a dynamic make ready facility serving the Vale of Glamorgan and to support Cardiff.

The Clinical Contact Centre at Vantage Point House, Cwmbran requires an upgrade to its infrastructure. In addition, feasibility works to relocate to the joint facility at Llandrindod Wells with Mid & West Fire and Rescue Service and Dyfed Powys Police will be progressed in 2018. Further works to introduce a retrofit MRD at Pembroke Dock and the relocation of the ambulance station from New Quay to Aberaeron to a health board facility will also be reviewed.

The estates function has also attained ISO 14001 accreditation for environmental management, although this is an ongoing process and is reviewed annually. All three regions have been assessed and further inspections are expected in 2018.

Whilst the above provides an outline of the 2017/18 estates priorities, there are many more that will form part of the Trust’s improvement plan. In implementing the delivery of the SOP, the Trust will continue to implement developments in Cardiff and the Vales and Hywel Dda health board areas as a priority.

We will continue to explore partnership opportunities with blue light partners, primary care and other public sector organisations. It is therefore important that we are engaged in wider service planning discussions from the outset, so that we can maximise opportunities to use resources efficiently and effectively.

8.4 Our Discretionary Capital

In 2017/18 the Trust had a Capital Expenditure Limit, including discretionary funding, of £17.575M. This has been utilised within the Trust on replacement vehicles (£8.25M), implementation of the CAD system (£3.5M), discretionary capital funding (£5.825M) which encompasses various estates projects such as the development work to relocate to Barry fire station (£950k), acquisition of unit 7 (£950k), VPH infrastructure upgrade (£660k) and other minor improvements to the estate and ICT equipment.

The most significant capital development in 2017/18 was the implementation of the CAD system in November 2017 which will provide resilience to the CCC function at a level not previously experienced. There are, of course, multiple operational benefits to the implementation of the new CAD including auto dispatch to Red category calls, complete elimination of inter-CAD transfers and the ability to allocate resources all over Wales regardless of the location of the incident. A full list of benefits have been included within the business case and are currently being monitored by the project team and will also form part of the Gateway 5 review in due course.

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Priorities for 2018/19 and Beyond

The Trust has been allocated a recurrent discretionary capital budget of £5.825M. The prioritisation process identified that the acquisition of unit 7 to replace the HM Stanley facility was key as this piece of work had been identified as one of the key actions for the service. Due to the financial commitment required to ensure that unit 7 provided all the necessary modern day working facilities, the development of a full refurbishment work package would be developed by the end of the financial year 2017/18. Other priorities identified included development of a Vale of Glamorgan make ready solution at Barry fire station with South Wales FRS. Other estate works have also been identified. These range in value from £40k to £660k. Other equipment developments include the roll out and connectivity of the omnicell cabinets and SAT NAV equipment.

Although reduced because of a reduced level of capital funding, in the region of £8.25M has been allocated for vehicle replacement, with the main emphasis being placed on the replacement of 67 NEPTS vehicles, as well as a number of EMS and specialist vehicles.

A high level overview of our current capital plan includes:  Continued investment in vehicle replacement and fleet - which will align with the requirements of changing service delivery models including that of the new clinical model and patient transport.  Unit 7 refurbishment and relocation of staff from HM Stanley and disposal of this facility.  ICT infrastructure development and individual staff devices  Further phases of the Control and Dispatch system to include the expansion of the 111 service  ESMCP & ARP  Estates projects to reduce levels of high risk maintenance  Phase 2 Digi-Pens leading to ePCR

Year three of this capital plan will continue to focus on enhancing the clinical equipment available for use with our patients across Wales, vehicle replacements, along with the implementation of the significant estates programme as detailed above.

8.5 Our Fleet

The Fleet department operates and maintains over 700 vehicles across Wales to enable the delivery of the Trust’s core frontline services. The fleet includes Emergency Medical Services (EMS) Ambulances, Rapid Response Vehicles (RRV), Non-Emergency Patient Transport (NEPTS), Hazardous Area Response Team (HART) and other specialist and auxiliary vehicles. The fleet department also manage and maintain 87 vehicles on behalf of the Health Courier Service.

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In 2017/18 we said we would  Implement a Virtual Fleet and Logistics Help Desk in our Clinical Contact Centre  Install and fully utilise a new computerised Fleet Management System  Develop a vehicle movement solution  Roll out vehicle telematics throughout the fleet  Develop a Trust Board approved fleet Strategic Outline Plan (SOP)

This is a summary of how we have done  Implementation of the Fleet and Logistics Help Desk is dependent upon implementation of the new CAD Project and is planned to be initiated in 2018.  The new computerised Fleet Management System went live in 2017 and is being rolled out across the entire fleet maintenance operation.  A total of nine fleet driver cleaners have been recruited in to post, four in the North and five in the South and East. They are undertaking fleet related vehicle movements and carry out the cleaning of vehicle exteriors.  The majority of the EMS fleet is now fitted with the telemetric system with the remainder being installed into the new vehicles as they are commissioned into service.  We have developed a Fleet SOP which is to be submitted to the Trust Board for approval in Q4 2017/18; this was informed by the initial findings from the Demand & Capacity Review.

Whilst positive progress has been made over the last year to implement a range of national projects and service initiatives there is still considerable work to continue to take forward as set out in the Fleet Local Delivery Plan.

In 2018/19 we will:

- Implement the recommendations outlined in the SOP; - Review the Fleet profile in conjunction with the recommendations of the demand and capacity review; - Pilot a virtual Fleet Logistics Help Desk in CCC; - Progress a New Ambulance Workshop in the South East - Finalise the Vehicle Maintenance Project; - Utilise the Vehicle Telematics system data. - Develop EMS Fleet CQDF measures

Implement the recommendations outlined in the SOP: The SOP (pending Trust Board approval) provides a clear framework for delivering the following three core programmes of work during 2018/19 and beyond; (i) framework for delivering the vehicle replacement programme, (ii) vehicle maintenance, repair and servicing, and (iii) developing the Make Ready concept in conjunction with the Operations and Estates directorates.

Review the Fleet profile in conjunction with the recommendations of the demand and capacity review: The future profile of the fleet will be reshaped using the findings outlined in the demand and capacity review. This information will help to assist us in determining the optimum fleet profile to meet the increasing and changing future demand for EMS services. Findings to date indicate that there will be a requirement for fleet re-profiling in terms of an uplift in both the number of EMS vehicles and RRVs across Wales. The outcome of the demand and capacity was used to determine the strategic direction and development of the fleet Strategic Outline Programme (SOP).

Pilot a virtual Fleet Logistics Help Desk in CCC; A joint project team with key internal stakeholders will be established to develop and trial the concept of implementing a virtual Fleet

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Logistics Help Desk in CCC. The key principle of the desk is to provide access to dedicated Fleet operatives in the CCC environment to manage and co-ordinate every day Fleet related activity (e.g. co-ordinate vehicle servicing, managing on the day Fleet issues). This will therefore free up considerable capacity of CCC ‘Day Controllers’ who currently undertake this work. Additional resources / funding will be required to support the trial and, if successful, the roll out of this model to provide pan Wales coverage.

Progress a New Ambulance Workshop in the South East: The current workshop facility in Blackweir, Cardiff is in a poor state of repair and although well equipped, is not a fit for purpose environment for maintaining our fleet. The workshop in Blackwood, although sufficient for delivering our current workloads has many constraining factors to prevent any development which would enable us to increase the amount of vehicles that use it for maintenance, repair and servicing. We are currently exploring options for a combined workshop in the Caerphilly and Taffs Well areas. Any new premises identified will be fully evaluated to establish the opportunities for any wash and make ready operational models that suit the Trust’s requirement.

