Welsh Ambulance Services NHS Trust Discretionary Capital Programme Allocation Is Funded from the Welsh Government All Wales Capital Programme (AWCP)

2017/18

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

3 STRATEGIC OVERVIEW ...... 10

3.1 Developing a Long-Term Strategy ...... 10

3.2 Performance ...... 18

3.2.1 Overview of our Performance ...... 18

3.2.2 Our Performance Ambitions 2016/17: A Review ...... 19

3.2.3 Our Performance Ambitions for 2017/18 ...... 19

3.3 Our Service Initiatives ...... 23

3.4 National Policy Context ...... 23

3.5 NHS Wales Strategic Change Agenda ...... 23

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

3.7 Emergency Ambulance Services Committee (EASC) and the Commissioning Quality and Delivery Framework...... 31

3.8 Service Change in Collaboration with Blue Light Partners ...... 32

4 OUR ACHIEVEMENTS IN 2016/17 ...... 34

4.1 Key Headlines of our Successes ...... 34

4.2 Our Strategic Change Portfolio ...... 34

4.3 Our 154 Point Plan ...... 34

5 OPPORTUNITIES AND CHALLENGES IN 2017 - 2020 ...... 35

5.1 Specific Challenges ...... 35

5.2 Demand and Capacity Review ...... 36

5.2.1 Amber Performance...... 36

5.2.2 Workforce Challenges ...... 36

5.2.3 Clinical Risk Assurance Review ...... 37

5.3 Specific Opportunities ...... 38

5.3.1 The New Clinical Response Model ...... 38

5.3.2 Realising Benefits from the Demand and Capacity Review ...... 38

5.3.3 Primary Care ...... 39

5.4 Other Opportunities ...... 39

6 QUALITY, SAFETY AND PRUDENT HEALTHCARE ...... 40

6.1 Strategic Context ...... 40

6.2 Structures – Strengthening Quality Assurance and Improvement across the Trust ...... 42

6.3 Processes – to Strengthen Quality across the Trust ...... 43

6.4 Outcomes - (Assurance, Improvement and Learning)...... 45

6.5 The Organisation and Prudent Healthcare ...... 47

7 OUR SIGNIFICANT SERVICE CHANGES ...... 49

7.1 OUR EMS SERVICE DEVELOPMENTS ...... 49

7.1.1 STEP 1: Help Me Choose ...... 49

7.1.2 STEP 2: Answer My Call ...... 52

7.1.3 STEP 3: Come to See Me ...... 57

7.1.4 STEP 4: Give Me Treatment ...... 61

7.1.5 STEP 5: Take me to…...... 63

7.2 OUR NON-EMERGENCY PATIENT TRANSPORT SERVICE DEVELOPMENTS ...... 65

7.2.1 The NEPTS Business Case ...... 65

7.2.2 The NEPTS Four Step Model ...... 67

7.3 SPECIFIC PATIENT GROUP SERVICE DEVELOPMENTS ...... 70

7.3.1 Amber calls- responding to the challenge ...... 70

7.3.2 Welsh Government Together for Health National Delivery Plans...... 72

8 OUR ENABLERS ...... 73

8.1 Our People ...... 73

8.2 Our Finances ...... 96

8.3 Our Estate ...... 113

8.4 Our Discretionary Capital ...... 116

8.5 Our Fleet ...... 117

8.6 Research & Development ...... 118

8.7 Improvement & Innovation ...... 121

8.8 Health Informatics and Business Intelligence ...... 123

8.9 Information Communication & Technology (ICT)...... 125

8.10 Partnerships and Engagement ...... 130

8.10.1 The Well Being of Future Generations (Wales) Act 2015 (WBFGA) ...... 133

8.10.2 Patient Experience and Community Involvement (PECI) Team ...... 133

8.11 Corporate Governance and Risk Management ...... 134

8.11.1 Corporate Governance ...... 134

8.11.2 Meeting our Statutory Obligations: ...... 135

8.11.3 Business Continuity ...... 136

8.11.4 Plan Delivery ...... 136

8.11.5 Welsh Language ...... 138

Annexes (Separate Document)

Annex 1: Overview of 17/18 Strategic Actions Annex 2: Strategic Statement of Intent Annex 3: Alignment of 16/17 & 17/18 Strategic Aims Annex 4: Overview and Progress Against 16/17 Performance Ambitions (Q3) Annex 5: Overview of Service Change Initiatives Annex 6: 2016/17 Strategic Change Portfolio Annex 7: Progress Against our 2016/17 154 Actions Annex 8 Demand and Capacity Review Annex 9 Welsh Government National Delivery Plans Annex 10 Research Activities Annex 11: Mid Wales Healthcare Collaborative (MWHC) – Key Actions 2016/17

Annex 12: The Mid Wales Healthcare Collaborative (MWHC): Priorities for Mid Wales 2017/18

1 MESSAGE FROM THE CHAIR AND CHIEF EXECUTIVE

Welcome to our refreshed Integrated Medium Term Plan (IMTP), which builds on our initial document approved by the Cabinet Secretary for Health, Wellbeing and Sport in the spring of 2016. In the last 12 months or so, we’ve made some significant progress in delivering against our strategic priorities, but we are not complacent and recognise that we still have a considerable way to go before we can be confident that the improvements we have made are well-embedded and beginning to deliver positive benefits for patients and staff. Similarly, the reshaping of an ambulance service is a long term process, which means changing the way we think about, and deliver, our services. Over the next few years, we will be redefining the role of the ambulance service, focusing much more on keeping people at home, either by treating more people at scene or by supporting people over the telephone. This will mean ensuring our teams have the right skills and abilities to care for patients without the need to travel to hospital, and working far more closely with primary care and multi-disciplinary teams to deliver care at home and in the community. We need to change because the type of patients we see is changing. Our ageing population means many of our patients have complex care needs and are frail, needing care which is often best provided at home, rather than in a hospital. We need to be able to play our part in this, by ensuring our teams have the skills they need to support patients in the right way, and that our services are geared up to operate in this rapidly evolving environment. In the future, ambulances won’t simply be a mode of transport for patients. They will act as mobile clinics, able to access on-board and remote diagnostics to support better care for patients wherever they are. We know already that only a small, if important, sliver of our work is dealing with life-threatening emergencies. Our challenge in the future is to position ourselves at the heart of our communities, delivering emergency, non-emergency and community care in a way that builds resilience and adds value for local people. We need to be open to collaboration and opportunity, with a clear focus on working together to deliver improvements. To achieve all these ambitions, we need to start to build that future now. What’s clear is that we cannot achieve any of this without the support of our many partners, in the NHS more broadly, other emergency services, local authorities, the voluntary and private sectors, and the wider public. Developments like the new 111 service that we host, the way we are changing our non- emergency patient transport service (NEPTS), our work with primary care clusters on the emerging community paramedicine model and our work with partner agencies on co-responding, shared facilities and learning all point towards an organisation that is receptive to change and committed to moving forward in ways that meet the needs of the people we serve. This latest version of our IMTP is true to the original vision we outlined last year, but rearticulates it in a more well-developed way, reflecting the discussions and developments which have taken place over the last 12 months. While we continue to improve as an organisation, our focus is increasingly shifting to how we place collaboration at the heart of our agenda, and you will see from this plan that we are now defining ourselves more clearly within the wider public service in Wales, something which will continue to grow and develop over the coming years.

In addition, we have tried to make sure that this year’s refreshed IMTP focuses very much on the strategic actions that will make a significant difference to the organisation and the services we provide, to ensure our ambition and actions are clear, and to ensure our monitoring against performance is more straightforward. That doesn’t mean that there isn’t lots of supporting work happening across the organisation. There is. It simply means that, in this document, you will be able to see how we intend driving really significant change across ambulances services in Wales that will deliver benefits for patients, staff and the wider population. The coming years will be exciting and challenging in equal measure for the Welsh Ambulance Service and we hope you feel that our commitment, ambition and energy are reflected in this plan.

Mick Giannasi, Chairman

Tracy Myhill, Chief Executive

2 INTRODUCTION AND HOW TO READ THIS PLAN

Our Plan at a Glance

Our plan is detailed and comprehensive. 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 have set our plan against our purpose, vision and behaviours:

We have identified 10 priorities:

1 We will progress our quality improvement journey, implementing our Quality Strategy with a focus on:  assurance;  patient experience and  improving outcomes This will incorporate actions from the Clinical Risk Assurance Review. (section 6) 2 We will further transform our EMS service using the 5 step pathway, and focusing on moving from a focus on steps 4 and 5 of the Ambulance Care pathway to steps 1, 2 and 3, including:  realising benefits from telephone assessment & triage;  next phases of 111;  improving clinical outcomes, and  maintaining Red performance. (sections 7.1) 3 We will progress NEPTS transformation with a focus on: • successful novation of contracts and management of associated risks; • delivering on the priorities supported through business case, and • sustainable resourcing plan. (section 7.2) 4 We will deliver further improvements to Clinical Contact Centre transformation including: • implementation of a new CAD; • agreeing the CCC Estate reconfiguration, and • workforce and process efficiencies. (section 7.1.2) 5 We will maintain our focus on workforce engagement including: • embedding our behaviours framework; • working with our unions to ensure staff are recognised for the work they do, and • enabling them to be their best and work to the top of their skill set to deliver high quality care. (section 8.1) 6 We will continue to develop and re-shape our workforce, focusing on • leadership and clinical leadership; • transforming training and clinical education to maximise future workforce development and patient care; • developing the career pathway, with particular focus on the role of advanced practice and developments in paramedic role and banding, and • opportunities for collaborative approaches to roles and models, e.g. joint posts, rotations. (section 8.1) 7 We will deliver a programme of improvement and efficiencies, including: • spread of existing good practice across Wales; • realisation of efficiencies identified as part of the Demand and Capacity review and the benchmarking exercise, and • cost reduction and cash releasing as part of our savings plans. (section 8) 8 We will deliver patient and system benefits through our health partnerships:  delivering on our jointly agreed priorities with LHBs  and on priorities agreed across the wider unscheduled care system. (section 3.7) 9 We will realise further benefits from our collaborative stakeholder relationships, with a focus on our Blue Light partners and wider public sector opportunities offered by the Well Being of Future Generations Act such as: • public education; • community resilience and response, and • estate and fleet

(sections 3.9, 3.10, 8.4, 8.9) 10 • We will continue our journey to becoming a highly effective organisation including developing a longer term strategy; • improving governance systems; • strategic approach to improvement, innovation and R&D, and • delivering our financial plan to achieve financial balance, (sections 3.1, 8.6, 8.10.1)

How to Read Our Plan

In our original 2016/17 plan, we listed 154 actions which we would be progressing during the life of the plan. Whilst we provide a detailed overview of where we are with all these actions in Annex 7, we also provide a snapshot of progress against those actions which were identified as Year 1 actions throughout this plan. For example, you can see where we are with regard to the Year 1 actions relating to our workforce in the workforce section of this plan. You will always find this snapshot in the green call-out boxes as shown below:

In Year 1 we said we would

 This is a summary of how we have done



As an organisation, we were really proud to produce, for the first time, an Integrated Medium Term Plan (IMTP) which was approved by the Trust Board, the Chief Ambulance Services Commissioner and the Cabinet Secretary for Health, Wellbeing and Sport. In our 2016/17 plan, we wanted to be really clear on the tangible actions which needed to be undertaken in order to continue the transformation of the organisation. This is why we drew out the 154 actions referred to above. This enabled absolute clarity on what our commitments were and we have systematically tracked delivery against those actions. Learning from last year’s approach, we recognise that there was a great deal of variability within these actions. Some were very strategic, whilst others were very operational. All needed to be done, but not all had their place in a strategic document like an IMTP. Consequently, this year, whilst we will again be explicit about what actions we will progress, and we will track them in a similar way, in developing our plan we have taken more time to consider these actions and grouped them into tiers.

TIER 1: Highly strategic and significant actions which, when executed, will fundamentally support service and organisational transformation TIER 2: Actions of significance which will directly affect the performance of the organisation in the coming period

In this 2017/18 plan, we will detail all Tier 1 actions we have identified as needing to take place over the three-year life of the plan and all Tier 2 actions identified for year one of the plan. An overview of all the actions which we commit to in this plan can be found in Annex 1 at the end of this document.

3 STRATEGIC OVERVIEW

This section is intended to offer assurance that our refreshed plan is set in the context of both our own emerging long term strategy but 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.

In Year 1 we said we would

 Actively work with Public Health Wales and engage with the Well-being of Future Generations Act (Wales) 2015 agenda in order to better develop the Trust’s strategic responses to predicated changes in our population.  Establish a performance framework that enables us to monitor and review the impact of the approaches we have taken and the work we have done.  Develop a long term strategy for ambulance services in Wales.

This is a summary of how we have done

 We have engaged in the Well-being of Future Generations Act (Wales) and have attended key all-Wales events. We have also held discussions with Trust Board regarding how we want to embed some or all of the seven principles in our organisation. The Well-being of Future Generations Commissioner has also attended a Board development day.

 We have in place a Board-approved Planning and Performance Management Framework

 We have actively engaged with staff and Board members on issues that will influence a 10-year strategy

3.1 Developing a Long-Term Strategy

In our 2016/17-18/9 IMTP, we outlined a strategic statement of intent regarding where we wanted to be in 10 years’ time and gave a commitment to develop a long-term strategy for ambulance services in Wales. This statement of intent can be found in Annex 2.

We also outlined the work which had been undertaken to re-baseline the organisation’s purpose, vision, strategic aim and priorities. This culminated in the publication of a strategy map.

Through the course of 2016/17 we have continued the conversation with our staff and our Board around both our long-term strategy and our strategy map. These conversations have allowed us to refine our thinking further.

Recognising that we operate as part of an unscheduled care and wider health and social care system, we will redefine our role within it and bring our influence to bear on the system more broadly. Clearly, we cannot conclude our thinking on our longer term vision without exploring further with our key stakeholders. Key partners in this process are:

 EASC and the Chief Ambulance Services Commissioner

 LHBs in their provider role (as opposed to as our Commissioners via EASC), specifically linking in with their vision for unscheduled care and pre-hospital care in particular  Primary Care Clusters  The Unscheduled Care Programme  Blue light partners  Local authority and third sector partners

Critical to this thinking will be the emerging NHS Wales Strategy and the direction from the Parliamentary Review.

We are not starting from a blank page. In addition to our strategic statement of intent we are, through this IMTP, testing some approaches and concepts that will help inform and shape our offer to the wider system, for example the piloting of community paramedics and our role in the 111 Pathfinder.

We will work with our stakeholders over the next six months to explore and further our thinking in this area to inform our longer term strategy.

Our IMTP should be considered in this context. We continue to consolidate and mainstream our improvement journey whilst still committed to exploring our future potential. This IMTP reflects our position of evolution not revolution.

Whilst our behaviours, purpose and vision remain the same, we have further developed our strategic aims. We are now clear these are the areas of the business which we need to be focusing on over the next 10 year period. Diagram 1 below articulates our revised strategic aims.

Diagram 1: Our Strategic Aims

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;

Table 1: Our Priorities for 2017/18

Based on our diagnostic of what we have achieved to date and the current context for us, we have summarised our priorities and mapped them to our strategic aims.

No Priorities

xcellent

Efficiency

PatientCare

Fantastic People Vibrant Leadership Vibrant

Qualitythe at heart

StrongPartnerships Deliveryof E Value,Innovation and 1 We will progress our quality improvement journey, implementing our Quality Strategy with a focus on:  Assurance,  Patient experience and     Improving outcomes This will incorporate actions from the Clinical Risk Assurance Review (sections 6) 2 We will further transform our EMS service using the 5 step pathway, and focusing on moving from a focus on steps 4 and 5 of the Ambulance Care pathway to steps 1, 2 and 3, including:  Realising benefits from telephone assessment & triage

 Next phases of 111     Improving clinical outcomes  Maintaining Red performance (sections 7.1) 3 We will progress NEPTS transformation with a focus on: • Successful novation of contracts and management of associated risks

• Delivering on the priorities supported through business case    • Sustainable resourcing plan (section 7.2) 4 We will deliver further improvements to Clinical Contact Centre transformation including: • Implementation of a new CAD    • Agreeing the CCC Estate reconfiguration  • Workforce and process efficiencies (section 7.1.2)

5 We will maintain our focus on workforce engagement including: • Embedding our behaviours framework, • Working with our unions to ensure staff are recognised for the work they do,      • Enabling them to be their best and work to the top of their skill set to deliver high quality care. (section 8.1) 6 We will continue to develop our workforce, focusing on: • Leadership and clinical leadership • Transforming training and clinical education to maximise future workforce development and patient care • Developing the career pathway, with particular focus on the role of

advanced practice and developments in paramedic role and      banding • Opportunities for collaborative approaches to roles and models, e.g. joint posts, rotations (section 8.1) 7 We will deliver a programme of improvement and efficiencies, including: • Spread of existing good practice across Wales • Realisation of efficiencies identified as part of the Demand and    Capacity review, the benchmarking exercise • Cost reduction and cash releasing as part of our savings plans (section 8) 8 We will deliver patient and system benefits through our health partnerships, delivering on our jointly agreed priorities with LHBs and

across the wider unscheduled care system.     (section 3.7) 9 We will realise further benefits from our collaborative stakeholder relationships, with a focus on our Blue Light partners and wider public sector opportunities offered by Well Being of Future Generations Act such as:

• Public education   • Community resilience and response • Estate and fleet (sections 3.9, 3.10, 8.4, 8.9)

10 We will continue our journey to becoming a highly effective organisation including: • developing a longer term strategy • Improving governance systems    • Strategic approach to improvement, innovation and R&D and • Delivering our financial plan (sections 3.1, 8.6, 8.10.1)

By bringing all these together, we have been able to refresh our strategy map - see diagram 2 below.

Diagram 2: 2017 – 2020 Strategy Map;

Annex 3 shows how we have ensured continued alignment between our 16/17 aims and those areas we have identified here.

We recognise that it is important that these strategic aims do not stand in isolation from how we now subsequently monitor our progress and performance. In refreshing the performance ambitions which we set ourselves last year (section 3.3.2, 3.3.3), we have ensured that there is clear read across in the performance which we aspire to and how those performance improvements are helping to deliver our strategic aims.

ACTION 1: During 2017/18 we will finalise our long term strategy for ambulance services in Wales.

3.2 Performance

3.2.1 Overview of our Performance

We have made good progress in improving key elements of performance during 2016/17. This is underpinned by improved management process across all directorates, including a strengthening performance management approach. We are increasingly using the wealth of intelligence and information that we have in the Commissioning: Quality and Delivery Framework (CQDF), including Ambulance Quality Indicators (AQIs) and learning 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 narrative is in Annex 5. The following summarises the Trust’s performance:

 The 111 pathfinder, “Shocktober”, “Restart a Heart Day” and the frequent callers project all demonstrate innovative approaches to Step 1 – Help Me Choose and the opportunity to develop a more cohesive programme of work around the behavioural agenda;

 Enhanced Hear & Treat resulted in 1,700 ambulance dispatches being prevented in December 2016, with performance in December on some days touching 10%. The enhanced service is being provided through non-recurrent winter pressures monies

 RED performance levels across all LHBs have achieved a performance level of 65% or higher, with the exception of Powys in May and October;

 AMBER performance remains an area of concern. Our clinical indicators are not showing the improvement we would wish for. Our complaints and concerns from this patient group confirm the need to refocus our efforts in this area. Responsiveness can be linked to patient experience and, for some cases in the Amber cohort, clinical outcome. As at September 2016, our 95th percentile performance was one hour, 19 minutes. As performance against metric alters through the winter months, which is linked to available resource and handover delays, the number of Serious Adverse Incidents (SAIs) also increases;

 The Trust’s See & Treat rate and referrals to alternative providers have remained fairly static through 2016/17 and this is recognised as an area for improvement by the Trust. A 2% increase in See & Treat rates could prevent 14 ambulances per day arriving at A&E;

 There is variance in conveyance rates between LHB area which, linked to the last point, is an area of opportunity for WAST as part of our joint working with LHBs on pathways and directories of service and our focus on clinical leadership;

 Overall, when WAST does convey patients, more than 90% go to major A&Es. There is an opportunity here to collaborate with LHBs and avoid conveyance to major A&Es through the greater use of direct admissions, Minor Injury Units (MIUs) and other entry points (maternity, mental health units etc.). When conveyance is an appropriate response, conveyance to definitive place of treatment is an objective.

 Non-Emergency Patient Transport Service (NEPTS) performance metrics will be overhauled as part of the developing commissioning arrangements for NEPTS. A key area of focus will be the need to novate the LHB contracts to the Trust; and

 WAST’s performance across its support services, which are key enablers for Operations and NEPTs have generally improved: staff sickness is below 7%, staff turnover below 1%, with staff numbers increasing, Unit Hours Production (UHP) above 90% and financial management being much stronger.

3.2.2 Our Performance Ambitions 2016/17: A Review

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 performance 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 performance reporting and monitoring.

Performance against our 53 performance ambitions is monitored through our Monthly Integrated Quality and Performance Report and through our Directorate Quarterly Performance Reviews.

A full copy of our Q3 performance report on our performance ambitions can be found in Annex 4.

3.2.3 Our Performance Ambitions for 2017/18

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. The table below outlines our refreshed performance ambitions for 2018/19. We will continue to test and refine these in line with the work of the Assistant Chief Ambulance Services Commissioner on measures and metrics and in line with the outcome of the clinical model evaluation.

Baseline Measurable Q3 2017/18 2018/19 2019/20 COMMENTS Ambition 2016/17 Key: Aware: Scattered approach, internal controls Mental Mental Mental embedded Delivery of the health health health Plan Defined: Strategy and policies in place and Mental Health Improvement Improvement Improvement agreed communicated Improvement plan Plan Status: Plan Status: Plan Status: Managed: Trust wide approach developed and Aware Defined Managed communicated

Quality at the Embedding 486 staff Gradually developing and building capacity Aspiration for all staff to achieve bronze and Heart Improving Quality bronze and capability proportion silver trained. Numbers to be determined. Together (IQT) - trained

Improving Infection IPC IPC Improvement Plan approved by Quest Jan 17. IPC Aware IPC Defined IPC Enabled Prevention & Control Managed Developing IPC team to support.

Ambitions to be continually reviewed in context of RED 8 Minute 77.3% 65.0%-75.0% demand and capacity review, particularly with Performance regards levels of relief staffing.

Delivery of Performance 65% for all LHBs, variation RED Performance 57.1%- Review targets against outcomes of demand and Excellent Patient decreasing; but dependent on demand and by LHB 87.5% capacity work Care capacity modelling work.

Ambitions need to be reviewed and refreshed to AMBER 95th consider demand and capacity review, handover 01:42:09 01:28:00 01:14:00 01:00:00 percentile response delays, improvement actions and critically against phase 2 of the clinical model evaluation.

Baseline Measurable Q3 2017/18 2018/19 2019/20 COMMENTS Ambition 2016/17

Fracture hip/femur who are documented 81.2% 90% 95% Sustained Baseline based on performance during Q3 as receiving analgesia Acute coronary syndrome patients who are documented 64.9% 75% 80% 90% Baseline based on performance during Q3 as receiving appropriate STEMI care bundle Reducing the % of staff who say they Impact reducing across the period - to below have been injured or NHS Wales average of 28% (or lower) - Baseline based on performance from 2016 NHS 43% felt unwell as a result measurement subject to further local or Wales Staff Survey of work related national staff survey stress Increasing % staff Increasing across the period - measurement Fantastic People who would Baseline based on performance from 2016 NHS 48% subject to further local or national staff recommend Trust as Wales Staff Survey survey a place to work Reducing the % of staff who feel bullied, Impact reducing across the period, Baseline based on performance from 2016 NHS harassed or abused 21% measurement subject to local or national Wales Staff Survey at work by a staff survey colleague

Staff Engagement; 53% 56% 59% 62% Baseline based on staff survey results for 2016 Index Score Vibrant Leadership % of Team Leaders who have completed 0% Increasing 100% the Team Leader programme

Baseline Measurable Q3 2017/18 2018/19 2019/20 COMMENTS Ambition 2016/17

Development of Symptom Checkers 27 33 36 40 Baseline based on Q3 performance on NHS Direct Wales website

Baseline based on performance during Q3 however additional temporary funding increased staffing and Hear and Treat 7% 7% 8% Sustained performance during Q3. Target adjusted for year 3 in line with demand and capacity review.

Value, Reducing impact of Frequent Callers Reduction by Reduction by Reduction by Reduction in calls to 999 and associated resources Innovation and through appropriate Cohort 75% per 75% per 75% per per cohort of identified frequent callers. Cohorts Efficiency management on an cohort cohort cohort managed and monitored over 4 month period individual basis Number of online bookings received 22% 30% 40% 50% Baseline based on Q3 performance for NEPTS

Finance: Breakeven Breakeven Breakeven over 3 year accounting period Duty

Number of To show a year on year increase in the attendances at key 65 Baseline based on total attendances within Q3. amount of appropriate events attended. stakeholder events Strong Number of Partnerships Community / Co and Baseline based on total attendances within Q3 only. Uniformed 4,766 20,900 22,990 25,289 Data capture changed within year to include all Responder responders. attendances on scene

3.3 Our Service Initiatives

Our 2016/17-18/19 IMTP identified a number of initiatives, many of which had accompanying CAREMORE templates and went through the Quality Assurance & Improvement Panel (QuAIP) process Other opportunities have arisen in year and initiatives instigated at local and national level. We recognise the opportunities inherent in keeping track of the range of initiatives which we have either piloted and/or are piloting and we are strengthening our approach. Having a more systematic approach will support our ambition to roll out and “scale up” initiatives once evidenced to be effective. Annex 5 gives an overview of the current version of this register, recognising that it is a live working document.

3.4 National Policy Context

Our full 2016/17 plan outlined the national policy context within which we are operating and we remain cognisant of this wider context. Where new policy has emerged or existing guidance updated we have ensured this plan is reflective of that.

