Annual Report 2017-18

1 www.ambulance.wales.nhs.uk welshambulanceservice @welshambulance

Contents Welcome from the Interim Chair and Interim Chief Executive ...... 4 The Welsh Ambulance Service… at a Glance ...... 7 Our Year in Review: The Highlights ...... 11 Planning and Delivering Our Services ...... 16 A Clinically-Led Service ...... 18 Our Performance in Summary ...... 21 Emergency and Urgent Care Services ...... 37 Investing in Technology ...... 38 Non-Emergency Patient Transport Services (NEPTS) ...... 39 Development of the Five Step Model for NEPTS ...... 41 Transfer of Non-WAST NEPTS Work From Health Boards ...... 42 Enhanced Services ...... 42 Our Volunteers ...... 48 Emergency Preparedness ...... 51 Pushing the Boundaries of Knowledge: ...... 53 Research & Innovation...... 53 Our People… Our Places ...... 56 Keeping us Moving: Our Fleet ...... 69 Quality at the Heart of What We Do ...... 71 Working across Boundaries ...... 76 Working in Partnership ...... 78 Wider Unscheduled Care System/Primary Care ...... 78 Blue Light Collaboration ...... 79 The Wales Air Ambulance and Emergency Medical Retrieval Service (EMRTS) ...... 80

Quality at the Heart of Good Governance: ...... 83 Managing Ourselves Effectively and Efficiently ...... 83 Integrated Medium Term Plan (IMTP) and our Longer Term Strategy ...... 85 The Year Ahead 2018/19 ...... 87 Financial Performance against Statutory Financial Duties ...... 92 Sustainability Report 2017/18 ...... 109

Welcome to our 2017/18 Annual Report, which we hope will give you Welcome an interesting insight into our work here at the Welsh Ambulance from the Service over the last 12 months.

Interim It’s been an exciting year, but one not without its challenges. The winter period, in particular, was one of the most difficult we have encountered, with poor weather and a significant rise in demand for our services, coupled with pressures across the whole of the Chair and NHS Wales system.

Interim These factors came together to make the winter of 2017/18 one which tested our resilience as an organisation, and the resilience of our staff.

Chief It is testament to the sheer hard work and dedication of our colleagues that we managed to maintain our service during this challenging period. The tales of grit and determination to Executive get into work, and then to care for patients, are many and varied.

From call handlers to paramedics and non-emergency colleagues, finance and HR staff to our planners and communications team, directors to receptionists, mechanics to managers, everyone did their bit to keep our wheels turning, literally and metaphorically.

We know we still have much to do. We will learn from our experiences this winter to understand what we need to do differently, and what needs to be different across the NHS in Wales, to ensure we can maintain high standards of care for our patients.

Our approach is focused on two strands: improving what we do and how we do it, and collaborating and influencing across the wider NHS in Wales to develop services which better meet the needs of patients.

There have also been some real positives this year.

We have continued with our journey to become the most clinically innovative ambulance service in the UK, with a range of initiatives being trialled to ensure we can treat far more people at home or on scene, minimising the need to take patients to hospital.

We replaced the Computer Aided Dispatch (CAD) system in our clinical contact centres with a modern CAD that will help us deliver a more efficient service and improved care to our patients. This was possible thanks to £4.5m support from Welsh Government.

We have put a real focus on improving mental health care, both for our patients and our staff, thanks to a £100,000 investment from Welsh Government to help support our Mental Health Improvement Plan.

In recognition of our work to improve the wellbeing of our staff more generally, we were awarded with the “Gold” Corporate Health Standard in December 2017. While there remains more to do, we were delighted to secure “gold” status and are now working towards achieving the “platinum” standard.

We have started work on our long term strategy, engaging with our staff, stakeholders and the public on our shared vision for the Welsh Ambulance Service in 2030. We had some great debate and ideas about the sorts of services we need to think about for the future, and how they might be delivered. We will be finalising our ideas this year and will continue the process of modernising our services, working with our partners to build strong, resilient communities, with health and wellbeing at their core, and access to high quality health services when you need them.

We hope this annual report will help you understand the full range of our work, our passion for improvement and our commitment to the people we serve.

We operate in a complex environment, where systems and people need to work better together to ensure patients receive the right care for them. We are committed to playing our full part as a leader across the NHS system in Wales, with quality of care and the needs of our patients very firmly at the heart of what we do.

Your support is equally important, whether that’s as one of our many volunteers who are on the front line of caring for patients, as Community First Responders, or as part of our volunteer car service.

You can also support us by using our services wisely, following the Choose Well message, and using 999 for real emergencies only.

Finally, it would be remiss of us not to mention our former Chair and Chief Executive, Mick Giannasi and Tracy Myhill, both of whom moved on to pastures new in 2017/18. Their contribution to our organisation, and to moving us forward on our improvement journey, cannot be overestimated, and we wish them both the very best for the future.

We hope you enjoy reading this document and find it helpful. We’d love to hear your feedback. You can connect with us in a range of ways, for example, by keeping up with developments on Twitter @welshambulance, finding us on Facebook, checking out our website or emailing us at [email protected]

You are also very welcome to come to one of our regular Board meetings, which are open to everyone and are held across Wales. On a number of Board days, we spend the afternoon listening to our staff, patients, stakeholders and anyone who wants to come along. There’s an opportunity to chat openly with our Board members and to pose any questions you might have. You can find out more here or keep an eye on social media for events near you.

In the meantime, stay in touch and we hope you enjoy reading this year’s Annual Report.

Patsy Roseblade Martin Woodford Chief Executive (Interim) Chair (Interim)

Who We Are and What We Do The Welsh 2018 marks the 20th anniversary of the establishment of the Welsh Ambulance Ambulance Service.

Service… Over the last two decades, we have evolved to become one of the most clinically advanced ambulance services in the world, with a focus on providing all our patients with high quality at a Glance care and service.

We are the forefront of innovation in unplanned clinical care, something which you can read more about later in this document.

We provide thousands of patients a year with advice, support and signposting to the right services through our “hear and treat” services. This includes NHS Direct Wales, the 111 service (in the Abertawe Bro Morgannwg Health Board area and Carmarthenshire) and our Clinical Desk, and we take hundreds of thousands of patients to a place of care, or home, every year through our Non-Emergency Patient Transport Service (NEPTS).

Our call handlers and clinical contact centre staff deal with more than half a million calls every year, 24/7 and 365 days a year. And we are at the frontline of service delivery, making sure that patients get the right advice and help.

We serve three million-plus people in Wales, and provide services across the country – that’s an area of some 8,000 square miles, spread across a diverse and challenging urban, coastal and rural landscape.

We continually work to improve what we do and how we do it, and we’ll tell you more about this later on.

To give you a flavour of our organisation, here are some facts and figures:

 We answered 540,891 999 calls in 2017/18, which is significantly up on the previous year’s figure of 486,085

 That translated into 479,444 verified incidents (we often receive more than one call about the same incident)

 Our Non-Emergency Patient Transport Service (NEPTS) made 787,666 patient journeys during the year

 NHS Direct Wales dealt with 301,640 calls and some 3,871,348 visits were made to its website

 The 111 service, which currently operates in Swansea, Bridgend, Neath Port Talbot and Carmarthenshire and brings together the services of NHS Direct Wales and the GP out-of-hours service, dealt with 225,757 calls

In 2017/18:

There were 714 vehicles in our fleet, comprising:

Emergency ambulances (including UCS and neonatal) 260 Rapid response vehicles 130 Non-emergency patient transport service 268 Specialist vehicles 56

Total 714

We occupied:

 113 buildings

We employed more than 3,000 people. The figures relate to the average number of employees under contract of service in each month of the financial year, divided by 12 (and rounded to nearest whole time equivalent). The table below excludes agency and seconded in staff.

Category 2017/18 2016/17

Additional Clinical Services 1,428 1,356

Administrative & Clerical 470 476

Allied Health Professionals 982 986

Estates & Ancillary 45 48

Medical & Dental 4 2

Nursing and Midwifery 130 92

Total 3,059 2,982

Staff Composition

The gender balance of our leadership team roughly reflected that of the organisation as a whole, with 41.2% of our senior leaders being women and 58.8% male, compared with a Trust-wide staff composition of 42.71% female, 57.29% male.

Gender Headcount %

Female 7 41.2

Male 10 58.8 Grand 17 100 Total

In 2017/18, we continued to promote our behaviours, together with our statement of vision and purpose, which was developed in partnership with colleagues in 2015/16. We have continued to measure how satisfied our staff are through quarterly “pulse” surveys, and have shared results with team leaders and senior managers so that they can address any concerns. Trends are also analysed to identify issues which may require an organisational response.

We have also been gearing up for the 2018 NHS Wales Staff Survey, which runs over the early summer of 2018, and will review its findings as part of our commitment to improving levels of engagement and the wellbeing of our colleagues across the organisation.

2017/18 was another important year for the ambulance service in Our Year in Wales and the second year in which the Clinical Response Model Review: The (CRM) was in operation through the entire year.

Highlights Our “red” performance, i.e. responses to immediately life threatening incidents, was maintained above the Welsh Government’s target to respond to 65% of these incidents in eight minutes.

Clearly, the Trust wants to respond to as many of these incidents as possible within eight minutes and, for most of the year it was above 70%, achieving and average 74.6% for the year.

Thanks to more than £4m of Welsh Government funding, we were able to replace the Computer Aided Dispatch (CAD) system in our Clinical Contact Centres (CCCs) with a modern CAD system that is helping us to deliver a more efficient service and improved care to our patients.

The CAD is our most critical IT system, and successful delivery of the project was a huge achievement for everyone involved.

Engaging with colleagues and working in partnership with our trade union partners remains central to the way we work, as evidenced by the very successful work undertaken jointly to secure support and funding for the new Band 6 paramedic role in Wales.

We are committed to working in tandem with those who work with, and for us, in delivering the best possible service to our patients, and supporting us as an employer of choice. We continue to ensure that we are supporting local communities to look after their health and know what to do in an emergency.

We are very grateful to the many people across Wales who act as Community First Responders (CFRs) for the Welsh Ambulance Service.

These community life-savers are often the first on scene at an emergency and are critical in supporting the chain of survival for patients in a life threatening state.

We also continue to work with thousands of primary and secondary school children across Wales, teaching them the basics of CPR through our ‘Schoctober’ and ‘Restart a Heart’ initiatives, which are now annual fixtures in our community engagement calendars.