Finalise the Vehicle Maintenance Project: This is a joint project with NWSSP to review the contractual arrangements the Trust has in place with external service providers across Wales who undertake and support fleet maintenance and servicing.

Utilise the Vehicle Telematics system data: Following the successful roll out of the telematics systems across the fleet there is scope to utilise the rich data source to support safe driver behaviour and deliver driver efficiencies through realising anticipated fuel efficiency savings.

Develop EMS Fleet CQDF measures: As part of the development of the EMS CQDF core requirements provide assurance that there is a balanced set of metrics for fleet.

Strategic Action: We will implement the recommendations outlined in the fleet strategic outline programme.

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8.6 Research and Development

In 2017/18 we said we would  Deliver Rapid Analgesia for Prehospital Hip Disruption (RAPID) Feasibility Trial / Paramedic-2 / RIGHT-2 Trials:  In addition to the above we would deliver on an additional 10 research studies and registries, including: o Paramedic Acute Stroke Treatment Assessment (PASTA) trial; o Out of Hospital Cardiac Arrest Outcomes Programme; o Ethnographic study of emotion work; o Public and Clinician’s view of Prudent Healthcare; o Ethnography of ‘Primary Care Sensitive’ Ambulance contacts; o Prevalence and trends in UK Ambulance Service Staff Suicides; o Emotional impact of telephone-assisted CPR on EMS call takers; o Electronic Records in Ambulances (ERA) o Evaluating the Diversion of Alcohol-Related Attendances (EDARA) o Transient Ischaemic Attack 999 Emergency Referral (TIER)

This is a summary of how we have done  In 2017 WAST delivered and led three studies of international significance (i) PARAMEDIC 2 Trial (which was the largest recruiting Trial in NHS Wales for 2017 (due to end in Feb 2018); (ii) RIGHT-2 trial (due to end in July 2018); and is a Clinical Trial of a Medicinal Product (CTIMP) now recruiting in ABMU, HD, AB and soon to be BCUHB (iii) RAPID: Now successfully delivered. Met all of the progression criteria. Now planning a UK wide Trial  The Trust has also made significant progress delivering against the 10 research studies outlined above. WAST is a high recruiting site for the PASTA Trial. WAST has had challenges in meeting our commitments to the Out of Hospital Cardiac Arrest Outcomes Program, and whilst a sample data set has been submitted, we have missed out on our ability to attract some research because of our continued inability to contribute.

The research and development functions for the Trust are delivered by HCRW@WAST (Health and Care Research), which is part of the Health and Care Research Wales arm of Welsh Government. The Executive Director Lead for R&D is the Medical Director, Head of Research and Innovation assumes responsibility for research activity within WAST and engagement with Welsh Government. The current R&D strategy set out the current aims and objectives of research within the Trust, and reflects current R&D strategy as set out in the ‘Health and Care Research Wales Strategic Plan 2015-2020’. The WAST R&D strategy works towards the vision:

'To build a culture where research can flourish, influencing practice for patient benefit'.

The benefits of this strategy are now being realised, and recent HCRW performance figures and benchmarking reflects WAST to be among the top three research active ambulance Trusts in the UK, with year on year increases in the number studies and patients recruited into these studies.

In 2017 the Trust delivered and led studies of international significance such as the PARAMEDIC 2 Trial, RIGHT-2 will continue in 2018/19. Whilst it is recognised that the research evidence base in ambulance services and pre hospital care is relatively less well developed than other areas, the success of current trials and maturing of the organisation’s internal research arrangements have ensured that WAST continues to attract a wide range of high profile research projects across Wales. The table overleaf summarises the research portfolio for 2018/19 and beyond which includes the continuation of a number of research projects along with further scoping of potential new projects including TIME and PTSD.

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Expected Research Trial Status Completion Date Paramedic 2 trial: The PARAMEDIC2 trial is looking at whether adrenaline is helpful or harmful in the treatment of a cardiac arrest Underway End of Feb 2018 that occurs outside a hospital Right 2 trial: a CTIMP of a blood pressure lowering patch for pre Underway End of July 2018 hospital application in ultra-acute Stroke Rapid: WAST/Swansea University led research testing the Successfully feasibility of paramedic initiated Facia Iliaca Compartment Block delivered. Ended (FICB) which is an injection into the hip to alleviate pain in hip Planning for full fracture UK wide Trial TIER: WAST/Swansea University led research exploring feasibility End of March of Paramedic referral of low risk Transient Ischemic Attack (mini Underway 2018 stroke) directly to specialist TIA Clinics Prehospital Recognition and Antibiotics for 999 patients with Severe sepsis Study (PHRASe): a feasibility study for a cluster randomised controlled trial. The study aims to determine the feasibility of undertaking a randomised controlled trial (RCT) or a Underway End of Feb 2019 protocol for paramedics to assess and administer IV antibiotics to patients with suspected severe sepsis and to prepare for a full trial if indicated. ERA Research Project: UK wide study exploring Electronic TBC trial being Underway Records in Ambulance Services extended PASTA Research Project: UK wide research to determine whether a Paramedic Acute Stroke Treatment Assessment (PASTA) pathway can speed up access to emergency stroke Underway April 2019 treatments, especially thrombolysis treatment, and so improve recovery after stroke. EDARA Research Project: UK wide research evaluating the effectiveness, cost-effectiveness, efficiency and acceptability of End of June Underway Alcohol Intoxication Management Services (AIMS) in managing 2018 alcohol-related Emergency Departments’ attendances. CARE Research Project: scope of the trial to be finalised End of June Underway 2018 WA Gatekeeping Strategy Management: scope of the trial to be Underway August 2020 finalised Take home naloxone Multicentre Emergency setting feasibility Naloxone reverses the effects of opioid overdose, including Funded Scoping heroin (TIME): TIME will look at the practicalities of offering Take TBC out delivery Home Naloxone (THN) kits to people at risk of overdose, as well as their friends, relatives and carers. Paramedics working in GP Practices and Unscheduled Care Working with Researchers on TBC funding bid Pre-Hospital Stumble: A multi-centre randomised feasibility study Working with evaluating the impact of a prognostic model for management of Researchers on TBC blunt chest wall trauma patients in pre-hospital care funding bid Work, health and wellbeing in Ambulance Trusts in England Working with and Wales: strengthening staff supports for improved care quality Researchers on TBC (WHATSUP) funding bid

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By working with the HCRW infrastructure, we will build on the significant developments we have made in recent years. We will streamline our approvals process in line with the four nations approach. The HCRW finance policy is also now in transit through WAST committees for formal adoption; this will further develop transparent and efficient mechanisms to allocate resources and recover costs from relevant sources (e.g. industry, research grants).

Developing and delivering our research draws on the expertise of many individuals and groups, and our experiences and maturing networks will continue to evolve and further refine our approach to research going forward. We will continue to build links and enhance our relationships with external research partners including universities, life sciences, industry partners along with other Health and Care Research Wales initiatives. We will also continue to engage and support a range of research groups including the advisory group of Swansea University Trials Unit and new partnerships emerging with Public Health Wales, the Secure Anonymised Information Linkage Data Bank Wales Stroke Hub, Respiratory Innovation Wales and many more.