3.5 NHS Wales Strategic Change Agenda

In our 2016/17 plan, we recognised that the ambulance service operates as part of a complex health and social care system which is progressing a number of complex service changes and developments both at internal health board level, as well as at regional level. Significant progress has been made in the last twelve months in engaging in this work in a more systematic way and in creating an internal infrastructure to effectively manage the impact of these changes on the organisation. We have now established an internal Strategic Planning Forum which acts as the focal point of intelligence related to external service change and assessing what work we need to undertake in order to robustly respond to these. As our partners seek to deliver sustainable configurations of services both within their geographical footprint and across regions, the impact on our services takes a number of forms:

 Travel times (job cycle times) – when services move closer or further away from current status  Secondary transfers – in models where patients are transferred from a fewer number of specialist centres to local hospitals after short acute phases  Workforce implications – if our workforce conveys acutely ill patients over longer distances there may be training and/or equipment requirements  Impact of redesigning scheduled/planned services may impact on our non-emergency patient transport services

ACTION 2: 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.

The map below provides an overview of the NHS Wales Strategic Change Programmes in which we are engaged;

Living Healthier, Staying Well

BCU have recently launched their Living Healthier, Staying Well Strategy and we are engaged in the appropriate work-streams.

Future Fit

The NHS Future Fit Programme focuses on the hospital services provided by Shrewsbury and Telford Hospital NHS Trust and Shropshire Community Health NHS Trust. We are engaged in the appropriate fora including the programme Board and the Quarter Ambulance Service Liaison Group.

South Central Acute Care Alliance (SCACA)

We are represented within the SCACA structure and the work to quantify the impact of the service changes within the umbrella of this Alliance, namely Paediatric Obstetric & Neonatal (PON) and Ear, Nose and Throat (ENT) services.

Aneurin Bevan – Specialist and Critical Care Centre

We recognise that, in these early stages, ABHB is still establishing and agreeing its governance mechanisms and delivery structures for this major project. A key action for us over the life of this plan is to ensure that we are engaged early and proactively contribute.

Mid Wales Collaborative South East Wales Vascular Services We have been a key partner in the Mid Wales The South East Wales Vascular Network is comprised Cardiff Healthcare Collaborative and Vale UHB, Aneurin Bevan UHB and Cwm Taf UHB. Board (MWHCB) over the past year and have We have been engaged in the project board driving work to contributed to many of the centralise emergency and elective activity at UHW. Board deliverables . We will continue to play our role in contributing to these Transforming Cancer Services (TCS) Programme

We are appropriately engaged in the programme and are In Annex 11 and Annex 12 A Regional we provide progress Collaboration for cognisant of the implications that this change programme will against Mid Wales have for our NEPTS service. Health (ARCH) Healthcare Collaborative (MWHC) Key Actions The ARCH (2016/17) and the priorities Programme sets out a All Wales Collaborative – Major Trauma Project for MWHC in 2017/18 vision for an respectively. integrated and The Collaborative is currently working on only one piece of collaborative medical service re-design which has a material impact on ambulance and life sciences services- the development of a major trauma centre (MTC) for regional economy South Wales and South Powys. delivering high quality patient care, We remain well represented across the various workstreams developing doctors, and in the course of the last year have completed a piece of healthcare work to quantify the impact of placing an MTC at either Swansea professionals and life or Cardiff from a workforce and activity perspective. scientists to drive excellence for the sustainable benefit of health, well-being and wealth creation in South West Wales. We are linked in with key programme leads and when formal project/programme structures emerge we will engage.

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

In considering how we could most effectively work with our health board partners over the life of this plan, we have taken a number of things into consideration:

 Detail contained within our Local Delivery Plans (LDPs) at LHB level as these will be built upon key operational links which we have with local health board operational teams.

 The output of the meetings which the CASC has held with Health Boards that has subsequently been shared with us by the Assistant CASC.

 The lead role we took in organising an NHS Wales IMTP inter-dependency day on the 30th November 2016. This was designed to support not only us, but to allow all Health Boards and Trusts to share their emerging priorities to ensure plans are naturally aligned as best they can be.

We have subsequently held follow up meetings with Health Boards where we have felt there has been a more material need to explore plan alignment. We do not see these meetings as ‘one off’ exercises; in the spirit of planning being a continuum we have arranged a series of quarterly Planning2Planning meetings with a number of Health Boards to ensure not only that our plans align, but that so too does our subsequent implementation.

Throughout this plan there are subsequently examples of where we need to work collaboratively with our Health Board partners to ensure the best possible care for patients.

The table below outlines how we have drawn many of these opportunities together in one place, and provided a ‘snap shot’ overview of the opportunities we will be looking to exploit with partners over the life of this plan.

ACTION 3: We will work with our Health Board partners to support regional service change and on an individual Health Board basis to deliver local joint priorities that this plan identifies.

Step 1 - Help Me Step 2 - Answer Step 3 - Come to See Step 4 - Give me Step 5 - Take me to Support Service Choose My Call Me Treatment Hospital Redesign Pilot of Manchester Hear & Treat to A focus across Wales of triage model as Work with the SCACA Ambulance re- Choose Well deliver 8-10% on a high call volume / next phase of regarding PON direction protocols sustainable basis attendance nursing homes Paramedic redesign Pathfinder work Work with the SE Vascular network Frequent Caller work with Clinician Presence in Maximise access to regarding Care Home Sector and Police Control urgent care services centralisation of CSIW Centres services across SE Wales Explore opportunities All & potential protocols Wales / 111 Pathfinder & realising regarding the 'timing' NEPTS – reflect Regional opportunities of Clinical of when card 35 Maximise safe wait commitments in the Support Hub, Directories Health Care areas NEPTS BJC of Service Professional & Inter Hospitals Transfer calls are made Alignment with HB bed bureau resource Development of a for better directory of services management of HCP and green calls Rapid extended triage outside ED Rapid Handover- Develop the alcohol Paramedic Pathfinder Full roll out of frequent Evaluate the community BCU treatment centre to be implemented in caller model assistance team model Ysbyty Gwynedd and Ysbyty Glan Clwyd

EDs

Implement pathways on; Support / engage Joint working with Mental Health, MIU, with the the Health Board to Preparatory work for 111 District Nursing, D&V, development of the redirect HCP calls to Work on EMRTS DAG and health strategy for community services Caernarvon North Wales

Single Point of Access- Work with LHB, Powys Work with the Health People Direct, and joint Board on the Community paramedic Powys Association implications of the pilot PDSA Voluntary Organisations Future Fit Powys (PAVO) /Powys County programme Council (PCC)

Implement pathways Mental Health

MIU (refresh) Support / engage Implement following with the Full roll out of frequent Expansion of tele- pathways; Mental Health, development of the caller model health Frailty & Stroke health strategy for Hywel HDHB. 111 Pathfinder Dda Support HB in Carmarthen and Develop the Big addressing cardiac preparation for rest of Room initiative flows issue(s) Hywel Dda DAV vehicle Ongoing update of Work closely with Continuation of Frequent ABMu APP in Primary Care hubs directories of Health Board caller programme services to reflect colleagues regarding

new pathways the significant shift of services which may take place between Morriston and Singleton hospitals over the life of the plan Refinement of 111 Pathfinder Nursing home Help point plus Opportunities from demand management - 'I continuation ARCH programme Stumble' fallers pilot in Bridgend Ongoing review and refresh of the following Nursing home demand pathways; Stroke, Mental management - 'I Stumble' Health, Singleton SAU, fallers pilot in Bridgend MIU, Falls, Resolved hypoglycaemias, Resolved epilepsy Acute Clinical Team x 3 Implement new D&V Pathway pathway PDSA with NPT ACT for advanced nurse practitioners APPs in Primary Care hubs Continuation of Frequent Community paramedic caller with a focus on high pilot PDSA in the Cynon PAU pilot call volume Care Homes Valley Develop, refresh, reinvigorate where Cwm appropriate the following Taf alternative pathways; Potential roll out of 111 in COPD, Ambulatory care, 2017/18 Mental Health, MIU, COPD, Stroke, @ Home Services, District Nursing, Medical Assessment Unit, 28

Neck of Femur, Social Services & CFR / Non- injury faller pilot across Pontypridd area Direct Access pilots in; #NOF, Gynae, Ambulatory Engage with LHB on Community Paramedic Emergency Care SOP Continuation of frequent development of pilot in Western Vale for development and caller programme Unscheduled care alignment implementation, strategic plan Exploring additional direct access criteria for cardiac cohort Evaluation of HCP taxi Hospital Avoidance Car pilot and next steps

Cardiff Ongoing work with nursing and care homes & Vale and independent living to reduce demand

Collaborative work on

fallers Exploring further opportunities to link with Single Point of contact and hub – i.e. link into district nurses and all community services Frequent Flyer work Engage in SCCC implementation planning including Full roll out of frequent District Nursing any Physician Response Unit caller model Pathway transition/contingenc y plans for acute Aneurin services in advance Bevan of SCCC opening

Potential roll out of 111 in Mental Health Joint response Unit 17/18 Pathway MIU Pathway (over Falls Vehicle the border in Ross) Care home D&V pathway

#NOF pathway with dedicated T&O bed YYF admission pathways

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

Quality and Delivery Framework Agreement –Emergency Ambulance Services Ambulance commissioning in Wales is a collaborative process underpinned by a national Collaborative Commissioning Quality and Delivery Framework (CQDF). The framework introduces clear accountability for the provision of emergency ambulance services and sees the Chief Ambulance Services Commissioner (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. This plan assumes the reader is familiar with the detail of the CQDF and it is not re- articulated here. Working with the Chief Ambulance Services Commissioner (CASC) and his office on development and delivery of the CQDF continues to be critical and core business for WAST. Quality and Delivery Assurance Framework for Non-Emergency Patient Transport Services. During 2016/17 it has also been agreed that EASC will be the commissioner of our Non- Emergency Patient Transport Services (NEPTS). A framework has been developed throughout the year, again using a collaborative commissioning approach and encompasses the outcome of the business case for NEPTS. The assurance framework is an overarching document which outlines the expectations of EASC for the commissioning and delivery of Non-Emergency Patient Transport. The framework will go live in April 2017, although some schedules within the framework will continue to evolve. The assurance framework will be held on behalf of all organisations by EASC and will govern the overall expectations which will apply to NEPTS directly provided by the Trust or sub contracted by the Trust, provided through a plurality model. The framework follows the CAREMORE approach. The NEPTS Commissioning and Delivery Assurance Group (DAG) was established during 2016/17 and is sponsored by EASC to manage and monitor the implementation and development of the NEPTs Framework. Chaired by the CASC, membership includes health board and Trust Champions and Welsh Renal Clinical Network and WHSCC representatives. Service change and development of the service will require the support and evaluation of the existing Quality Assurance and Improvement Panel. The scope of services covered by the framework includes all non-emergency patient transport provided by WAST, all commissioned currently by Health Boards, Trusts and WHSCC. The original business case was developed for patients that met an eligibility criteria. There have been discussions at DAG meetings about the benefits of a wider scope to include all types of transport. This needs to be formalised and agreed with health board colleagues, ensuring appropriate handover and risk sharing arrangements are in place. We will work with colleagues to ensure the best quality outcome and value for money for our patients.

Commissioning Intentions In November 2016, draft commissioning intentions for EMS and NEPTS were issued to WAST and the LHBs.

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.

We will work with the Commissioner and his office to bring this process further forward in the planning cycle.

Welsh Audit Office Review of EASC Arrangements

The Welsh Audit Office undertook a review into the commissioning arrangements and how they were being embedded across NHS Wales. We have engaged in this process and, once the final WAO Report is published, are committed to working with Welsh Government, the CASC and members of EASC to respond to the recommendations positively and in a way that focuses on building on the work collaboratively delivered to date.

ACTION 4: We will ensure the successful implementation of the Quality and Delivery Assurance Framework for NEPTS.

3.8 Service Change in Collaboration with Blue Light Partners

Over the last twelve months we have done some innovative work with our partners. Three such examples include;

 The Community Assistance Team (CAT) in North Wales.

The CAT was a collaboration between Welsh Government, Betsi Cadwaladr University Health Board, Galw Gofal, Conwy County Borough Council, Denbighshire County Council, North Wales Fire and Rescue Service (NWFRS) and ourselves over 12 months to deal with non-injury fallers that have been identified by our clinical desk within Conwy and Denbighshire.

Over the period August 2016 – January 2017, 250 calls were dealt with and 235 patients stayed at home. 211 incidents resulted in home safety checks and 188 had crime prevention checks completed, demonstrating the holistic service the CAT was able to provide

 WAST/Police Joint Response Unit (JRU) in the Gwent Police area

A ground-breaking partnership between ourselves and Gwent Police started in July 2016 when the JRU was launched, after it was found that, between October 2015 and March 2016, the two emergency services attended 2,249 incidents together.

Under the new pilot scheme, a paramedic and a special constable in a WAST RRV carry out joint response shifts during identified periods of high demand for both services (mainly weekend evenings and bank holidays). The JRU is dispatched by either the police or WAST control rooms. The team is also able to self-select appropriate 999 incidents via remote access.

Between July ‘16 - Jan ‘17, the JRU responded to 378 incidents, requiring further ambulance support on only 106 occasions. The team achieved a non-conveyance rate of 72%.

 Clinicians in Police Control Rooms.

During 2016 we established a team of clinicians in the North Wales Police control room and have deployed clinicians on key dates to the South Wales Police control room. In South Wales, during 189 hours of clinical time in Police control during high demand periods such as rugby internationals and the Black Fridays, the clinicians stopped 198 ambulance dispatches and released 135 Police patrols back onto policing duties.

Looking Forward to 17/18 and Beyond

To achieve our ambitions, our whole plan is predicated on effective working with our many partners- both in the NHS more broadly, local authorities, the voluntary and private sectors, the wider public but also, importantly, our blue light partners. Examples of where we are doing this and, more importantly, where we plan to do some of this joint working exists throughout the plan. A summary of our specific intentions in regard to our blue light partners is summarised below;

 Fire Co-Responders. Will remain a key part of our plans to get skilled help quickly to immediately life threatening calls, particularly cardiac arrests where a patient’s chance of survival decreases by 10% per minute until a defibrillator is used.

We will seek to increase the number of fire stations offering this service across Wales.

 Public access defibrillators. We will explore what role emergency services staff can play in the checking of public access defibrillators.

 Information Sharing. We will develop systems to share information on vulnerability and ensure that we are referring patients who may benefit from a home safety check to the fire and rescue services.

 Joint maintenance. We will continue to explore opportunities which will see all our NEPTS vehicles in the Hywel Dda area (which are currently maintained and serviced externally within the private sector) being brought into a new facility run by Mid and West Wales Fire and Rescue Service (section 8.3 provides more information here)

 Estate Opportunities. Continue to explore the benefits of sharing estate on a variety of scales- from social deployment points through to larger scale initiatives such as the locations of our contact centres.

Older patients who fall are the most common type of emergency we attend. Whilst some fallers sustain injuries and require treatment, many are uninjured but cannot get up off the floor. These patients are often vulnerable and are not afforded a high dispatch priority because of their being uninjured, so other calls can take priority. Patients who have fallen represent a high proportion of our complaints.

Across Wales, we have developed several systems to get the right help to uninjured fallers more quickly. Elsewhere in this plan we focus in more detail on our holistic approach to non- injury fallers. However, we will also continue to maximise the use of our blue light partners to support us with this type of patient.

ACTION 5: We will realise additional benefits from our partnerships with our blue light partners and other key agencies.

4 OUR ACHIEVEMENTS IN 2016/17 This section provides an update on progress in implementing year one of the Trust’s 2016/17 three year plan, both in terms of achievements and challenges.

4.1 Key Headlines of our Successes

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

 Progress with Quality Strategy implementation, including new quality, safety and patient experience reporting and assurance mechanisms, development of seven LHB specific Quality Reports  Successful implementation of the 111 Pathfinder with ABMU  Demonstrated quantifiable benefits in terms of an increased focus on the early steps of the clinical model; for example, increased hear and treat rates and effective frequent caller programmes  Decreased variation in red performance  Progress with the NEPTS Business Case implementation  Strengthening relationships with our staff- demonstrated through the 2016 Staff Survey  Recognition at NHS Awards of our frequent caller work  Alignment of recruitment & training plans with vacancies of less that 4% in our EMS workforce  Opening of the Joint Ambulance and Fire Centre in Wrexham  Forecasting financial balance in line with 2016/17 – 2019/21 IMTP  Secured funding for the implementation of telemetry  Developed, agreed & rolled out seven clinical indicators for monitoring patient outcomes

4.2 Our Strategic Change Portfolio

Our 2016/17 plan also outlined a portfolio of strategic change programmes which the organisation committed to taking forward. Annex 6 details the high-level status of these change programmes.

Our 2016/17 plan detailed 154 actions which we committed to delivering over the life of the plan. Annex 7 shows the current status of these actions and provides detailed information on each. In line with our statement of intent within the introduction of this plan, we remain committed to being explicit and upfront with regard to the actions we will be taking to continually take forward the organisation.

Whist challenges remain, we will continue to build on these achievements and celebrate successes.

4.3 Our 154 Point Plan

Our 2016/17 plan detailed 154 actions which we committed to delivering over the life of the plan. Annex 7 shows the current status of these actions and provides detailed information on each one. We want to be absolutely transparent in the actions we committed to, where we have delivered and when there is more to do. Consequently, the final column in this annex identifies which of those actions are outstanding, what ‘Tier’ classification they are and consequently whether you can then expect to find them rolled over into this refreshed plan. 34

5 OPPORTUNITIES AND CHALLENGES IN 2017 - 2020

This section outlines the key opportunities and challenges facing the organisation in the coming three year period.

Over the life of this plan we have identified a number of general opportunities and challenges we will face along with many other health boards and/or ambulance services. These include:

 Political Landscape. The life of this plan will be against the backdrop of Brexit negotiations. The outcome of these negotiations may have a profound impact on Wales.

 The wider unscheduled care system in NHS Wales. We are a vital partner in the unscheduled care system (USC) 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.

 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 and a shift in behaviours needed to transform and deliver our Trust vision.

 Key events and the impact and our service. The UEFA Champions League (UCL) Cup Final (UCL) is being held in Cardiff over a four day period in early June 2017. Billed as the largest sporting event in the world in 2017, it will bring the focus of a worldwide TV audience to Cardiff and to Wales. Reputationally, it is essential that Wales is able to put on a successful event and we have been fully involved in multi-agency meetings and planning groups to determine WAST’s role, working closely with Welsh Government through a UCL Health Assurance Group. Our commitment will be around providing professional planning expertise, support to the event medical teams where legislatively required, providing a suitably staffed command structure to reflect key event timings, enhancing local resources to protect our core business using staff from across Wales and providing specialist assets to support multi agency assets such as Covert Assessment Vehicles (CAV) and Multi Agency Scene Assessment Teams (MASAT). The security aspect cannot be overestimated and, through our specialist teams and National Interagency Liaison Officers (NILOs), we will be fully engaged in providing a flexible response for threat and risk preparedness.

5.1 Specific Challenges

We have also identified a number of more specific opportunities and challenges which, in many respects, are much more unique to us. These include:

5.2 Demand and Capacity Review

In line with our commitment in last year’s plan, we undertook a Demand and Capacity review for our EMS services in 2016/17. The timeframe for the work was 2015/16 – 2020/21. The review identified a number challenges:

 Demand Projection - Due to rise by around 4% each year for next 5 years – totalling circa 20% rise

 Existing Capacity - Identification of deficiencies in relief capacity and challenges of maintaining red performance in context of demand increase

 The impact of system wide pressures - Review shows “cost” of inefficiencies in current system, including those internal to WAST and those across the system, for example handover delays at hospitals. Further analysis of these challenges can be found in Annex 8.

5.2.1 Amber Performance.

Amber calls account for approximately 65% of our workload and make up a very large cross section of conditions, which range from suspected stroke and breathing difficulties through to suspected broken ankles and elderly patients who have fallen.

We fully recognise that our performance for this cohort of patients is not where we would want it to be. This is reflected not only in variation in terms of our responsiveness but, critically, through themes and trends through our quality systems. We have also not yet seen the improvements in Clinical Indicators that we would wish for. In addition, the PACEC evaluation of the Clinical Response Model Pilot recommended that amber is a large category and further work is required to better differentiate and, therefore, ensure our response is more appropriate.

A key feature of this plan is to respond to this challenge, both making immediate improvements alongside working with the CASC and EASC following the announcement by the Cabinet Secretary for Health, Well Being and Sport on 28 February 2017 confirming the permanency of the model. Across section 7.3.1 of this plan, we go into more detail around the specific actions which we will be taking to move forward this agenda.

5.2.2 Workforce Challenges

The overall challenge of matching the capacity and shape of the workforce and getting right the appropriate levels of resource with the right skill type and qualification to match demand, has been highlighted by the recent capacity and demand work, described above. We are also being challenged to respond to UK wide developments such as NHS England discussions around the introduction of degree level education for paramedics and the band 5/6 paramedic role and its implications for Wales. Recruitment and Training of EMS staff. There still remains a national shortage in the availability and recruitment of qualified paramedic staff and, so far, our education commissioning numbers have been just about sufficient to ensure adequate supply of qualified staff, provided we are able to secure employment of the graduate paramedics. The move to a degree requirement for future paramedics has still not been formally approved in Wales, but we are confident it will follow, and steps are already being taken to plan for

the potential impact on our current career pathways and supply channels of EMTs converting to paramedics. We will continue to target our recruitment activities and plan our training courses appropriately

Addressing the ‘Diversity Deficit

By this we mean the lack of diversity throughout our staffing, in senior management teams and on our Trust Board. This is a recognised picture across ambulance services, and there is a growing body of research that highlights the benefits of diversity to organisational performance. Within the NHS, the benefits are far less widely explored, but it is assumed that a more diverse workforce will bring benefits to both patient care and experience, and also staff experience.

Our enabling plans demonstrate a clear intent on behalf of the Trust to take appropriate action to address the ‘diversity deficit’ over the next few years. We will be seeking particularly to achieve a shift in workforce composition to better reflect the demographics of local community BME backgrounds and actions to tackle recruitment bias and harassment and bullying concerns in line with our English colleagues, who have committed to a number of measures designed to improve performance in four of the nine Workforce Race Equality Standard (WRES) indicators

National Developments on Paramedic Banding. NHS Employers have agreed a deal with the unions on behalf of the Department of Health in England, which will see the role of a paramedic being re-banded from band 5 to band 6 and paramedics moving up the pay scale to band 6, where appropriate, from April 2017. Under this change, paramedics will be expected to develop and deliver the necessary skills in order to address the root cause of demand on urgent and emergency care services and to put in place measures to look after more people in the community. This is expected to deliver reduced conveyance to hospitals through more 'hear and treat' and 'see and treat' to ease operational and financial pressure on hospitals. The Trust has been actively involved in this debate on a UK-wide basis but, as health is an area devolved to the Welsh Government, the funding deal in England does not extend to Wales.

In WAST, we are committed to working with our trade union colleagues to explore the possibilities of new roles and create more opportunities for our paramedic staff to work at a Band 6 level. There is a clear expectation that any developments within Wales must support the triple aims of improved patient outcomes, improved value for money for NHS Wales and improved patient experience. We will be working closely with our trade union colleagues, Welsh Government and our Commissioners to understand the implications of what has been agreed in England and what this means for us in Wales.

An Ageing Workforce We have already described the potential implications of an ageing population on demand for ambulance services in the future. Our workforce profile continues to tells the same story, with a large proportion of staff in the 50+ category, presenting challenges to succession planning, health and wellbeing and sickness absence

These challenges are all recognised and responded to by our People Strategy enabling plans.

5.2.3 Clinical Risk Assurance Review

We acknowledge that this is a critical piece of work that will highlight clinical and quality issues and challenges that we will need to respond to.

5.3 Specific Opportunities

5.3.1 The New Clinical Response Model

On the 28th February 2017, the Cabinet Secretary for Health, Wellbeing and Sport, Vaughan Gething gave a statement in the Senedd, confirming the new clinical response model would move from a pilot stage to full implementation with immediate effect. In doing so he noted; “The new model has helped to deliver a service that is more focused on the quality of care that patients received and it has improved efficiency in the use of ambulance resources. The new model has provided additional time for call handlers to better assess patients and ensure that they get a response from the right type of clinician and vehicle in the first instance. It’s allowed the Welsh ambulance service to explore alternative ways of responding to calls, either over the telephone, known as ‘hear and treat’, or at the scene, which is known as ‘see and treat’. The number of calls ended through hear and treat has significantly increased since the beginning of the pilot.” He went on to state; “I recognise that it takes time for new ways of working to become established. The clinical model has proven to be effective in enabling the Welsh ambulance service to prioritise a response to the greatest level of need. However, the model itself is not a panacea. There is a clear acknowledgement from the Welsh ambulance service and from EASC that there are opportunities to improve care for patients in the greatest need, and to ensure patients with less serious need continue to receive a safe and timely response. I have, therefore, written to Professor Siobhan McClelland, directing EASC, to develop a way forward in response to the evaluation report’s recommendations to support the work that is already under way to deliver high-quality ambulance services for the people of Wales”.

In response to the Cabinet Secretary’s statement, we give our full commitment to work with both the Ambulance Commissioner for Wales and EASC to develop the continued way forward for the new CRM so that people in Wales continue to benefit. Action 6: Following the successful pilot of the new CRM, we will develop a plan that will support the implementation of the recommendations of the PACEC external evaluation report.

5.3.2 Realising Benefits from the Demand and Capacity Review

Just as the demand and capacity review has presented a number of challenges, it has equally presented some opportunities;

 Internal WAST efficiencies, including opportunities to realign some shifts to better match demand

 Highlights the impact that the Hear and Treat model has in managing activity at Step 2 (section 7.1.2)

 Provides evidence base upon which to base any future changes to response target and likelihood of achievability

 Through the modelling of community paramedic resource, provides a platform to explore the model as part of not only an EMS response, but as a more general support to the unscheduled care and primary care system. (section 7.1.3)

 Provides basis for our developing workforce plan (section 8.1);

 Informs the Strategic Estates Plan through identification of optimal sites of social deployment points etc. (section 8.3)

 Informs our fleet plan (section 8.4) How we will respond to these opportunities is detailed as part of our planned service changes within Section 6.