There were a number of other additional highlights throughout the year, including:

 Accreditation of all three Clinical Contact Centres as centres of excellence with the International Academy of Emergency Dispatch South East Wales at two sites (this speeds up the turnaround of ambulances and availability to crews)  Our North Wales Advanced Paramedic Practitioner Pilot being shortlisted for an NHS Wales Award  Paramedic Ed O’Brien becoming the first paramedic to be adopted by Macmillan for his work on end of life care  The restructures of the Medical Directorate and Operations Directorate being completed  Supporting a successful UEFA Champions League Final operation in Cardiff  The introduction of the Omnicell automated medicines cabinets for WAST being completed  Our achievement of the Gold Corporate Health Standard

Once again, we managed to deliver all of our services and initiatives within our budget, with a very small surplus of some £70,000. We could not have achieved this without the efforts of all our colleagues, working prudently, but we know that the coming years will present even further challenges to us in terms of resourcing, as we face increasing demand for our services.

This is why we have more to do to reconfigure what we do and how we do it, changing the shape of our ambulance service to meet the evolving needs of patients and communities, while never losing sight of the importance of quality at our heart, and clinical innovation as our driving force.

Read on to find out more about all of these developments.

While we aim to give you a flavour of our year here, in the Annual Report, you can also follow the hyperlinks you see highlighted throughout this document to find even more detail on specific areas of our work.

* To find out more about these new developments, follow the hyperlinks highlighted throughout this document 13

Emergency ambulance services are commissioned on a collaborative Planning basis by the seven local health boards through the Emergency and Ambulance Committee (EASC) and the Chief Ambulance Services Commissioner (CASC), acting on their behalf. Delivering The Commissioning & Quality Delivery Framework for emergency ambulance services is Our the document which sets out what is expected of us.

Services We have developed, in collaboration with our commissioners, five-step pathways for both our emergency and non-emergency services, which focus on delivering real

improvements in services for our patients.

Figure 1: Five-Step Emergency Ambulance Care Pathway

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

The focus of the pathway is to ensure that patients are supported to make the right choice for them, and receive the care most appropriate to their needs.

Step one supports patients to choose the right service for them, which may not be the ambulance service, while step two focuses on providing patients with the right advice when they call. Steps three and four focus on ensuring that more patients can be treated at scene or referred to other services, where that would be more appropriate for them, while step five makes sure we take to hospital only those patients who absolutely need to go there.

The NEPTS Five-Step Model also shows what is expected of us for non-emergency services, and became operational in shadow format from November 2017.

Figure 2: NEPTS Five Step Model

You can read more about the ambulance care pathways, what they mean and how they work later in this document and in our Performance Report

A Clinically- The Welsh Ambulance Service is one of the most clinically advanced ambulance services in the world, with a commitment to delivering Led Service services that truly place it at the clinical forefront of unscheduled

care.

Our clinical response model, which began as a pilot in October 2015, and was confirmed

as permanent last year, was ground-breaking in focusing on quality and clinical outcome

as key indicators, using time targets only for those conditions where time has a

significant impact on patient outcome.

Since 2015, similar approaches have been adopted across many parts of the UK. There

has also been international interest in our model here at the Welsh Ambulance Service,

with visits in 2017/18 from ambulance services as far afield as Canada and Australia

interested in learning about what we do, and how we do it.

Simply put, the aim of the model is to focus on the quality of care for patients and the

outcome achieved, while maintaining an eight-minute response target for those patients

with an immediately life threatening condition, for whom time is of the essence. This includes patients in cardiac or respiratory arrest, for example.

The new model has three types of call – Red, Amber and Green.

 Red calls are immediately life-threatening calls –someone is in imminent danger of death, such as a cardiac arrest. There is compelling clinical evidence to show that, for these patients, an immediate emergency response will make a difference to a person’s outcome. The eight-minute target has been retained for this group, with a target of 65% of calls receiving an eight-minute response.

 Amber calls refer to those patients with conditions that may need treatment and care at the scene and fast transport to a healthcare facility, if appropriate. Patients are prioritised on the basis of clinical need, and patients receive a rapid, blue light response. There are no time-based target for amber calls; instead a range of clinical outcome indicators (the Ambulance Quality Indicators) have been introduced to measure the quality, safety and timeliness of care being delivered, alongside patient experience information, which is published every quarter.

 Green calls are non-serious calls, which can often be managed by other health services, including by providing telephone-based healthcare advice, or through self-care. This category also includes many calls from healthcare professionals.

While there remains work to be done, it is clear that the Welsh Ambulance Service has led the way on a UK and global basis in focusing its response model on those patients in most critical need of care.

Our challenge now is to work on improving our performance for the many patients who are seriously unwell, but not in a life threatening condition. These are patients who fall mainly into our amber category of calls. Summer 2018 will see a review of the amber category, led by the Chief Emergency Ambulance Services Commissioner, the outcome of which will inform the next phase in the development of our clinical model.

You can read more about the clinical model in our Performance Report

MEASURING QUALITY: AMBULANCE QUALITY INDICATORS

For the overwhelming majority of patients, time is not the best indicator of clinical outcome. It is doing the right thing, delivering the right care and, if necessary, taking the patient to the right healthcare facility, that have the most bearing on how well a patient recovers from their illness or injury.

We continue to work closely with our commissioning partners on the development, implementation and publication of Ambulance Quality Indicators (AQIs). These indicators provide information on the quality of care we give to patients and the outcomes achieved.

The information that is being gleaned from the AQIs is invaluable in providing us with accurate insights into some of the things that matter most to our patients, as well as our performance in those areas. All this helps drive us on, as we strive to become better, safer and more advanced in terms of our service quality and clinical skills.

The AQIs are published quarterly, and you can find them in our Annual Quality Statement

We have also begun to use patient stories to illustrate the Ambulance Quality Indicators, and our performance data more generally, bringing the statistics to life. You can find some examples of these stories on our website Click here.

Our Performance in Summary

2017/18 was another a pivotal year in the transformation of the Welsh Ambulance Service. It was the second full year of operation for our revised clinical model and one which saw some challenges, both in terms of rising demand and also an extremely challenging winter period; periods of poor weather and increased demand for our services combined to put pressure across the whole unscheduled care system in Wales. The Welsh Ambulance Service was no exception and maintaining our performance for those in immediately life threatening need (red incidents) during this period, is testament to the sheer grit and hard work of colleagues across the organisation.

In fact, we maintained our performance for the red calls eight minute target, above the 65% Welsh Government and Commissioning Quality & Delivery Framework (CQDF) target throughout the year. Demand saw an increase of 4.4% in 2017/18, compared to 2016/17, against a backdrop of increasing pressure on services across the wider NHS in Wales.

Figure 3: Red Incident Eight Minute Performance

Over the next few pages, you can follow a summary of our performance, which is linked to the five steps of the Ambulance Care Pathway. You can also find more detail about our performance in our full Performance Report

Helping people to choose the right NHS service for them is an important part of our work, especially as we need to make sure we are optimising the use of our resources to care for those in most need.

1Step One: Help Me Choose

NHS Direct Wales (NHSDW), and the 111 service, which currently operates in the Abertawe Bro Morgannwg Health Board area and in Carmarthenshire, are integral to our work in this area, supporting patients with telephone and online advice. 111 brings together the NHSDW and local GP out-of-hours services.

Our call activity to NHSDW is shown in the graph overleaf. While call volume was lower than 2016/17, the service still took 301,640 calls.

The decline in call volume can be attributed to the roll-out of the 111 service and also to the greater promotion of NHSDW’s online symptom checkers, which were very heavily promoted via social media in the last year as one of the first reference points for people feeling unwell and seeking advice

Call volume also mirrored some of the worst of the winter weather, with a clear spike in calls in December 2017 and March 2018.

Figure 4: NHSDW Call Activity

Figure 5: NHSDW Website Performance

The growth in the use of web-based information and advice is shown through the sustained increase in the number of unique website visits in 2017/18, which reflects work to improve the website and its active promotion through social media.

In 2017/18 there was a gradual increase in calls made to the 111 service, which is hosted by the Welsh Ambulance Service. The 111 service is currently live in the Abertawe Bro Morgannwg University Health Board area and in Carmarthenshire. The 111 strategic plan outlines the next phase of indicative roll out for 2018/19 and also includes the development of Clinical Support Hubs in the South East and North regions.

Figure 6: 111 Call Activity

Number of calls made to 111 30,000

25,000

20,000

15,000

10,000

5,000

In addition to these services, our Patient Engagement and Community Involvement Team (PECI) shares our message about “choosing well” with a wide range of patient groups to ensure people know how to get the help they need, when they need it, and to understand more about the services available across the NHS that provide advice and care.

We are also extending our work on “frequent callers”, those people who make more than five 999 calls in any given month. We had an average of 2,033 calls from patients classified as frequent callers in 2017/18.

In the last three months of 2017/18, frequent callers accounted for 6.5%, 6.9% and 7.1% of the overall number of incidents we attended. We have a team in place to work with frequent callers, including working with other public and voluntary sector organisations, to assess the needs of frequent callers and provide the support they need, rather than them calling 999 repeatedly.

Figure 7: Frequent Callers – Total Calls

Each month the Trust identifies a new cohort of frequent callers and works on reducing their calls. The following graph illustrates how the December cohort reduced their calls over a four month period.

Figure 8: December 2017 Cohort: Impact of Frequent Caller Interventions

We received some 540,891 calls in 2017/18 a significant increase on the previous year’s figure. This demonstrates the level of demand across Wales for our services and exemplifies why we need to work differently in the future. Of those calls, we attended 479,444 incidents (we often have more than one call about the same incident).

2 Step Two: Answer my Call

One of the ways we are trying to help people differently is by extending the use of our “hear and treat” services. Some of these, like 111 and NHSDW, we have already looked at in Step One, but we also provide “hear and treat” through our Clinical Desk, which is staffed by nurses and paramedics and provides additional clinical triage and advice to callers when it is appropriate to do so.

We achieved a “hear and treat” rate for 2017/18 of 7.3%, exceeding our performance ambition of 7%, and a significant increase on the 2016/17 rate of 6.1%.

The graph below shows the percentage and number of calls ended following hear and treat advice, freeing up more ambulances and crews to go to those patients in greatest need.

Figure 9: Hear & Treat Rate and Calls Ended

As a result of this work, 34,965 calls were stopped at this stage in the five step ambulance care pathway in 2017/18. This means that we avoided dispatching ambulances to these calls, releasing them to respond to other 999 calls in the communities we serve.