We recognise that research evidence needs to be mobilised and transferred into improvements in care through many mechanisms across the Trust and more widely. This will be achieved through ensuring that WAST R&D leads are fully embedded and hold membership on key decision making boards and committees across the Trust. This will ensure that the findings and key recommendations of research projects are effectively cascaded and considered to influence evidence informed policy and clinical practice development. 8.7 Improvement and Innovation

In 2017/18 we said we would • Establish a cross functional working task and finish group to research and write an Innovation and Service Improvement Framework for WAST • Draft Innovation and Service Improvement Framework to be available by 30 September 2017. • Any structure implications for delivery of the framework to be consider in the second part of 2017/18. • Any resource implications for delivery of the framework to be considered in the second part of 2017/18. • Agreed Framework to determine the organisational structures, processes (techniques) and culture (philosophy) required for innovation and service improvement. • Further investigate the opportunities which collaboration with the NHS Wales Business Schools Programme could offer by fostering and developing knowledge transfer between Business Schools in Welsh Universities and WAST through a structured student placement programme

This is a summary of how we have done The cross functional task and finish group was established and reported its findings to EMT in November 2017 (see further detail below).

In the 2017/18 IMTP we identified that, as an organisation we already had a developing track record of improvement and innovation, but that we lacked a systematic, joined up and strategic approach. We consequently set ourselves a number of actions (shown in the green box above).

The task and finish group was established and reported its findings to the Executive Team in November 2017. The task and finish group made the following recommendations of principles that will underpin all future work. These were agreed:

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 Improvement and innovation needs to be the responsibility of every Board, non-executive and executive director  A clear and concise set of improvement & innovation principles and a framework to describe “the WAST way” that gives clear permission to staff to innovate  All WAST staff should be exposed to action learning training and/or IQT  Development of top team leadership (subject to resourcing)  Staff and service users should help to identify priorities  A communication and engagement plan is a key component of the framework, with a consideration of branding  Establishment of an improvement hub and network where tools, best practice and support and celebration of success can come together  Explore models of development of delivery including partnering with other agencies/companies  This work needs to link with a more structure and supported approach to programme and project management

There were no 2018/19 resource implications to these recommendations and no structure changes, with the concept of a central transformation team being rejected in favour of an improvement hub, with improvement and innovation being in every director’s portfolio, and everyone working to an agreed set of principles.

Actions for 2018/19 • Roll out of the framework as agreed within the resource parameters determined in the second half of 2017/18. • Development of the WAST Continuous Improvement Platform with the design of the Continuous Improvement hub and framework • Strengthen our links with the 1000 Lives Improvement Team to link our continuous improvement hub with health board hubs to maximise partnerships for improvement work

Actions for 2019/2020 • Fully implementation of the framework and initial evaluation at the end of 2019/20.

A national approach to improvement was a key theme of the Parliamentary Review and therefore any emerging models or infrastructure will be reflected in this work. Recognising that this is all part of a long term service improvement ‘journey’ which we are on, we are reiterating within this plan our commitment to the existing action below.

Strategic Action: We will develop and implement over the life of this plan an Innovation & Continuous Improvement Framework.

8.8 Health Informatics and Business Intelligence

The overall purpose of Health Informatics has been defined as:

“Enable, promote and support the effective use of data, information, knowledge and technology to support and improve health and health care delivery”

In order to support the organisation’s change programme, a number of strategic developments have been identified that will require health informatics support; the 111 pathfinder implementation programme, the Trust’s commissioning requirements for emergency and non-emergency services, the clinical modernisation programme, the non-emergency patient transport services programme and the Clinical Contact Centre modernisation to name but a few.

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As the Trust has re-orientated itself as a clinically-led quality-driven service, rapid transformation is reflected in the Trust’s business information assets, as there is an increased dependency to continuously increase the access to, and analysis of, clinical and non-clinical information to improve and optimise decisions and improve patient care.

In addition to these requirements is the production of the Trust’s commissioning dataset for unscheduled care and non-emergency patient transport services to support the new commissioning agenda. As the roll-out of national and local commissioning arrangements continue, how we share information with our partners and regulators is rapidly changing. It is expected that this service will continue to develop over the lifetime of this plan.

The focus in 2018/19 will be to build upon and further develop the work from the previous year. While there is a multiplicity of tasks to undertake to support our overall objectives, detailed below are the highest priority actions which it is anticipated will make a significant difference to the organisation and the wider healthcare community. It should be noted that the directorate’s local development plan outlines further actions, while any actions outstanding from the 2017/18 IMTP will also be picked up, where they remain appropriate.

2018/19 focus

• Introduction of Qlik reporting solution that provides enhanced intelligence to our decision makers and informs our decision making process and practices. This will support our strategic aim of “value, innovation and efficiency”; • Continue to rollout a suite of mobile applications to support the Trust’s requirements as part of local delivery plans; • Further support the information requirements of the national 111 rollout including a review of the current National Directory of Services database currently hosted by WAST. • Continue to provide and develop the requirements arising from the CASC and develop the Non-Emergency Patient Transport Commissioning suite of information. • Compliance to the General Data Protection Regulation (GDPR), as we transition from the UK Data Protection Act (DPA) which gives us compliance to the latest legislation for the Trust. This will support our strategic aim of “highly effective organisation”; • Develop a records management programme that ensures clinical and corporate records are retained, archived and disposed of in accordance with guidance given by the Department of Health in ‘Records Management: NHS Code of Practice’ Parts 1 and 2 held by the Trust. This will support our strategic aim of “highly effective organisation”. • Supporting the development of the Trust’s long term digital innovation and transformation programme • Supporting the development and introduction of Phase 2 of the CAD (Computer Aided Dispatch) programme.

2019/20 and 20/21

While Health Informatics’ priorities are dynamic and fluid, there are a number of areas where we will focus on during the following years, these include:  Supporting the deliverables of the Trust’s ePCR programme.  Meeting the requirements set out as part of the Trust’s long term digital innovation and transformation programme.  Supporting the requirements of the Welsh Government’s strategic objective for improvement and innovation with better use of data and information to improve decision making, plan service changes and drive improvement in quality and performance.  Harnessing the local requirements of the ‘Informed Health and Care: a digital health and social care strategy for Wales’.  Ensure local digital advances and innovation by supporting the information requirements of the ‘Once for Wales’ technical platform.

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Whilst the exact nature and content of these strategic plans are yet to be finalised, it is expected that they will heavily impact the health informatics work programme for the medium term.

Strategic Action: We will expand our robust information framework with the appropriate governance, to allow our stakeholders to get the information they require, in a timely manner and to make the most effective decisions

8.9 Information Communication & Technology (ICT)

The Trust ICT Department forms part of the Finance and ICT Directorate. It provides all information systems and services for the Trust.

The ICT Department is made up of a number of specialist teams based at five key Trust sites. These teams provide day to day support to existing ICT service but also work on projects that support the delivery of the Trust strategic aims. The Trust’s programme for modernisation of its services and clinical practice will require a sustained and focused investment across several areas of Information and Communication Technology.

The ICT department will play a key role in supporting the development of the Trust’s long term digital innovation and transformation strategy, ensuring it aligns with national developments and programmes and wider Welsh Government and NHS Wales Strategy. In this spirit, this section of the document is framed within the four key themes of the Strategy: Information for You; Improvement and Innovation; Supporting Professionals; and Planned Future. The section provides a reflection on progress to date and the table below builds on this, and sets out the key milestones over the coming three years.