5.3.3 Primary Care

There is an opportunity for us to engage more meaningfully with the transformation of primary care services in Wales, not only to bring increased benefits to the patient and people in Wales but also to support us with the transformation of ambulance services in Wales. Working with our LHB partners and, in particular, the network of primary care clusters to develop a clear, persuasive narrative that explores and describes the role for paramedics within the primary care setting, clearly forms part of the development of the longer term strategy work, as well as the next phase of the demand and capacity review.

5.4 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. 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 for us. 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 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 2016/17, we have demonstrated our commitment to providing high quality care to our service users as defined in our Quality Strategy (2016- 2019). Year one of this strategy has focused on determining our position, strengthening our foundations and developing and improving our indicators and measures, aligning to the requirements of our Commissioners with the quality core requirements of the Commissioning Framework. Years two and three 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 and staff feedback. Our aim is to continue to develop 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 quality improvement including:

 Ensure that standards are achieved

 Triangulate quality data and patient, carer, stakeholder and staff feedback

 Plan, drive and measure continuous improvement

 Identify, share and ensure best practice across NHS Wales During 2015/16, the Trust has adopted the Health & Care Standards (2015), 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. The Board has also approved the Trust Risk Management Strategy & Framework (2016-19) to deliver improvements in patient safety and care, as well as the safety of staff, patients and visitors. 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 adults, children and staff are safeguarded. The Trust is engaged with the implementation of the publication of Volume 2 Child Practice Reviews Guidance and Volume 3 Adult Practice Reviews Guidance. The Trust has representation on each of the Regional Safeguarding Boards across Wales. We are also cognisant of the Violence Against Women, Domestic Abuse and Sexual Violence (Wales) Act (2014) (VAMDASV) which received Royal Assent on 29 April 2015. One of the key mechanisms for delivering the Act is the National Training Framework on VAWDASV and launch of statutory guidance in 2016.

During 2015/16 we committed to the following actions to promote quality of care:

 Strategic oversight of the implementation of the Infection Prevention and Control (IPC) two year operational plan; this will include monitoring of staff immunisation rates with Occupational Health.  Auditing of peripheral vascular cannulation rates.  Implement a task and finish group to address vehicle cleaning Trust-wide.

The Trust annual infection prevention and control report for 2015/16 provided assurance of the progress with promoting staff immunisation and sustained reduction of patient cannulation rates at 20%. Staff needle stick injuries reduced by 32%. The IPC Improvement Plan (2017-19) was approved by the Trust in January 2017 and an integrated approach to vehicle and station cleaning model is being tested prior to roll out across the Trust in 2017/18 as part of the 10 year Estates Strategy for make ready centres.

 To commence from April 2016, a quarterly quality assurance report triangulating intelligence (qualitative and quantitative) to make sustainable improvements at corporate level 2016/17 including our own locally determined quality measures aligned to the Core Requirements and national mandatory targets and measures.

The Trust has undertaken a look back exercise regarding compliance with the Health & Care Standards (July 2016) and a self-assessment against the Commissioning Core Requirements (September 2016) demonstrating progress. The development of the Trust’s quarterly quality assurance report for monitoring and measuring compliance with the standards, as well as the annual (7) health board quality reports, supports this work.

 Review the capability and development requirements of the Trust’s risk management information system, Datix, to support the development of our monthly and quarterly reporting, heat mapping and early warning systems.

The Trust has funded a new post to lead the development of the Datix system and e-risk assessment /electronic risk register during 2017/18.

 Development of a training strategy to meet legislative requirements including PREVENT.  Implementation of the safeguarding review outputs.

The safeguarding team has embraced the Social Service and Well-being Act and PREVENT, leading staff training across the Trust and monitoring compliance

 Develop programme for walk rounds and feedback mechanisms.

Executive and Non-Executive walk rounds are coordinated and there is rotation of the Board meetings in public across Wales. Feedback is presented at the Board in public to inform learning and improvements.

 Implementation of our accreditation plan to be a Dementia Friendly organisation.

The Trust has embraced dementia awareness, development of the Trust’s dignity brochure and dementia champions across the organisation and has won national awards in recognition of this work.

Moving Forward: During 2017/18, the Trust will 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, Experience and Safety Committee (QuESt) with the quarterly Quality

assurance report. Quality assurance is provided through our improving compliance with the Health and Care Standards and core requirements and this assurance is provided by the:  Quarterly quality assurance report  Quarterly health & safety 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, excellent patient, carer and staff experiences, building robust structures and processes as our foundation to achieve the best outcomes for our patients and staff.

6.2 Structures – Strengthening Quality Assurance and Improvement across the Trust

During 2016/17 we have made changes to our organisational structures to strengthen the governance arrangements strategically and operationally for Quality, Safety and Patient Experience across the Trust to support front line teams and working with key stakeholders across the following functions:

 Safeguarding adults and children

 Concerns- complaints, patient safety incidents, claims & inquests

 Patient experience & community involvement

 Professional practice development

 Quality governance & assurance

 Quality improvement

 Risk management

 Health and safety

 Mental health (structure planned for 2017/18) During 2016/17 the structure of the Trust corporate and local risk registers has been designed and developed to provide assurance and confirm mitigating actions for the risks identified and to align these within the IMTP. The structure of the Quality, Experience & Safety Committee (Quest) has also been reviewed and the establishment of the Quality Steering Group (QSG) to triangulate the quality measures to provide assurance, inform improvements and learning. The QSG also reviews national reports and documents to inform learning. The sub groups reporting to the Quality Steering Group have also been reviewed. The Trust has re-established the Improving Quality Together (IQT) forum to build capacity across the organisation with embedding the model for improvement going into 2017/18. The Trust IQT framework will be core to the Trust’s Leadership Development programme to drive improvements forward with local teams. 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 new structure and the Trust’s Concerns Sustainable Implementation Plan (2016) have generated significant improvements with the management of concerns and approach to investigation, support and engagement, timeliness and quality of responses, informing learning and improvements.

2017/18 Next Steps: To continue strengthening our quality governance structures we will:

 Develop the structure for mental health across the Trust – implement the Trust Mental Health Improvement Plan. The plan focuses on developing our mental health clinical structure, staff well-being, staff training, and development of care pathways with Health Boards for people in mental health crisis, meeting the needs of children, adults, people with dementia /cognitive impairment, substance misuse and those at risk of suicide and self- harm. We will continue to work collaboratively with key partners, including the police to support people in mental health crisis.

 We are committed to developing our organisational dementia strategy, based on the Welsh Government Draft Dementia Strategy and AACE draft Dementia Strategy and working in collaboration with the Alzheimer’s Society and partners.

 To design and implement the family support model for WAST to provide appropriate support and signposting for families at times of bereavement and distress

 Develop Quality, Safety & Patient Experience team business partnership model to support operational teams across the Trust

 Incorporate 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. Submit a training plan by March 2017 to achieve compliance with the training requirements by 2020.

 Build IQT capacity across the Trust with local teams via the leadership programme. Develop quality trainers, coaches and assessors

 Work 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

 Work with the Bevan Commission to embrace advocates for the Trust and drive innovation and improvements

 Work with the Children’s Commissioner to embed the Children and Young People’s National Participation Standards

 To undertake a review of health and safety and to review the Risk Management Strategy to incorporate the health and safety priorities

6.3 Processes – to Strengthen Quality across the Trust

During 2016/17 we have designed the quarterly Trust quality assurance report to present to our Quest Committee with regard to quality assurance and monitoring of quality improvements across the Trust. The Trust undertook a review of our compliance against the Health & Care Standards in July 2016 as part of the first quality assurance report to Quest Committee. This quarterly report is coordinated by the Quality Steering Group and supported by a technical document mapped to the Health and Care standards and Quality Core Requirements within the Commissioning Framework. Our Board members actively visit staff and patients, listen and engage through ride-outs, connecting the Executive Team members and Non-Executive Board members with frontline staff to seek feedback and inform improvements.

The Trust designed seven individual Health Board Quality Reports for the first time to share the 2015/16 quality data and information for pre hospital care for each Health Board. These reports have been shared at local Health Board committees, quality events and to inform the development of IMTPs. The development of the Serious Case Investigation Forum (SCIF) process has been established to provide a framework for effective investigation for serious adverse events and learning. The Trust has supported the training of over 40 staff with developed guidance to support staff with writing statements and preparation for inquests. 2017/18 Next Steps: To continue to strengthen our quality assurance and improvement processes we will:

 Respond to the Commissioning Clinical Risk Assurance Review. Continue to build on the risk maturity of the Trust and development of our Board Assurance Framework; refresh the Risk Management Strategy; develop a clinical supervision model for our staff; review the Patient Care Record design and standards of record keeping; implement the plan for review of clinical policies

 Align our internal audit and clinical audit programmes to our quality assurance requirements;

 Develop quality reports for each of the seven Health Boards for 2016/17

 Develop the quality dashboard to enhance monitoring and measurement of quality data and information

 Development of WAST Quality Improvement Plan from triangulation of quality data, patient and staff feedback (monitored by Quality Steering Group)

 Review the DATIX system for WAST to ensure that it is fit for purpose

 Develop e-risk assessments and reporting to inform electronic Risk Registers

 To take forward the next steps of the sustainable improvement plan for concerns management (complaints, SAIs, Incidents, Claims, inquests)

 To test the implementation of technology (tablets) for local teams to access clinical guidelines, reporting datix incidents, safeguarding, e-learning

 Development of a quarterly health and safety assurance report

 Implement the Trust Infection Prevention and Control Improvement Plan, including the integrated approach to vehicle and station cleaning across Health Board areas

 Promote professional standards with our paramedic professionals and registered nurses, embrace learning and development from measuring quality standards to achieve a skilled workforce. To identify the priority actions for registered nurses to align with the Chief Nursing Officer for Wales’ priorities

 Develop a 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)

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. We published our 2015/16 Annual Quality Statement in September 2016 to share our achievements, challenges and our priorities for the year ahead. The Patient Experience and Community Involvement team has embraced the Ageing Well in Wales programme with the Commissioner for Older People. The Trust has engaged with older people to develop 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.

The Trust online engagement directory has been designed and launched to capture all engagement activities across the Trust and to maximise the Choose Well and key messages with our public and stakeholders.

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

2017/18 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 2016/17 by June 2017

 Implement 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 development of alternative care pathways working with Health Boards and key stakeholders

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.

The Quality Governance Framework:

Developing through Engagement and Improving through Continuous Feedback.

Our Quality Governance Framework will ensure 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.

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.

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?

ACTION 7: We will continue to strengthen our structures and processes to improve patient outcomes and experiences of patients, carers and staff

ACTION 8: We will drive forward our Mental Health improvement plan

ACTION 9: We will design and implement our falls improvement plan

ACTION 10: We will implement our Infection Prevention and Control (IPC) improvement plan

ACTION 11: We will lead the improvements identified following the Clinical Risk Assurance review

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.

ACTION 12: We will develop our information systems for the management of risk and concerns for monitoring and measurement to inform learning and improvement. 6.5 The Organisation and Prudent Healthcare

The Trust Board is resolute in its determination to ensure that the organisation delivers a suite of 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 tables below provide an overview of where across the organisation the four principles are completely embedded. Further details can be found throughout this plan.

Achieve health and wellbeing with the public, patients and professionals as equal partners through co-production

Our Trust Behaviours Restart a Heart, Shoctober, Concerns Improvement Plan Defibruary

Learning Disability engagement Choose Well Sensory loss

Dementia Friendly Trust Bevan Advocates Careers campaign

Our Promises for Older People Implementation of the Promises for Children AWDASV Act

Care for those with the greatest health need first, making the most effective use of all skills and resources

Red 8 minute response Clinical model – phase 2 111 roll out (Amber Green) focus

New CAD Band 6 developments NHSDW website

Clinical desk expansion Career pathway

Do only what is needed, no more, no less; and do no harm

Clinical supervision model Infection prevention and control improvement plan

Review of PCR Pathway developments

Reduce inappropriate variation using evidence based practices consistently and transparently

Falls improvement plan Leadership Development Health and Safety review programme & Clinical and Improvement Plan supervision

Mental Health improvement plan Frequent callers National Delivery Plan improvement project priorities

Standards for vehicle cleaning Family support model Build IQT Capacity

Monitoring & improving compliance with Ambulance Quality Indicators

7 OUR SIGNIFICANT SERVICE CHANGES

This section, along with “Our Enablers”, 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 four 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 4 step NEPTs model. III. We place a focus on specific patient groups

7.1 OUR EMS SERVICE DEVELOPMENTS

7.1.1 STEP 1: Help Me Choose

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.

In Year 1 we said we would

 Demonstrate effective management of frequent callers who impact upon 999 demand in each Health Board area This is a summary of how we have done

 The Trust has implemented a policy for the management of our frequent callers to enable us to work with our partners to better meet the needs of individuals

 Developed a reporting tool for effective monitoring of frequent callers

 Between October 2015 and September 2016, 452 patients have been managed through the frequent caller process established by the Trust. This has resulted in 2575 resource hours being made available to respond to other patients.

The 5 Step Ambulance Service Care Pathway requires us to achieve a change in the way in which the public accesses our services. Whilst this will require a change in service user behaviour, we need to play our part in helping patients, often in a crisis situation, navigate what can sometimes be a complex set of NHS offerings. 999 is the easiest service to access as it is free and comes to you. The commissioning framework requires a move from steps 3, 4 and 5 towards steps 1 and 2.

At a national level, the strategic leadership for step 1 sits with Public Health Wales. Whilst we will engage with this work, our specific contribution is to use the evolving Choose Well agenda to help patients access the right service at a local level. We will do this by:

 Pursuing local Choose Well initiatives with our health board partners and other local agencies

 Engaging with schools and communities, stakeholders and the wider public

 Exploring opportunities to work collaboratively with the Fire and Rescue Services to deliver joint education schemes

 Sharing information with our partners such as Fire & Rescue Services (FRS) to ensure vulnerable members of our community receive prevention and safety advice. Our other strategic intent aligned to step 1 focusses on demand management and demand reduction approaches. It is anticipated that, following full consideration by our commissioners of the Demand and Capacity Review, further opportunities for mitigating the impact of projected demand will emerge. We will keep our plan updated accordingly with progress in this area. These opportunities will be around options for signposting of patients at step 2 into other NHS Services, for increasing referral pathways at step 3 and 4 and for a wider range of receiving units and “direct to speciality options” other than ED at step 5. As part of this work, we will seek to explore the potential for “a demand management unit” and the identification of dedicated capacity within each of our Clinical Control Centres to work dynamically in real time with frequent callers. This development will, however, be subject to full scoping and indication of resources. In addition, we will pursue the next phase of work for our award winning Frequent Caller Programme which includes developing the model further, with Health Board colleagues, to pursue the full adoption of the model across all areas. We will expand the frequent caller work from predominantly individual case management to focus on nursing and residential homes and other areas of the community that would benefit from the model. Much work has been undertaken in developing an effective relationship with Care Standards Inspectorate Wales (CSIW) and collaborating around the care and residential home agenda to support the roll out of i-Stumble falls assessment tool. This focus complements the work started with the police in control centres. Our efforts to manage demand will, however, not exclusively focus on frequent callers. We will also look to work with health board partners on the volume of Health Care Professional (HCP) and other green calls which we receive. We will do this by:

 Maximising the use of own transport and taxi use for appropriate HCP patients. This approach is currently being trialled in Cardiff, Abertawe Bro Morgannwg UHB and Cwm Taf.

 Looking to agree protocols which will support healthcare professionals in determining when the appropriate time is to contact us and request transfer of a patient (a card35 call).

 Currently for example, a GP may contact us immediately once they have determined that a patient requires admission to a particular ward within hospital without knowing if there is capacity in that ward. If we, with help from Health Boards, can encourage these calls to be

made after the GP has determined if/when there will be capacity, we can ensure a vehicle is sent at the right time and in the interim we are making best use of our resources.

 Exploring opportunities to align Health Board bed bureau resources with better management of HCP and other green calls. HCP calls alone represent 12% of our total demand and 16% of our conveyance (see table below). By definition, the vast majority of these patients transfer to hospitals and require capacity at a number of levels.

Verified Incidents Resulting in a Conveyance

AS1 incidents 467,782 272,164

Protocol 35 56,351 42,534

12% 16%

The graph below shows the volume of HCP calls which we receive on a typical Monday- in particular the ‘spike’ which occurs in the middle of the day. This pattern is replicated across Monday to Friday.

The better alignment of Bed Bureau LHB roles to CCC operations in respect of HCP calls has the potential to allow the proactive review of these types of calls which currently wait on our call stack. The role would be able to determine if/when there will be capacity in the appropriate ward for the patient in question to be conveyed. This will mean the call can be dealt with appropriately, quicker and more efficiently. Where patients arrive at hospital in core business hours, they are clinically assessed and managed without admission. HCP patients that we transfer to hospital in the evenings, because of daytime capacity issues, frequently appear to be admitted by junior staff to see a senior clinician or have tests the following day. ACTION 13: We will continue to proactively pursue demand reduction and improved demand management opportunities working with HBs and other partners

7.1.2 STEP 2: Answer My Call

Our Clinical Contact Centres (CCCs) are at the centre of the entire WAST operation, and it continues to be one of our priority areas for improvement (Priority 4) with some of the biggest returns to be made in regard to efficiency and effectiveness of EMS, NHSDW (111) and NEPTS operations. 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 making 1,200 “999” calls every 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:

In Year 1 we said we would

 Work with the 111 project board to ensure successful implementation of the 111 Pathfinder project in association with ABMU  Increased Hear and Treat services through the Clinical Desk.  Implement appropriate service provision for non-injury falls.

This is a summary of how we have done

 Across Hear and Treat in our Clinical Support Desk:  The CSD has moved 4.56 posts from VPH to the North Wales CCC. An additional 5.4wte have been seconded to CSD until Mar 2017 following funding for winter from WG.  Improved our responsiveness to fallers who previously were passed as Green 3 to NHSDW, 80% of which were then passed back. This was not a good patient experience. The Clinical Desk now retains some falls calls and works with a range of responder agencies to safely resolve without the need for ambulance attendance.  CCC Clinicians are now operating out of police control rooms in North Wales and South Wales force areas.  Taxis are now being utilised following assessment by a clinician for HCP calls, discharges and other alternatives to an ambulance conveyance. The option of taxis for appropriate patients has also been made available to NHS Direct Wales nurses during 2016.  Successfully launched the 111 Pathfinder in ABMU, including the successful recruitment of additional call takers and nurse advisors, redeveloping the decision support software and developing the joint protocols with ABMU OOH team

In addition, we process mapped the CCC call cycle from BT Connect to close of call, in order to identify: areas of risk and concern, inefficiencies, further process metrics, the current state (pre- implementation of the new CAD) and to help engage CCC staff in the change process.

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 strategic actions within this step which 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 four key areas:

1. The implementation of the new CAD

The benefits of this significant, complex change will see replacement of three separate instances of the CAD move to a single instance across our three ambulance control rooms. The upgraded system will bring a number of productivity gains following implementation through a phased switching on of functionality such as “auto dispatch” for red calls and much improved status planning.

WAST’s business case for a new CAD was approved in November 2016 and a preferred supplier has been awarded. Early technical discussions have been held with the supplier and an implementation plan is nearing completion for an autumn 2017 implementation date.

Our staff will be key to the successful deployment of the new CAD and, as a result, we have clearly identified the need for ongoing refreshing and modernisation of workforce processes and the resulting engagement of staff on the changes to CAD that is needed. A two year engagement, consultation and change process for a revised staff structure to support the new CAD processes has already started and will continue as part of this plan until the system is fully implemented. ACTION 14: We will successfully implement a new CAD.

The delivery of this new CAD will happen in two phases. Phase one (to be completed in year one of this plan), which will culminate in the ‘go-live’ of the system. In real terms, this will see us operate the same processes on a new CAD, with the exception of the addition of an auto-dispatch function for red calls.

Phase two (which will be delivered across year two and three of this plan) is where we will start to be able to realign our processes to the new CAD system- this is where real transformational change and benefits will start to be realised.

2. Our CCC Estate.

We know that moving forward we have insufficient physical CCC building space capacity to manage current staffing levels, particularly when we build in the additional requirements created by the hosting of the new 111 service.

An options appraisal for the Central and West CCC site in Carmarthen has already commenced and we see this particular piece of work moving forward at pace during the lifetime of this plan. This is dealt with in our Estates section.

3. Further Improve our Hear and Treat rates

Over the previous year, we have received Welsh Government funding that has supported an initiative to place additional “Hear and Treat” staff in our CCCs. In November and December 2016 alone, our expanded cohort of Hear and Treat stopped 1000 and 1700 Ambulance dispatches respectively.

Unless we are able to identify a funding stream, the additional winter staff will return to their substantive roles at the end of March and the team will reduce from 24 to 18, our funded establishment.

This enhanced model has had a demonstrable impact, as the graph below demonstrates. We will continue to work with Welsh Government and the CASC to explore resourcing options.

Number of Ambulances Stopped

2000 1800 1600 1400 1200 1000 800 600 400 200 0

Number of Ambulances stopped

Currently, we have a 24/7 Hear and Treat presence in both of our South Wales CCCs and a seven day split between our CCC and police control centre in North Wales. We want to expand our capacity so that we have a 24/7 presence in all our CCCs.

In addition, whilst we currently have a Hear and Treat presence in both North Wales and in our Carmarthen centres, this is not on a 24/7 basis. We will, therefore, over the full life of this plan, look to understand and close the capacity gap that exists between our current service in Carmarthen and the resources required to create a 24/7 Hear and Treat presence.

4. Wider CCC Modernisation.

Implementation of the CRM pilot in October 2015 has created significant operational change within the CCCs. As a result, there are further challenges which need addressing during the life of this plan around ensuring that the systems and processes that support the CRM are fit for purpose at a time when there are ongoing changes to the model.

We will pursue performance gains through reducing variation between CCC call answering by providing additional support for training and development and, in addition, our CCC staff are working closely with our health informatics colleagues to develop a ‘CUBE’ for CCC performance reports.

Development of the CCC quality, governance and risk processes are also key to the modernisation of our CCCs. As such, we will develop an improved concerns Action Plan to capture, monitor and learn from near miss errors and incidents.

We will also explore strategies for flexing our call taking and triage capacity so that we can be more responsive to short-term spikes in demand. Such strategies might include looking at how we can make better use of remote working technology to allow those with the appropriate call handling skills to, for example, log on from home.

ACTION 15: We will review CCC processes, practices and environments to support our staff to do their jobs even better

NHS Direct Wales

Our NHS Direct Wales service is a vital component of our Step 2 offering, providing people in Wales with appropriate choices and health information 24/7.

We have done much work to ensure that the service becomes even more integrated in the organisation and, over the life of this plan, we will evaluate our requirements for a secondary / non- emergency telephone triage system to ensure that we achieve a seamless fit across 999 / 111 / 0845 calls.

The focus for the NHS Direct teams has been on the preparation for, and transition to, the 111 Pathfinder. An OD approach is required to underpin the required changes in process, service and workforce models.

111 Pathfinder

The 111 Pathfinder in the Aberdare Bro Morang area was a priority for WAST in 2016/17. The pathfinder built on the existing NHS Direct Wales and the GP OOH service within ABMU, bringing them into a single service. It provides real opportunities to lever transformational change in the unscheduled care system, and aligns with the 10 step unscheduled care model. It requires a collaborative approach with WAST, ABMU and the all-Wales 111 Programme infrastructure working together across organisational boundaries.

Although some delays were experienced from the original launch dates, the pathfinder successfully launched across ABMU in October 2016. Whilst it is still relatively early days, the 111 pathfinder has made an encouraging start. Up to the end of December, the service had taken circa 31,000 calls with a notable increase in demand during the festive period. Key points of note include:

 The abandonment rate has shown significant improvement throughout the year, although this did rise during the busy winter period.

 A redesigned prioritisation and triage system and technical connector has been in use from mid-October and the new system is now embedded and stable.  The Clinical Support Hub has been operational from July in advance of formal launch. This gave significant benefits prior to going live, and will be repeated when future health boards come on board. With the additional GP, pharmacist and nurse input, it has provided far greater support, resilience and stability to both the OOHs and wider unscheduled care service within ABMU  No adverse impact on EMS service, in-hours GP services or Emergency Departments reported.  There have been no reports of significant patient safety issues  Strengthened and growing relationships between the ABMU paramedic workforce and the Clinical Services Hub has led to a reduction in conveyances for green calls

Whilst the launch has been successful, there have been a number of lessons learnt that are dynamically fed in where appropriate.

In 2017/18, we will continue to work with the national 111 Programme on the following key areas of work:

 Engaging into the national evaluation on the pathfinder  Agreeing target operational model based on learning from demand and capacity work. Until this demand and capacity work has been revisited with the programme team, it is not possible to outline the requirement form a workforce perspective.  Recently established Directory of Service work stream as a key enabler for future roll out  Progressing the longer term replacement of the CAS system (see ICT section)  Continuing to refine the service, workforce and operational models to drive up performance efficiencies  Decisions regarding future hosting of the 111 service

In terms of next steps, the pathfinder evaluation expected in early summer is a key milestone, and we expect the Cabinet Secretary for Health, Well Being and Sport to make an announcement on any future roll out before the end of 2016/17. However, in line with emerging national discussion, we will be testing the deliverability of the draft indicative timeline below:

2017/18 roll out of 111 service

Hywel Dda – Pembrokeshire/ Ceredigion

Establish clinical support hub for the South East

South East Wales LHB 1 or 2

2018/19 roll out of 111 service

South East Wales LHB 1 or 2

South East Wales LHB 3

Establish clinical support hub (north)

Active build time /training for new replacement IT system

2019 /20

North Wales Quarter 1-2 (due to size of organisation, this will likely be a three phased approach)

Launch of the new IT system (Sept 2019)

There are a number of challenges to the all-Wales roll-out including:

 Capacity within WAST to train, manage and support increasing staff numbers  Physical capacity to house the services  Ability to recruit and retain staff for the long term

There is a clear link with this 111 component of our plan and our finance section (assumptions regarding funding), our workforce section (assumptions on workforce numbers and workforce modernisation), our estate section (our work on CCC configuration) and our ICT section regarding the future CAS replacement.