This is a 24.4% increase in activity year on year, with 28,114 calls being stopped in 2016/17.

As detailed earlier in the report, we implemented a new computer aided dispatch system (CAD) in November 2017. Implementing a new CAD is a major project and the most significant change for our organisation since the implementation of the Clinical Response Model in October 2015.

Highlights of the first phase of the project delivery include: a single CAD system across WAST for emergency calls, which allows for standard operations across clinical contact centres; auto-dispatch of red calls and Community First Responders, reducing response times for life-threatened patients. The new CAD is also a safe, secure, resilient system, reducing down time through failures to almost zero; it provides a dedicated clinical support desk queue to improve the clinician contact for patients and increase the numbers of “hear and treat” activities and improves mapping and location searching to ensure accurate responses.

There are many patients for whom “hear and treat” or self-care is not an option, and who absolutely need our care, sometimes urgently.

Step Three: Come to See Me 3 Call

Our main target is for those calls categorised as “red”, which means the patient is in an immediately life- threatening condition, for example when their heart has stopped or they are not breathing.

Red performance was maintained above the Welsh Government and commissioning target of 65% throughout 2017/18.

In addition, the gap between the highest performing local health board (HPLHB) operational area and lowest performing local health board (LPLHB) area narrowed through 2017/18, compared to 2016/17.

Figure 10: Red Performance and Local Health Board Variation

% responses to RED incidents within 8 minutes including LHB variation 100.0%

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0% Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18

RED8 Indicator HPLHB LPLHB

While red performance was maintained, it did become more difficult to do so during the winter months, as incident demand increased and the wider unscheduled care system came under more extreme pressure. These wider pressures in the system are best illustrated by the increase in lost hours to handover delays at hospitals. The following graph shows how there was a significant rise in handover delays in 2017/18 and how this impacted on our amber performance. The majority of our calls fall into the amber category, where patients are seriously ill or injured, but their condition is not life threatening.

Figure 11: Red, Amber Percentile and Lost Hours

You can read more about the way calls are categorised and our performance in our Performance Report

Treatment given by our expert ambulance clinicians before a patient reaches hospital, is major factor in their chance of survival and recovery. Our clinicians also use packages of care, assessment and treatment, known as care bundles, for certain conditions.

4 Step Four: Give Me Treatment

A key part of our Clinical Response Model is a set of clinical indicators, performance on seven of which is reported formally by the Emergency Ambulance Services Committee through the Ambulance Quality Indicators (AQIs).

Performance against the clinical indicators has been analysed, and a targeted plan of improvement is underway, focused initially on fractured neck or femur, stroke, hypoglycaemia and STEMI (ST-elevation myocardial infarction).

As many of the clinical indicators are reliant on the recording of condition codes to generate the reports, an emphasis is being made on improving compliance to condition codes.

During the winter of 2017/18, we piloted the use of 10 Advanced Paramedic Practitioners (APPs are paramedics educated to Masters level) working in two Rapid Response Vehicles (RRVs) and rotating into our Llanfairfechan Clinical Contact Centre (CCC), in the Betsi Cadawaladr University Health Board area.

The APP within the contact centre tasks the two responding APPs to incidents where they feel there is an opportunity for patients to be safely cared for on scene, rather than being conveyed to major Emergency Departments (ED).

The impact of this initiative on conveyance, and patient care, has been significant. While the data is at a pilot and evaluation stage, the initial assessment suggests a significant reduction in ED avoidance, with a low patient re-contact rate, highly favourable patient survey feedback, and positive data on patient safety. Further work will be undertaken on this pilot in 2018/19.

The work on Steps 1, 2 and 4 should help us “shift left” on the EMS Ambulance Care Pathway, where it is clinically safe and appropriate to do so. This means taking fewer people to hospital and either providing patients with self-care and other advice, redirecting them to a more appropriate part of the NHS, or treating more patients at scene and/or referring them to another healthcare professional.

We are making progress, and there has been a steady reduction in the Trust’s conveyance rate, following face to face assessment.

While our staff treat many patients safely and effectively at scene, there are clearly times when we have to take the patient to a hospital for the right care and treatment.

5 Step Five: Take Me to Hospital

Figure 12: Conveyance Following Face to Face Assessment 5

This measure of conveyance is useful, but does not show the impact of “hear and treat” or conveying patients to non-major emergency department hospital locations, for example minor injury units, direct admission to acute services or other inpatient environments, such as maternity units and mental health units.

In 2017/18 the Trust conveyed 53.1% of patients to major emergency departments (as a percentage of verified incidents), compared to 54.4% in 2016/17.

We took fewer patients into hospital in winter 2017/18 than the previous year, despite demand for our services going up.

Figure 13: Major ED Conveyance v Verified Incidents

NHS Wales guidance states that the handover of care of patients from an ambulance crew to hospital staff should be within 15 minutes. This is important, as taking more than 15 minutes means that the patient has to stay on the ambulance, which is often not appropriate for them given their condition.

It also means that the ambulance is not available to respond to other calls in the community.

Delays in discharging patients to the care of hospital staff have had a major impact on us in the last year, particularly over the challenging winter period. These delays meant fewer ambulances available to respond to calls in the community, with the impact on patients in our amber call category being particularly pronounced.

We are working with health boards to share our experiences, and those of our patients, and to identify ways of making things better for patients, and staff, in the future.

There’s more information about all aspects of our performance in our Performance Report

2017/18 was a busy and challenging year for our emergency and urgent Emergency care services, balancing a rise in demand with a need to drive change to and Urgent enable us to meet that demand in future years. Dealing with today while Care planning and delivering for tomorrow has been at the heart of our ethos this year. Services Amber Perform 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.

The impact of delays in handing over patients at hospitals, and the rise in demand for our

services, means we have to think differently about how we deliver our services. One of our

major innovations this winter was to trial, in North Wales, a new approach to the use of some of

our most skilled staff, Advanced Paramedic Practitioners (APPs), with the aim of treating more

of our patients at scene and conveying fewer to hospital, many of whom would fall into the

amber category.

You can read more about this work on Page 33 of this, report and we will be looking at how we can do more of this in 2018/19.

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, is one we have to meet. We are working closely with our colleagues, education providers, our trade union partners and others to ensure that we can provide fulfilling, long-term careers for a new generation of ambulance clinician, whose pattern of working is likely to be very different from what has been experienced in the past.

Investing in Technology

One of the highlights of the year was the successful implementation, in November, of a new £4.5m Computer Aided Dispatch system (CAD) into our control rooms. The CAD is used by our staff to assess 999 calls and dispatch resources. It is important in the way we manage our emergency service and represented one of the biggest projects ever undertaken by us, with Operations and ICT staff working closely with the supplier of the system to manage this multi-million pound project.

With the new system, our clinical contact centres are now able to automatically assign vehicles, crews and other resources to a call– a task normally completed manually by our allocators.

The system will ensure a location is confirmed and then check for all available appropriate resources. This is vitally important, ensuring we can reach the sickest patient first, with the right resources to help them.

We continue to work to realise the full benefits of the new system, recognising that having the new CAD in place, coupled with our clinical model and our forward- thinking approach to what it means to be an ambulance service in the 21st century, places us at the forefront of ambulance services, not just in the UK, but globally.

You can read about this and many of the other challenges and opportunities for our emergency and urgent care service arm of the Welsh Ambulance Service throughout this document, and in our Performance Report

Our Non-Emergency Patient Transport Service (NEPTS) is a really Non- important part of what we do at the Welsh Ambulance Service.

Emergency Every year, hundreds of thousands of unwell, elderly or disabled patients rely on us to take them to planned appointments and treatment. Patient NEPTS also plays a vital role in the smooth running of the NHS, by taking home, or to other Transport places of care, patients who have been discharged from hospital.

2017/18 was a very important year for NEPTS. After the approval of the NEPTS business case Services by Welsh Government in January 2016, the service has been on a journey of improvement, (NEPTS) implementing the business case recommendations.

During the course of the year, NEPTS undertook 787,666 journeys. This was a reduction of 1.2% in comparison with the previous year, and continues a trend that has been seen over recent years.

Although the number of patient journeys has reduced, there has been a change in the type of journey being undertaken by patients as a result of the reconfiguration of services across health boards, with patients more frequently requiring additional support because of complex mobility requirements.

The figure below illustrates the decline in journey numbers over recent years.

Figure 14: Number of Patient Journeys since 2010/11

Total NEPTS Patient Journeys

1000000 949566 928145 898298 900000 871764 843656 816289 797599 787666 800000

700000

600000

500000

400000

300000

200000

100000

0 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018

Development of the Five Step Model for NEPTS

As part of the new NEPTS commissioning arrangements, the NEPTS service model has been developed across five key steps. Throughout 2017-18, the Commissioning Quality Assurance and Delivery Framework has captured service improvements and key actions across each of the steps, which set out the patient journey from ‘help me choose’ to ‘take me to my destination’. The framework provides a clear structure against which the delivery of the service can be captured and measured.

The framework also provides for a complete suite of information about current health board use of non-WAST NEPTS, which sets the baseline for the transfer of work to the Welsh Ambulance Service, in line with the approved business case. Over the last year, we have worked closely with health boards to capture the activity and resource information which will support the transfer, and we have developed a detailed project plan which is discussed in further detail below.

The framework went live ‘in shadow form’ on November 1st 2017, and will be implemented in full during 2018/19. Work has already begun to develop a detailed suite of quality indicators, and this is being developed through the Delivery Assurance Group.

Figure 15: 5 Step Model for Non-Emergency Patient Transport Services

Transfer of Non-WAST NEPTS Work From Health Boards

A key enabler of the framework is the transfer of health board commissioned non-WAST NEPTS services to WAST. This a complex and lengthy process, which has been developed during 2017/18 and will continue to be delivered during 2018/19. The first step in the process is to ensure that the information provided to us is as accurate and robust as possible. We have done a significant amount of engagement with health boards to ensure that we can accurately capture the current position, and this is reflected in the schedules of the framework.

By transferring the work to the Welsh Ambulance Service, we expect to realise opportunities to create better value for money for NHS Wales through better coordination of services and efficiencies. This will allow savings to be re-invested to improve the service further, especially around discharge provision to support unscheduled care. The transfer of work will also improve the quality of service and governance, by ensuring that both WAST and non-WAST providers deliver services in line with the new framework.