Good progress was maintained in the delivery of the ICT programme of work for 2017/18, despite the main focus of the department being on the introduction of the new CAD. Progress made is summarised in the following narrative:

Information for You

Our year one priority areas were to work with non-emergency patient facing departments such as NEPTS and NHSDW to implement opportunities for patients to access services electronically and in doing so reduce demand on staff. This would include alternative access channels, directory of service and links with the national programmes around electronic patient access.

To date we have delivered:

 Improved functionality to our NHSDW patients through a revision of our website and associated content. Further work is ongoing to provide a new access service for the hard of hearing community via the Interpreter Now service, in partnership with the national 111 programme.

 We have upgraded our NEPTS systems to provide web based access to allow patients to book journeys online and are currently working through introducing other patient facing service improvements with colleagues within NEPTS.

Improvement and Innovation

We said we would work with partners across health, including NWIS and national programmes to provide two way exchange of information to aid both clinical and operational decision making

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across all health organisation. We will also look at opportunities to transfer information across emergency services to improve incident response.

We have played an active role in discussions with partners to progress electronic information exchange:

 We have commenced live transfer of ECG traces to specialist cardiac units to aid decision making and patient outcomes, while also providing performance and management information to our partners across NHS Wales

 With the successful implementation of the new CAD we are in conversation with our colleagues across the Emergency Services sector to plan for electronic incident transfer within Phase two of CAD.

Supporting Professionals

We committed to work with corporate departments and programmes within the Trust to improve or replace operational information systems, while ensuring they meet the needs of the Trust and, as far as possible, comply with national standards. We will need to ensure that systems are optimised for mobile access, thereby providing access to information for operational staff wherever care is being delivered.

Six key priority areas will be;

 Implementation of the new CAD (Phase 1),  Continued preparation and mobilisation for the replacement of Airwave services through the national ESMCP and ARP programmes.  Continued operation and support for the national 111 pathfinder along with the leading the national procurement of a replacement system  Review ePCR capability and its suitability to replace the Trust current digi-pen solution in the future. In the interim progress with digi-pen further enhancement and capability review. The Trust is committed to the implementation of the SNOMED-CT to align with organisations across NHS Wales. The initial area for action will revolve around the project to implement a Trust wide digital ePCR solution. We will also look at other clinical information held within the Trust and whether SNOMED-CT can be implemented as a coding structure.  Implement the pilot mobile device solution for staff ensuring efficient and effective communications and access to appropriate clinical information  Provide access for clinicians in the CCC to the master patient index (e MPI) and individual health records (IHR) as well as investigating options to provide Trust information into national repositories, such as Welsh Clinical Records Service (WCRS) and national systems such as Welsh Emergency Department System (WEDS) and Welsh Community Care Information System (WCCIS).

To date we have:

 completed the successful implementation of the C3 CAD across the Trust (Action 14)  continued our preparatory works to replace the Airwave services, actively working with the WG, ARP and JESG to ensure the Trust is aligned to the national rollout plans, both operationally and technically  continued to support the 111 pathfinder and its extension into other HB areas. We have continued to play an active role in the procurement of the new 111 system and have seconded Trust staff into the programme to provide additional support

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 commenced the roll-out of the mobile devices with tablets devices issued to an initial cohort of 250 staff. We have also commenced the roll-out of Wi-Fi equipment to 30 EMS vehicles that can be used by staff to access Trust information systems when away from the bases. (Action 45)  We have worked with NWIS to ensure that the governance and audit is in place and robust. We are waiting on the release of the next Welsh Clinical Portal version to progress access to the GP Summary Record and WCRS. We are in dialogue with NWIS and health boards to identify early opportunities to access the WCCIS for community care information from both the clinical desk and NHSDW/111. (Action 44)

Planned Future

We recognised that to support both the Trust transformation and alignment with the national strategy and programmes, a robust and resilient ICT infrastructure would be required and we looked to continue with a programme to improve and enhance the ICT infrastructure to provide a basis to support the implementation of new systems and solutions, including the greater use of mobile and remote working technologies.

We have extended the mobility pilot to ensure all staff have easy access to an electronic device. Mobile devices will also support clinical decision-making when caring for patients by providing electronic access to tools like the paramedic pathfinder and alternative care pathways for treatment.

In order to achieve this ambitious programme of work, it will be essential that ICT staff are given the appropriate skills to ensure they are equipped to play their part in supporting future developments and technologies.

We have:

 continued with improvement in the ICT Infrastructure to provide a scalable, resilient and robust platform. This has included o upgrades to our network which improved availability and performance o improvement to security across the Trust with improved capability for proactive detection of potential incident and vulnerabilities o new server and storage to improve availability and performance  commenced the staff mobility pilot focused on the requirements of clinical and operational staff for secure access to appropriate information whilst away from their station.  worked extensively with all directorates across the Trust to deliver improvement and enhancements to current systems and service.  ensured our ICT staff are knowledgeable and skilled to support the new technologies and systems now being deployed across the Trust.

The table below sets out the key actions for the next three years. WAST will continue to develop its Strategic Outline Programme for ICT provision, in line with ongoing discussions on our Long Term Strategic Framework. The digital agenda is a key component of the Framework, and we acknowledge that significant investment will need to be made, once the priorities are identified.

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2018/19 2019/20 2020/21

Patients will be able to look after their own well-being and We will look to build on previous We will look to review and connect with health and social care more efficiently and work to scale out alternative access revise our patient access effectively, with online access to information and their channels, a revised website and capabilities in light of the own records. continue to work with the national major national programmes programmes around Directory of delivering new systems to We will continue to work with the national programmes Service and electronic patient our patient facing services. Information around electronic patient access. access. for you

We will continue to work with our colleagues in non- emergency patient facing departments such as NEPTS and NHSDW to implement opportunities for patients to access services electronically and in doing so reduce demand on staff. We will work with partners across health and other We will work with partner across We will work with partner sectors to improve information sharing and collaboration. health and other sectors to improve across the Trust, national Within the Trust we will look for further improvements in information sharing and programmes and other data capture and quality to improve capability in analysis collaboration. Within health we will partner organisations to including financial costing, whilst also looking at work with NWIS and national review and enhance our opportunities to deploy innovative technology solutions in programmes to increase the information sharing and support of the 5 step pathways. exchange of information as new collaboration as we Improvement National systems are developed and undertake major changes in & Innovation Within health, we will work with NWIS and national rolled-out. our patient facing service. programmes to provide two way exchange of information to aid both clinical and operational decision making across all health organisations.

We will also look at opportunities to transfer information across Emergency Services to improve incident response.