ACTION 16: We will plan and implement roll out of the 111 Pathfinder Service across Wales in line with the agreed project plan and timelines, subject to appropriate funding and clarity of resource implications.

7.1.3 STEP 3: Come to See Me

This step focuses on how WAST makes decisions about what resources to dispatch to assessed/prioritised calls and the timeliness and appropriateness of our response.

In Year One we said we would:

 Undertake a Demand and Capacity Review  Implement HCP desk implementation plan to ensure efficient management of HCP calls at a local and regional level.  To finalise and gain Trust Board sign off of a CFR Strategy  Explore and expand where possible the provision of co-responding groups across Wales (Fire and Rescue Services, Police Services, RNLI, RLSS etc.)  Review CFR dispatch/activation protocols for more effective distribution of resources This is a summary of how we have done

 Recruited clinicians to manage the calls that we receive from Healthcare Professionals in line with our HCP policy to enable us to manage requests effectively. Developed a HCP Desk Standard Operating Procedure to ensure consistency of application and to ensure appropriate standards are maintained  Accredited CFR training package has been introduced  Scope of practice for CFRs has been defined and approved  CFR response has gone live for non-injury fallers  Went live with mobile data solution for CFR’s to improve activation  Our Community First Responders and Co-Responders during 1st April to 31st August 2016 saw 1006 allocations to Red incidents and were first to arrive at scene over 70% of the time resulting in a pan Wales contribution to Red patient care of circa 9%. When we compare the total number of 57 allocations to all suitable codes for CFR and CR we see over 1000 more allocations in 2016 period

compared to 2015  Completed the Demand and Capacity Review

Demand and Capacity

In section 5.2 we highlighted that the demand and capacity review presented a number of opportunities.

Over the life of this plan, we have ambitions to realise the opportunities which are solely within our gift. All these opportunities have an emphasis on efficiency, by ensuring our ambulances and response cars are available for calls a higher percentage of the time than they are now. These opportunities include:

a. Increase in Unit Hour Production (UHP)- the number of ambulances available by hour b. Review shift patterns c. Reduce activation time by <30 sec

We will also work with health boards to identify where we can work together to realise joint opportunities. In so doing, we recognise, as mentioned under step 2, that all organisations have their natural capacity for ‘new’ initiatives, so there will need to be a focus on assessing whether what we have collectively established works and then an effort to scale up across Wales.

ACTION 17: We will use the findings of the demand and capacity review to inform service provision internally and externally.

Our Role with Primary Care

In section 5.3.3 we described the opportunity which exists to work more closely with primary care. There is a clear policy direction from Welsh Government in terms of a strengthened primary and community cares system that places clusters at its heart. Our work on the 111 pathfinder and our approach to improving management of healthcare professional calls demonstrate that we have made some progress in this area. Similarly, there are examples of our Advanced Practitioners working as part of primary care teams. However, we recognise that there is more we can do to be clear on our offer, through testing new approaches. We will try to realise those opportunities by looking to work with primary care over the life of this plan through three ‘lenses’:

Lense 1: Multi-Disciplinary Team Pilots

The Pacesetter Programme evidenced the potential for new cluster models to manage the increasing demand on primary care services, ensuring patients see the right professional within a Cluster Team without unnecessary delays. We want to help maximise the potential that these clusters can bring to the patient, our service and the wider NHS system.

As such, a key priority agreed for 2017/18 between ourselves and primary care is the development of an MDT approach and we will focus on developing and evaluating the MDT pilot models that have been agreed and initiated with Clusters during the last quarter of 2016. These are:

1. ‘GP Out of Hours Service (OOHs) model’ - Agreement to test a MDT model in the GP out of hours service (OOHs) in Aneurin Bevan. This involves two Advanced Paramedic Practitioners undertaking home visits on behalf of the GP OOHs in Aneurin Bevan Health Board area. The posts will be rotational, with the Advanced Paramedics continuing to undertake shifts for WAST as well.

2. ‘Primary Care Practice model’ - Agreement to test a MDT model in the Aberdare day time primary care practice in Cwm Taf. This is where four Paramedic Practitioners will undertake home visits on behalf of the Aberdare practice, as a result of the calls being triaged by a GP, and allocated accordingly to the Paramedic Practitioners. In addition, the Paramedic Practitioners will also support Cwm Taf GP OOHs and WAST with any operational resilience plans, and will still be required to undertake shifts for these services (as and when required).

3. ‘Community Based Partnership’ model - agreement to test a community-based model, with the Western Vale Primary Care Cluster Group (Cardiff & Vale Health Board). This is to develop and test a new pathway, which links the local Rapid Response Vehicle (RRV) directly to the 3 local primary care practices within the Western Vale of Glamorgan. This will create collaborative working between the two unscheduled care services in that geographical area.

4. ‘Community Based Partnership’ model - agreement to test a community-based model, with Powys Health Board, involving a similar scheme to that of the Western Vale Cluster, but enabling four paramedics to be part of an integrated team in the Llandrindod Minor Injury Unit.

During year one we will focus on an evaluation framework to collate lessons learnt from all the above MDT models. The evaluation of these pilots will inform the objectives for years two and three around-

 Identified training needs (ITN) for paramedics to work in an integrated way with Primary Care, which will inform WAST’s Strategic Education and Development Group (SEDG) in setting future curriculums (via a work – based model of education) that will develop our clinicians beyond their current critical care skills, and meet the changing patterns of disease with more people requiring community care for multiple long term conditions.

 Development of business cases to inform service planning / commissioning of joint services for agreed MDT models with Clusters to meet the healthcare needs of the population (Health Care Needs Assessment – HNA).

 Cost effective sourcing of new estate development opportunities, where WAST and Primary Care could undertake feasibility work to identify any options to efficiently bring together joint centres / ‘hubs’ of community care.

Year three will also provide the opportunity to consider the review HNAs, and establish a joint vision and strategy with primary care for a safe and equitable integrated community model of care. This would include elements such as a Directory of Service (DOS), to be coordinated via the 111 telephone service, agreed protocols / pathways for ambulance teams to access community based services, and avoid unnecessary transportation of patients to Emergency Departments and a national model for the scheduling of ‘same day’ admissions of patients to hospital, who require transport within an agreed timeframe, but not necessarily a ‘blue light’ ambulance.

Lense 2: Training & Education

Education and training for ‘Community Paramedics’ 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.

Providing Advanced Paramedic Practitioners (APPs), educated to Master Degree level, to work as part of a multidisciplinary team (pharmacist, district nurse etc.), and staff Primary Care Hubs / Support Teams as part of enhanced services provided by Clusters.

Lense 3: Realising Estate Opportunities

We have identified the potential opportunities of taking a collaborative approach to estate solutions with primary care partners. Realising opportunities to co-locate stations and or social deployment points with primary and community care developments would support enhanced services, create a working relationship for clinical leadership by General Practitioners, 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. ACTION 18: We will evaluate the impact and benefits of the community paramedic trails to support community models of care in 2017/18 as part of this overall shift to a clinically led, quality driven service.

Community First Responders (CFRs)

Our Community First Responders (CFRs) are a valued part of the emergency response team and provide a resource to us to support the provision of our EMS. CFRs also have an important role in developing community resilience and public awareness. CFRs provide pre-hospital emergency care within a defined set of protocols before the arrival of an ambulance resource.

There are currently more than 200 Community First Responder schemes across Wales comprising approximately 2,200 volunteer members and these schemes contribute more than 3% to RED performance pan Wales. The summary box earlier in this section shows the work which we have progressed in the last twelve months. We recognise, however, that there is more to be done. As such our focus will be to-

 Embed Terrafix Mobile data and enable auto allocation

 “Go Live” of CFR desks in all CCCs

 A further fifteen schemes responding to non-injury fallers

 The implementation of a new scope of practice that will see three tiers of responders

 Staff responder presence in BCU, Aneurin Bevan and Hywel Dda Health Boards

 Increase third sector engagement and enter into partnership / formal MOU with Cariad Emergency Medical Retrieval Service (EMRTS) We work closely with the EMRTS in the running of the current service which is commissioned by EASC and hosted by ABMU LHB. We welcome further opportunities to engage in the longer term planning and development of the service, in line with any evaluations and reviews. Our priority in respect of EMRTS for 2017/18 is to engage collaboratively, through the EMRTS Delivery Assurance Group (within the EASC arrangements) and specifically the North Wales Air Ambulance Implementation Group, to enhance the provision of service from the North Wales Air Ambulance base in Caernarvon.

It is recognised that the current model of provision does not provide equity of access in terms of emergency air support and we recognise the risk that this poses to the system. Working with our partners in BCU LHB, the Air Ambulance service and EMRTS we will work on the following areas of development:

 Placement of the Caernarvon base under EMRTS governance  Standardisation of Caernarvon base infrastructure and medical equipment to match that at the other EMRTS bases.  Recruitment to a full complement of Critical Care Practitioners as per the EMRTS model, ensuring equity across Wales and the resulting increased capability in terms of the clinical skills and experience offered by CCPs.  Provision of Consultant medical input to the base.

7.1.4 STEP 4: Give Me Treatment

This step focuses on the development and delivery of a range of clinical care services able to offer a variety of treatment options. The treatment provided by ambulance clinicians in the pre-hospital setting is a major factor in their 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. The Trust will then monitor how ambulance clinicians deliver the care bundles to ensure continued improvement in clinical care.

In this first year we have developed and will 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 to how their teams have delivered clinical care we will be able to demonstrate improvements in the delivery of clinically effective care.

In Year 1 we said we would

 Deliver 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 2

 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 18th 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 that 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 patients 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 yet to be diagnosed with ECG abnormalities and refer these patients to primary care for early intervention. Omnicell Project We are commissioning 20 Omnicell Automated Medicines Supply Cabinets across Wales. These will be located in hospitals and on some ambulance stations in Powys. Again, this is an Efficiency Through Technology funded project with the aim of modernising our medicines supply arrangements for Prescription Only Medicines (POMs) and Controlled Drugs (CDs). The Project objectives are to vastly improve governance, audit and monitoring capability on the supply and use of medicines by the Trust. The system will replace existing medicines cupboards that are reliant upon paper documentation for the withdrawal of drugs. The new cabinets will use biometrics to record all drugs transactions. We have already procured the medicines cabinets and are now undertaking a programme of training for staff and pharmacy users. We have a phased approach to roll out by Health Board area with the project planned to be completed by March 2018. 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 around 8,000 victims of out of hospital sudden cardiac arrests occur 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 were improved. We will have a local planning and delivery group and link in with those of the Health Boards. We have been working with Public Health Wales, British Heart Foundation and various other partners to deliver the ‘Restart a Heart’ day on 18 October 2016 when we helped to train 12,000 pupils in the life-saving skill of CPR. 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.

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, return of spontaneous circulation, sepsis, hypoglycemia and febrile convulsion.

We are now working with our Clinical Team Leaders to provide them with access to three of the indicators initially to move the focus of their work to the quality of the clinical care that we provide. Members of the Medical and Clinical Services Directorate are currently meeting 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, STEMI, and hypoglycaemia, will be the 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.

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 & Effectiveness Programme has been revised, allowing it to be more easily monitored, realistic and achievable, keeping in mind clinical audits that relate to the new Clinical Response Model and are not duplicated as Clinical Indicators. The revised format now includes a ‘summary’ table of clinical audits (RAG) to easily monitor their progress through Q1, Q2, Q3, & Q4 along with a table containing ‘full information’ should more detail be required for each clinical audit. Updates on this programme are presented to various committees and is 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.

ACTION 19: We will develop a framework to continually deliver and monitor the clinical effectiveness of the clinical care we provide.

7.1.5 STEP 5: Take me to…..

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 Year 1 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.

 Implemented a non-injury faller’s pathway approved through our Clinical Pathways Approval Group.

 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 had 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 3.7 our joint priorities with LHBs, all of which are relevant in this section. In addition we have a strategic focus on the following:

 The next phase of Paramedic Pathfinder. We recognise that we did not have the success we aimed for in the implementation of the Paramedic Pathfinder tool. Whilst we undertook training with our staff (94%), our recent evaluation demonstrated low compliance. During the evaluation phase of the Pathfinder project, we were presented with the opportunity to test the newer, more clinically focussed Manchester Triage Tool. No further action on Paramedic Pathfinder will be taken until we have assessed the outcome of the Manchester Triage trial. Early indications show that paramedics using the full MTS suite generate higher levels of safer care closer to home for patients when compared to paramedics using the PPF based algorithms.

 Ongoing roll out of an All Wales End of Life Care Pathway. The EoLC Pathway is in place in four LHB areas so a priority is to achieve full roll out.

 Full Roll Out of Mental Health Pathway. The Mental Health Pathway first adopted in Cardiff and Vale has been proved to be effective at management this patient group. However, it is not yet fully rolled out across Wales.

 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 to identify suitable holding areas in times of pressure and agreeing the underpinning governance, operational and workforce models.

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

 Substance Misuse. In particular the excessive consumption of alcohol in our night time economies and the strain that this can put on our services. We will continue to exploit the opportunities which alternative treatment options such as the alcohol treatment centre in Cardiff can provide.

7.2 OUR NON-EMERGENCY PATIENT TRANSPORT SERVICE DEVELOPMENTS

The Non-Emergency Patient Transport Service (or NEPTS) is part of the Welsh Ambulance Service NHS Trust (WAST). It is one of three operational directorates of WAST, alongside the Emergency Medical Service (EMS) and 111/NHS Direct. However, unlike EMS and NHS Direct, NEPTS is part of the Director of Finance portfolio.

7.2.1 The NEPTS Business Case

NEPTS, previously referred to as PCS, has gone through a significant period of uncertainty, 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 & social care

These were also reinforced by the current Cabinet Secretary, who also highlighted specifically the clinical risk associated with individual renal patients arriving late on regular occasions and that this should be eliminated. As explained further in this section, this has now been achieved for the last 12 months.

These service improvement initiatives formed a major part of our plan last year, and we give a brief update in the call-out box below.

In Year 1 we said we would

 Agree and establish a dedicated NEPTS management team within WAST. This will include establishing the NEPTS principles, vision and purpose  Establish a single point of contact  Improve discharge and transfer service for all scheduled care  Extend operating hours of the service.  Develop an enhanced service for renal, oncology and end of life care.  Engage a range of third party transport providers to help support the delivery of NEPTS  Creation of a new NEPTS brand.  Explore how health and social care might work together on transport issues.

This is a summary of how we have done

 Fully implemented the dedicated management and supervisory team with a shared vision and purpose  Introduced a single 0300 number for Wales and developed on line services  Scoped existing discharge and transfer transport across Wales  Provision of transport from 0600 to 2200 hours six days per week.  Significantly improved the timeliness and quality of service for enhanced patients  Increased third party providers from 5% to 10% of all NEPTS activity  Embedded the term NEPTS across the NHS in preference to PCS  Modelled the benefits and challenges of integrated transport within North Wales

The above is just a snap-shot of our achievements. Over the last twelve months we have relentlessly pursued the delivery of the requirements set out in the business case and annex 2 provides ‘the detail’ on:

 What we have done.

 What has been the benefit?

 What still needs to be done.

We recognise, however, that there is still much to do and more improvement is needed particularly around the transport of oncology patients. Despite the introduction of the enhanced service, we know that the service provided to oncology patients could be even better and that additional focus is needed to ensure the service meets the high standards already achieved for renal dialysis patients. These further developments are reflected in our actions below.

We will need the full engagement of all Health Boards to support us in delivering the service that patients need. We will also require full transparency of the existing service level agreements from Health Boards regarding other transport provider organisations to assist us in the development of a Plurality Register and Plurality Transition Plan, reducing risk to NHS Wales.

7.2.2 The NEPTS Four Step Model

In line with the approach taken around the Emergency Medical Service (EMS) we have agreed with the Commissioner a four step approach to delivering NEPTS. Our delivery model and service improvement will be based across these steps.

This focus on a four step patient flow approach to commissioning of NEPTS is being further supported through the Deputy Director NEPTS piloting the Vanguard Systems Thinking methodology.

7.2.2.1 STEP 1: Help me choose

This step focuses on public and health care professional education regarding the services provided by NEPTS and effectively signposting non eligible callers to alternative ways of accessing planned healthcare.

Our other focus under this step will be a focus on demand management and demand reduction approaches. The valuable NEPTS resource should be focussed on patients who have no other means of accessing appropriate transport. 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 the eligibility criteria.

7.2.2.2 STEP 2: Book my transport

Call Taking

Our three NEPTS Journey Coordination Centres (JCCs) are at the centre of the entire NEPTS operation and continue to be one of our priority areas for improvement, with some of the biggest returns to be made in regard to efficiency and effectiveness of NEPTS. Performance is dependent on our journey planners and on day coordinators getting it right, and this requires appropriate systems to support staff to deliver the best outcomes for patients.

In addition the three JCCs, WAST also operates three small call centre teams taking bookings directly from patients and health care professionals (HCP). Two additional call centres are operated by Powys Teaching Hospital Health Board and Cwm Taf University Health Board respectively. NEPTS, in total, handles in excess of 1500 calls per day.

Our aim is to simplify the existing booking process for users through the implementation of the single 0300 number for the whole of Wales, reducing the number of ‘access routes’ into NEPTS. This will create additional capacity elsewhere in the system.

In addition, we will also continue to invest in the development of on line services (including on line booking) to reduce the overall call demand. Improvements in other parts of the NEPTS system will also reduce the ‘failure demand’ currently experienced as a result of uncertainty from users.

Eligibility

Our Patient Needs Assessment (PNA) tool will be continually developed to ensure the right patients get the right service. 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,

Plan Efficiently

As stated above, the key to unlocking efficiencies and quality improvements within NEPTS lies within our JCCs. This is where the transport requests are co-ordinated and allocated to resources using scheduling software with significant user involvement.

Using technology we will shift the balance from user to system planning to reduce workload and reduce variation in approach.

In addition, we will increase the availability and flexibility of our resource base through increasing our use of alternative providers. All use of alternative providers will be supported by good governance and the use will be fully auditable for commissioners to demonstrate value for money.

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, one of our key priorities for the first year of this plan will be the introduction of a new Journey Coordination Model.

The new model will increase the use of tried and tested technology to improve the utilisation of resources and will also improve working processes and environment in the Journey Coordination Centres. This will lead to improved staff retention and reduced training costs.

To increasing 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 trial in North Wales will be extended and the model rolled out to other local authority areas during the next three years. These savings, in both physical and financial resource, can be re-invested to enhance quality and safety.

7.2.2.3 STEP 3: Take me to my appointment

Demand and Capacity

It is critical that NEPTS gains a better understanding of its demand to allow it to ensure enough capacity is secured to deliver the standard of service commissioned.

Our proposed journey coordination model described above will place an increased focus on forecasting demand and securing resource.

From the 1st April 2017, WAST will be responsible for the provision of all eligible NEPTS within NHS Wales and this will require the novation of existing contracts and agreements, currently held with non WAST ambulance providers by Health Boards, into WAST.

We have planned for this to take place for the key providers during the first six months of 2017/18 and have resourced to achieve this. Some existing contracts have already been rolled forward by Health Boards and, due to their value, require a full tender process to be undertaken. These have been recorded in our Plurality Resister and have planned dates agreed with the Health Boards that are reflected in the Plurality Delivery Plan.

This will offer significant opportunities around improving efficiency, maintaining quality and offering better value. However, it will also create risks that we will have to mitigate through the development and delivery of a Plurality (Contract) Register and Delivery Plan. This will be needed to ensure that

the existing arrangements and contracts are novated in a planned way that does not increase risk or cost to the 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.

The savings associated with the novation of existing contracts and ad hoc spot purchasing into a single organisation (WAST) was a fundamental part of the Business Case agreed by Welsh Government and EASC. The savings identified through this improved coordination will offset, in part, the increased cost of providing the enhanced service and the extended operating hours and discharge capacity.

Supporting the plurality model we will be introducing a brokerage service that will identify the most cost effective method of conveying patients. This will provide complete transparency to our commissioner and the health boards around the use of alternative providers and value for money.

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 developed in lean service improvement techniques and will constantly be looking for opportunities to implement lean methodology.

In our first year we will focus on the improvements in the Journey Coordination Centre whilst also developing the End of Life service, specialist handing and moving resources and ways of supporting work currently undertaken by the EMS service that could be undertaken by NEPTS.

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 develops meet the current and future requirements of NHS Wales

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 has been achieved, with WAST significantly investing in the service both financially and in focus.

The improvements in safety have been significant, with the clinical risk associated by individual patients having multiple reduced treatments now eliminated for over 12 months.

7.2.2.4 STEP 4:Take me home.

Enhanced Services

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 NEPTS becoming ready for return.

For patients going home to die, our focus is to ensure that they are all picked up by a specially trained end of life crew within one hour of receiving the request.

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. Support for patients waiting We will be changing the focus of our hospital liaison staff from being a desk based role to a front of house, concierge type role. This will improve the patient experience of patients waiting whilst improving the turnaround times of NEPTS crews at hospital. ACTION 20: We will engage with key internal and external stakeholders around the development and implementation of different ways of working within NEPTS

ACTION 21: We will work with Health Boards and Local Authorities to develop an integrated transport model.

ACTION 22: We will work with the Commissioner and Health Board partners to identify and develop new NEPTS initiatives that add value for patients.

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, whilst Red 8 minute performance is maintained, these amber waits increase and are a source of complaints and concerns.

Our response to these amber challenges sit across a number of the 5 steps. We have, therefore, put an “amber lens” on our plan at this juncture and coalesced the actions we have in a number of

sections to demonstrate our commitment to improving this area. You will find further details across each of the steps below and in other relevant areas of the plan. Our package of actions are interrelated but sit across two interrelated themes:

 Development of new operational models, tactics and pathways to respond in a more appropriate way to these patients

 Clinical practice and leadership.

New Models and Pathways Clinical Practice and Leadership

 Mental Health Improvement Plan  Clinical Leadership model

 Clinical Desk development  Use of Clinical Data at team level to support meaningful PADR and feedback  Falls Improvement work to bring together  Career pathway focus in particular: - Non-Injury Faller work in Clinical Desk - NHSDW pathways  Development of Advanced practice - Directories of Service models - iStumble projects in ABMU - C&V multi agency exercise  Benefits through the Band 6 - Falls Vehicle in AB development - Community Assistant Team in BCU - Community Paramedic pilots and  Clinical Audit Programme evaluations  Clinical Indicator Improvement Plan

 Review of training and education

Moving forward we will use the findings of the Demand and Capacity review as a platform for discussions with Health Boards around responses to the needs of these patients. Furthermore, we will review our amber actions in line with the Clinical Risk Assurance Review which we expect to be published in March 2017.

In addition, a clinically led WAST Falls Strategic Oversight Group has been established, bringing together existing projects across Wales where WAST is a key partner. The aim is to address new and innovative ways of responding to patients who have fallen (injured and non-injured falls). Many of these projects are now in their evaluation phase and the group will assess progress to date with falls interventions within the organisation and help make an assessment of the way forward. The WAST strategic group will also face externally with key stakeholders and partners and ensure that the organisation is represented and has a voice on the National Falls taskforce, which is supported by the 1000 Lives Improvement Team. Action 9 in our quality section commits us to taking this agenda forward.

Following the independent review of the Clinical Response Model, the Cabinet Secretary for Health, Well Being and Sport requested further work be done on the categorisation of amber calls. As well as working on the improvements outlined above, we will work with the EASC and CASC on review of amber call categorisation.

7.3.2 Welsh Government Together for Health National Delivery Plans

Part of our early thinking has been to identify which of the national plans / implementation boards we should be either working more closely with or start working with. We have identified the following as our key opportunities- Stroke, Cardiac, End of Life, Diabetes, Mental Health and Primary Care. We have aligned our proposed work packages to the priorities of the national plans and this is highlighted in Annex 9.

We recognise that, historically, the Trust has not maximised the opportunity which being fully part of the national delivery plans and the associated implementation boards can bring to both us as an organisation and the patient groups which these plans focus on.

ACTION 23: We will deliver a series of actions to support implementation of the national delivery plans working collaboratively with implementation boards to ensure WAST is integral in influencing change within the wider health system.

8 OUR ENABLERS

This section describes how we will enable and facilitate change.

The transformation we continue to seek in our service and patient-facing areas 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

This section should be read in conjunction with the relevant sections of the 2016/17 – 2018/19 Integrated Medium Term Plan published last year, and section 5 (Challenges and Opportunities), section 6 (Our Significant Service Changes) and section 7.3 (Our Finances) of this document to understand the wider context and some of the detail. Our people are our most significant asset and it is through the commitment, professionalism and dedication of our staff that we are able to provide high quality and safe services to the individuals, families and communities we serve. The way in which the Trust plans, recruits, supports and develops and deploys its staff, is vital to its ability to meet the increasing service and financial challenges it faces and sits at the heart of our People Strategy 'Being our Best', which we introduced in 2016 (see model below – Four-Step Model – Our People Strategy). Underpinning our People strategy and action plans sit the principles of prudent healthcare and a prudent workforce “only doing what only you can do.” 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 outcome of the Demand and Capacity work will drive a change to the shape and skill set of our existing and future workforce.

Four-Step Model – Our People Strategy

Details of our People Strategy map can be found in our previous plan and provided an overview of the strategy, context and challenges, enabling frameworks and plans with key dependencies and outcomes. ACTION 24: We will ensure implementation of the actions within the People Strategy enabling plans and delivery of Key Workforce and OD Performance targets in 2017/18.

The Trust employs approximately 3,186 members of staff (2,992.72WTE) (as at 31/12/16). 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 2016)

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

Our frontline teams are supported by colleagues working within our Corporate / Executive functions and our fantastic volunteers, including our Community First Responders (CFRs) and circa 360 Volunteer Car Drivers.