Enhanced Services

 RENAL DIALYSIS

In September 2016, we introduced the NEPTS Enhanced Service for renal dialysis patients, and patients attending oncology treatment. The aim of the enhanced service was to ensure these vulnerable patients arrive and depart within 30 minutes of their treatment time starting and finishing. There are increased clinical risks if renal dialysis patients regularly have reduced treatment times because of the late arrival of transport, and it is important that all patients are collected and taken home promptly following the end of treatment.

The significant improvements made during 2016/17 have been continued during 2017/18. Throughout 2017/18, only one patient received three reduced treatments over a four-week period. This occurrence was not directly related to ambulance transport.

Figure 16: Renal Dialysis Enhanced Service Performance

Number of renal patients having 3 or more reduced treatments in a 4 week rolling period 14 12 11 11 10 8 6 6 6 5 4 4 3 2 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Jul-15 Jul-16 Jul-17

Jan-16 Jan-17 Jan-18

Jun-16 Jun-17

Oct-15 Oct-16 Oct-17

Apr-16 Apr-17 Apr-18

Sep-15 Feb-16 Sep-16 Feb-17 Sep-17 Feb-18

Dec-15 Dec-16 Dec-17

Aug-15 Aug-16 Aug-17

Nov-15 Nov-16 Nov-17

Mar-16 Mar-17 Mar-18 May-17 May-16

 END OF LIFE

2017/2018 saw the successful introduction of the NEPTS end of life service, providing terminally ill patients with transport to the place they choose to spend their final hours.

The service provides a timely and coordinated response for patients using the service. Colleagues providing the service have completed specialist training in supporting end of life patients and their families. In 2017/18, NEPTS undertook 1,297 end of life journeys.

 DISCHARGE SERVICES

During the year, NEPTS continued to play an important role in supporting the Welsh NHS through the discharge of patients from hospitals across Wales.

During 2017/18, NEPTS undertook 50,687 discharges. This is a reduction on 2016/17, which is in-line with an overall reduction in NEPTS journeys in 2017/18. That said, the number of discharges being undertaken by NEPTS demonstrates the importance of the service in supporting patient flow within our hospitals.

 PATIENT EXPERIENCE

Improving patient experience across all areas of our organisation is a key priority for us, and is one of our key NEPTS objectives, underpinned by the Care Standards defined in the NEPTS Commissioning Quality Assurance and Delivery Framework. In 2017/18, NEPTS introduced a number of local and national projects to support improvements in patient experience.

 NATIONAL CALL TAKING

In 2017 we merged our Central & West and North Wales NEPTS booking centres to increase call taking capacity, in an effort to reduce patient call waiting times. This is the first step towards the implementation of a national call taking model, with the South East Wales booking centre starting to be merged in summer 2018.

 VEHICLES

In March 2018, NEPTS took delivery of 67 new NEPTS ambulances. These new ambulances are part of our fleet modernisation programme, supported by Welsh Government, to replace our older vehicles. These vehicles provide our patients with an improved experience and are able to support patients with varying clinical and mobility requirements.

The new vehicles are also more environmentally friendly as a result of reduced emissions and improved fuel efficiency.

To enhance our patients’ experience during transport, a trial was undertaken in 2017/18 in Cardiff where information screens were installed in vehicles.

One of new 18 Plate NEPTS Ambulances, funded by Welsh Government

Hybrid Vehicles

In our first steps towards reducing the carbon footprint of our fleet, we introduced two hybrid fuel vehicles. These two vehicles have been used to convey patients within the urban areas of South Wales, and have allowed us to understand how alternative fuel sources can be used in the real world.

GOOD TO GREAT

We introduced our Good to Great project in our Cardiff and Vale operational area in 2017/18.

The aim of the project was to work closely with our operational teams to implement service change ideas that would improve service delivery and improve patient experience.

These projects included the introduction of mobile phones so staff could contact patients in advance of their journey.

Additionally, staff were provided with torches and umbrellas to help when supporting patients into their homes.

Once evaluated, those successful projects will be One of Our NEPTS Hybrid Vehicles trialled and introduced in other areas of Wales.

COMMUNITY TRANSPORT

During 2017/18 we continued to develop our partnerships with non-NHS community transport providers across Wales. These services play an important role in providing access for people living in rural communities and, by working in partnership with these organisations, we are able to provide a valuable income stream that they can use to support their other work in the community.

Community transport organisations and voluntary ambulance services conveyed 52,455 patient journeys on behalf of NEPTS, equating to 6.6% of all our patient journeys in 2017/18. This is a 7.7% increase on 2016/17, when community transport and voluntary ambulance services undertook 48,679 journeys. To ensure we are able to capture the great work carried out by these community transport organisations, in 2017 we provided hand held devices to such organisations across Wales. Linked to our existing NEPTS computer aided dispatch system (CAD), these hand held devices allow community transport providers to accurately record their performance when conveying NEPTS patients. Figure 17: Community Transport and Voluntary Ambulance Service Journeys since 2013/14

Non-Emergency Patient Transport Services (NEPTS)

Community Transport & Voluntary Ambulance Service Journeys 60000 50000 40000 30000 20000 10000 0 2013/14 2014/15 2015/16 2016/17 2017/18

Over the 2017/18 winter period, the NHS as a whole experienced significant challenges with an increased demand for services, coupled with periods of adverse weather conditions. During these challenging periods, NEPTS worked closely with our Emergency Medical Service (EMS) colleagues, providing resources and support to help flow into and out of hospital.

There remains much to be done but there is the momentum and will to continue the NEPTS journey of improvement in 2018/19 and beyond. Our Volunteers

We very much value the contribution that our many volunteers make to the Welsh Ambulance Service, whether that’s as a volunteer car driver or as a Community First Responder. Many of our patients benefit from the skills and contribution of our volunteers, and we are very grateful to the many people across Wales who give up their time to support us and our patients.

Investing in our volunteers, whether that be in training, in equipment or in recognising their contribution, is high on our list of priorities, and we remain committed to building on these relationships further in the coming years.

VOLUNTEER CAR SERVICE

Our Volunteer Car Service (VCS) is an important and highly valued part of our NEPTS team. The service provides a comfortable, reliable and caring way to travel long distances across the rural areas of Wales, especially for those patients travelling for life sustaining treatments like kidney dialysis or radiotherapy, for example.

Training for our VCS drivers includes first aid, safeguarding, health and safety and conflict resolution. Volunteer drivers must re-qualify annually and are provided with an Automated External Defibrillator (AED). Just like our community transport providers, our volunteer car service drivers have been provided with hand held devices allowing them to effectively communicate with the NEPTS Control Centre and record journey data. Volunteer cars are also checked on a regular basis to ensure they continue to maintain the high standards we expect.

Attracting volunteers is a challenge most organisations face, and NEPTS is no exception. We are constantly looking for volunteer drivers to help provide this valuable service to our patients, and we would be delighted to hear from anyone interested in supporting us. Expenses are covered at a rate of 39p per mile and volunteers receive training and support, as well as a great deal of personal satisfaction from knowing they are making a real difference to the lives of some of our most vulnerable patients.

If you are interested in joining our Volunteer Car Service, please telephone us on 01633 626262 or e-mail us at [email protected].

Community First Responders

Community First Responders (CFRs) are volunteers who give their time freely to help care for people and save lives in their community. They are everyday people who are trained to deal with a wide range of potentially life threatening conditions or, sometimes, simply to provide reassurance until the arrival of an ambulance.

Supported by our first responder departments across Wales, in 2017-18 our CFRs attended an incredible 20,084 emergency calls, which equates to an average of 1,674 per month, arriving first on scene more than 75% of the time.

Figure 18: Percentage CFRs Arriving First on Scene

% CFRs Arriving First On Scene 95.00%

90.00%

85.00%

80.00%

75.00%

70.00%

65.00%

The Welsh Ambulance Service is a Category One Responder under Emergency the Civil Contingencies Act 2004 (CCA), the UK Government’s Preparedness Counter Terrorism Strategy (CONTEST) and the Security and Counterterrorism Act (2015)

The Resilience and Specialist Operations department comprises an area manager, three regional resilience managers responsible for specific health board areas across Wales and Local Resilience Forums (LRFs), as well as the Hazardous Area Response Team (HART), the Special Operations Response Team (SORT), business continuity officer and an event planning manager.

The resilience managers work closely with key partners in delivering against statutory (Civil Contingencies Act 2004) and non-statutory guidance in relation to emergency preparedness, resilience and response (EPRR).

Resilience managers engage through the Local Resilience Forums (LRF), which are co- terminus with the four Welsh police forces. The department is also engaged in national (UK) fora to support the area of operations from Resilience / EPRR, HART and SORT.

We also engage, at a Welsh level, with the relevant resilience fora, and are engaged in the UK Contest Board and the UK counter terrorism strategy.

Under the Civil Contingencies Act 2004 (CCA) Category One responders are subject to the following full set of legal civil protection duties:

 Risk assessment  Emergency planning  Business continuity planning  Warning and informing  Information sharing and Co-operation

In ensuring we are fully discharging our legal obligations, and ensuring that we are in a suitable state of readiness to react to any situation, the Trust’s preparedness, resilience and business continuity processes are constantly reviewed and updated.

The Welsh Ambulance Service’s HART team forms the central core of what would be the Trust’s response to any major incident, physical incident or weather-related event (including, in the current political climate, the organisation’s response to any acts of terrorism). It employs 35 paramedics and seven HART Team leaders, supported by 2.8 whole time equivalent (WTE) management and administration staff.

Welsh Ambulance has long recognised the need for research and Pushing the development to be a core activity in the development and delivery of its Boundaries services. of The research and development (R&D) functions of the Welsh Ambulance Service are delivered by the Pre Hospital Emergency Research Unit (PERU), which is funded by Health and Care Research Wales (HCRW). The 2015-2019 R&D Strategy outlined our vision as to: Knowledge “Build a culture where research can flourish, influencing practice for patient Research & benefit.”

Innovation In 2017-2018, PERU continued to serve its function as the R&D office for WAST by ensuring that all research adheres to the principles of good practice in the management and conduct of

health and social care research.

We worked closely with HCRW on many policy and organisational changes, which included

work with the four UK countries’ National Compatibility Programme and changes with the set

up and carrying out of health research across the NHS and Health and Social Care. We also

continued to achieve the following aims within our IMTP:

 Adopt the HCRW Finance Policy and framework for Health Boards

 Continue to build a culture where research can flourish, influencing practice for patient

benefit

 Develop the number of principal and chief investigators within WAST

 Work with our partners to build capacity and attract research funding

 Continue to deliver our current research efficiently, on time and target  Mobilise knowledge gained from our research into policy and practice

In 2017 we worked with HCRW to develop and adopt the NHS Research and Development Finance Policy, which was also supported by a Welsh Health Circular (2018), and has been accepted for adoption by the organisation.