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Staff will use digital tools and have improved access to We will continue to work with We will continue to work information to do their jobs more effectively with corporate departments and with corporate departments improvements in quality, safety and efficiency. programmes within the Trust and and programmes within the across the NHS to improve or Trust and across the NHS We will work with corporate departments and replace operational information to improve or replace programmes within the Trust to improve or replace systems while ensuring they meet operational information operational information systems while ensuring they the needs of the Trust and, as far as systems while ensuring they meet the needs of the Trust and, as far as possible, possible, comply with national meet the needs of the Trust comply with national standards. We will need to ensure standards. Some key areas of focus and, as far as possible, that systems are optimised for mobile access thereby are: comply with national providing access to information for operational staff • continue with the phase 2 standards. Some key areas wherever care is being delivered. Seven key priority implementation of the new CAD of focus: areas will be: • continued preparation and • Implementation of the  continue with the phase 2 implementation of the new mobilisation for the replacement of national 111 integrated ICT CAD, Airwave services through the solution  continued preparation and mobilisation for the national ESMCP and ARP • continue to support the Supporting replacement of Airwave services through the national programmes. development of the Trust Professionals ESMCP and ARP programmes. • continue to support the ePCR solution  continued operation and support for the national 111 development of the Trust ePCR • Implementation and pathfinder along with providing significant support to solution replacement of the current the procurement of the National 111 Integrated system • continued operation and support Airwave services through  support the working group to define the trust for the national 11 pathfinder. the national ESMCP and requirement for ePCR capability. In the interim • continued support and ARP programmes. continue to work with the suppliers to maximise use of participation in the procurement of digi-pen solution. the national 111 integrated ICT  review the benefits of mobile device pilot for staff, and solution continue to build capability with access to more Trust • support NEPTS with system systems. Build a robust case to secure required funding requirements and improvements (capital and revenue) to extend the solution to all operational staff.  continue to work with NWIS to provide access to clinical staff to National information resources.  support NEPTS with systems requirements and improvements

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We will play a key role in supporting the development of We will continue to improve and We will continue to improve the Trust’s long term digital innovation and enhance the ICT infrastructure to and enhance the ICT transformation strategy provide a basis to support the infrastructure to provide a implementation of new systems and basis to support the To support both the Trust transformation and alignment solutions including the greater use of implementation of new with the National strategy and programmes, a robust, mobile and remote working systems and solutions resilient and secure ICT infrastructure will be required technologies. We will review including the greater use of and we will continue with a programme to improve and opportunities to replace systems and mobile and remote working enhance the ICT infrastructure to provide a basis to technologies as existing contract technologies. We will Planned support the implementation of new systems and solutions expire, support for existing continue to develop our Future including the greater use of mobile and remote working technologies used across the Trust staff to ensure they are best technologies. are withdrawn by the manufacturer placed to support the Trusts and new or improved technologies as the technologies used In order to achieve this ambitious programme of work, it are developed and brought to continue to change. will be essential that ICT staff are given the appropriate market. We will continue to develop skills to ensure they are equipped to play their part in our staff to ensure they are best supporting future developments and technologies. placed to support the Trusts as the technologies used continue to change.

Strategic Action: We will work with NWIS and other partner organisations on the development of clinical information sharing arrangements.

Strategic Action: We will continue to pursue the agile working model through the use of staff mobile devices.

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8.10 Partnerships and Engagement

In 2017/18 we said we would  ensure that everyone with an interest in our work, including staff, stakeholders, patients and the wider public, understands what we do and our ambitions for the future, through a proactive programme of two-way engagement and communication that delivers tangible outcomes, supports delivery of our organisational priorities and informs future development.  agree (and implement) our approach to embedding the principles of the Wellbeing of Future Generations (Wales) Act 2015.

This is summary of how we have done  agreed our approach to engaging formally with the formal structures of the WBFGA, the Public Service Boards across Wales  identified key areas for collaboration, namely a more strategic approach to working with the fire services across Wales, finding collaborative solutions to our estates challenges and working with partners on possible opportunities to maximise training and occupational health services

8.10.1 The Well Being of Future Generations (Wales) Act 2015 (WBFGA)

Whilst we are not one of the 44 named organisations in the WBFGA, we have formally acknowledged through previous iterations of our IMTP that we wish to work within the spirit of the Act. We recognise the benefits to citizens/patients of better, more integrated planning and service delivery across the public service, recognising the need to optimise the benefit derived by citizens from the public service “pound” by harnessing more innovative ways of working. Similarly, we recognise that, as a relatively small but important body, we are not working in isolation, but are part of a wider public service system, beyond the NHS, and that we must look beyond our traditional horizons if we are to overcome some of our organisational challenges and meet our ambition of becoming a leading ambulance service delivering excellent services to people in Wales.

We have agreed three key collaborative objectives in the realm of estates, training and development/occupational health and fire/ambulance service strategy. The aim of developing these priorities is to provide broad areas for the exploration of collaborative opportunities in areas where we know we cannot deliver independently on a sustainable basis, nor would doing so optimise the use of public money for the benefit of citizens. 2017/18 was the first year that such objectives have been articulated and progress is being monitored at Board through the Engagement Framework Delivery Plan quarterly updates.

Progress made in 2017/18

We have been working actively on a range of operational collaborative initiatives which not only demonstrate intra-organisational mutual support, but also deliver better services for citizens. These include:

 Placing of ambulance clinicians in police control centres across Wales to support both services in managing their demand

 The Falls Response Team and Joint Response Unit in the Aneurin Bevan Health Board area

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 The tri-service station in Abertillery

 The optimising of estate with South Wales Fire and Rescue at Barry, Roath and Ely for example.

Such initiatives not only result in better services, they also help introduce a more open, externally focused and modern culture into the service which, in turn, helps the organisation move forward and supports the realisation of its organisational ambitions.

We are also making progress in relation to the sustainability goals. Some of our achievements are detailed below.

 Transitioned from the old ISO14001:2004 standard to the new ISO14001:2015 standard in June 2017

ISO14001 is an internationally recognised Environmental Management System that recognises:

 Better environmental management reducing waste and energy use & cost.  Improved efficiency  Demonstrates compliance & meet legal obligations  Helps to conserve energy and also prevent air, water and noise pollution, which in turn reduces our impact on the health of the Nation.

The Welsh Ambulance Services NHS Trust is the only ambulance service in the UK to have achieved ISO14001 certification for all of its activities

 Developed an Environmental Strategy, a key deliverable of which is a Sustainable Travel Plan

 The Trust’s Estates Strategic Programme was recently endorsed by Welsh Government. This SOP also demonstrates our commitment to embed and respond to the sustainable development principles in the implementation of the strategy.

 In December 2017 we were successful in securing the Gold Corporate Health Standard. The requirements focus on employee wellbeing, promoting physical activity and enabling policies and procedures. Work is already in train to scope out development actions for the Platinum Corporate Health Standard.

 The trial of electric cars (Cardiff and Swansea) and Euro 6 engines in Emergency Ambulances.

 All our new buildings have environment friendly features such as video teleconference whilst attaining a Breeam rating ranging between very good and excellent.

 Introduced a renewable energy resource at several sites throughout Wales.

We recognise that as outlined above, we are still very much at the early stage of our journey in properly articulating and embedding our approach to the WBFGA but we are committed and recognise that it provides us with a platform to make some step changes in the way we deliver services and the way in which we operate on a structural level. We recognise the fiscal environment in which public services will have to operate over the coming years and the concomitant pressures on demand and the upturn in social need, based on a number of factors including demography, economic activity, health and wellbeing of future generations etc. We understand that a status quo model of delivery is neither viable nor desirable, as we need to

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respond to the changing needs of our society in a more timely way, with a focus on managing demand, improving health, maintaining independence and optimising the skills of our staff to deliver higher level care in the community. The narrative around our organisation has already begun to shift from a transport model to a clinically led ambulance service, and we are committed to ensuring that everything we do adds value for the citizens we serve.

2018/19 onwards

Our key actions which we intend to take in embedding the sustainable development principle is a focus on if/how we engage with PSBs. Not being one of the 44 named organisations means we do not have a place at the 19 PSB tables across Wales as of right, although we are actively engaged in some areas, for example in the Vale of Glamorgan.