Our Workforce Plan We continue to build a solid foundation for future workforce planning by improvements to establishment control, confirming budgeted and actual establishments and aligning recruitment and training plans. There are several key factors to our approach and successful workforce planning:

1. Understanding our demand and capacity, and ensuring the supply chain through educational commissioning, recruitment and succession planning 2. Reducing variable pay expenditure through effective deployment and rostering efficiencies; and keeping a focus on general workforce efficiency and productivity such as sickness absence management 3. Identifying opportunities to modernise and redesign clinical roles, practice and re-balancing the skill mix – reshaping the workforce to make the future look different

In Year 1 we said we would

 Develop a workforce plan based on the output from the ORH demand and capacity work, to enable us to :

 Identify staffing required to meet demand by 2020, to address the variable

relief capacity and opportunities to review the skill mix of Emergency

Ambulance crews

 Development of specialist roles such as community-based paramedics in rural areas and critical care paramedics

 Review of CTL position/management time as part of workforce planning

 Reduce abstractions and reliance upon overtime and private ambulances through improved recruitment and reduced vacancy rates among EMS staff

 Improve accuracy of our ESR data and alignment with financial data This is summary of how we have done

 Concluded the ORH project and identified the differential between existing funded establishments, staffing needed to increase relief capacity and to meet demand by 2020.

 A review of the CTL role has been undertaken, options for CTL time modelled and a bespoke development programme will be rolled out from April 2017

 Improvements made to data quality with the ESR system ensuring it is better aligned with our financial data, giving us one reliable source of workforce establishment data.  Trained a number of HR staff in workforce planning and developed closer links and understanding between our workforce and resource planning teams.  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 during 2016/17 as a result of better workforce planning and timely recruitment.  Launched Community Paramedic Pilots75 (as described earlier in plan)

Our Emergency Medical Service Workforce

Our EMS workforce is our biggest resource and, therefore, continues to remain a focus for our workforce planning activities. Our ability to workforce plan depends upon an understanding of current and future demand, what that means for the workforce, and the supply chain of staff.

We know from the work undertaken by ORH that the demand for 999 services will continue to grow by approximately 4% year on year to 2020/21 (this assumes no action to reduce demand for purposes of modelling) and is linked to an increase in the frail elderly population of Wales. An increasing number of our patients are now over 65 and this change in demographic will also result in a change of case mix. It is worth remembering that our staff are also getting older (as highlighted earlier in this document) and will require an increasing support on health issues associated with frailty, musculoskeletal injuries and chronic illness (including stress and anxiety) as well as injury patterns associated with old age.

Details of the workforce financial planning assumptions including turnover (5 - 7%), incremental and inflationary pressures and the apprenticeship levy are contained within section 7.3 of this plan.

As a result of the analysis provided by the ORH work, and a number of pilot projects that have been evaluated relating to the clinical desk and hear and treat capacity, we now have a better understanding of the opportunities that exist to re-shape our workforce over the next few years to increase capacity and capability across STEP 2 (Answer my call) and STEP 4 (Give me Treatment) and to efficiently and effectively meet demand and response targets now and to 2020/21.

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

In section 7 we describe the important role our NHS Direct Wales (NHSDW) team play within our services, providing vital advice, guidance and signposting to callers seeking help and advice. We also highlighted the progress made so far in the launch of the 111 pathfinder project within ABMU Health Board and the lessons we have learnt from this.

Learning from the pathfinder will inform the final workforce and service model of the Clinical Support Hub and staffing number requirements. The service is assumed cost neutral in finance terms, but in workforce terms we saw an increase in triage nurses (11.78 WTE) and call handlers (13.24WTE) recruited during 2016/17. The creation of such hubs will provide exciting opportunities to look at the future potential for specialist clinical and/or nursing roles to be part of the multi-disciplinary team, caring for patients with chronic conditions such as diabetes, along with paramedics and/or advanced practitioners. A rotational opportunity between ABMU nursing and 111 is currently being piloted and early results are encouraging.

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 2016/17 and consequently the planning for future roll out across Wales. These numbers will be updated within the plan as soon as this modelling exercise is complete.

CCC Modernisation further detail of the scale of opportunities related to the CCC is contained in Section 7.1.2. We note the positive impact that the increase of 6 WTE Hear and Treat clinicians in 2016/17 has had on ambulance dispatch in this period. However, we await the outcome of further

discussions with Commissioners and Welsh Government on the potential to continue this investment into 2017/18 and beyond. This would go some way towards meeting the additional resource requirement identified by the ORH work as needed to deliver our performance ambition of an 8% Hear and Treat rate in future.

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

In Section 5 of this plan, we refer to some of the challenges that have been made clearer through the ORH modelling work done to test efficiencies and resource requirements for Red calls (Stage I) and Amber calls (Stage II) in 2020/21. The modelling work has highlighted a range of efficiency opportunities within the gift of the Trust to deliver an immediate improvement in performance (described at section 5.2.1), and also set out some future and more immediate challenges we face in terms of our capacity and ability to continue to meet red performance targets in the face of increasing demand for services, described in further detail within Annex 8.

We will take the opportunity to rebalance the skill mix of UCS, paramedics and EMTs over the life of this plan by:  Splitting, where appropriate, double paramedic crews on an Emergency Ambulance and crewing with an EMT.  A commitment to review and replace paramedic posts with an EMT where appropriate, through natural wastage (note age profile discussed in Section 5). From an assessment of our turnover and current skill mix we anticipate that around 20 paramedic posts each year could be converted to EMT as we move from double paramedic to mixed crews. This is reflected in our financial efficiencies.

The Impact of Changes to Paramedic Banding

We are absolutely committed to ensuring that our paramedic workforce is properly rewarded for its skills, in line with other clinical professionals, and welcome the implementation of Band 6 profile and the scope that it offers to expand clinical practice and critical decision making as a means to improve the key metrics of hear and treat, see and treat and non-conveyance. Wales is unique in having a collaborative commissioning agreement with clear five step Ambulance Care Pathway and regularly published Ambulance Quality Indicators (AQIs) which include seven clinical indicators. This is the framework against which service developments, priorities and future actions are set, and which will enable us to truly focus on clinical outcomes that will support improved clinical practice, education and drive professionalism as we move forward. This opportunity is positively received, and has the potential to both reward and recognise staff for the work that they do, and contribute to delivery of future improvements across the unscheduled care system, providing an enhanced role for paramedics meeting the changing needs of patients with a range of complex and long-term illness and diseases within the primary care setting. Key to the realisation of such future benefits are high quality clinical education, training, and strengthened clinical leadership, a clear career pathway and support to clinicians on a day to day basis. Given the timeline for Welsh negotiations, the detail of this development is not yet confirmed or fully worked up. The costs of implementing the re-banding have been excluded from the base case within our IMTP pending the outcome of negotiations on the Wales offer and identified funding.

Commissioners and Welsh Government colleagues have, however, been kept informed of the development, and are sighted on the potential cost implications and benefits.

To summarise, the Trust’s current base position within the Workforce /Financial Plan assumes no changes or increase to workforce numbers across the period to 2020/21 in response to the ORH modelling work pending the outcome of ongoing discussions with Commissioners. This is referred in narrative terms only in more detail at A8. The Plan, therefore, takes account only of those operational efficiencies that are within WAST’s gift to control, such as changes to rostered skill mix at certain stations where appropriate (so called quick wins). It also does not include any costs associated with the implementation of changes to paramedic banding.

Securing the Supply – Education Commissioning

Paramedic education has evolved significantly in recent years, with the introduction of diploma level education in 2008. In preparation for potential development to degree level education, we have worked closely with Swansea University to develop a three- year undergraduate degree. If this goes ahead we will run the two programmes simultaneously for one year to ensure continuous output of paramedics, avoiding a fallow year.

Workforce Education and Development Services (WEDS) has agreed that the EMT Conversion programme will continue until 2020 at diploma level (30 places per year) giving current EMTs the ability to work within the timescale to progress to paramedic roles. Our paramedic educational commissioning numbers to 2020 will be just about 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.

Our Non-Emergency Patient Transport Service Workforce

A well designed workforce plan allows us to reduce variation in staff availability, reduce risk, improve safety, reduce waste, build confidence in the team and ensure we are able to meet the future demand on non-emergency patient transport.

The Workforce Plan, although owned by the NEPTS management team will be continually developed through close working with staff groups primarily but also other key players.

The current and future roles have been listed in the table below to identify how it is anticipated the head count (WTE used for ACA) will change over the next three years.

As can be seen from the summary below the actual number of employees on NEPTS is projected to decrease by 5% per annum over three years due to the use of alternative providers. The number of volunteers is also planned to decrease due to retirements and the difficulty in attracting new volunteers.

Reducing sickness rates among our NEPTS teams will also be a priority for us in 2017/18.

Corporate Directorates and Support Services

Through this coming year we will continue with our plans to restructure our Operations Directorate leadership structure, which seeks to strengthen strategic and operational management across all Field Operations and CCC Operations teams through the introduction of a regional based management structure. We also plan to restructure within our 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 Field Operations Area Managers.

The Trust is assuming that any proposed restructuring exercises must be cost neutral. Earlier in this plan we also highlighted the potential resource implications of our mental health improvement plan, which is subject to a bid for external funding support. Later in this section we also describe our plans to review our current Occupational Health provision to ensure a sustainable staffing model for delivery. The WTE implications of any potential development have not been assumed within this workforce plan pending further consideration.

Further benchmarking work will be undertaken through 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.

General Workforce Efficiency and Productivity Opportunities

As we plan and develop our future workforce, we recognise the need to ensure we do not lose focus on opportunities to increase workforce efficiency and productivity. We have described above some of the opportunities identified by the ORH modelling work. Other 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 by a further 2% over the next three years (effectively rolling forward our targets set in 2016/17 – see below)  Improving the working lives of staff by reducing overruns and improving meal break compliance. Providing local solutions to ensure staff are given opportunity to take rest 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 2016/17, we have maximised the short term benefits of holding / delaying filling where we have had 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 2017/18 as they arise

Improving Attendance at Work

WAST considers reducing sickness absence the number one priority and in 2015/16 we developed a comprehensive Sickness Action Plan to deliver a 1% point target reduction in 2016/17, with a further 0.5% reduction in the following 2 years. This stretch target was an ambitious target given the substantial progress made in reducing absence across the Trust in 2015/16, and we have only been able to sustain (but not improve on) this lower level of absence through 2016/17. As a result, we will roll forward our sickness targets into 2017/18 – 2019/20.

Trust Absence Rates at 31/12/16

However, we have not been complacent and continue to robustly manage absence. A holistic approach to our employee health and well-being remains instrumental to delivery against our target reduction and we previously described the importance of this agenda which spans not just physical, and mental wellbeing, but will be extended in 2017/18 to consider aspects of individual financial

wellbeing. There are further details of some of our wider health and well-being planned actions later in this section.

We already have a sickness action plan in place that will once again be refreshed into 2017/18 to take account of learning from our own success and that of other ambulance services. There are several key things that we will maintain a focus on in 2017/18:

 ensuring Return to Work interviews are completed in a timely manner;  ensuring Executive and Board level focus on sickness absence, and robust monitoring and reporting continues;  expanded access to counselling and stress management support to protect staff mental wellbeing;  consistent application of the revised Sickness Policy and Industrial Injury Process;  delivery of refreshed training programme on sickness management skills for managers and supervisors; and improving support and guidance for dealing with musculoskeletal problems and access to ‘fast track’ physiotherapy.  supporting staff on long term sickness to return to work.

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. In order to realise the full benefits of ESR, we encourage all staff and managers to use ESR. We will continue our roll out programme throughout 2017/18, with a particular focus on raising awareness and the use of the business intelligence elements of ESR to enable line managers to access comparative management data and reports from their desktops. This will significantly enhance individuals’ and line managers’ ability to ‘live report’ and provide intelligent data to drive managerial decisions. We have refreshed our project arrangements for the roll out of ESR and associated systems to accelerate implementation. Progressed is monitored by our local WFIS Programme Board.

The first phases of ESR Enhance have been introduced. There are 16 areas for improvement. The first release has seen a new more intuitive and engaging homepage that provides key information for Self-Service users regarding their compliance with mandatory training and appraisals and their absence record. It provides far greater accessibility as it will shortly be available through the internet, on mobile devices and via Apps, giving both online and offline capability. Employees will have full or view-only self-service access which includes access to national e-learning, easy access to their payslips and information on training and professional registration. Future developments will cover payroll admin improvements, data management, expenses management, reporting, workforce data, finance, data validation and medical revalidation.

Our ability to maximise the true benefits of this depends on accessibility for our staff, particularly those based across Wales in the many ambulance stations we have with limited numbers of computers. In section 8.8 we describe some of our ICT priorities over the next three years, which recognise the need to increase accessibility for all staff to mobile electronic devices. Reshaping and Developing the Clinical Workforce – Making the Future Look Different In our previous plan we referenced a number of potential future roles and opportunities that the Trust plans to develop and progress over the next three years. We continue to progress these and

collaborate on expanded roles for paramedics and nurses within our own services and across the wider NHS Wales unscheduled care services, GP Out of Hours services and Primary Care – as described earlier in Section 5 and 6 of this plan.

In Year 1 we said we would

 Collaborate on expanded roles for paramedics across NHS Wales unscheduled care services, GP Out of Hours services and the potential for paramedics to undertake GP home visits and also with education providers  Development of specialist roles  Review the number of APPs in training for future years, scope proposal to develop workforce modelling tool with WEDS to facilitate this action.  Progress proposal for the development of a structured approach for newly qualified APPs to make the transition from novice to expert.  Develop a career pathway and educational framework for frontline staff  This is summary of how we have done

 Advanced Practitioners in Hywel Dda working in GP OOHs  Introduced a pilot for community paramedics in Cwm Taf  Developed a proposal to introduce ‘job plans’ for advanced practitioners to maximise their value and contribution to patient care, particularly among the amber category of patients  Developed a draft job description for an advanced practitioner, with outline scope of a new clinical leader role as the next step in the career pathway for APPs  Held a stakeholder career pathway event attended by frontline staff all over Wales to inform development of the career pathway.

A Career Pathway Stakeholder Event, held in August 2016, provided the opportunity for colleagues across the Trust to play an active part in forming and shaping the way forward in the development of roles and a career pathway for frontline staff. The output is being used to inform the focus for our 2017-20 priorities described within this plan. The workshop shone a light on some key issues and opportunities and we have been working together with clinical, professional, operational and workforce colleagues to address these through several working groups, engaging staff and trade union representatives. The work of these groups will continue into 2017/18 as appropriate:

 The Apprenticeships Working Group Support has been tasked with development of an apprenticeship route for WAST starting in NEPTS with a target date of September 2017.  The NEPTS modernisation project will review the opportunities for step down roles for paramedics within the NEPTS service at the appropriate time.  National Paramedic Banding Negotiating Group is considering the implementation of a Band 6 paramedic role, with increased individual autonomy and practice expectations, and will also seek to address frustrations surrounding the role of the ‘advanced’ EMT and opportunities to refresh this role within the career pathway as a ‘step up’/‘step down’ option for existing EMTs and paramedic staff. We expect this work to be completed by the summer of 2017.  The Work Based Learning and Education Group is reviewing the need for clarity of scope of practice and educational requirements for Band 6 paramedics in the future, for community

paramedics and developing a fresh approach to the training of newly qualified paramedics. We expect this work to be completed by summer 2017.  Addressing inconsistencies regarding the UCS scope of practice and deployment of staff  A new nursing workforce modernisation group will be established in early 2017 under the leadership of the Director of Quality, Safety and Patient Experience to further explore the role of registered nurses in pre hospital care (see and treat, hear and treat).  The role and maximisation of the advanced practitioner role is currently being addressed through a number of workshops with existing advanced practitioners. At present the focus has been on maximising the contribution of existing APPs, but further work is needed to expand this and develop a vision for advanced practice in WAST. This is described in a little more detail below.

A visualisation of the pathway with clear educational requirements will be developed for consultation with staff on completion of the national paramedic banding negotiations.

In addition to developing the career pathway, our workforce modernisation developments and opportunities, described in more detail elsewhere in this plan, have focussed on 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:  Community-based paramedics in rural areas - paramedics will be working with GP clusters in a geographical area in RRVs on behalf of either WAST or GPs directly  Critical care paramedics - paramedics will be responding in RRV and be directly linked to GP practices to undertake home visits in either the out of hours setting or in hours as part of a MDT identified by primary care.  Reviewing the evidence base and potential benefits of the specialist paramedic role within the Trust which will enable the paramedic to deliver a more enhanced level of assessment and care to patients and access more referral pathways.  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  Introduction of rotational posts for nursing staff between ABMU Health Board and the 111 Pathfinder service  Proposal to introduce formal clinical leadership roles (clinical lead / consultant paramedic) into the Trust. This will be an organisational development role in areas of new and innovative clinical practice for paramedics delivering patient care. Working at a strategic level they will be developing new care pathways whilst liaising with central heath policy makers.

Through 2017/18, we will continue to explore and pilot new ways of working and new roles, and also increase focus on improving our frontline clinical workforce skills, confidence and capacity to deliver benefits to patients across the unscheduled care and primary care systems through:

 Using clinical information via the Digipen system to allow clinical team leaders to discuss alternatives to conveyance with colleagues;  Using training and education plans to improve access to educational modules which staff can take using their KSF hours which will increase staff confidence in using alternative pathways;

 Developing a decision making support app which staff can use to support their clinical decision making; and  Ensuring mechanisms are in place so staff feel confident to refer patients to alternative e pathways, and supported when cases go wrong, providing there are good records of decisions made and the rationale behind them.

The Future of Advanced Practice Advanced Practitioners (APs) are experienced professionals with the skills to address complex decision-making processes and manage risk in unpredictable situations. They are able to work in primary, acute, urgent and emergency care and other emerging roles, providing expert care and clinical leadership. They have extensive knowledge of applied pharmacology, evidenced-based practice, public health and health promotion. Accountable for the management of service user care, they have responsibility for quality assurance and are cognisant of the benefits of research in changing practice. They undertake the mentoring and clinical supervision of developing specialist, and advanced paramedics, and other health professionals in their area of expertise. Prescribing for advanced paramedics is predicted to be supported by the Commission for Human Medicine within the next two years, which offers another significant opportunity for this important body of staff to treat and discharge.

We have 26 WTE funded advanced practitioner posts within the establishment (23 Paramedics and x3 dual trained Registered Nurse/Paramedic roles), but we recognise there are insufficient Advanced Practice posts and hours in operational rotas to be reliably deployed to all 999 calls for which they are the ideal response, mainly in the Amber and Green categories where a referral to another pathway following face to face assessment is likely and clinically appropriate. We are developing a plan to strengthen clinical leadership across the Trust, and the advanced practitioners will play a key role in this future vision.

Subject to the necessary funding availability, we propose to appoint an advanced practitioner to a Clinical Lead post in each Health Board area. They will provide advice to operational leads on clinical standards and drive forward the delivery of outstanding pathway development as well as staff utilisation and understanding of these pathways. 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 creation of a working job plan which will be agreed before the end of 2016/17.

There are also opportunities to develop a role for the advanced practitioner within the CCC ensuring that our proposed arrangements for the dynamic management of frequent or complex callers (see section 6) include the availability of advanced clinical advice for crews 24/7 via CCC. 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. Over the second and third years of this plan, as we develop our community paramedic strategy, we will be informed by current trials in Aberdare and the Vale of Glamorgan as to the role of AP staff in the community. We will need to develop a programme to recruit train and supervise AP staff for the future. Currently, this will be developed in discussion with the out of hours and in-hours primary care workforce to ensure the contribution of APP staff is maximised, as described earlier in the plan.

Recognising all that we have outlined in this workforce plan section we have identified three strategic workforce actions which we will take forward over the life time of this plan.

ACTION 25: We will explore how we can benchmark our corporate and support service teams to identify potential opportunities for streamlining, reduced variation and increased efficiencies in future.

ACTION 26: We will plan for implementation of a Band 6 paramedic role within the career pathway, and develop a clear benefits realisation plan linked to the Ambulance Care Pathway and AQIs.

ACTION 27: We will ensure that the roles to support community based models will have the skills and capability to deliver the goals of this initiative.

Recruitment Plan (Resource) Successful and timely resourcing plans are fundamental to our success. We continue to take 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 of the Trust.

In Year 1 we said we would

• Fill all EMS vacancies • Progress the Trust’s corporate recruitment branding and development of new promotional boards and materials.

• 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 • Recruited 121 additional front line staff through 2016/17. Our current vacancy rates run at less than 4% for the EMS workforce

• Refreshed our recruitment re-branding and produced applicant information packs for use at open days

• Created a 'Big Bang' recruitment event for qualified paramedics and successfully recruited 34. The majority of these became operational prior to Christmas 2016. More events are planned for 2017 with a focus on EMTs and increasing our intake from BME communities.

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. This will be our ‘employee value proposition,’ and we will continue to develop this in 2017/18.

As part of our recruitment campaigns, we want to show potential candidates just how much Wales has to offer as a place to train, work and live and the benefits of working with us at WAST. We will ensure we link our work to that being undertaking 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’.

As at 31 Dec 2016 we had 57 WTE (3.73%) EMS vacancies across the Trust as illustrated in the table below:

Recruitment continues to fill vacancies across the Trust. We will, however, hold and review our AP vacant posts in light of developments planned for a new clinical leadership structure.

Recruitment of Qualified Paramedics Our workforce plan illustrates that, over the course of the three years, we have commissioned sufficient student placements to meet demand for paramedic staff within our current staffing model. This does not, however, account for any increase in capacity identified as a result of the ORH, and the actual impact of this on education commissioning numbers is being worked through (at Jan 2017). However, on an annual basis, demand is likely to exceed supply at different points of the year because of natural turnover. This is at least until October each year when we will see the paramedic degree course student outturn. Last year we set ourselves the ambition of getting to a place where we ensure we stay ahead of the recruitment curve, and are able to move to a place where we can confidently make a contingent offer of employment to all HEI students on commencement of their diploma or degree subject to successful completion of their studies and practice placement training.

We were clear that our ability to do this is dependent upon robust workforce planning and a clear understanding of our future capacity and demand. We believe that in 2017/18 we will be much closer to achieving this ambition as a result of the output from the capacity and demand work undertaken by ORH.

We remain fortunate in that we do not experience or foresee any future difficulties in recruiting to our Advanced / Emergency Medical Technician, Urgent Care, Call Taker or NEPTS vacancies. We have targeted recruitment in place for our nursing workforce via the 111 project. Reducing Time to Hire

The ‘Hire to Retire’ Streamlining Programme for NHS Wales: Once for Wales is the methodology that underpins the Streamlining Programme with deliverables focused around

standardisation, automation and portability of data, to maximise efficiencies and enhance the quality of NHS Wales’ workforce information. The Hire to Retire Programme has five strategic objectives, one of which is:

 Reduce recruitment timescales through the full deployment of ESR functionality and related interfaces (e.g. Trac) and well developed processes

In 2016/17 the group continued the work needed to confirm vacancy requirements and successfully developed a recruitment plan aligned to a training plan. The group also facilitated a process mapping workshop to identify opportunities to streamline recruitment processes, organised targeted recruitment training sessions (supported by NWSSP), introduced a recruitment link advisor role into the WOD structure and piloted a new approach to bulk recruitment, a “One Stop Shop” approach for Paramedic, EMT and UCS.

As a result there was a significant improvement on the average time to recruit from 2015 to 2016, and an improving downward trend shown. Comparing performance in January 2015 (169 days), January 2016 (82.8 days) and January 2017 (86.1 days), we can see that we need to re-focus our efforts in this area for 2017/18 to bring about a further reduction in time to hire.

There is more we can do to further reduce time to hire, particularly by reviewing the process map and targeting constraints experienced within our Occupational Health service, and our focus for 2017-20 will be on:

 Building on the success of events such as the Loudoun Square Cardiff Career Event in January 2017 to increase awareness of careers in WAST among the BME community, increasing applications from members of ethnic groups currently under-represented in the workforce  Ensuring timely recruitment and training plans in line with demand and capacity review outcomes and commissioned workforce.  Increasing our presence in schools and at careers fairs, ensuring we are visible and increasing opportunities for work experience (as appropriate).  Implementing efficiency opportunities such as the new electronic starter form from April 2017 and utilising TRAC for volunteer recruitment  Developing a refreshed recruitment and subsequent training plan  Developing of a pool of trained assessors  Further development of our recruitment material for our other roles, including BAME staff members.  Refreshing membership of the Recruitment & Selection Group  Completion of the Welsh Baccalaureate modules development with WJEC.  Supporting military colleagues with the facilitation of operational placements for medical personnel, in line with the recommendations of AACE

Recognising all that we have outlined in this recruitment plan section we have identified one strategic workforce action which we will take forward over the life time of this plan.

ACTION 28: We will ensure a streamlined, timely recruitment processes are in place to meet operational needs; ensure unconscious bias and barriers to entry are removed from our processes to widen the potential

pool of candidates; and ensure a positive experience for all seeking to work at the Welsh Ambulance Service.

Education, Training and Development of Our People (Train)

The Education & Training Team recognises the value and importance of embedding critical thinking and reinforcing Trust behaviours from the outset of every educational journey. As the only team that interacts face-to-face with all operational staff, we have the ability and responsibility to positively influence attitudes and behaviours, acting as ambassadors for the Trust.

2016 has been a 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 have delivered a number of developments and improvements.

In Year 1 we said we would

 Develop a business case for transformation of the NATC  Introduce a bespoke e-learning platform for Driver Education  Compile a CPD directory for all staff groups and a CPD programme that reflects current and future changes to clinical practice, learning and identified development needs  Benchmark skills development for existing, vocationally trained paramedic staff  Work with the Operations Teams to improve CPD and Statutory and Mandatory Training compliance to ensure targets are met.  Launch the new Staff Bursary Scheme

This is a summary of how we have done  Two of our Driving Instructors have completed the FutureQuals Level 4 Diploma in National Principle Assessing, which will help us to develop our own Driving Instructors  Successfully introduced the Trust’s Staff Bursary Scheme, supporting staff in the personal and professional development  Reviewed work based learning models at academic level 6 and 7 to support future development of Community Paramedics, and also a proposal for supporting transition of existing paramedic staff to a Band 6 role.  Front loaded CPD training during Quarters 1 and 2 to increase compliance against targets. 2017 will see a new model of delivery trialled, increasing accessibility through local training.  Creation of a vision for the future of the NATC, subject to engagement exercise  Successful introduction of the FutureQuals Level 4 Diploma for Ambulance Associate Practitioners (EMT level qualification) and the Level 3 Certificate in Emergency Response Ambulance Driving

Vision and Future Capacity

In 2016/17 we set ourselves the challenge of designing a vision for a flag ship NATC of the future, and we are currently developing that vision and sharing it with key stakeholders for their view and support.