R&D performance continued to grow in our organisation throughout 2017 to the highest level in the history of ambulance services in Wales, delivering the research shown below on time and target.

Figure 19: Increases in WAST Research Performance: HCRW 2018 Business Intelligence Report

We are now a leading UK research active ambulance trust, contributing to eight studies adopted on to the HCRW Clinical Research Portfolio, with a further eight non-portfolio studies.

We have also developed home grown research, and our collaborations with Prime Centre Wales, Swansea Trials Unit and others have resulted in grants being secured, and studies being led by WAST as sponsor for the first time.

These studies explored areas of international significance contemporary for pre-hospital care, including stroke, hip fracture and SEPSIS.

We continued to develop the research culture in our organisation, and more than 877 staff have now been trained to deliver research within the Trust. We continue to provide learning opportunities in the form of CPD events, research grant writing courses, and have attracted funded MSc and PhD opportunities. Within the R&D Strategy, we recognised that evidence based practice is integral to clinical leadership, and we contributed to the newly introduced clinical structure. Research now features as a core activity in a wide range of roles within this structure.

We have continued to disseminate knowledge gained from our research to influence policy and practice. We have been authors on 19 peer publications in a wide range of journals. We have delivered 24 peer reviewed presentations to a range of local, national and international conferences, and contributed to eight non-peer reviewed seminars and events.

The results from our research achieves far reaching impact on patient care, influencing high level policy and guidelines, such as the Joint Royal Ambulance Liaison Committee (JRCALC), Resuscitation Council Guidelines, National Institute of Clinical Excellence, and many others.

Our publications on paramedic care for people who self-harm was cited in the International Handbook of Suicide Prevention, and knowledge from this study has been drawn upon to inform evidence for a range of Government and parliamentary inquiries

OUR PEOPLE Our People… As an ambulance service, we are all about our people. We cannot deliver high quality care or continue to improve our services without Our Places the support of everyone who works for us.

We employ more than 3,000 people, clinical and non-clinical. You can see the make-up of our workforce in the table below:

Category 2017/18 2016/17

Additional Clinical Services 1,428 1,356

Administrative & Clerical 470 476 Allied Health Professionals 982 986 Estates & Ancillary 45 48 Medical & Dental 4 2

Nursing and Midwifery 130 92

Total 3,059 2,982

The figures relate to the average number of employees under contract of service in each month of the financial year, divided by 12 (and rounded to nearest whole time equivalent). The table below excludes agency and seconded-in staff.

Our employee base has risen this year, in part as a response to last year’s demand and capacity review, which looked at the type of staffing and skills we need over the coming years to meet the projected demand on our services in the future.

As part of our response to rising demand and the need to re-profile our workforce, we have invested in our frontline staff across the organisation to ensure we have the right skills and abilities across our services to meet the needs of our patients.

We continue to strive to be a balanced and diverse employer of choice, where colleagues are valued, and treated, as individuals. Our gender balance remains approximately 40:60 female to male, and our senior manager balance in 2017/18 was very similar. We have also published our gender pay gap information, which you can learn more about here.

You can read more about our plans to achieve a more diverse workforce and our progress so far in our Treating People Fairly Plan and find out a bit more later in this report.

Band 6 Paramedic Project

Since the development of extended skills for ambulance staff in the late 1980s, the role of the paramedic has fundamentally changed. By 2017, the role of a paramedic spanned both emergency and unscheduled care, providing advanced treatment for patients with acute clinical needs, but also assessing and signposting patients to the right part of the system for lower acuity problems.

Paramedics provide advanced life support, make emergency treatment decisions and practise in an environment with autonomy which is arguably not shared by other healthcare professionals of similar banding. This challenging and changing role has also resulted in paramedics working across the healthcare sector, rather than being restricted to traditional ambulance crew roles. This changing role, and the wider contribution of paramedics across the unscheduled care system, was recognised in 2016 with the UK profile for a paramedic moving to Band 6 pay level. In early 2017, the Trust, in collaboration with trade union partners and Welsh Government, entered into discussions on the implementation of a Band 6 paramedic role in Wales.

These discussions resulted in a distinctive Welsh agreement for paramedics living and working in Wales. The Band 6 job description/person specification for a paramedic in Wales was reviewed and updated, along with the scope of practice, to reflect better the role and demands on the modern day paramedic, with an enhanced set of competency requirements based on the top 10 most common conditions.

Arrangements were agreed to support the transition to the Band 6 role, with a comprehensive training programme to both refresh existing and learn new competencies. And a new “Emergency Medical Technician 3” role was created at a Band 5 level to enable a ‘step across’ for those who did not wish to operate at the Band 6 level, as a dignified alternative. These changes are all seen to support the next stage in the evolution of the paramedic profession in Wales.

A “robust” business case was agreed with Welsh Government in September 2017 to fund the changes, with 55.41 FTEs “stepping” across” to the EMT3 role while the remainder of the approximately 900-strong paramedic workforce indicating their wish to move to the Band 6 role in October 2017.

A range of measures has been identified so that the Trust and its stakeholders can measure the benefits of the introduction of the Band 6 for paramedics and the training programme on future patient care.

The Band 6 paramedic project is a good example of how we want to go about our business: creatively problem solving, in partnership with our trade unions and with strong clinical leadership.

Staying Well

The health and wellbeing of our colleagues is crucial to delivering and maintaining safe, high quality healthcare. We know that, by looking after our colleagues, and encouraging colleagues to look after themselves and each other, this benefits our patients and communities across Wales.

Working at the Welsh Ambulance Service can be mentally and physically challenging, regardless of the roles we are in, because of the nature of the services we provide and the pace at which we work. Our colleagues are often placed in positions where they can quickly become unwell, so supporting people before they do, or if they do become unwell, and helping colleagues to be as healthy, well and resilient as possible, continues to be a priority for us.

To help build a culture where people are healthy and well, we have continued to use our shared vision, purpose and behaviours as a focus. This is helping to create a culture where everyone is valued and supported. An example of this during 2017-18 has been the collaborative development of our updated approach to 1:1s and Personal Appraisal Development Reviews (PADRs).

The nature of our work means that we face challenging situations every day and we are continuously working to ensure we have the right interventions and support in place to support both the physical and emotional health and wellbeing of our colleagues. This was recognised in December 2017, when we were awarded the Corporate Health Standard Gold level.

In 2017-18 we placed a real focus on taking action to improve the mental health and wellbeing of our staff.

Building on our signing of the Time to Change Wales pledge, we have continued to create a culture where individuals are supported to know that it is “ok to not be ok”. We take every opportunity to build resilience, such as the mindfulness support provided in our Clinical Contact Centres and the Shift Your Stress licensed packages we have trialled.

We also recognise that, for many of our frontline colleagues, there is a need to support them, particularly when they have been exposed to traumatic incidents.

In 2017-18 we were able to develop our approach to TRIM (Trauma Incident Management) so it could be launched in April 2018. Additionally, we put in place Sustaining Resilience at Work (StRaW) in our Clinical Contact Centres to help recognise and provide support for colleagues who are more likely to be placed under mental duress. We have also built partnerships with MIND Cymru to access specific support for blue light organisations, as well as TASC (the Ambulance Services Charity), by them supporting/training colleagues.

Sickness Absence

It is important that we continue to performance manage absence robustly and fairly, and we have provided line managers and staff with resources to do this in the form of sickness audit toolkits, local sickness action plans, signposting access to support through the Employee Assistance Programme and TASC.

2017/18 saw our sickness rate fail to reduce in line with the set targets and, while an increase would be expected to reflect seasonal variations in the winter months, rates across December and January were among the highest we have experienced for a number of years. This is despite implementation of a range of actions to support achievement of the Trust’s target, a number of ‘deep-dives’ to look more closely at the problem, and a real focus on improving the health and wellbeing of our colleagues, as described above.

Figure 20: Sickness Absence 2017/18

2017-18 2016-17 Days lost (long term) 58,437.04 53,593.42 Days lost (short term) 21,604.64 20,339.59 Total days lost 80,041.68 73,933.00 Total staff years 3,073.03 2,982.19 Average working days lost 1,627.92 1,548.12 Total staff employed in period (headcount) 3,274 3,166 Total staff employed in period with no 836 842 absence (headcount) Percentage staff with no sick leave 26.76% 28.00%

The Trust’s sickness absence target for 2017/2018 was 5.90%. Rates did not decrease in line with the planned sickness target and in March 2018, we achieved a sickness rate of 7.58%. While an increase would be expected to reflect seasonal variation, the unprecedented harsh winter would appear to have impacted substantially on sickness rates, with January’s sickness rate being the highest recorded since 2013, as an example.

The Trust continues to performance manage absence robustly and implemented a number of actions in 2017-18 that built on those reported in last year’s Annual Governance Statement. These will continue to be refined by the Trust in 2018-19 and include:

 proactive management of individual long-term sickness cases  exploration of a business case for physiotherapy services  review and refresh of the sickness audit toolkit and  creation of a redeployment policy

Particular focus on proactive management of individual long-term sickness cases continued throughout 2017/18, which saw a decrease in the number of long term sickness cases over 90 days in a number of areas across ambulance response, along with corporate directorates.

There’s more information about this in our Performance Report

Flu

In 2017/18 we saw an increase in staff receiving the season flu vaccination, with 40% of all staff and 39% of patient-facing staff having their vaccination.

We are keen to work with staff to improve our uptake of the flu vaccination again this year, by building on the peer vaccinator model which has proved successful in many areas.

We will be striving to achieve the Welsh Government target of 60% of patient-facing staff receiving the vaccination. We know there are a number of practical and other barriers to staff being vaccinated and planning for our 2018/19 flu campaign has already started, with each area within the Trust being asked to submit their individual flu plans by the end of June 2018.

Future Vision for Education and Training

During 2017/18, we began to develop our vision for the future education and training provision in the Welsh Ambulance Service, engaging with key internal and external stakeholders in order to progress this into a transformational programme for delivery commencing 2018/19. As part of this programme, we have begun work on a supportive people strategy, to prepare our education and training workforce for the modernisation and transition ahead.

A Place for Everyone

At the Welsh Ambulance Service, we value equality and diversity and are working hard to make us a more diverse and inclusive organisation.