Strategic Action: We will ensure that everyone with an interest in our work, including staff, stakeholders, patients and the wider public, understands what we do and our ambitions for the future, through a proactive programme of two-way engagement and communication that delivers tangible outcomes, supports delivery of our organisational priorities and informs future development.

Strategic Action: We will agree (and implement) our approach to embedding the principles of the Wellbeing of Future Generations (Wales) Act 2015.

8.10.2 Patient Experience and Community Involvement (PECI) Team

The Patient Experience and Community Involvement Team (PECI) forms part of the Quality, Safety and Patient Experience Directorate and has, at its heart, a commitment to engaging with patients on their experiences of our services, helping us to understand what it feels like to be a patient in our care and to use that learning to help improve our practice.

NHS Wales is required to establish a consistent evidence based approach across Wales in providing every patient the opportunity to co-produce and evaluate their own care. The progress of Patient Reportable Experience Measure (PREM) captures the individual’s perception of their experience with a health care or service. We will continue to link in with the PREMS (and PROMS) Programme Board to ensure that we continue to capture experiences to measure how the Trust is doing in delivering quality services for people. We will continue to measure and report against the Health and Care Standards, National Service User Framework and Commissioning Quality Core Requirements.

Work will continue to strengthen the integration of the work of the PECI team and colleagues across the organisation throughout 2018/19. This work will continue to be reported regularly to the QuESt committee and Board, providing the organisation the evidence and quality assurance required.

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Such an approach should ensure that the Trust’s engagement activities, in their broadest sense, are focused on the delivery of outcomes and that, cumulatively, they contribute to the organisation’s broader ambitions.

8.11 Corporate Governance and Risk Management

In simple terms, governance refers to the way in which organisations ensure that they are doing the right thing, in the right way, for the right people, in a manner that upholds the values set for the Welsh public sector.

8.11.1 Corporate Governance

In 2017/18 we said we would

 Implement and embed the Risk Management Strategy & Framework 2016/19 approved at Trust Board in March 2016 and assess maturity in 2017/18  Develop a Board Assurance Framework (BAF) document mapped to the strategic aims and priorities  Review the effectiveness, reporting and monitoring arrangements of groups sitting below sub-committee level.  Implement a document management system with supporting policy and guidance.  PREVENT training (counter terrorism)  Tier One Multi-Agency Exercise  Re-write of the Trust’s Major Incident Plan to meet best practice  Commander Competency training and roll out of National Occupational Standards  Deliver and improve processes which support the Board to do business. This includes a programme of Board and Committee business and development, ensuring the timely issue of papers and other information and the induction of a new Non-Executive Director Board member.  Introduce a system which supports paperless Board, Committee and other meetings.  Introduce and deliver a governance training module into the leadership training programme.  Introduce and, where necessary, refine systems and arrangements for reviewing, amending and updating Trust wide policies  Further develop the governance mapping for the Trust and ensure proper governance arrangements exist with committees, groups, programmes and projects.  Further refine the systems and processes for ensuring the Trust meets its obligations on such matters as the Welsh language, Freedom of Information requests and other requests for information and direction.

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This is summary of how we have done  Delivered a Board approved Risk Management Framework and Strategy  Launched the Trust’s Board Assurance Framework and introduced quarterly progress reports to Audit Committee and Trust Board  Reviewed the effectiveness of groups sitting below sub-committee level including mapping governance structures for each of the directorates  The Document management system including paperless meetings was re-programmed as a result of the CAD, with an expected go live now of March 2018.  Delivered PREVENT training (counter terrorism)  Engaged in the Tier One Multi Agency exercise  Reviewed and re-launched the Major Incident Plan  Undertaken initial work on Commander Competency training and roll out of National Occupational Standards, but further work is required in 2018/19  Put in place a Board Development programme and a Plan of Board Business.  Delivered induction training for NEDS.  Delivered the governance training module, as part of the leadership training programme, was developed and delivered.  Procured software to support paperless agendas, which has been re-programmed to March 2018, to free up capacity to support the CAD.  Introduced a Policy on Policies which is now being delivered as business as usual.  Completed stage 1 of the governance mapping work as planned i.e. the mapping out. The next stage is to ensure that everything is “wired up” correctly e.g. standing orders, hierarchy of meetings etc. This work will be completed in 19/20.  Revised the process for FOIs.  The Trust has also revised and approved new Standing Orders (SOs) and new Standing Financial Instructions (SFIs).

Corporate governance broadly refers to the rules, practices, processes and relationships by which an organisation is controlled and directed. It ensures accountability, fairness and transparency in everything that the organisation does. In essence, it’s about making sure we do the right things in the right way at the right time.

The Board has overall responsibility for ensuring good governance within the Trust. The Board is responsible for setting strategic direction and satisfying itself that there is a good system of governance and internal control in place, underpinned by an effective risk management system. The Board will oversee the delivery of the Trust’s strategic priorities and the non-executive members of the Board will hold the Executive Team to account for performance and delivery.

Governance cannot be confined to a directorate or be a single team’s responsibility. Exercising good governance is the responsibility of all staff and it is the responsibility of the Corporate Governance Directorate to create the environment which encourages, fosters and nurtures good governance.

The corporate governance priorities for the period covered by this plan are based on, and informed by, work which was carried out during 2016/17 to establish current governance arrangements, feedback from Board members, senior management, staff and reviews and inspections by internal and external auditors and other external regulators.

The Corporate Governance Directorate works closely with all areas of the Trust and each directorate’s plan will impact and influence the Corporate Governance Plan. In particular, the Corporate Governance team links closely with the Quality, Safety and Patient Experience Directorate and also the Partnerships and Engagement Directorate. The plan has also been informed by key stakeholders such as the Welsh Government.

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We recognise that the effectiveness of our governance arrangements has a significant impact on how well the Trust meets its aims and objectives. We also recognise that, as the Trust evolves and grows, so too must our governance systems and processes.

2018/19 Plan

The focus for the 2018/19 plan is to capitalise on the foundation work which was carried out in 2016/17 and 2017/18. This is principally to ensure good governance exists in our systems and processes and that we have the right environment where governance is understood and encouraged.

We must not forget though, that the work of the Governance Team also has an important role in directly supporting the Board by providing a programme of Board business and development and ensuring the timely issue of papers and other information. These are the foundation stones upon which good governance is built.

Key actions for 2018/19 and beyond are:  Develop and deliver an annual programme of Board and Committee business.  Induction of a new Board Chair  To meet the ICO target of responding to 90% of all FOI requests within 20 working days.  To ensure Trust policies are up to date and are subject to regular review  Continue the governance mapping of groups, programmes and projects  Embed Board Assurance Framework into Committee and Board business.

Strategic Action: We will develop our Corporate Governance function to make us an even more effective organisation.

8.11.2 Risk Management

The Trust Corporate Risk Register has identified the high scoring risks which are being monitored and reviewed as part of our Board Assurance process and local risk registers at local team meetings. During 2017/18 we have further matured our Corporate Risk Register to include target dates, controls assurance ratings and aligning risks to our Strategic Aims.

We have continued to build on the work undertaken during 2016/17 to develop the structure of the Trust corporate and local risk registers to provide assurance and confirm mitigating actions for the risks identified and to align these within the IMTP.