This vision includes the establishment of a Hub and Spoke model centred around the development of an Ambulance Academy (replacing the existing NATC), supported by Locality Learning Cells, with agreement for training facilities to be included in all future operational estates developments (see diagram to the left)

The idea of creating Locality Learning Cells for the local delivery of nationally designed CPD programme has been well received so far, and we plan to test some of our assumptions by launching a pilot of this model to commence in April 2017. It is envisaged that local delivery will result in greater rates of attendance and therefore compliance with CPD requirements, with shared ownership . between operational staff, managers and the Education & Training Team.

In last year’s plan we also flagged concerns regarding constraints on capacity within the NATC. There is a regular review of training timetables and constraints to delivery as part of the ongoing workforce planning process. This enables us to ensure capacity to deliver training courses can be matched with demand going forward and there is sufficient flexibility within the resource to accelerate timetables where required in the future. However, our current staffing levels do not benchmark favourably against other ambulance services, and there is a need to review current staffing ratios and potential alternative models to delivery. The output of the ORH Demand & Capacity review and initial considerations also point to potentially significant training and education implications of any increase in WTE that could result from future investment to meet demand etc. We continue to work closely with colleagues in the Medical Directorate and Estates to address capacity constraints and ensure our education, training and development facilities and programmes are fit for future purpose.

CPD / Statutory & Mandatory Training Compliance In response to constructive feedback received from all levels of staff, 2017 will see the review and introduction of an alternative CPD delivery model. In order to embed a culture of mutual accountability and shared ownership, CPD programmes will be designed nationally and delivered locally, utilising our substantive team of educators to operate a Business Partner Model, working collaboratively with Educational Champions, a network of AP educators, LMs and CTLs.

Virtual Learning Environments

In line with the Technology Enabled Learning (TEL) strategy, the Education & Training Team continues to progress proposals 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. A business case for the purchase of tablet devices was approved during 2016/17, with a pilot due to commence in April 2017 which will not only improve the learning experience for students and lead the way in terms of ambulance education nationally, but will also reduce costs associated with the purchase and issue of key reading materials for WAST education programmes and course printing. In order to advance this agenda, we have employed an OLM / ICT / eLearning Lead, whose priorities include development of business intelligence reporting, management of eLearning and ICT training. We also purchased an immersive training environment tent in 2016, and will be rolling the use of this facility out across Wales. Our plan to do so will be enacted by early summer 2017.

Further Improving Ambulance Education and Widening Access The creation of our Strategic Education Steering Group in 2016 has created an opportunity for a more strategic dialogue on future educational requirements across the whole Trust. Building on the success collaboration and partnership between the Trust and Swansea University (SU) there are plans to review and evaluate the existing paramedic education delivery model, with a view to exploring alternative methods of delivery, to enable the provision of quality teaching with an emphasis not only on research but also on the delivery of effective academic and practical training, skills and experience. We are also keen to learn from wider NHS and HEI partners in this respect, and this is supported by membership of strategic forums such as ARCH and the South Wales Trauma Network.

Good progress has been made, and in 2017/18 we aim to introduce a Level 3 Award and Certificate in Non-Emergency Patient Transport Services (NEPTS), providing 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.

Recognising all that we have outlined in this training & education plan section we have identified three strategic workforce action which we will take forward over the life time of this plan.

ACTION 29: We will continue to develop and engage on our vision for a flagship Ambulance Academy and develop a clear business plan for implementation. ACTION 30: We will increase availability of apprenticeships across the Trust, developing a NEPTS apprenticeship in 2017/18, through to qualified paramedic by 2020/21

ACTION 31: We will review existing paramedic education and training to ensure our staff are better equipped to treat the people they see, and in so doing, the wider health community is able to maximise the benefit of an upskilled Band 6 paramedic workforce

Our Organisational Development Plan (Retain)

We continue on our OD journey that started several years ago to transform the Trust. Much of the detail of our OD plan was set out in last year’s 2016/17 plan, including the operating context and our measures of success. In 2016/17 we further developed overarching principles/approaches to ensure consistent messaging across the organisation, developed and set about embedding our Trust behaviours, approved our Treating People Fairly Strategic Equality Plan and focused on developing leadership behaviours to help the transformation.

In Year 1 we said we would

 Use every opportunity to promote understanding and valuing of difference such as highlighting and marketing specific Wales and UK campaigns.  Achieve a PADR target of 85% by 31st March 2017.  Work in partnership with TU colleagues to use the data from the staff survey to help support development of local and organisational action plans.  Review and expand our opportunities to recognise staff through development of our ‘Appreciating our People’ Awards Ceremony  Build links with partners across the public sector with a renewed focus on supporting colleagues to “ask and listen” including refreshing the coaching and mentoring plan  Create and market leadership development opportunities through the development of a prospectus for all staff  Develop planned activities that support individuals and teams to understand the benefits of trusting each other and working together; support individuals to develop their partnership capabilities including skills and approaches through our leadership development plans  Sign the Welsh Government ‘Time to Change Wales’ campaign pledge

This is a summary of how we have done

 Board approval of our Strategic Equality Plan Treating People Fairly and actions to deliver including use of workshops, team developments, approaches embedded with day-to-day activities.  Increased awareness of the importance of good quality regular 2 way feedback  Achieved a 34% participation in the Staff Survey; local plans are being developed with actions being evident in LDPs; corporate analysis and actions are evidenced and contained within the IMTP  Programme of support for teams to improve their effectiveness – focusing on CCC and Quality  Staff Awards Event and Celebration Day took place in November 2016 with great success and excellent feedback which will become a cornerstone of the Trust’s approaches  The Team played a significant role in the development and delivery of a refreshed coaching network for the Welsh Public Services; coaches and mentors identified across the Trust; increased take up of coaching and mentoring  Supported leadership development and learning across the whole the Trust through in-house learning, public services collaboratives and specific activities (e.g. Academi Wales)  We signed the Time To Change Wales Pledge in 2016 and launched our Wellbeing Advocates Network

We will continue to focus on behaviours through: People by supporting individuals and groups/teams to develop; Processes by further developing approaches and systems.

Building on our 2016 Staff Survey results – Engagement, Participation and Leadership

Colleagues feeling supported and owning their actions and behaviours is at the heart of the Trust’s developing culture. Using feedback from our 2016 Staff Survey results will inform the actions we will take to improve our services and continue to make our Trust a great place to work. Overall we are proud of our 2016 Staff Survey results which highlighted some key successes and areas of significant improvement. Our engagement index score has risen significantly. In 2009, it was 37%. In 2013 it was 43% and in December 2016 it was 53%. We believe this has been achieved through the approaches we have put in place to change our culture. We trust the engagement index score as well researched, widely understood key metric which clearly measures the key factors of employee engagement.

WAST Eng Amb WAST 2013 NHS Wales 2016 2016 2016 3:03 3.43 3.65 3.43

Overall the results provide a number of issues for us to collectively consider, such as:

 The engagement index scores for the Trust have increased from 3.03 (2013) to 3.34 (2016) which demonstrates a 10% increase in engagement levels (NHS Wales index increased by 7% for the same period. English Ambulance Services have increased slightly from 3.39 (2015) to 3.43 (2016), which is comparable to the WAST score).  Overall job satisfaction has seen significant improvements since 2013 but conflicting demands, time and resources continue to pose a challenge  All scores about line managers and senior managers have improved since 2013 indicating progress but remain some of the least positive scores in the survey  Scores relating to change have improved since 2013 but dissatisfaction remains relating to management of change  An increasing number of staff can provide services in Welsh but this remains low  Levels of work-related stress have decreased slightly but still remain high, and will continue to be a priority for our work  Our PADR rates in 2009, only 18% of colleagues reported as having received an annual appraisal. In 2013, this figure had risen to 26%. By 2016, this figure had risen again to 57%. This demonstrates an increased desire and willingness to participate in the Trust and take ownership.

Based on the issues identified, we are developing local and Trust wide action plans collaboratively and these will be refined during the spring of 2017 and implemented through the lifecycle of this plan. Specifically, these actions will include:  Maintaining continued visible, vibrant and compassionate leadership at Executive and Senior Management  Delivery of our refreshed Clinical Leadership Development Plan  Delivering Treating People Fairly through the reinvigoration of our LGBT and BME networks, appointment of a Trust TPF (BME) Ambassador and we await the outcome of our application to join the NHS Employers Diversity & Inclusion Partners Programme 2017/18

 Launch of our new bespoke Team Leader programme in April 2017 and planned creation of a senior manager development programme growing leaders who passionately care about our patients, our teams and the services we deliver  Continued development and implementation of the Staff Awards and Recognition programme  A focus on developing support to staff financial wellbeing, a continued focus on Mental Health & Wellbeing and the achievement of the Corporate Health Standard Gold  A focus on action needed to reduce the number of staff who report being bullied, harassed or abused by members of the public and / or their colleagues and,  Implementation of sustainable regular immediate colleague feedback to enhance the PADR experience and improve opportunity for clinical reflection and practice development

Delivery of these actions will be key to achieving some of our Fantastic People and Vibrant Leadership performance ambitions referenced earlier in this plan within section 3.2.

Leadership, Team and Individual Development We will continue to maintain a focus on team development, working with challenging teams and individuals to effect positive change and lay the foundations upon which we will build our team working and succession planning framework. We will also build upon the Trust’s celebration day and evening awards which took place in November 2016 and was a good example of where we are moving towards recognising staff for their efforts in role modelling the behaviours. We are also delighted that our bespoke, accredited team leading programme is now ready to be launched in April 2017 and has been supported to do so financially. We will build on this in 2017/18 to develop leadership opportunities for those in Senior Manager positions such as locality managers, department heads etc. We will continue with our plans to run a programme of workshop events with staff based on our Strategic Equality Plan Treating People Fairly (described in detail in our 2016/17 Plan) and an exploration of behaviours that support difference and challenge biases wherever we can. The promotion of mentoring and coaching opportunities for staff at all levels from within and external partners, and access to tailored learning for individual leaders is key to enabling the style of compassionate leadership we want to see now and in the future.

Clinical Leadership Clinical leadership is at the heart of developing and leading an organisation such as WAST, and strong clinical leadership across the organisation is seen as key to achieving our vision to be a ‘leading ambulance service providing the best possible care through a skilled, professional and healthy workforce.’ Clinical leaders can be found at all levels throughout the organisation and are identifiable through their passion for their role and for patient care. In identifying and developing clinical leaders, we are seeking those clinicians who are involved in providing direct care, but are also motivated to influence others to improve the care they provide to meet the Health and Care Standards and Quality Core Requirements of the Commissioning Framework. They are able to add value through engaging with colleagues and peers to change and improvement by identifying barriers and obstacles that exist within the organisation and individual, and which potentially compromise the delivery of effective patient care.

We have refreshed our Clinical Leadership plan to focus on the following:

 Securing approval for the implementation of a new ‘clinical leadership’ infrastructure with the introduction of clinical leads in each Health Board (discussed earlier)  Development of a clinical leadership skills and competence framework and aligned development opportunities, linked to PADR and the developing career pathway  Create a robust mechanism for provision of clinical supervision for all clinical staff, and for post masters clinical supervision and development of competence for our advanced practitioners  Strengthening clinical governance and accountability arrangements across the organisation

Occupational Health and Well-being Setting the conditions for the health and well-being of our staff will remain a core focus for us in terms of the realisation of our vision of valuing staff.

In Year 1 we said we would

 Develop further the internal Occupational Health and Well-being teams  Reduce sickness absence by 1% across the Trust  Provide in-house immunisation for staff, to include flu  Provide pre-employment screening for volunteers  Transfer LHB held health records to a central point  Improve well-being of staff

This is a summary of how we have done

 Established full staffing level of Occupational Health & Wellbeing Team to ensure we can respond to the needs of the service  Sickness absence management is now managed more consistently and proactively  Developed In-house staff immunisation programmes  Pre-employment screening which also now includes all Community First Responders and volunteers  Occ Health records from LHBs have now been received digitally and (in process) of being uploaded to Cohort System  Developed a Wellbeing Advocates Network and established the Trust Health & Wellbeing Steering Group

It has become apparent that there are significant constraints within our existing Occupational Health Service arrangements, and a full review will be undertaken of the function at the beginning of 2017/18, to assess capacity, demand and opportunities to ensure a more robust, sustainable model of delivery. In the meantime, the OH Service will work closely with the OD Team and Quality and Medical Directorates to ensure a fully comprehensive immunisation programme is in place for staff in 2017/18. This includes the implementation of a robust Flu Immunisation Programme for 2017/18. Despite continuous efforts to dispel myths and to present professional and personally framed arguments for immunisation, the feedback has been that it was obvious from rates of compliance that our clinical staff are still very reluctant to engage. The 2016/17 campaign utilised traditional forms of correspondence including email and letters to staff, and also social media and video messages to widely promote messages reinforcing professional and clinical responsibility to not only protect self, and others. Unlike other Ambulance Services and Trusts / Health Boards, we decided not to incentivise uptake of the flu vaccination by offering gifts or other benefits. Key learning points

from the 2016/17 campaign which will inform the 2017/18 campaign include the need for strengthened line manager levels of ownership, increased clinical leadership and support from advanced practitioners, availability of peer vaccination immunisation fridges at outlying stations and increased numbers of staff trained to administer immunisations locally.

There is also a need to review and plan to improve the Trust’s Statutory Health Surveillance arrangements to ensure our staff receive the best possible support and care both whilst they are in work, and when they are unwell. This work will be scoped and any capacity requirements addressed as part of our review of our Occupational Health Service.

We maintain our commitment to improve on the arrangements already in place to support staff to stay mentally well, focussing on development and implementation of mental health wellbeing pathways for staff. In 2017/18 our focus will be on increasing resilience, self-care, early identification and access to interventions such as Wellbeing Support Services as well as external resources such as elearning modules. We will also be implementing the Trauma Risk Incident Management (TRiM) approach across the Trust from April 2017.

Recognising all that we have outlined in this OD plan section we have identified five strategic workforce actions which we will take forward over the life time of this plan.

ACTION 32: We will continue to promote and embed our organisational behaviours and implement our Treating People Fairly action plan.

ACTION 33: We will develop, embed and operationalise a structure to implement clinical leadership which will support improved clinical effectiveness across the Trust.

ACTION 34: We will continue to increase access to our leadership development opportunities and implement our newly developed, bespoke Team Leader Development Programme in 2017/18, and design a similar opportunity for Senior Managers (including Locality Managers) for implementation from 2018/19.

ACTION 35: We will develop and implement our mental health pathway for staff and increase the resource available to support individuals and promote mental wellbeing.

ACTION 36: We will take the necessary action to stabilise and ensure a resilient and fit for purpose Occupational Health and Wellbeing Service in 2017/18 ensuring equity of access, support and timely advice across Wales; with potential for increased capacity to deliver enhanced services of Health Surveillance to all staff from 2018/19 onwards.

8.2 Our Finances

The past year has seen the implementation of significant service developments that are focused on delivering the best outcomes for patients and improving performance. Some of these 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 extension of the initial pilot of the new clinical response model.

 An external and robust demand and capacity review has undertaken simultaneously to consider the levels and mix of staff required to maximise the benefit of the new model along with the potential change in fleet requirements.

 CCC with the recent approval of funding to support the CAD capital project.

 Delivery of the first phase of the roll out of the 111 service across Swansea, Neath Port Talbot and Bridgend.

 The implementation of the Non-Emergency Patient Transport Service (NEPTS) In addition there are further key service developments planned for implementation over the immediate and medium term that will increase productivity and efficiency and enhance services. 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 will provide 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 mental health funding as our current income base does not include any provision for these developmental posts. 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. 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, such as estates but also the potential to establish joint posts that could provide both financial and service benefits.

The current revenue financial position – 2016/17 The table below presents a summary of the Trust’s financial position for the year to date at 31 December and the forecast year end outturn for 2016/17.

Plan Actual Variance Annual Annual Annual Financial position at 28 February 2017 YTD YTD YTD Plan Forecast Variance £000s £000s £000s £000s £000s £000s INCOME Total Income 158,253 159,037 784 172,827 173,269 442 EXPENDITURE Pay - Sub Total 109,407 109,397 - 10 119,516 119,526 10 Non Pay - sub total 31,066 31,944 878 34,414 34,918 504 Total Expenditure 140,473 141,341 868 153,930 154,444 514 Profit / Loss on asset disposal - 1,396 - 1,478 - 82 - 1,400 - 1,478 - 78 Total Depreciation, Accelerated 19,035 19,035 - 20,144 20,144 - Depreciation & Impairments Total Interest Receivable - 30 - 26 4 - 33 - 27 6 Total Interest Payable 171 172 2 186 186 - Net Surplus / (Deficit) 0 7 7 - 0 - 0

Our plan has included a challenging savings target of £6.2m (4%) for 2016-17. The table below presents a profile of savings delivery and indicates how this is split between recurring and non- recurring savings.

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 by the Cabinet Secretary for Health, Well-being and sport.

 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 2016/17

 We are on track to deliver our savings plans of £6.2m, of which £4.9m relates to recurring schemes.

 We have put in place robust 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 11 was over 99% against the 95% WG target set for non-NHS invoices by number.

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.

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 an increase in 2016/17 and has subsequently provided a further increase for 2017-18 of £240m for core NHS services, of which £20m is specifically targeted toward mental health services.

WHC (2016) 059 Specifically highlighted that the additional investment of £240 million revenue funding is intended to recognise the cost and demand pressures facing the NHS in Wales which were outlined in the 2014 Nuffield Trust report, and more recently in the Health Foundation report – The Path to Sustainability.

The WHC provided details of Health Board allocations and identified how £90m of the additional funding has been allocated “to meet pay awards for NHS employees, the costs to NHS Wales of the UK Government’s Apprenticeship Levy and other inflationary cost pressures”. 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.”

The table below presents our assumptions in relation to how this uplift has been applied in relation to the baseline income that WAST receives from Welsh Health Boards and Trusts. At £3m this is £1m less than had been assumed within our 2016/17 three year plan, and is £1.4m less than our inflationary and unavoidable costs for 2017/18.

Uplift assumptions in line with WHC (2016) 059 Baseline Uplift @ 2 % Income Source £m £m EMS baseline 122.9 2.5 Dereciation element 12.7 0.0 Total EMS 135.6 2.5 Renal Transport 1.1 0.0 NEPTs 18.4 0.4 Income from Health boards & Trusts (including 111) 5.8 0.1 Total income from NHS Wales 160.8 3.0

In addition WAST receives funding from Welsh Government, to support the Hazardous Area Response Team (HART), PIBS and training and also a small level of income from English health organisations and non-health organisations.

We assumed

 A £5m 3.2% uplift in 2016/17 in line with a national increase of £200m to NHS core funding, and for the years 2017/18 and 2018/19 uplifts of £4.0m and £4.5m respectively. Our revised assumption are

 That we will receive as a minimum funding at the same level as has been allocated to Health Boards which has been calculated as £3m across all services funded through (EMS, NEPTS etc.).

 This increase is purely to meet inflationary pressures and additional funding will be required to support the costs of demand pressures and it is expected that this will include ambulance services.

 £1m short of the expectation presented within our 2016/17 financial plan.

 Inflation and unavoidable costs

The table below presents the updated costs that have been calculated demonstrating how inflation is likely to impact on the current cost base and which have been provided by WAST as part of national modelling work. 2017/18 2018/19 2019/20 Inflationary pressures £m £m £m Pay award and increments 2.504 2.748 2.615 Pension admin charges & discount rate change 0.084 0.000 1.399 Non-pay inflation & Statutory costs 1.213 1.200 1.200 Apprenticeship levy 0.530 0 0 Total 4.331 3.948 5.214

The net financial impact of changes to inflationary uplifts and unavoidable costs (including apprenticeship levy) are summarised in the table below which also demonstrates how our revised assumptions compare to the 2016/17 financial plan.

Summary of Financial Implications 2016/17 2017/18 2018/19 2019/20 within 2016/17 plan £m £m £m £m Assumed additional funding 5.00 4.00 4.25 Less:- Inflation and unavoidable costs (including 5.51 4.35 4.25 apprenticeship levy) Assumed Financial Impact Shortfall Shortfall Balance £0.51m £0.35m

This compares to:- Summary of Revised Financial 2016/17 2017/18 2018/19 2019/20 Implications £m £m £m £m Assumed additional funding 3.0 3.1 4.5* Less:- Inflation and unavoidable costs (including apprenticeship levy) 4.3 3.9 5.2 Revised Financial Impact Shortfall Shortfall Shortfall £1.3m £0.8m £0.7m

Difference / change to plan £0.95m £0.8m £0.7m

*It is assumed that the significant additional pensions cost in 2019/20 will be funded.

We assumed

 Inflationary pressures of £4.4m for 2017/18.

 A shortfall of £0.35m between additional funding and costs of inflation for 2017/18 Our revised assumptions are

 Our expected costs are in line with our plan at £4.3m.

 However when compared to our revised funding uplift this shortfall is now £1.3m for 2017/18.

2017/18 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 2017/18, and future years.

100

o That baseline income for 2017-18 will remain constant in real terms with the £135.6m 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 (2016) 059.

In previous years the full impact of the inflationary uplift has been routed through WHSSC which would increase the baseline to £138.6m for 2017/18 (which increases to a total of £139.7m 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.

 Continuation of additional hear and treat resources for which non-recurring winter pressures funding of £0.186m was provided by Welsh Government in 2016-17 to cover the winter months. This is due to cease on 31st March 2017.  Band 6 paramedics. Our financial plans have excluded the financial impact of re- banding paramedics from band 5 to band 6. Balanced against this cost will be potential for system wide opportunities of improved patient outcomes, improved value for money for NHS Wales and improved patient experience  Community Paramedics. The full potential for the community paramedic role is being explored in a number of pilots across Wales including Cwm Taf where the project has been awarded Bevan Exemplar status. 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 primary care streams, can be secured  Demand and Capacity Review. As detailed elsewhere within this IMTP, the Trust has complete a comprehensive demand and capacity analysis. The key messages emerging from this work include:

o A forecast increase in demand of over 20% by 2020/21 o That additional capacity and investment will be require to meet this demand, and to maintain our performance. o That this capacity could be provided through a range of solutions and that the forecast increases in demand will require a broader system response.

Whilst at an early stage of understanding the full implications, it is likely that there will be financial costs both in terms of revenue to support additional staff capacity and transport costs and also capital for fleet and infrastructure. These will need to be built into our financial plan and will form a key part of commissioning discussions and will need to reflect a system wide approach.

 Local schemes to provide additional capacity. 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. In total these sum around £3m (excluding 111) and it is assumed that an uplift of 2% will be applied to these in line with WHC (2016) 059. For those schemes where funding has been provided on a short term basis it is assumed that activity and costs are similarly non-recurring.

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 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 to offset any additional costs.

 Renal Transport funded through WHSSC

It is assumed that income for renal services will remain, as a minimum, constant in real terms with 2016/17 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.

Our plan has assumed that the baseline NEPTS income for 2017-18 will remain constant in real terms with 2016/17 values and that this will be uplifted for inflationary costs by a minimum of 2%, in accordance with WHC (2016) 059.

We will work closely with our commissioners to develop the framework for NEPTS with an expectation that any changes to future service delivery / contracts with 3rd parties will be supported by additional and full funding.

We said we would

 Implement the NEPTS business case We assumed

 That funding would remain in real terms constant with 2015/16 levels

 That the costs of service improvement would be met through efficiencies. Our revised assumptions are

 That funding will remain, as a minimum constant, in real terms, at 2016/17 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

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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.

2018/19 and 2019/20

 Funding uplifts Whilst the Welsh Government draft budget provides only for 2017/18, 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 £3.1m and £4.5m respectively.  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 Further developments in CCCs, on top of 111. This includes the further investment in staff and the clinical desk resource to increase Hear and Treat rates in line with other ambulance services across the UK. The implementation of a new CAD system will also see operational efficiencies within CCCs, as will the further review of the configuration of CCCs as part of the wider estates review and rationalisation. This may see the number of dispatch desks required reduce due to greater automation, especially during the night, alongside reviewing shift patterns;

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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 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 2016/17 to 2019/20 which has been revised to reflect our updated planning assumptions.