This means being a place where, regardless of background, belief, gender, sexuality or ethnicity, people feel comfortable to be themselves and one which reflects more closely the communities we serve.

More Than Just Words: Our Commitment to the Welsh Language

As an all-Wales service, we recognise the important role that the Welsh language plays for our patients and staff. Supporting our Welsh-speaking staff and patients in feeling comfortable to use their preferred language on a day-to-day basis is central to our commitment to being a culturally inclusive organisation. We remain committed to the Welsh Government’s More Than Just Words strategy which places being able to use your own language as an integral part of care.

As a result of the Welsh Language Measure 2011, the Trust’s Welsh Language Scheme was replaced in 2015/16 with the new Welsh Language Standards. We will continue to implement our approach until the new Welsh language standards for the health sector come into existence, working closely with the Welsh Language Commissioner to ensure we meet our obligations to staff and patients.

To improve the Welsh language skills of our staff, we have registered with the ‘National Centre for Learning Welsh’.

This provides opportunities for colleagues to receive a free 10 hour online course teaching basic Welsh suitable for use in the workplace. Staff are able to meet and greet colleagues, customers and stakeholders using Welsh phrases. More than 70 of our staff have registered on to the course, with one member of staff taking the opportunity to attend an intensive Welsh language residential course at the Welsh Language Centre, Nant Gwrtheyrn.

Figure 21: Welsh Speaking/Listening Levels 3-5 (intermediate to fluent) @ December 31st 2017

Assignment Achieved % Level 3-5

Count

3035 453 14.93%

We are committed to ensuring that the services our patients receive, and our policies and initiatives, are consistent with the Welsh Language Scheme. To support this, the Equality Impact Assessment process includes a section to identify how service changes impact on Welsh speakers. We are committed to the Welsh Government More Than Just Words Strategy and will put in place action plans to meet the requirements of the strategy and improve bilingual patient information, recruitment of Welsh speaking staff, and education, awareness and training.

You can read more about our work in this area by reading our More Than Just Words Annual Report

Equality, Diversity and Inclusion

We continue to make progress in our second year of Treating People Fairly which is our equality and human rights strategy. Very simply, our aim is that we create an environment where, regardless of background or circumstances, each patient is provided with a high quality service to meet their needs and every colleague achieves their full potential.

Our aim, at the heart of all of our plans, is to move from “treating people how we want to treat them” to “treating people how they want to be treated”. Treating People Fairly is significant as it links how we are playing our part in delivering the Equality, Welsh Language, Well-being of Future Generations and Social Services and Well-being Acts. The most important part of delivering Treating People Fairly is helping every colleague to recognise, understand and value difference in everyone by recognising that everyone is a unique individual and ensuring that no-one is excluded.

We have had a number of achievements during this year; these include developing and implementing our Workforce Race Equality action plan in response to the NHS England Workforce Race Equality Standard (WRES). Although the standard does not apply to Wales, we felt it was an important one for us to adopt, as a Trust, in line with ambulance services in England.

By focusing on support for positive action and challenging ourselves to improve our BAME workforce diversity, we are already seeing culture change, which we plan to accelerate in future years. To help us, during 2017-18, we were also accepted as part of the NHS Employers Diversity Partners Programme and actively participated in this UK learning network, the first Welsh NHS organisation to be involved.

Sharing Expertise Overseas: Wales for Africa

The Welsh Ambulance Service has been supporting the charity Partnerships Overseas Networking Trust (PONT) since 2009, working in the Mbale region of Uganda to tackle poverty and improve access to basic health care. We have continued to support the scheme throughout 2017/18 and it continues to go from strength to strength, providing a lifesaving resource to the rural communities.

Sharing passion, expertise and knowledge, our staff have been instrumental in the development of a motorbike ambulance service in Mbale. The region has poor roads and infrastructure, and motorbikes are more suited to the terrain than four-wheeled vehicles. The scheme also provides bicycle stretchers and mountain rescue stretchers to help reach the more remote communities.

The service, which mostly operates on a 24/7 basis, has now completed more than 25,500 journeys since its launch in December 2010. It operates through a network of volunteer Village Health Teams, whose workers make an initial triage of patients and call for ambulance transport if they feel it is appropriate.

Approximately 65% of patients transported continue to be maternity or obstetric related; the remaining 35% of journeys convey children and adults with various other illnesses and injuries. Staff are planning their next visit in early 2019 to carry out further training with the Village Health Teams, and also to carry out monitoring and evaluation work.

With the support of WAST, the ‘Pennies from Heaven’ scheme is now in place. This is a simple fundraising scheme to support the work of the charity; it allows the contributor to donate the odd pennies from their pay to the charity each month. The charity is also currently seeking support from any individual who would be happy to donate a fixed amount each month.

More details are available on the website PONT Mbale and on the Welsh Ambulance website. The scheme is organised by Julian Newton and Tony Rossetti who can be contacted by email: [email protected] and [email protected]

Our Places OUR PLACES

The Trust has 113 buildings. The effective management of our building stock is another key plank of our improvement journey. A dynamic approach is required to rationalising the estate to better reflect individual locality requirements and to expedite the wider programmes of change in our organisation, for example, our strategic plan for fleet.

Key drivers for change in our estates include:

 Providing the right quality of premises resulting in an estate portfolio which is safe, appropriate and flexible; meeting all statutory obligations. The current backlog maintenance could be largely eliminated, and there will be a planned preventative maintenance regime to ensure properties are maintained to appropriate standards

 Providing the right type of premises in the right location to allow for the effective and efficient control, management and deployment of resources, including exploration of partnership opportunities with local partners

 Developing and rationalising the operational estate on a hub (Ambulance Resource Centre – ARC / Make Ready Depot - MRD) and spoke (Social Development Point - SDP) basis

 Developing the non-operational estate to include three Clinical Contact Centres (CCCs) and regional administrative centres with the potential to include training facilities

 Implementing locally adapted solutions to implementing the concept of washing and stocking to support cost effective operational services and minimise risk of cross infection; and

 Providing sustainable solutions towards the environment

The Estates Strategy and Strategic Outline Programme 2017 is now endorsed by Welsh Government. This provides (subject to funding) a radical estates transformation programme designed to support the fleet function, in particular, to implement a “make ready” approach to effective vehicle washing and stocking on a hub and spoke basis. The “make ready” approach provides a

purpose built facility with colleagues whose primary responsibility is to ensure that our vehicles are both clean and appropriately stocked. This enables frontline colleagues to concentrate on service delivery, as well as reducing infection risks.

During 2017/18, the estates capital programme delivered, among other things, the acquisition of Unit 7, St Asaph Business Park, which will be partly refurbished in the latter part of 2018 to serve as an improved administrative centre in North Wales, replacing the current base at HM Stanley.

In addition, the estates capital programme directed funding into maintaining and improving Trust premises and, in so doing, reduced risk around backlog maintenance and contributed to improvements in staff wellbeing. Completed schemes at ambulance stations included:  Blaenau Ffestiniog – returned to property condition B  Relocated operational crews to Barry Fire Station  Technology refresh to Control Room at Vantage Point House  Increase in floor area at Vantage Point House – training on 1st floor  Started projects to relocate operational crews to Fire Stations at Llanidloes and Whitland

Also of note during 2017/18 is that the Estates Department continued to manage the Trust’s emissions and environmental objectives arising from Welsh Government’s mandate for all Trusts in Wales to operate an environmental governance system (EGS) and to have the EGS accredited under the international standard ISO 14001 Environmental Management.

At the Welsh Ambulance Service, we have one of the most modern and Keeping us well equipped fleets in the country, thanks to continued support from Moving: Welsh Government, which funded replacement of emergency, specialist and non-emergency vehicles during 2017/18. Our Fleet This year, we also developed a longer term strategic outline plan for our fleet of the future, which complements a similar plan for our estates. This plan outlines the preferred model for fleet moving forward, to ensure we can continue to meet the needs of our operational staff in the future. For example, from work undertaken in 2017, it is clear that carrying out vehicle servicing, maintenance and repair (SMR) in Trust workshops by our own staff is the most cost effective model.

The strategy is to develop fleet services so that the department is in a position to undertake the entirety of the SMR in-house.

We have been fitting telematics to all new vehicles since 2014.The majority of ambulances and rapid response vehicles are now equipped with both black box technology and forward facing camera systems, both of which help to reduce road risk for staff, patients and the general public. The strategy is to fit the entire fleet through the vehicle replacement programme.

During 2017, the Fleet Department constructed and implemented a replacement computerised fleet management system.

This state-of-the-art system has revolutionised the way the department operates and we are already benefitting through improved efficiencies.

One of the key objectives for the coming year is to implement a fleet and logistics help desk. The desk will be able to access the vehicle on-board telematics and, in conjunction with the new fleet management system, will have the ability to assist all stakeholders involved with regard to all vehicle-related incidents and activities.

The desk will be able to coordinate all non-operational vehicle movements, utilising in-house vehicle movement teams as well as third party contractors to ensure vehicle down time is kept to a minimum, and availability is maximised.

Quality at The Welsh Ambulance Service is committed to being a quality-driven organisation. This means that quality underpins everything we do. Every the Heart year, we publish an Annual Quality Statement, which tells you more of What We about what we are doing to bring our quality agenda to life across the organisation. Do As the only ambulance service in Wales, we know how important it is that we are there for you when you really need us. We are continuously reviewing and improving services based on patient, carers and staff feedback.

We use the key principles of the Welsh Government’s Health and Care Standards as the basis for our quality agenda. These are:

 Staying healthy  Providing safe care  Delivering effective care  Treating people with dignity and providing dignified care  Providing timely care

 Treating people as individuals

 Staff and resources

The Trust Board approved the Quality Strategy 2016-19 in March 2016 and the Health and Care Standards are aligned throughout the Strategy as a control framework to operate in. Our priorities to inform the strategy were identified through consultation with staff, patients, public and stakeholders, while also considering our Commissioner’s requirements through the CAREMORE© Commissioning Framework. This strategy will be reviewed during 2018 following publication of the Welsh Government Quality Delivery Plan.

You can read more about what we are doing under each of these headings to improve the quality of the services we provide in our Annual Quality Statement

This year, we have continued our drive for improvement on the quality front, with good progress made in a number of areas. However, the challenging winter period took its toll, and we saw a sharp increase in the numbers of concerns and serious adverse incidents reported.

Serious Adverse Incidents

The number of SAIs (Serious Adverse Incidents) recorded by incident date1 between April 1st 2017 and March 31st 2018 was 62.