During 2017/18, we established two key fora to assist our risk maturity:

 The Risk Register Advisory Group which advises Directorates across the Trust on the processes and risk assessments that inform the development of local and corporate risk registers and supports the building of confidence and competence of staff to achieve a consistent approach to risk management practice across the Trust with particular emphasis on the clarity of description, scoring assessment, evidence of proportionate assurance and control measures of risks identified informing the Board Assurance Framework (BAF) and development of the Trust Integrated Medium Term Plan.  The Risk Management Development Group supports Directorate risk leads across the Trust on risk management functions by creating a platform that provides support, direction and consistency with implementing the Risk Management Strategy across the Trust.

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To continue to strengthen our processes we will:  Lead and co-ordinate the response to the recommendations from the Commissioning Clinical Risk Assurance Review through the quarterly Quality Assurance Report and the QSG  Continue to build on the risk maturity of the Trust and development of our Board Assurance Framework; Implement the revised Risk Management Strategy

8.11.3 Meeting our Statutory Obligations

As an organisation, we have a range of statutory obligations, many of which are documented in our standing orders.

Under the Civil Contingencies Act 2004 (CCA) Category One responders (such as WAST) are also subject to the following set of legal civil protection duties:  risk assessment;  emergency planning;  business continuity planning;  warning and informing;  information sharing; and  co-operation.

These statutory obligations are delivered through the Head of Resilience and the regional Resilience Managers who work with their Local Resilience Forums, Welsh Government and national (UK) resilience groups to ensure that, in partnership, we can deliver a resilient response to emergencies in the community based on the above duties.

The work with the LRFs ensures that we are working in full partnership with other Category One and Two responders ensuring that we can, through these strategic partnerships, plan and prepare for the risks identified in each area through the national and community risk registers.

The provision of a HART and SORT capability, which is separately funded by Welsh Government, allows the Trust to contribute towards the UK Government’s Counter Terrorism Strategy (CONTEST) which is divided into four pillars i.e. Prepare; Prevent, Protect and Pursue.

 Prepare is addressed through the HART, SORT and the National Interagency Liaison Officers (NILOs) and is a provision that is funded and provided in preparation for a terrorist incident. Additionally, we have a network of major incident vehicles and equipment strategically located across Wales that can be deployed in the event of a major incident

 for Prevent we provide specific training to our operational and CCC teams to recognise the potential of persons who may be being drawn into radicalisation as part of the safeguarding strategy to meet the statutory obligation placed on public services through the Prevent Duty Guidance (2015) which is issued under section 29 of the Counter- Terrorism and Security Act 2015;

 for Protect again HART, SORT and NILOs allow us to have in place specially trained and equipped staff to address a terrorist incident, using training in managing firearms incidents, hazardous chemicals, decontamination and mass casualty provision to provide a dedicated specialist response to other challenging incidents. HART skills are also able to be utilised to support normal operations on a day to day basis in flooded areas, confined space, working at height, unstable terrain and remote locations including hazardous chemicals. SORT skillsets have been further developed to include Ambulance Intervention Team (AIT) to support HART at firearms incidents with casualty treatment and the SORT

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Flood Response Team who are able to provide a regional response to assist with patient access in flooded environments;  Pursue is a Police and security services issue only.

Based on the changes in terrorist and security threat to the UK and subsequent assumptions made, the Welsh Government may at times require changes to the provision of specialist operations functions i.e. Hazardous Area Response Team (HART) and Special Operations Response Team (SORT) capability, skillset and numbers. This will be the result of formal structured discussions potentially based on UK wide action that needs to be reflected in devolved nations along with the necessary funding streams to support it. These discussions will probably take place separately to the normal commissioned service route using the Memorandum of Understanding process currently in place for HART and SORT.

National Interagency Liaison Officers (NILOs) are a select group of specially trained commanders who act as advisors to the tactical and strategic levels of command.

Having undertaken a formal training course at the Fire Service College NILOs are the Trust’s main counter terrorism advisors and work closely with all partner agencies including the Welsh Extremism and Counterterrorism Unit (WECTU) to advise on WAST capability to manage an incident and assist to develop plans. At the beginning of 2018 we will be embedding one of the NILO cadre who has undertaken enhanced security clearance into WECTU on a day a week basis to further strengthen our relationships and information sharing processes.

NILOs also act as Firearms Commanders in the event of a firearms incident and will work alongside other NILOs at the Forward Command Point (FCP) to develop joint plans using JESIP doctrine and provide a timely response using ballistically protected HART staff to save life in the warm zone.

8.11.4 Business Continuity

The Trust has undertaken significant work to address recommendations from the 2014 audit on business continuity and, as part of that, has completed a review of the Trust’s Pandemic Flu Plan. The plan has been updated to include the latest information and planning assumptions and has been tested at Exercise Cygnus and further updated with lessons from that. The plan has been through our internal governance processes and has been formally approved with ongoing staff awareness planned as well as table top exercises.

Further exercises will be taking place throughout the year and a further BC audit is planned for quarter 4 of 2017/18.

Event planning has been further developed to include a ‘business as usual’ section that looks at the operational preparedness to deal with the consequences of large scale events on service delivery. Tying this in with an online event calendar that can be viewed by all operational managers will ensure that full communication is maintained around events that may have an impact.

An online event calendar has been developed that will allow managers to access and view upcoming events across Wales, see plans as they are developed and determine the impact on their area of service provision.

8.11.5 Welsh Language

During October 2017, the Trust provided a response to Welsh Government’s consultation on proposals for a Welsh Language Bill where the role of Welsh Language Commissioner would be

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abolished and replaced by a single body who will have responsibility for promoting the Welsh language and regulating Welsh language Standards. We await the outcome of the consultation.

We remain committed to the principles and actions of Welsh Government’s More than Just Words Strategic follow on Framework 2016-19 where it sets out the importance of delivering the principles of the ‘Active Offer’ to service users. A progress report was presented to Welsh Government on delivering the Year 1 action points. Key developments in this area have included: ensuring that the principles of the Active Offer were considered and incorporated into the new 111 Pathfinder Service in the ABM UHB area, where callers are able to make a positive language selection and receive bilingual message prompts. These principles have also been incorporated into the 111 service within areas of Hywel Dda UHB. The Trust will continue to ensure that Welsh language considerations are met for the implementation of the new 111 service across Wales.

In up-skilling the Welsh language skills of its staff, the Trust has registered with the National Centre for Learning Welsh in order to provide opportunities for its staff to receive a free 10-hour online course which teaches basic Welsh suitable for use in the workplace and will enable staff to meet and greet colleagues, customers and stakeholders using Welsh phrases. The online course has been advertised across the Trust with an uptake of 104 members of staff registered with the National Learning Centre to complete the course. Staff have found the course to be very informative in gaining a basic understanding of the Welsh language that will assist them in their role within the Trust. In addition to the online course ‘An Introduction to Welsh – Level 1 CD’ is being developed by the Trust that will contain bilingual terminology specifically related to the Trust.

Moving Forward

Welsh Language Standards (Health Sector) - once approved by Welsh Government we will receive an imposition notice from the Welsh Language Commissioner indicating which standards we must adhere to. When we receive the imposition notice, preparations and plans for changes in our Welsh language requirements will be prepared and communicated amongst staff. Until such a notification of changes is received, we will continue in our commitment to implement our Welsh Language Scheme.