2016-17 2017-18 2018-19 2019-20 Summary of assumed financial changes R NR Total R NR Total R NR Total R NR Total £m £m £m £m £m £m £m £m £m £m £m £m

Brought forward recurring deficit/-surplus 0.00 0.00 0.0 0.0 0.0 0.0 0.0 0.0 Income changes Share of £200m -5.0 -5.0 0.0 0.0 0.0 Future years inflation 0.0 -3.0 -3.0 -3.1 -3.1 -4.5 -4.5 Additional Funding 2015-16 3.5 3.5 0.0 0.0 0.0 Variable element of EASC 1.2 1.2 0.0 0.0 0.0

Assumed funding for continuuation of capacity -2.0 -2.0 0.0 0.0 0.0 Assumed increase in funding for 111 (via ABUHB) -1.8 -1.8 -1.5 -1.5 -3.2 -3.2 0.0 0.0 Total income changes -4.1 0.0 -4.1 -4.5 0.0 -4.5 -6.3 0.0 -6.3 -4.5 0.0 -4.5 Expenditure changes Unavoidable costs - Inflation, pension, statutory compliance etc 5.5 5.5 3.8 3.8 3.9 3.9 5.2 5.2 Apprenticeship levy 0.0 0.5 0.5 0.0 0.0 0.0 0.0 Continued capacity 2.0 2.0 0.0 0.0 0.0 0.0 0.0 0.0 Reduction of non recurring costs -1.5 -1.5 0.0 0.0 0.0 0.0 0.0 0.0 Non-recurring savings delivery / gains 2.5 2.5 1.4 1.4 0.2 0.2 0.0 0.0 Underlying cost pressures 2.2 2.2 0.0 0.0 0.0 0.0 Assumed increased 111 costs 1.8 1.8 1.5 1.5 3.2 3.2 0.0 0.0 Total expenditure changes 10.3 0.0 10.3 9.4 0.0 9.4 7.3 0.0 7.3 5.2 0.0 5.2

Sub total deficit / -surplus (inc bfwd) 6.2 0.0 6.2 4.9 0.0 4.9 1.0 0.0 1.0 0.8 0.0 0.8 Efficiencies / service re-design / gains Planned accountancy gains (profit on disposal) -1.0 -1.0 Potential savings -4.9 -4.9 -4.7 -4.7 -1.0 -1.0 -0.8 -0.8 Non recurring savings -0.4 -0.4 -0.2 0.0 -0.2 0.0 0.0 0.0 0.0 0.0

Total efficiencies / service re-design / gain -4.9 -1.4 -6.2 -4.9 0.0 -4.9 -1.0 0.0 -1.0 -0.8 0.0 -0.8

Total deficit / -surplus 0.0 0.0 0.0 0.0

Recurring deficit/-surplus carried forward 0.0 0.0 0.0 0.0

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Savings and efficiency During 2016/17 we put in place a significant and challenging programme of savings totalling £6.2m (4%). This built on savings of £4.5m which formed part of the 2015/16 financial plan. As at 28th February a total of over £5.8m of savings had been achieved. Progress against specific schemes is presented within the graph below.

What this indicates is that whilst many schemes are on track for full delivery or have over achieved (e.g. disposal of assets) others have either produced a lower or slower profile of saving. 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 £6.2m of savings in 2016-17. This is summary of how we have done

 We have already delivered £5.8m 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 £4.9m for 2017/18 is achievable.

Savings requirement for 2017/18

The revised table of assumed financial changes above indicates that a further £3.2m of savings and cost containment measures will be required to achieve financial balance in 2017/18. This is in addition to the planned savings for 2017/18 contained within our 2016/17 financial plan bringing the total savings target for 2017/18 to £4.9m (3.3%). Savings Plans Our savings plans have remained consistent recognising the need to deliver recurrent and sustainable cost reductions. For 2017/18 our plans total £4.9m and include:  Further reductions in variable pay and external providers. 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. In addition we have dramatically reduced our reliance on external providers. Our plan commits to reduce costs in 2017/18 by a further £1.7m.

 In addition we will contain current cost pressures within NEPTS which it is planned will reduce costs by £0.2m

 Management of (non-operational) vacancies is expected to save a further £0.2m in 2017/18, in addition through reviewing our skill mix and managing the implementation of structure changes we will reduce costs by a further £0.4m.

 Estates and utilities, including energy - savings of at least £0.2m will be achieved through improved energy efficiency and rationalising estates costs in line with our estates strategy.

 Potential to maximise income generation will generate £0.28m from English NHS trusts and non-NHS sources.

 Maximising Fleet efficiencies – Predominately through 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. This will deliver £0.35m of savings.

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 Corporate savings including examining the potential to maximise the use of technology to reduce costs such as:-

a. Reviewing and minimising travel costs – will save £0.25m through:-  Extending 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.  Increasing the use of video / teleconferencing to reduce levels of travel across Wales.

b. Efficiencies to contain ICT and telephony costs will save £0.17m

 Consumables, Drugs and Medical Gases – through a combination of Trust wide and local schemes we will reduce non-pay costs by £0.8m. Our continued drive towards cost effective procurement, and working to maximise this with colleagues in NWSSP, will result in additional savings being delivered in 2017/18.

 Other local schemes will deliver £0.35m of savings and efficiencies.

The graph below presents the cumulative levels of savings planned between 2015/16 and 2017/18. As well as indicating the total savings it demonstrates a reducing reliance on non-recurring savings.

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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, for example the recent co-location of ambulance, fire and police in Abertillery. 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. The independent demand and capacity review has helped to quantify, and validate, expected levels of additional demand with rises of 20% forecast by 2020. This highlighted 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 (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. 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 across all areas of care (primary, community and secondary). 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. 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

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 Working with other ambulance services to identify opportunities and to promote comparison.

More broadly, the efficiency framework will 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.

NHS WALES - Value & Efficiency Framework

Efficiency Plan Analysis 2017/18 Total Workforce Value, Pathways, Models, Referrals and Service Improved Workforce Efficiency & Treatment Reconfiguration, Controls & Cost Total Management, Productivity Thresholds, Premises Reduction Recruitment & Clinical Decision Rationalisation Retention Making £'000 £'000 £'000 £'000 £'000 £'000

Planned Care 0 0 0 0 0 0 Unscheduled Care, Frailty, Long Term Care 1512 1540 275 0 0 3327 Primary and Community 0 0 0 0 0 0 Mental Health 0 0 0 0 0 0 Clinical Support 0 0 0 0 0 0 Non-Clinical Support 973 600 0 0 0 1573 Commissioning 0 0 0 0 0 0 Across Service Areas 0 0 0 0 0 0

Total 2485 2140 275 0 0 4900

Cash Releasing Workforce Value, Pathways, Models, Referrals and Service Improved Workforce Efficiency & Treatment Reconfiguration, Controls & Cost Total Management, Productivity Thresholds, Premises Reduction Recruitment & Clinical Decision Rationalisation Retention Making £'000 £'000 £'000 £'000 £'000 £'000

Planned Care 0 0 0 0 0 0 Unscheduled Care, Frailty, Long Term Care 1112 1390 275 0 0 2777 Primary and Community 0 0 0 0 0 0 Mental Health 0 0 0 0 0 0 Clinical Support 0 0 0 0 0 0 Non-Clinical Support 773 600 0 0 0 1373 Commissioning 0 0 0 0 0 0 Across Service Areas 0 0 0 0 0 0

Total 1885 1990 275 0 0 4150

Cost Avoidance / Opportunity Costs Workforce Value, Pathways, Models, Referrals and Service Improved Workforce Efficiency & Treatment Reconfiguration, Controls & Cost Total Management, Productivity Thresholds, Premises Reduction Recruitment & Clinical Decision Rationaisation Retention Making £'000 £'000 £'000 £'000 £'000 £'000

Planned Care 0 0 0 0 0 0 Unscheduled Care, Frailty, Long Term Care 400 150 0 0 0 550 Primary and Community 0 0 0 0 0 0 Mental Health 0 0 0 0 0 0 Clinical Support 0 0 0 0 0 0 Non-Clinical Support 200 0 0 0 0 200 Commissioning 0 0 0 0 0 0 Across Service Areas 0 0 0 0 0 0

Total 600 150 0 0 0 750

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We assumed

 A requirement of £1.7m of recurring savings would be required in 2017-18. Our revised assumptions are

 That our savings target will increase by £3.2m to £4.9m which reflects: o £1m shortfall between inflationary costs and assumed income to meet these. o Current cost pressures of £2.2m in total

 We have in place plans to meet our target. These plans include measures to reduce our costs through o Further efficiencies including variable pay costs. o Efficiencies presented within the Demand and Capacity review (e.g. skill mix) o Estates and utilities, including energy savings and “green” schemes o Maximising fleet efficiencies o Consumables and drugs o Corporate savings including examining the potential to maximise the use of technology to reduce costs.

In addition we have committed to work across (and in some cases beyond) NHS Wales at a national level to establish system wide efficiency, value and sustainability.

Benchmarking In developing the financial plan for 2017/18 to 2019/20 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 2016/17 we have worked 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.

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 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 year we have reduced the costs of overtime and external providers by over £3m. This is demonstrated in the graph below. This was a key element of the financial (savings) plan for 2016/17 with a further reduction of £1.7m planned for 2017/18.

We assumed

 Increases to our workforce by around 80 whole time equivalents by 31st March 2017.  That the majority of these increases would be operational staff.  That we would reduce our reliance on overtime and external providers.  That our sickness levels would continue to reduce from 2015/16 and 2016/17 levels.

This is summary of how we have done

 We have increased our establishment to operational posts.  Our year to date costs of overtime and private providers have reduced by £3m when compared to the same period in 2015-16  Our sickness levels have reduced to 6.76% as compared to 8.24% in 2014-15.

Our revised assumption are

 To be updated in line with the workforce profiles

At this stage 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. The plan will be revised to reflect the impacts of further developments and service changes as they are agreed and implemented.

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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 and non-pay inflation;  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;  Outcomes of Demand and Capacity work;  Delivery of cash releasing savings and efficiencies. 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 2016/17 the Trust’s Capital Expenditure Limit (at 28th February) is £19.257m.

There are two elements to our capital plans:

1. Discretionary Capital

2016/17 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 2016/17, with a further £1.9m allocated on the approval of the IMTP. This together with a non-recurrent investment of £1.3m to provide defibrillators for Rapid Response Vehicles has meant a total discretionary capital allocation of £7.1m has been received in 2016/17.

2017/18 Funding for 2017/18 has recently been confirmed to include recurrently 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 2017/18 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 2017/18

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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 £12.728 in accordance with the allocation value presented within WHC (2016) 059. 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.

8.3 Our Estate

We provide high quality pre-hospital emergency care and treatment throughout Wales. The organisation aims to be a leading ambulance service and therefore requires an estates infrastructure that is not only fit for purpose but supports 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 actions:

 Provision of modern facilities;  Improved working environment bolstering staff morale and productivity;  Provide the right type of premises in the right location to allow for the effective and efficient control, management and deployment of resources;  Improved infection control outcomes;  Provide value for money for the public purse with a rationalisation of overall estate, redevelopment of existing freehold assets and partnership working wherever possible;  Sustainability of our building stock

In addition to the overview of what we committed to achieve in year 1 of our original plan we have also made progress with the following estates schemes:

In Year 1 we said we would

 Commence the process of establishing the organisation’s next ARC in Cardiff.  Review and update the Trust’s National Estate Strategy 2011 to include all Trust estate.  Review WAST / Mid & West Wales Fire and Rescue Service (MWFRS) vehicle maintenance pilot.

This is summary of how we have done

 The establishment of an ARC facility in Cardiff to replace the dilapidated Blackweir station and the amalgamation of the leased facility off Rover Way has progressed albeit to discount the preferred option on Wedal Road. Further assessments of new sites have not yet resulted in identification of a suitable site. The original accommodation brief has been updated whereby NEPTS do not require accommodation.

 An updated SOP is going to Trust Board on March 2017

 A partnership arrangement with MWFRS to service NEPTS vehicles at their Earlswood facility in Briton Ferry is progressing with changes to their accommodation to accommodate the increased workload. This piece of work is being led by the Deputy Director of NEPTS

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Relocate the organisation’s northern administrative centre from its current site at St Asaph to another site in North Wales. An options appraisal process has been completed leading to a preferred option of sharing administrative facilities with North Wales Police Service. Unfortunately due to changes of circumstance with the NWP this was not achievable. However, an opportunity has arisen to procure an office unit on the St Asaph Business Park; this is in an ideal location and is sufficiently large to accommodate the needs of the service. This option will be progressed at pace during the early part of 2017/18. 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 Shared Services colleagues to evaluate options within the Swansea area. This will be progressed during 2017/18. 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 / maintenance work undertaken over previous years. At present, the backlog maintenance liability is in the region of £15 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 required. 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. In 2016/17 the new Ambulance and Fire Service Resource Centre (AFSRC) in Wrexham and the Make Ready Depot in Flintshire became operational. The approach is being successfully operated in these two areas. However, it is recognised that there has not been significant progress elsewhere and a refreshed approach to the National Estates Strategy is in development. Indeed there is an Estates Strategic Outline Programme (SOP) close to being finalised which will be submitted to the WG Capital team next month. The SOP provides detail on the proposed configuration of estate over a 10 year period. 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

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time saving both at the start and end of shifts would 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 Develop the non-operational estate to include is also 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 significantly rationalised, reducing future costs and management effort, improving environmental sustainability and health, whilst increasing the ability to provide an improved service. This will form the proposal in the Estates SOP as described above. Estates Priorities for 2017/18 Aside from 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. This will include enhancing the maintenance programmes of work at Tredegar Ambulance Station and the Vale of Glamorgan to include the ‘Make-Ready’ function, thus improving our operational productivity and infection control processes. The Clinical Contact Centre at Vantage Point House, Cwmbran requires an upgrade to its infrastructure, along with significant essential work to relocate to the fire station in Llandrindod Wells (shared site with Mid & West Fire and Rescue Service and Dyfed Powys Police), works to introduce a retrofit MRD at Pembroke Dock and the relocation of the ambulance station from Newquay to Aberaeron where we will share the site with the local health board. The estates function has also attained ISO 14001 accreditation for environmental management, although this is an ongoing process and is reviewed annually. At present the south east region is being assessed for the processes in managing waste, energy usage and also the sustainability of the estate as a whole. 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. ACTION 37: We will significantly progress the move away from HM Stanley into a suitable premises in an appropriate location ACTION 38: We will submit a Trust Board approved Estates SOP to Welsh Government and assuming approval in full or part will progress

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the development of areas in greatest need of attention. This will start with the Cardiff ARC.

8.4 Our Discretionary Capital

In 2016/17 the Trust had a Capital Expenditure Limit, including discretionary finding, of £19.3m. This has been utilised within the Trust on replacement vehicles (£11m), ICT infrastructure (£2.5m), estate maintenance and enhancement (£2.5m) and clinical equipment (£2m). This has enabled substantial improvements in all areas of operations from clinical safety with the procurement of Corpuls Defibrillators for the entire RRV fleet to improved ICT resilience with the purchase of replacement servers. The most significant capital development in 2016/17 was the submission and approval of the CAD business case. This, once implemented in the autumn of 2017 (current estimate of time frame barring unforeseen incidents) 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 has been included within the business case and will be monitored within the Trust along with a Gateway 5 Review at an appropriate time in the future. Priorities for 2017/18 and beyond

Full and successful implementation of the new CAD will be a major priority for 2017/18. The Trust has been allocated a recurrent discretionary capital budget of £5.8m. Whilst the prioritisation process for internal allocation of funding has yet to be concluded there are schemes clearly described within this refreshed IMTP that have been agreed and will form a pre-commitment, for example the extension of the mobile devices as described within the ICT section. The move away from the HM Stanley building in St Asaph, North Wales will be prioritised during the first quarter of 2017/18 as this is no longer fit for purpose and does not represent an acceptable working environment for many of our staff. During 2016/17 there has been a relatively small investment in electric vehicles for use by the Non- Emergency Patient Transport (NEPTS) teams in both the city centres of Cardiff and Swansea. There will be a full assessment of the economic and sustainability effectiveness of this with a view to additional investment going forward. The details of the capital programme for 2017/18 are currently under discussion with officials within Welsh Government. 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.  CCC configuration to support service developments  Blackweir ARC together with Bangor ARC and Newport MRD  ICT infrastructure development and individual staff devices  Replacement of operational system including the Control and Dispatch and 111  Community First Responders  ESMCP & ARP

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 Estates review  Phase 2 Digi-Pens leading to ePCR

Years two and three of this capital plan will continue to focus on enhancing the clinical equipment available for use with our patients across Wales, along with the implementation of the significant estates programme as detailed above.

ACTION 39: We will deliver an OBC for the Cardiff ARC (subject to suitable site identification)

ACTION 40: We will deliver against our significant discretionary capital commitments

8.5 Our Fleet

We operate 736 vehicles; the majority of those vehicles being Emergency Medical Service Ambulances (EMS), Rapid Response Vehicles (RRV), Non-Emergency Patient Transport (NEPTS), and Hazardous Area Response Team (HART). The remainder are specialist and auxiliary type vehicles.

In Year 1 we said we would

 Implement a Virtual Fleet and Logistics Help Desk in CCC  Install and fully utilise a new computerised Fleet Management System  Develop a vehicle movement solution  Roll out vehicle telematics throughout the fleet

This is a summary of how we have done

 The Fleet and Logistics Help desk is dependent on the new CAD Project and is now planned to be completed in 2017/18  The new computerised Fleet Management System has been installed and is on target to go live in March 2017  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.

Similar to our estates, our fleet will also be impacted by the demand and capacity review as we look to it to help us determine our optimum fleet profile to meet our demand. We currently dispatch the ‘IDEAL’ response to 999 calls around 80% of the time. We will need to re- profile our fleet to ensure the ideal response ratio increases. Although still under consideration, it is likely that we will require more ambulances and fewer RRVs in the future.

Clearly, therefore, as the outcome of the demand and capacity review becomes clearer and agreed with our stakeholders and commissioners it will inform the strategic direction of our fleet. This tool will allow us to develop our fleet strategic outline case for Welsh Government.

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With such a critical enabler as our fleet we must not stand still in the interim. Therefore we will:

Progress a New Ambulance Workshop in Cardiff

The current workshop facility in Blackweir, Cardiff in in a poor state of repair and although well equipped, is not a fit for purpose environment for maintaining our fleet. We are currently exploring options for collaboration with local authority colleagues to co-locate our Cardiff workshop in a new Cardiff Council facility.

Mid and West Fire and Rescue Services (MWFRS) Vehicle Servicing Trial.

We do not have any in-house workshops or support staff operating in the Central and West area and all the vehicle maintenance and repairs are currently carried out be third party suppliers.

To respond to the risks presented by this we are working in partnership with MWFRS to scope out the option of the fire and rescue service taking on and carrying out the maintenance and repair for a large number of our NEPTS vehicles in the Hywel Dda area.

We have proposed a one year pilot followed by full evaluation. The finer points of the arrangement are being finalised and the infrastructure is being constructed to support the project.

We hope that this new service will provide both an improved level of service at a lower cost.

We will also work with Carmarthenshire County Council to scope out the opportunity to collaborate in a new vehicle maintenance facility planned for the Crosshands area.

Strategic Outline Plan (SOP)

An updated Strategic Outline Plan for fleet will be finalised and agreed in the early part of year one of this plan. ACTION 41: We will produce a Board approved fleet strategic outline plan.

8.6 Research & Development

In Year 1 we said we would

 Delivery of RAPID / TIER / PARAMEDIC-2 / RIGHT-2 trials  Develop a work plan to support the R&I Strategy  Develop Intellectual Property Rights and Revenue Sharing Agreements

This is a summary of how we have done

 Successfully obtained support and funding for the four clinical trials identified in the IMTP which are underway. In addition to this the Research Department has secured a further nine trials.  Developed and implemented a Trust Board approved Intellectual Property Rights Policy

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We are proud of the research that we conduct, and recognise the pivotal role that research and innovation (R&I) has to play in the organisation. The R&I functions for the Trust are delivered by the Pre-Hospital Emergency Research Unit (PERU), which is part of the Health and Care Research Wales arm of Welsh Government. The Trust is widely recognised as having a strong research focus and as an attractive place to undertake pre-hospital research because of our exemplary track record in delivering on trials.

In order to deliver the 2015-2019 R&D Strategy, the first stage of our work plan was to administer a research capacity assessment tool. Through the National Ambulance Research Steering Group (NARSG) the Trust influenced the administering of a research capacity building audit in UK Ambulance Trusts. This audit provided the information needed to ensure resilience and capacity to continue to attract and deliver high quality research and innovation. The audit covered areas of finance, governance, collaboration, policy, education and skills development.

Financing the development and delivery of high quality research and innovation is increasingly competitive, and in order to be successful we recognised the need to work collaboratively with local, national and international research partners. The Trust was a successful co-applicant on the Primary and Emergency Care Research Centre ‘Prime Centre Wales’. PERU attracts external funding from HCRW to deliver an R&D office function and to develop high quality research. Along with this we have successfully collaborated on funding applications totalling £5,010,637 of which £1,220,637 has been attracted into the Trust. The management of this finance requires robust governance and reporting mechanisms, along with strategic re-investment of resources. In a recent performance review, the Trust was applauded for its ‘exemplary’ use of the AcoRD framework for attracting funding to support research. Working closely with HCRW the Trust has influenced the development of a Finance Policy and framework for Health Boards in Wales, which is to be adopted in 2017.

In order to create an inclusive and sustainable R&D future, our R&D Strategy and the research capacity building audit revealed a need to support the development of a wide range of staff including clinicians, leaders and support staff in being active partners in developing and delivering research and development. It was also important for research to be integrated into daily practice and activities. We have made progress in the following areas:  We aimed to develop the number of principal and chief investigators within the Trust and PERU. We now have two Chief Investigators (CIs) leading collaborative studies. We are also expanding our number of Principal Investigators (PIs) to include areas such as the Clinical Contact Centre, Workforce and Organisational Development.  We recognised that research and innovation is an integral component in clinical leadership and we continue to support and influence this in roles, job plans and annual appraisals of staff including: Advanced Practitioners, Clinical Team Leaders, nursing and medical Staff,  We sought to support the development of critical appraisal skills, supporting education and increased knowledge mobilisation. Staff within the Trust have now been trained to deliver research in all areas of Wales, with some staff contributing to Research Trial Management Groups. Staff are also are encouraged to undertake the Good Clinical Practice course (GCP), face-to-face or online.  Working collaboratively with Learning and Development, PERU has made available an individual portfolio for all Trust staff.  We have provided learning opportunities in the form of CPD events and research grant writing courses with the Research Design and Conduct Service, and attracted and advertised funded MSc programmes in areas such as Informatics and Research based PhD opportunities.

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In order to attract and deliver these studies, we have drawn extensively on the Health & Care Research (HCRW) infrastructure such as the Heads of Workforces, Specialty Research Leads and the HCRW support centre around contract review, R&D finance and research delivery.

We have drawn on our collaboration with the Primary and Emergency Research Centre PRIME Centre Wales to build capacity and attract research funding. This collaboration has been vital to building research capacity, and has resulted in successfully attracting Research for Patient and Public Benefit (RfPPB) funding for two feasibility trials identified in the IMTP which are now underway, and success again in the 2016 RfPPB call. This is the first time for the Trust to be a ‘sponsor’ on research, and is allowing us to develop research to answer questions important to the Trust and the people of Wales, along with developing Chief Investigators to lead future research.

In addition to this we have secured a further nine research studies, many of which are registered in the HCRW portfolio. Further trials that the R&I Department is taking forward include:

 PASTA Trial  Out of Hospital Cardiac Arrest Trial  Ethnographic study of emotion work  Public and clinicians views of Prudent Healthcare  Ethnography of 'Primary Care Sensitive' Ambulance Contacts".  Prevalence and Trends in UK Ambulance Service Staff Suicides  Emotional Impact of Telephone-Assisted CPR on EMS Call-Takers  Electronic Records in Ambulances  EDARA

We recognise that research findings need to be translated into better care for patients, and in our strategy we set out how we were going to achieve such mobilisation of knowledge. Our Research & Innovation annual report captures a wide range of dissemination activities we have engaged in, which include a large number of publications in a range of high impact journals, and presenting in national and international conferences and events. We were proud to contribute to the National Institute for Health Research (NIHR) Dissemination Centre's first themed review of research in ambulance services. This themed review brought together the last twenty years of research and will be an influential document and essential reading for everyone involved in the planning and delivery of ambulance services. We have worked with leaders and policy makers in pre-hospital and emergency care to support the synthesis of the best available evidence into practice. This approach has been employed in many areas within research and innovation and PERU continues to offer advice and support to a range of groups including the Clinical Pathway Advisory Group (CPAG), Clinical Equipment Group, and the Quality Steering Group (QSG).

We recognise that research is not mutually exclusive from continuous improvement / innovation and that these functions support the Trust to develop an integrated approach towards innovative and sustainable change. We work collaboratively within the Trust on many of the forums to embed research and innovation

We are working to attract commercial research in the Trust through our links in HCRW, along with industry. We are also contributing to the development of effective new technologies and innovations, whilst disinvesting those which are proven to be ineffective. Our board membership and contribution to the newly formed Health Technology Wales is an example of our commitment to such activities, along with our work with our other innovation partners which include:

 South East Wales Academic Health Sciences Partnership Executive Board Membership  A Regional Collaboration for Health (ARCH)

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 The Bevan Commission  The Life Sciences Hub Cardiff Bay

Our Clinical Response Model (CRM) is of international significance, and considered by many to be the most important innovation in ambulance terms of our generation. The Wales CRM changes the emphasis of Ambulance Service performance to a clinical focus, rather than the time based measures which were first initiated in 1974. Following the initial one-year pilot the Wales CRM has now been given Cabinet Secretary approval and Scotland and England are now following a similar path.

Our emerging strategic direction underpins our intention have established ourselves as a provider of high quality teaching, research and innovation. We will continue to strengthen our strategic partnerships with academic and teaching institutions and become a Trust with university status.

Further details on a number of the studies which we are currently involved in can be found in Annex 10. 8.7 Improvement & Innovation

Significant innovation is already embedded throughout the organisation through its systems, structures, the nature of the business, and its need to develop strategic partnerships to deliver future sustainable services with partner Health Boards.

Innovation is something that happens across the Trust, rather than being a functional responsibility of a particular directorate or team. The Trust uses a range of techniques for innovation. These are set out in the table below, which provides a short commentary on each technique and where you can find out further information in the IMTP. Innovation & Continuous Improvement Techniques Used by WAST

Technique Summary IMTP Reference

ISO ISO is an independent non-governmental international Estates organisation with membership from 163 national standards Priorities for

bodies. ISO 14001 is a set of standards on environmental 2017/18 management systems and WAST is the only UK ambulance

service to hold this standard.

Systems Systems thinking is a management discipline that concerns an NEPTS Four Thinking understanding of a system by examining the linkages and Step Model interactions between the components that comprise the entirety

of that defined system, for example, the unscheduled care system.

Research Our Research and Innovation Team at the Pre-hospital Research & Emergency Research Unit in Cardiff is responsible for all of the Development research undertaken in WAST and for guiding researchers through the R&I process, ensuring their compliance with the Research Governance Framework for Health & Social Care in Wales and the Trust’s R&D Strategy. The team is part of the Health & Research arm of Welsh Government. The team is committed to promoting a culture that encourages research in order for the Trust to provide high quality evidence-based services for patients in the pre-hospital environment. The team

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is supporting a number of research trial projects during the lifespan of this programme.