The length of some amber waits and the spike in SAIs are a serious challenge for us, and one we will work hard on during 2018/19. While outside of the 2017/18 reporting period for this report, an “Amber Review” has been commissioned by Welsh Government, to be undertaken by EASC and completed by mid-2018/19.

Each concern and incident is investigated thoroughly and we aim to learn lessons from the experiences of our patients, their families and carers, and our staff. In reviewing these cases, our focus is always on the quality of care and experience that our patients receive, and we are sharing our learning with the wider NHS in Wales so that we all understand our roles in maintaining quality of care for our patients, even in the most challenging of circumstances.

There have been many patients and staff stories presented to our Quality Patient Experience and Safety Committee (QuESt). These have included people’s experiences of our services and the complexities in accessing our services for those with dementia or sensory loss, as well as the experiences of staff responding to people in mental health crisis.

The QuESt committee has been active in overseeing developments and results to improve the quality and safety of our services. The committee has overseen improvements in the way we investigate and respond to complaints and incidents.

Earlier in the year, the independent regulator of healthcare in Wales, Health Inspectorate Wales, conducted a review of how effective our governance arrangements were in promoting safe and effective care. It found that the Trust had fostered a ‘more

1 SAIs are recorded for the period between 01/04/2017-31/03/2018 based on incident date and not by reporting date, which may be different.

open and supportive culture’ and that there had been improvements in the way we manage complaints and serious adverse incidents, in particular the speed that these are responded to.

Our Mental Health Improvement Plan to deliver better experiences for patients in mental health crisis, and care for our staff, has been fully supported by Welsh Government, with funding made available for us to put in place a strong mental health structure and deliver appropriate training for staff over the next three years. Ensuring our compliance with health and safety requirements across the Trust has been another focus of our QuESt Committee. All issues that pose a potential threat to patient and staff safety are being accurately recorded and regularly reviewed.

We developed our “Promises to Children and Young People”. We worked on these with the younger members of our communities to really listen to things that were important to them when in contact with our services and we hope they make a difference to the experiences of children and young people who need to use our services.

As set out earlier in this document, our clinical response model also has a set of Ambulance Quality Indicators (AQIs), which are monitored monthly and published quarterly. In addition, we have developed a number of internal quality ambitions and outcome measures, which you can read more about in our Integrated Medium Term Plan (IMTP)

You can read more about quality governance and the way in which our Board receives assurance about our quality agenda in our Annual Governance Statement.

An Open Culture

One of our guiding principles here at the Welsh Ambulance Service is that of always listening to, and learning from, our staff, patients and the wider public about their experience of our services. This is a valuable element of our quality and improvement processes

While there has been significant progress in ensuring that complainants received a timely response to their concerns, there was an adverse impact from the challenging winter period, both in terms of the number of concerns we received and our ability to investigate them in a timely fashion. The most common reason for complaining was the service’s inability to respond to incidents in an appropriate timeframe.

Timeliness has been a common theme running through incidents, complaints, claims, coroners’ reports and patient experience feedback.

This meant that, while our Concerns Improvement Plan demonstrated sustained improvement until March 2018, compliance reduced in the wake of the high volume of concerns received. That said, we continued to achieve a 98% rate on our two- day acknowledgement and 68% rate on our 30-day response rate to complaints.

The graph below demonstrates the impact of a high volume of concerns received during the first three months of 2018 and their impact on our ability to respond to them within 30 days.

Figure 22: Concerns Response within 30 Days

Freedom of Information (FOI)

We dealt with 238 requests for information under the Freedom of Information Act in 2016/17. This is an increase on the 2016/17 figure of 209 and symptomatic of a generally growing trend.

If you would like to request information under the Freedom of Information Act, you can email us at [email protected] or write to our Board Secretary using these details:

Mr Keith Cox Board Secretary Welsh Ambulance Services NHS Trust Headquarters HM Stanley St Asaph Denbighshire LL17 0RS

The Well-Being of Future Generations (Wales) Act 2015 came into force Working in April 2016 and places a statutory duty on Public Service Boards, and across certain named public bodies, to improve the social, economic, Boundaries environmental and cultural well-being of Wales, in accordance with the sustainable development principles.

While the Welsh Ambulance Service is not a “named organisation” subject to the new duties, we are committed to working within the spirit of the Act, as outlined in our Integrated Medium Term Plan (IMTP)

In light of this commitment, we have kept our dialogue live on how best to engage with the tenets of the Act, its wellbeing goals and ways of working, and how we can engage with the public service boards across Wales.

We have conducted a self-assessment for a Wales Audit Office review of how well we are using the sustainable development principles to guide our future planning.

We have also attended a number of shared learning events to understand better where our work fits in the context of the Act, and how we can optimise our existing partnership arrangements to deliver more innovative, collaborative public service solutions, as well as where, and how, we need to engage differently.

Some of the key questions and issues which are on our radar 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 We will continue with this work as we move forward in 2018/19, using the outcome of the Wales Audit Office review to inform some of our next steps.

As an ambulance service, we recognise that we do not work in Working in isolation, but rather as part of the wider NHS system in Wales, and the Partnership Welsh public services more generally.

Working together is an important facet of improving patient experience and outcomes. We have three collaborative priorities where we believe there is a clear opportunity to add value. These include in estates, training/occupational health and in collaborative working with fire and rescue services. Our work with partners is extensive and detailed below is a flavour of our collaborative working in 2017/18.

Wider Unscheduled Care System/Primary Care

During 2017/18 we have engaged 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 our transformation of ambulance services in Wales.

Working with our Local Health Board partners and, in particular, the network of primary care clusters to develop a clear, persuasive narrative that explores and describes the role for paramedics in primary care, clearly forms part of the development of our longer term strategy work, for example, widening our clinical offer to fully utilise the skills of our people and provide support and services in different settings.

We have also worked closely with LHBs on jointly agreed priorities which have patient and system-wide benefit. You can read more about these in our more detailed Performance Report

Blue Light Collaboration

The Trust has continued to expand our interaction and joint initiatives with our emergency services partners. Over the course of 2017/18 we have:

 Explored opportunities with blue light partners in regard to estates solutions for Blackweir station in Cardiff and stations in the Hywel Dda Health Board area

 Worked towards signing off a strategic partnership plan with the three fire services in Wales to agree common strategic positions across three themes - prevention / response / other

 Worked with health board and local authority partners to maximise joint training and occupational health opportunities

 Been in negotiation with South Wales and Gwent Police Forces along with South Wales Fire & Rescue Service to create a Tri-Service Demand & Intelligence Hub. Our commitment to put a joint team of analysts in the same room sharing intelligence to identify the root causes of demand will create a seamless information sharing Hub

 Supported police colleagues in South Wales, Gwent and Dyfed Powys with clinicians based in police control rooms, ensuring the most effective use of both police and ambulance resources

We know there is still more for us to do in the collaboration and partnership realm, work which will form an important part of our agenda moving forward.

The Wales Air Ambulance and Emergency Medical Retrieval Service (EMRTS)

The Welsh Ambulance Service works closely with the Wales Air Ambulance Charity (WAAC) and the Welsh Flying Medics (also known as EMRTS Cymru). The helicopter operation is run through charitable fundraising, while the Welsh Flying Medics programme is the medical provision on board the helicopters.

Together, it is a unique partnership between NHS Wales and the Wales Air Ambulance Charity that is able to provide critical care to some of our most vulnerable patients, often in challenging conditions.

The Wales Air Ambulance Charity relies on donations to raise £6.5 million a year to operate three HEMS (Helicopter Emergency Medical Service) aircraft and a fourth helicopter dedicated to hospital transfers, which forms part of its specialist Children’s Wales Air Ambulance division. Since its launch on St David’s Day 2001, the charity has carried out almost 30,000 missions.

In 2017 Wales Air Ambulance introduced a brand-new fleet of custom-made aircraft which has significantly enhanced operations. Three Airbus H145 helicopters were launched after a competitive tender process as part of a new seven-year lease, which drew international interest for Wales.

The helicopters replaced the charity’s three EC135 aircraft used for HEMS missions, which were introduced to Wales in 2009. The new helicopters, based at Wales Air Ambulance airbases in Llanelli, Welshpool and Caernarfon, are the largest H145 fleet in the UK.

The charity continues to operate an EC135 from its Children’s Wales Air Ambulance airbase in Cardiff.

Equipped with advanced technology and night-flying capability, the H145 fleet has several key benefits for crew and patients and brings the charity a step closer to its vision of providing a 24-hour service.

The service, which is operational seven days a week between 08:00hrs and 20:00hrs from the Wales Air Ambulance Charity bases in Llanelli, Caernarfon and Welshpool (HEMS) and Cardiff (transfers), is tasked via the Charity-funded Air Support Desk (ASD), based at the Welsh Ambulance Service Clinical Control Centre in Cwmbran. The ASD is staffed by one EMRTS critical care practitioner and one Welsh Ambulance Service allocator.

2017/18 mission data

Total missions: 2,684  1,867 by helicopter  817 by car*

Medical missions: 1,317 including –  508 cardiac arrests and heart-related problems  297 neurological conditions

Trauma missions: 1,367 including –  544 RTC missions  315 missions due to falls  364 missions were paediatric

We will continue to work closely with the Wales Air Ambulance and EMRTS service over the coming year.

*Crews have access to Rapid Response Vehicles which are used on WAAC missions where appropriate.

Managing Ourselves Effectively and Efficiently Quality at Making sure we manage the organisation in the right way is pivotal to the the Heart success of the Welsh Ambulance Service. We are committed to the of Good principles of good governance and of taking a rigorous and ethical approach to the way we manage our organisation. Governance Every year we produce an Annual Governance Statement. This Annual Governance Statement (AGS) is a key feature of our annual report and accounts. It demonstrates how we managed and controlled resources in 2017-18 and the extent to which we complied with our own governance requirements. In so doing, it brings together all disclosures relating to governance, risk and control.

This year, we developed our first, functioning Board Assurance Framework (BAF), which was formally approved by the Trust Board in September 2017.

The BAF is designed to collate information relating to the Trust’s strategic aims and details the associated principal risks from the Corporate Risk Register. It also describes the key internal and external controls and where and how management and the Board receive their assurances. The framework will be further refined during 2018/19 following the planned update of the IMTP.