As part of the Trust’s Welsh Language Skills Strategy a revised and updated detailed audit of the Welsh language skills of the staff groups that deal with the public was carried out in 2017. This data was matched with the Welsh language population data from the 2011 census. This data will be disseminated to all Heads of Service managers to assist them in gaining a better understanding of their current Welsh skills mix of staff in relation to the percentage of Welsh speakers within their respective localities in order for them to make informed considerations as to further potential future actions required in providing Welsh language services. In addition, Welsh language considerations have been included in both the operational and corporate Local Delivery Plans for 2018 which include actions relating to capturing and recording Welsh language skills of staff on ESR and ensuring that Welsh speaking staff within service areas are known and offered the ‘Working Welsh’ logo (pin badges or lanyards) to enable people to identify Welsh speakers.

In order to ensure that the Trust has sufficient staff to communicate with patients in their own language, it was stated in 2017 that an audit to determine the bilingual skills requirements for the various workplaces and posts within the Trust would be carried out during 2017. In order to address this, a focussed action and intervention was implemented as a test case at the Trust’s North Clinical Contact Centre, which resulted in the recruitment of Welsh speaking EMS Call Handlers. This test case will be evaluated and the findings disseminated to other service areas to further develop this action in increasing Welsh language services for its patients. During 2018 posts for Call Takers for the North NHSDW/111 Clinical Contact Centre will be advertised where the ability to speak Welsh will be an essential skill.

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Work is progressing in relation to the inclusion of Welsh language considerations for the new 111 IT system to ensure that the patient’s language choice is recognised and recorded. A future ambition will be for the new system to have the ability to record information bilingually to minimise any risks, thus ensuring that Welsh and English speaking staff can access the information and take the appropriate action. The progress of the procurement process will be monitored in ensuring that Welsh language requirements are linked into the commercial dialogue debate.

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9 PLAN DELIVERY AND OUR PERFORMANCE AMBITIONS FOR 2018/19

We recognise that writing a good plan represents only half a job compete and there is an absolute requirement to deliver on the promises and commitments which we make in this plan.

On this basis, we are very clear how we will both monitor progress in the delivery of our plan but also how we will try and measure what positive difference the planning is making.

9.1 Plan Delivery

We continue to develop and ensure a strong focus on delivery. This is grounded in the organisation’s growing maturity towards developing a consistent, and robust approach towards performance management and project and programme management.

Last year our IMTP was tracked across its three main components: - The 48 actions - The performance ambitions - The financial plan

Equally, in terms of delivery of last year’s plan, we undertook a re-fresh of the IMTP Delivery and Assurance Group (iDAG) so that;

 All 48 actions identified within the plan (regardless of whether or not they were being delivered through a formal ‘project’ or ‘programme’ of work) were tracked through the group.

 The performance ambitions were also drawn into the scope of the group rather than via a separate process.

 iDAG was scheduled to meet directly before or after the Trust’s Executive Finance Group (EFG) meetings so that a more seamless perspective on both service delivery and financial delivery was achieved.

These delivery arrangements are summarised in the diagram below.

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Each of our 48 actions was assigned an Executive lead so that there is top level ownership.

This revised process was subject to an internal audit by NHS Wales shared services during 2017/18 and the organisation is very proud that this was concluded as having ‘substantial assurance’ and an exemplar across NHS Wales for good performance management of IMTPs.

The audit found three low level risks which needed to be addressed and these will be built into our plan delivery process for 2018/19.

Despite this highly positive internal audit, we want to continually maximise our chances of delivering on the commitments we make within our plans by refining and maturing our delivery processes. We will adopt this process into 2018/19, to oversee the delivery of our 44 strategic actions for 2018/21. We will develop plans on a page to support the specific actions for 2018/19 and ensure that the milestones for achieving the actions are clearly articulated.

We have recognised that, over the life of this plan and beyond, we are going to need to initiate a number of important programmes and projects of work. Whilst we have a number of staff within the organisation with sound project and programme management skills, we need to grow that number if the organisation is going to deliver the large scale change we describe.

Consequently over the course of year one of this plan, we will look to develop an internal project and programme management framework. We will then look to develop an internal mechanism for training staff in the principles of this framework so that it is brought ‘alive’ and deployed consistently across the organisation.

Strategic Action: We will develop a project and programme management framework for the organisation and subsequently develop bespoke training for staff on the principles of the framework.

9.2 Risks to Plan Delivery

The mechanisms set out above will provide rigour to the delivery and monitoring process. Despite this there remain a number risks in relation to plan delivery:

 System pressures – our ability to fully deliver on our plan will be impacted on by system pressures that are outside of WAST control. An example of this is the handover delays at ED sites. Whilst we continue to work with the CASC and LHB partners to improve demand management and flow, our ability to be our most effective and efficient is significantly affected by the inefficiencies of handover delays and their impact on quality and patient safety. Our internal escalation status (REAP levels) increases with the pressures and this reduces availability of clinical and operational staff. There is also a link between system pressures and experiences for our staff and workforce.

 Financial plan – our savings plan has a number of risks within it as identified in the financial section. The Executive Finance Group will track and monitor delivery of this element of our plan including our response to unforeseen or unknown internal or national pressures

 Non-Emergency Patient Transport and the transfer of work from LHBs to WAST - we continue to work with health boards and the CASC to develop the Commissioning Quality and Delivery Assurance Framework, and to obtain accurate and timely information in support of the transfer of NEPTS work into WAST.

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 Capacity to deliver change – this plan continues to represent an ambitious programme of change. The capacity of the organisation to deliver this change is a potential risk and links to system pressures above. Many of the actions and commitments with this plan will enhance our ability to deliver change, for example the development of the improvement and innovation framework, our new clinical leadership structure and our wider leadership development programmes. In addition, we will take a more systematic approach to reflecting project costs in capital business cases, and we will develop a programme and project management framework that provides consistency and clarity in the running of programmes and projects.

9.3 Our Performance Ambitions 2018/19

In section 3.1 we gave a review of the progress we made against our 2017/18 performance ambitions. As part of the development process for this, our 2018/21 plan, we have re-committed to setting ourselves a suite of performance ambitions.

For 2018/19, we have reviewed our performance ambitions by considering the following:

 Performance against the 2017/18 ambitions;  Performance issues identified as a result of the overview of performance (and supporting detail);  Quality, Safety and Patient Experience information  The EMS commissioning intentions;  The NEPTS business case;  17/18 strategic actions carried forward to 18/19;  The IMTP C1 Delivery Template;  The Welsh Government NHS Planning Domain indicators; and  The WAST JET Scorecard

Part of the testing of our performance ambitions over the course of the last 12 months has identified that some of the ambitions need to be considered, reviewed or different metrics developed to ensure accurate and robust capture of complex issues.

Annex 8 contains a table which outlines our refreshed performance ambitions for 2018/19 and how they map to the commissioning intensions which we have been issued and the strategic aims for the organisation. Whilst the embedded excel document shows how the performance ambitions map to each of the strategic actions we have set ourselves.

Conclusion This Integrated Medium Term Plan for 2018/19 – 2020/21 has provided a detailed and comprehensive summary of our three year organisational ambition. It reflects on the exciting but challenging time for the Welsh Ambulance Service as we transition from a traditional model of ambulance services to one which is at the forefront of ambulance services worldwide. The plan outlines the significant progress made during 2017/18, and reinforces our commitment to a wide range of strategic actions, supported by performance ambitions, and sets out how we aim to achieve them.

Whilst this IMTP represents the final year of our original plan approved in 2016, it also marks the preliminary year of our next phase of development, with an absolute focus on the needs of the people we serve, both now and in the future. As we move through 2018/19, we look forward to continuing our improvement journey across the range of our services, and articulating our long term strategic vision for a Welsh Ambulance Service which optimises its contribution to the health and care system in Wales.

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