CAREMORE CAREMORE is an innovative collaborative commissioning Service method and a registered trademark of Cwm Taf LHB. It has Initiatives

been used to develop the Commissioning: Quality & Delivery

Framework (CQDF) for emergency ambulance services and also for NEPTS. There is a strong link between CAREMORE and systems thinking.

Process Business process mapping is the visual display of the steps Step 2 Answer Mapping involved in a business process from start to finish which helps My Call identify how these processes can be improved. Process

mapping is being used to define the complex EMS Call cycle process - from BT connect to allocation of resource – as part of the CCC modernisation programme. Staff are currently being asked to validate the map at each CCC site to identify a true current state map. It will also be used to support some technical discussions with the new CAD supplier. The overall aim is to produce a future state process map which will aid training and communication of the new CAD processes.

Patient Flow Patient flow is a more health specific version of systems thinking Discharge and process mapping, which follows the patient’s journey

through the health system, for example, across the 5 Step emergency ambulance pathway.

Business The Trust regularly uses prescribed documentation from Welsh Implementation Case Government to develop innovation and service change of the New proposals into formal business cases, for example, the Business CAD Justification Case for the new CAD.

Implementing IQT originates from the 1,000 Lives Team in Public Heath Structures – Quality Wales. It adapted generic methods for improvement into the Strengthening Together/Plan, health sector. PDSA is a specific tool within IQT. A cohort of Quality Do, Study and managers is trained in IQT and the techniques are used within Assurance & Act WAST, for example, the HCP Desk, the AB joint response team. Improvement Across the

Trust

Clinical CPAG provides a mechanism for the appraisal and approval of Research & Pathways clinical pathways for the Trust. CPAG considers any proposal Development Appraisal & for innovative clinical pathways which are being introduced (or

Approval have the potential to be introduced) nationally. Group

Demand & During 2016/17 the Trust procured a demand & capacity review Demand & Capacity i.e. modelling, of emergency ambulance service provision. This Capacity Modelling technique brings together populations statistics, rosters and Review information from the CAD, which is uploaded onto geographic

modelling software and enables various scenarios to be tested.

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The tables demonstrates that the Trust has a developing track record of innovation, particularly, over the last three years as it has developed a more strategic approach to improvement quality and performance. However it is recognised that a more systematic approach is required, and that there is a lack of a clear Trust wider approach, with support services, which are critical to effective front line services, being noticeably absent. However, there are significant opportunities and the threat of the predicted levels of demand during continued austerity mean that this is a strategically critical area for the Trust moving forward. Year 1 (2017/18): • Establish a cross functional working task and finish group to research and write an Innovation & Service Improvement Framework for WAST • Draft Innovation & 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

Year 2 (2018/19): • Roll out of the Framework as agreed within the resource parameters determined in the second half of 2017/18. Year 3 (2019/2020): • Fully implementation of the Framework and initial evaluation at the end of 2019/20. ACTION 42: We will develop and implement over the life of this plan an Innovation & Continuous Improvement Framework

8.8 Health Informatics and Business Intelligence

Health Informatics: Our Strategic Intent 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 clinical modernisation programme, workforce and organisational development programme, the non-emergency patient transport services programme, the CCC modernisation, community engagement plan and the 111 pathfinder implementation programme. 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.

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In addition to these requirements is the production of the Trust’s commissioning dataset for unscheduled care and non-emergency patient 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. An important scheme of work has been to develop an information portal for how we locally engage with our communities which supports the benefits of prudent healthcare and coproduction. It is expected that this service will continue to develop over the lifetime of this plan. The focus in 2017/18 will be to build upon and further develop the work set ‘in flight’ in the previous year. While there are a multiplicity of tasks to undertake to support our overall objectives, detailed below are highest priority actions which it is anticipated will make a significant difference to the organisation. It should be noted that the Directorate’s local development plan outlines further actions, while any actions outstanding from the 2016/17 IMTP will also be picked up, where they remain appropriate. • Introduction of a common BI platform 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”; • Introduction of an analytics training programme that gives us improved numeracy and statistical knowledge across the Trust and for every member of the Trust. This will support our strategic aim of “engaged and skilled workforce”; • Introduction of 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”; • Introduction of a National Archives function and associated infrastructure, that provides a centrally managed services where all records will be 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”. 2018/19 While Health Informatics’ priorities are dynamic and fluid, there are a number of areas where we will focus on during 2018/19. These include:

 The 2017/18 plan will introduce the foundations of a common BI platform within the Trust, during this period we will build upon this work and start the migration process over to this enhanced platform;

 As digital media becomes the primary source of information, we will need to consider the technologies used to deliver these mobile data requirements within the Trust;

 Continuation of the GDPR project, implementing the 12 legislative steps in readiness for the mandatory 2018 go live date;

 Develop a Records Management strategy which outlines how we treat each type of information, insuring classification, retention and disposal guidelines are adhered to; 2019/20 While the landscape is likely to have changed further by 2019/20, there are a number of areas where we will focus on during 2019/20. These include:

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 Review of the Data Warehouse infrastructure, ensuring that its fit for purpose and will continue to meet the needs of the Trust in the long term;

 Expansion of the Records Management implementation across the Trust to ensure its meets the required legislation. Action 43: 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)

Substantial progress was made in the delivery of the ICT programme of work for 2016/17 which can be summarised as follows:

In Year 1 we said we would

 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 which will enable staff to access relevant information at the point of care and away from their ‘base’.  As reliance on ICT systems and electronic information increases, there will be a need to review and revise business continuity and disaster recovery procedures to ensure robust safeguards are in place  Delivery of the Emergency Services Mobile Communication Programme (ESMCP) having started will see a need to mobilise a Trust project to support implementation of the Emergency Services Network (ESN) and associated works for the Trust  Work with NWIS to provide access to national information resources, such as the Master Patient Index (eMPI) 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 EDCIMS and CCIS.  We will work with colleagues across the Trust to look for opportunities to maximise the benefits of patient self-service  Conduct a baseline of the current skills and abilities of ICT staff and identify any gaps in key technology areas. Develop a structured development programme for each member of staff

This is a summary of how we have done

 Improvement in the ICT Infrastructure to provide a scalable, resilient and robust platform.  Provided the ICT and telephony support for the successful introduction of the National 111 Pathfinder  Started a staff mobility pilot focused on the requirements of clinical and operational staff for secure access to appropriate information whilst away from their station.  Completed the successful procurement of a new CAD and started the implementation project.  Established the ESMCP project and contributed to the work of the ESMCP ARP and JESG programmes.  Worked with NWIS and colleagues within the Trust to introduce access to Canisc at the Clinical Desk in CCC  We have worked extensively with all directorates across the Trust to deliver improvement and enhancements to current systems and service

In refreshing this plan we have looked towards the objectives of Welsh Government’s Digital Health and Care Strategy, to ensure our plan is alignment with wider policy direction. We have mapped our ICT priorities to the theme of the strategy and this is summarised in the table below. In doing so we commit to two key strategic actions. ACTION 44: Work with NWIS to provide access to national information resources, such as the Master Patient Index (eMPI) and Individual Health Records (IHR) as well as investigating options to provide Trust

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information into national repositories, such as Welch Clinical Records Service (WCRS) and national systems such as EDCIMS and CCIS.

ACTION 45: We will deliver the pilot phase of the staff mobile devices project.

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2017/18 2018/19 2019/20

Patients will be able to look after their own well-being and connect We will look to build on previous work to We will look to review and revise with health and social care more efficiently and effectively, with scale out alternative access channels, a our patient access capabilities in online access to information and their own records; revise website and continue to work with light of the major National the National programmes around Directory programmes delivering new Priority areas will be to work with non-emergency patient facing Information of Service and electronic patient access. systems to our patient facing departments such as NEPTS and NHSDW to implement services. for you 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.

We will work with partner across health and other sectors to We will work with partner across health and We will work with partner across improve information sharing and collaboration. Within the Trust we other sectors to improve information the Trust, national programmes will look for further improvements in data capture and quality to sharing and collaboration. Within health we and other partner organisations improve capability in analysis including financial costing, whilst also will work with NWIS and national to review and enhance our looking at opportunities to deploy innovative technology solutions in programmes to increase the exchange of information sharing and information as new National systems are collaboration as we undertake Improvement support of the Trust Caremore model. developed roll-out. major changes in our patient & Innovation Within health we will work with NWIS and national programmes to facing service. provide two way exchange of information to aid both clinical and operational decision making across all health organisation. We will also look at opportunities to transfer information across Emergency Services to improve incident response.

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Use digital tools and have improved access to information to do We will continue to work with corporate We will continue to work with their jobs more effectively with improvements in quality, safety and departments and programmes within the corporate departments and efficiency. Trust and across the NHS to improve or programmes within the Trust and replace operational information systems across the NHS to improve or We will work with corporate departments and programmes within while ensuring they meet the needs of the replace operational information the Trust to improve or replace operational information systems Trust and, as far as possible, comply with systems while ensuring they while ensuring they meet the needs of the Trust and, as far as national standards. Some key areas of focus meet the needs of the Trust and, possible, comply with national standards. Where required we will are; as far as possible, comply with need to ensure that systems are optimised for mobile access and • continued preparation and mobilisation national standards. Some key capable to supporting mobile and agile working for operational staff for the replacement of Airwave services areas of focus; to be available wherever care is being delivered. Four key priority through the national ESMCP and ARP • Implementation of the national programmes. 111 integrated ICT solution areas will be; • continued operation and support for the • Implementation and  the implementation of the new CAD, as detailed in section 7.1.2 of national 111 pathfinder along with the replacement of the current this plan leading the National procurement of a Airwave services through the replacement system national ESMCP and ARP Supporting  continued preparation and mobilisation for the replacement of Airwave services through the national ESMCP and ARP • potential replacement of Trust’s programmes. Professionals programmes. systems Digi-Pen (may be 2019/20  continued operation and support for the national 111 pathfinder depending on developments during along with the leading the National procurement of a replacement 17/18), NEPTS and Trust rostering system systems.  review ePCR capability and its suitability to replace the Trust • Assuming successful pilot phase, secure current digi-pen solution in the future. In the interim progress required funding (capital and revenue) with digi-pen phase 2 implementation. to roll-out mobile staff devices.  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 EDCIMS and CCIS

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During the execution of this programmes the level of investment We will continue to improve and enhance We will continue to improve and required both in terms of resources and finance will be substantial the ICT infrastructure to provide a basis to enhance the ICT infrastructure to and a clear vision and focus will be required to ensure maximum support the implementation of new systems provide a basis to support the return on this investment. and solutions including the greater use of implementation of new systems Opportunities to review and revise systems and technologies will mobile and remote working technologies. and solutions including the naturally arise as existing contract expire, support for existing We will review opportunities to replace greater use of mobile and remote technologies used across the Trust are withdrawn by the systems and technologies as existing working technologies. We will manufacturer and new or improved technologies are developed and contract expire, support for existing continue to develop our staff to brought to market. technologies used across the Trust are ensure they are best placed to To support both the Trust transformation and alignment with the withdrawn by the manufacturer and new or support the Trusts as the National strategy and programmes, a robust and resilient ICT improved technologies are developed and technologies used continue to Planned infrastructure will be required and we will continue with a brought to market. We will continue to change. programme to improve and enhance the ICT infrastructure to develop our staff to ensure they are best Future provide a basis to support the implementation of new systems and placed to support the Trusts as the solutions including the greater use of mobile and remote working technologies used continue to change. technologies. Extension of 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.

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8.10 Partnerships and Engagement

Our 2016/17 – 18/19 plan reflected the organisation’s commitment to engagement and collaboration, identifying the need for strong partnerships with our patients, staff, NHS Wales organisations and public sector partners as one of our core priorities. This was similarly reflected in the development of the Partnerships and Engagement Directorate, which was established in December 2015 following the appointment of a Board-level Director of Partnerships and Engagement, a unique post in NHS Wales. 2016/17 has seen the first full year in the life of the Directorate, with this initial year focusing on laying the foundations for a more comprehensive and systemised approach to the partnership and engagement agenda, ensuring that the engagement work of the organisation is aligned to its strategic priorities and objectives. While 2016/17 has been a year of progress, there is no complacency about the need to continue to deliver with pace and clarity the tenets of the Trust’s Engagement Framework, which was adopted by the Board in December 2016. Partnerships and Engagement: Our Strategic Intent The Welsh Ambulance Service’s partnership and engagement agenda is underpinned by some basic tenets, which are outlined below and are reflected in our Engagement Framework which was approved by the Trust’s Board in December 2016.

 To ensure we listen and, where appropriate, act on the views of our stakeholders in improving our services

 That we are visible in the collaborative arena, and are a credible voice within NHS and the wider public service in Wales

 That we identify and explore opportunities for collaboration with partners, and that our relationships are sufficiently well developed to allow us to deliver on these intentions

 That our relationship with our employees, patients, stakeholders (including politicians and the media) and the people of Wales is predicated on trust and understanding, helping to build our reputation as a “brand” in which there is confidence and for which there is support

 To engender a sense of collective ownership in the Welsh Ambulance Service, as an organisation which employees and stakeholders have a mutual interest in supporting The delivery of this intent will be supported by robust evaluation of the Trust’s partnership and engagement work, ensuring that the Directorate is recognised as the strategic driver of this agenda and that intelligence, coupled with strategic alignment, inform our engagement activities moving forward, The Evolving Partnerships and Engagement Environment While the time is right for the Welsh Ambulance Service to systematise its engagement activities, in order that they are aligned with the organisation’s strategic objectives, the fact that the external environment for collaboration has also become more formalised in recent times adds additional incentive for this work. For example, the advent of 19 Public Service Boards, created as delivery vehicles for the Wellbeing of Future Generations Act 2015 and its seven wellbeing goals, plus the creation of seven Regional Partnership Boards as a result of the Social Services and Well-being Act, provide both significant

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opportunity for the Welsh Ambulance Service to become involved at a more strategic, collaborative level, while also potentially creating a burden of participation which we may struggle to meet. As we move into 2017/18 and beyond, we will crystallise our thinking as to where some of the landscape of public service collaboration and partnership might and should take us as we move forward. What is clear is that, in 2017/18, we must bring clarity as to how WAST will engage in this agenda, not just through the Public Service Boards, but through other fora. There will also be further debate on the organisation’s priorities for engagement, any specific collaborative outcomes/goals which it is seeking to achieve and the need to understand how best this work can be resourced, recognising that engagement resource too is fragmented across the organisation. Indicatively, these collaborative priorities are likely to encompass estate solutions, community resilience and public service visibility. Progress 2016/17 This year has seen a significant positive shift in organisational reputation, evidenced by much more balanced, and largely positive, media coverage, coupled with increased political confidence in the administration and performance of the organisation. In terms of 2016/17 actions relating to partnership and engagement, these are summarised in Annex 7. There has also been positive progress in a number of additional areas within the arena of the Partnerships and Engagement Directorate, notably improvements in the handling of contentious FOIs, which has contributed to improved confidence and reputation, working closely with the Board Secretary; the management of political concerns, with a new system implemented and delivering positive progress, working closely with the Director of Quality, Safety and Patient Experience and better quality, more timely briefing support for the Chair and Chief Executive. 2017/18 Plan The focus in 2017/18 will be to build upon and further develop the work set in train in the previous year. While there is a multiplicity of tasks to undertake to support our overall objectives, detailed below are those first order actions which it is anticipated will make a significant difference to the organisation. It should be noted that the Directorate’s local development plan outlines further actions, while any actions outstanding from the 2016/17 IMTP will also be picked up, where they remain appropriate.

 Develop an embedded “stakeholder intelligence” system which brings together feedback from staff/patients/external stakeholders and informs our decision-making processes, changes to practice, identifies trends and opportunities. This will support our organisational strategic aim of ‘Strong Partnerships’

 Deliver a system of improved internal communication that ensures staff and our volunteers are able to access up-to-date and appropriate information is essential to creating understanding and buy-in to our aims and priorities. This will support our organisational strategic aim of fantastic people

 Develop an organisational narrative/story that ensures staff and stakeholders have a clear line of sight to, and understanding of, our organisational ambitions and their role in delivering them. This will support our organisational strategic aim of ‘Strong Partnerships’

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 Deliver on the content of the Engagement Framework Delivery Plan, being developed in Quarter 4 2016/17, which will support the systemisation and planning of our engagement activities. This will support our organisational strategic aim of ‘Strong Partnerships’

 Ensure continued engagement/visibility in the Wellbeing of Future Generations Act agenda, with membership of Public Service Boards and other fora as appropriate. This will support our organisational strategic aims of ‘value, innovation and efficiency’ and “Strong Partnerships” ACTION 46: 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. 2018/19 Outline While the partnerships and engagement arena is dynamic and fluid, there are a number of areas where we will continue to focus in 2018/19 onwards. The sustained pressure on public service finances, coupled with predicted increases in demand, will mean that collaboration with other organisations will increase in significance. In light of this, we will need to review in 2018/19 our collaborative objectives and sense check the environment to ensure our approach to partnerships remains valid and continues to deliver benefit for the organisation. We will look to secure the commissioning of a BBC documentary series highlighting the broad range and challenging work of the Trust (content informed by the Trust’s Directorates’ key deliverables) to maintain the momentum already established. As digital media becomes the primary source of information and method of communication, we will need to consider investment in technologies which can facilitate this for our staff and the wider public. The current systems for publishing content on the website, intranet and Siren are archaic and create substantial pinch points, while not meeting the needs of a largely mobile workforce. Delivering a new Trust website, intranet and online magazine – which could all be accessed via mobile phones for example - will need a dedicated focus to research, plan and implement the technical aspect and co-ordinate the content across the Trust. This will be explored in 2017/18 with a full analysis and a supporting business case developed in 2018/19 if investment is required 2019/20: Indicative While the landscape is likely to have changed further by 2019/20, the key issue will be the proximity of next National Assembly for Wales elections and the likely impact of this on our political and partnership interfaces. In addition, it is feasible that the Trust will be in a position to look to either host or share posts for/with other public services in terms of communications and engagement in particular, and this option will be actively assessed in terms of its appropriateness and feasibility. The Office of the Chief Executive should have developed to a point where it can assume a more strategic function, with the possibility of a significant review of roles to move from a basic

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administrative function to the beating heart of the organisation as a source of intelligence, information and advice to the Chief Executive, Executive Team and wider Board.

8.10.1 The Well Being of Future Generations (Wales) Act 2015 (WBFGA) The Act places a statutory duty on 44 named public bodies to improve the social, economic, environmental and cultural well-being of Wales in accordance with the sustainable development principles, working through new Public Service Boards. Whilst we are not one of the 44 named organisations, our Board has, over the past twelve months, had conversations and discussions regarding what our contribution to the Act could be. Board also met with the Well-being of Future Generations Commissioner at its Board Development session in February 2017 to explore this. An early exercise of our Board was to baseline against each of the seven principles how the organisation is currently contributing to the Act and across which of the principles in the future it feels the organisation can make the biggest contribution. As an organisation we are keen to ensure we apply not merely comply with the act so this initial baseline exercise was seen very much as the beginning of the conversation which the organisation needs to have around the Act and not the end of the conversation. Some of the key questions and issues which we will need to explore over year one of this plan are:  What our WBFGA statement is and if/how it fits with our strategic aims  How we want to engage with Public Service Boards (PSBs)  Engagement with the well-being impact assessment process  What our internal governance approach to the act will be  The impact of the Act on quality, safety and prudent healthcare Action 47: We will agree (and implement) our approach to embedding the principles of the Well Being of Future Generations (Wales) Act 2015 (WBFGA)

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, to help us understand what it feels like to be a patient in our care and to use that learning to help improve our 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. Work will continue throughout 2017/18 to integrate the work of both the PECI Team and other colleagues across the organisation more closely. This will be achieved by ensuring the strategic intent outlined in the Engagement Framework, which covers all aspects of engagement and was adopted by the Board in December 2016, is reflected in the work programme of all relevant teams and is reported regularly to the Board. 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.

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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

In Year 1 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

This is summary of how we have done

 Delivered Board approved Risk Management Framework and Strategy  Engaged in the Tier One Multi Agency exercise  Reviewed and re-launched the Major Incident Plan

8.11.1 Corporate Governance

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 has been 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, this Corporate Governance team links closely with the Quality, Safety and Patient Experience

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Directorate and also the Partnerships and Engagement Directorate. The plan has also been informed by key stakeholders such as the Welsh Government. 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. 2017/18 Plan The focus for the 2017/18 plan is to capitalise on the foundation work which was carried out in 2016/17. 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 mustn’t 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 2017/18 and beyond are:

 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. ACTION 48: We will develop our Corporate Governance function to make us an even more effective organisation.

8.11.2 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.

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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.

8.11.3 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 being planned.

8.11.4 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, robust approach towards performance management and project & programme management.

Last year our IMTP was tracked across its three main components: - The 154 actions - The performance ambitions - The financial plan

Last year’s arrangements for delivering the actions which we promised in our plan were via two routes-

i. We created an IMTP Delivery and Assurance Group (iDAG) that was chaired by the Executive Director of Planning and Performance. This group had oversight of all the IMTP actions being delivered through formal programmes / projects.

ii. The remaining actions and our performance ambitions documented in the IMTP were tracked and reported on via the new quarterly Directorate performance review process.

In addition an Executive Finance Group (EFG) was created where part of the remit of this group was to monitor delivery of the financial plan which underpinned the IMTP.

This ‘three pronged approach’ proved extremely useful in providing the organisation with a direct line of sight on the progress being made against commitments and ambitions it gave in the plan. Assurance was able to be given to both the Executive Team and onwards to Trust Board as part of its own quarterly IMTP scrutiny.

Building on the established approach and incorporating recommendations from internal audits and the structured assessment, the approach for 17/18 will be modified slightly:

 All 48 actions identified within the plan (regardless of whether or not they are being delivered through a programme of work or through Directorate operations) and our performance

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ambitions will be tracked through the iDAG group on a monthly basis with a quarterly report going onwards to the Executive Team and Trust Board.

 iDAG and EFG meetings will be scheduled so that they run adjacent to one another thus offering a more seamless perspective on both service delivery and financial delivery.

These new delivery arrangements are summarised in the diagram below.

Each of our 48 actions have been assigned an Executive lead so that there is top level ownership. The table in annex 1 indicates where Executive ownership of these actions lay and when we anticipate delivery of these actions to commence.

For those actions where delivery will commence immediately (not all will commence on the 1st April as within and across them there are a complex number of dependencies) we have developed a plan on a page for them.

This plan offers a greater level of detail and assurance regarding;

 Key Milestones and associated timelines  Expected outcomes  Resource requirements  Measures of success  Risks to delivery  Management / delivery arrangements

As the ‘start date’ for others approaches, the requirements for a plan on a page will then be initiated via iDAG.

Risks to 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:

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 System pressures – our ability to fully deliver on our plan will be impacted on 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

 Workforce risks linked to Band 6 negotiations – as identified elsewhere in this plan, there are a number of opportunities that present through the re-banding of paramedics to Band 6. In addition we have also been clear that the costs associated with this change are not included within our plan. In this context, the risk is to industrial relations and recruitment and retention should we be unable to resolve the negotiations and the funding confirmation in a timely way. This risk is being managed through the negotiation process, through regular briefings with Trade Union colleagues and also through briefings to the CASC, EASC and Welsh Government

 Non-Emergency Patient Transport – there are two risks to delivering our NEPTS plans. The first is related to the successful novation of contracts from LHBs to WAST. Timescales for this have already slipped due to absence of a full data set from LHBs. The second relates to the financial framework of the NEPTS business case and the ability of WAST to use the current funding to deliver against the commitments e.g. enhanced services. These risks are being managed through the EASC NEPTS Delivery Assurance Group.

 Capacity to deliver change – this plan represents an ambitious programme of change. 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.

8.11.5 Welsh Language

As a result of the Welsh Language Measure 2011, our Welsh Language Scheme will soon be replaced by the new Welsh Language Standards once approved by Welsh Government. In our commitment to Welsh language we also provided a response to Welsh Government’s consultation on the Draft Welsh Language Standards for Health Sector on 14 October 2016. In addition on 30 November 2016 we submitted a Regulatory Impact Assessment to Welsh Government indicating where possible the potential financial impact of implementing the proposed regulations on the Trust. 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. An action plan has been developed to meet the requirements of the strategy. A six month update was provided to Welsh Government on delivering the Year 1 action points. Some of our key developments in this area have included: ensuring that the

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principles of the Active Offer were considered and incorporated into the new 111 Pathfinder Service in the ABM UHB area and that callers are able to make a positive language selection and receive bilingual message prompts. We have developed recruitment guidance for managers to determine Welsh language skills for vacant posts. This guidance is now embedded within our Recruitment and Selection Policy. In up skilling the Welsh language skills of its staff, an Introduction to Welsh – Level 1 CD has been developed. The course aims at developing linguistic courtesy skills and contains useful Welsh phrases and terminology associated with the Trust. Classroom based trial of course has been successfully completed with a group of learners at HQ. 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. No indication of timelines for implementation has been given to its next phase. 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. Our Welsh Language Skills Strategy has been in existence from 2013-16 and will be reviewed and updated for 2017-19. A revised and updated detailed audit of the Welsh language skills of the staff groups that deal with the public will be carried out and be included in Heads of Services’ Local Delivery Plans when they are next reviewed in 2018. An audit to determine the bilingual skills requirements for the various workplaces and posts within the Trust will be carried out during 2017. This will be achieved by examining the nature of the service, each post and workplace provides to the public and will establish a set of criteria against which the linguistic requirements of individual posts (the minimum level of bilingual skills needed to ensure the availability of services in both Welsh and English) can be determined. Following the trial of the Level 1 Introduction to Welsh course, the course will need to be approved during 2017. Once approved managers will be able to encourage newly appointed staff who are required to deal with the public via their local induction/ PADR meetings to achieve Level 1 (basic linguistic courtesy) within their first year of service.

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