During 2017/18 the Trust developed a governance map of the organisation in order to provide a greater understanding of the hierarchy between meetings, their reporting arrangements and relationships to Trust Board, its Committees and the Executive Management Team. Furthermore, the map will be utilised to understand the information flow between meetings and further streamline our reporting arrangements.

A subsequent review of all Terms of References, including membership, will take place during 2018/19.

The Trust implemented a new policy process during 2017/18 which was developed in partnership with our trade union colleagues.

The process is designed to bring all Trust policies up to date and will provide assurance to management and the Board that the Trust is complying with current legislation, is meeting mandatory requirements and is discharging its statutory duty.

A central policy register has been developed to provide tighter governance processes around version control and to track policies through the system. In addition, a new central repository and intranet page have been established for staff to access up to date information

Further information on the corporate health of the organisation, can be found in the Trust’s 2017-18 Annual Quality Statement

Looking forward, our targets and ambitions are explained in the Trust’s Integrated Medium Term Plan

You can read more about our governance arrangements in our Accountability Report and Annual Governance Statement.

Integrated The Trust’s Integrated Medium Term Plan for the three-year period from 2017-18 to 2019-20 was approved by the Cabinet Secretary for Health, Medium Wellbeing and Sport in the spring of 2017, and ensured the Trust met its Term Plan statutory planning duty.

We are proud that 2017/18 marked the second year of having an approved IMTP. (IMTP) and Having such a status has not only contributed to stabilising the organisation, but also afforded our Longer us the thinking space to consider what the long-term term strategic plan for the future of ambulance services in Wales needs to be. Term In the last 12 months, we have made significant progress in delivering against our IMTP strategic priorities but recognise that there remain areas where performance is fragile, where Strategy there is variation or where focused attention is required to demonstrate improvements.

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

In addition to this, the Trust Board (and its committees) and Welsh Government receive quarterly reports on performance against the delivery of the IMTP.

We submitted an updated IMTP for 2018/19 – 2019/20 in line with Welsh Government requirements by the end of March 2018.

We have made progress during the year on our first IMTP strategic action, which was to “finalise our long term strategy for ambulance services in Wales”.

Our Board and Executive Team spent the early part of 2017/18 considering what the cornerstones of our strategic framework should be. They identified four pillars:

 Widening our Clinical Offer

 Leadership and Workforce

 Working Together

 Embracing Technology

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

These exercises, which took place through the autumn of 2017, provided us with some rich and comprehensive information. Our Board considered all the available information at a Board Development Day in November 2017, and a further smaller workshop comprising executive leaders and some Board members took place in January 2018.

As a result of this work, we are now able to use this opportunity to begin highlighting some of the emerging indicative strategic ambitions. These will require further internal testing through 2018/19 as well as a targeted engagement process with some external partners.

We’ll be making more progress on this agenda in 2018/19.

2018/19 is likely to be a year of continuity and change for us here at the The Year Welsh Ambulance Service. While we need to continue to build on the Ahead progress we have made over the last few years, there is no time to stand still. 2018/19 We will be working hard to ensure that we continue to meet the likely rise in demand for our services by looking at new ways of using all our resources, human, financial and physical, to deliver optimum benefit.

This will inevitably mean changing, and improving, some aspects of the way we deliver services. Our solid and constructive relationships with our trade union partners will help us work through some of the challenges of change with our staff, building on the excellent and mature work undertaken over recent years, while we will be working across the wider NHS and public service in Wales to deliver new models of care where we believe we can make a real and supportive contribution to patient care.

The recently announced “Amber Review” will doubtless provide food for thought and will help inform the next stages in our development, while the finalisation of our long term strategy will inform the development of a new integrated medium term plan, which form a bridge to the future of the Welsh Ambulance Service.

Welsh Government’s newly launched health and social care strategy “A Healthier Wales” will also provide us with a context within which to develop and flourish.

This, coupled with the arrival in the autumn of 2018 of our new Chief Executive, Jason Killens, marks a new opportunity for us and we look forward to telling you about our progress in next year’s Annual Report.

Company Directorships

The following declarations of interest with regards to company directorships and other significant interests were submitted in 2017-18. Voting Members of the Trust are marked with an asterisk in the Table below.

Name Position Declaration Michael Giannasi * Chairman Director of Poolbank Consulting Ltd. Honorary Professor School of Human and Health Sciences, Swansea University. Helen Birtwhistle * Non-Executive Director of Wales For Europe. Director Lay Member of the Governing Body of the Church of Wales. Vice Chair of Standing Committee. Member of the International Advisory Board, Cardiff Business School. Volunteer with Oasis, an organisation to support asylum seekers/refugees. Emrys Davies * Non-Executive Director and Chair of Newport Road Director Maintenance Ltd. Retired Member of Unite. Kevin Davies * Non-Executive Army Reservist. Director Chair ABF The Soldiers Charity (Glamorgan) Member of the International Medical Panel, Halo Trust. Emeritus Professor, University of South Wales Independent Trustee St John Cymru Wales. Paton - The Motivation and Learning Trust.

Name Position Declaration Pamela Hall * Non-Executive Independent Member of Joint Audit Director Committee for North Wales Police. Chair of Steering Group for the Welsh Government Information Quality Improvement initiative. Secretary of Llandudno and Area Women’s Group. James Mycroft * Non-Executive Head of Customer Service, Principality Director Building Society, Director of Nemo Personal Finance Ltd (subsidiary of Principality Building Society). Martin Woodford * Non-Executive Secretary of Llandogo Memorial Green Director Committee. Secretary/Team Manager Tintern Sports Club. Paul Hollard * Non-Executive Independent Consultant for NHS Wales. Director Tracy Myhill * Chief Executive Director of Omnimark Ltd. (Company (1/4/17 to does not trade and never commenced 31/1/18) trading). Board Member, Trivallis Housing Association (Interim Chair September 2017 to January 2018). Honorary Colonel Welsh Field Hospital 203. Claire Bevan * Executive Honorary Contract Swansea University Director Quality, Lecturing. Safety and Patient Experience Brendan Lloyd * Executive None Director Medical

Name Position Declaration (1/4/17 to 31/1/18). Interim Deputy Chief Executive and Medical Director (1/2/18 to 31/3/18) Patricia Roseblade* Executive None Director Finance and ICT and Deputy Chief Executive (1/4/17 to 31/1/18), Chief Executive (Interim) (1/2/18 to 31/3/18) Christopher Turley * Executive None Director Finance and ICT (Interim) (1/2/18 to 31/3/18) Claire Vaughan * Executive None Director of Workforce and OD Richard Lee Director of Examiner for Royal College of Surgeons. Operations Hannah Evans Director of None Strategy,

Name Position Declaration Planning and Performance Estelle Hitchon Director of None Partnership and Engagement Keith Cox Board Secretary Treasurer of Thrive – Local Charity, Magistrate Cardiff and Vale.

Note: The Trust Board is the Corporate Trustee of the Welsh Ambulance Services NHS Trust Charity. All voting members of the Trust can act as a corporate trustee of the charity. In addition, four Non-Executive Directors have roles on the Charitable Funds Committee.

Report for the Interim Director of Finance, Financial Chris Turley Performance In 2017/18, the Trust achieved all of its financial targets as follows: against Achievement of 2017/18 Financial Duties and Targets Statutory Achievement of revenue financial balance √ Achieved Capital Spend = or less that the WG set Capital Resource Limit √ Achieved At least 95% of Non NHS Invoices by number are paid within 30 day √ Achieved Financial At the end of the 2017/18 financial year, the Welsh Ambulance Services NHS Trust reported Duties a small revenue surplus of £0.070m in its audited final accounts.

Each NHS Trust must ensure that its revenue is not less than sufficient, taking one financial year with another, to meet outgoings properly chargeable to the revenue account.

For Year Ended The first assessment of performance against the three-year statutory duty in NHS Wales was March 31 2018 at the end of 2016/17, being the first three-year period of assessment.

The Trust is, therefore, deemed to have met its financial duty to break even over the 3 years 2015/16 to 2017/18 as shown below:

Annual financial performance 2015-18 2015-16 2016-17 2017-18 Financial £000 £000 £000 duty £000 Retained surplus 49 44 70 163

 The Trust managed its cash resources and working capital to precisely achieve its External Financing Limit (EFL) target of -£0.929m.

 The Trust expended Capital Investment funds of £18.535m in new property, plant, equipment and ICT, utilising 100% of the Trust’s Welsh Government set Capital Resource Limit, without exceeding it.

 The Trust is required to pay at least 95% of the number of non-NHS invoices received within 30 days of receipt of goods or a valid invoice (whichever is later). The Trust met this target, paying 98.1% within the specified time.

REVIEW OF THE 2017/18 YEAR

In respect of the Trust’s total income, £177.9m was received in year (compared to £172.5m 2016/17), an increase of £5.4m.

Total revenue expenditure increased by £4.2m (2.43%) in absolute terms. This was predominantly the result of an increase of £6.3m relating to staff costs. A further £0.5m related to establishment costs and £0.9m to depreciation/amortisation. This was offset by a reduction of £0.5m in relation to reduced expenditure on disposable medical equipment, £2.0m relating to impairments of assets and £1.1m relating to losses and special payments.

In 2016/17 profit on sale from the disposal of three obsolete ambulance stations contributed £1.2m to the final balanced position. This explains why 2017/18 resulted in a balanced (small surplus) position even though income rose by £1.2m more than expenditure.

During the year there was a 1% pay award for all staff including Very Senior Managers.

The Trust continues to prepare and submit its accounts in line with International Financial Reporting Standards (IFRS). The accounts on page 92-109 are shown in this format in accordance with IAS 1.

STATEMENT OF COMPREHENSIVE INCOME (SOCI) FOR THE YEAR ENDED MARCH 31, 2018

Revenue from Patient Care Activities and Other Operating Revenue

 The Trust received £167.2m of revenue income from patient care activities during the year. This is an increase of £11.0m from the 2016/17 quoted figure. However, please note the explanatory comment in italics below

 £10.7m was received in respect of other operating income, a reduction of £5.6m from 2016/17.

 Total funding was £177.9m, an increase of £5.4m (3.1%) from 2016/17.

(Included within 'Revenue income from patient care activities' above of £167.2m are ARRP £2.0m (2016-17 £2.3m) and Air Ambulance £0.6m (2016-17 £0.6m). In 2016/17 these were included within 'Other operating income'. This is to reflect a realignment representing the true source of the funding involved. There has been no restatement of the comparator figure in the 2017/18 accounts.)

The main changes in funding were as follows:

£ million Increase in funding from the Welsh Government including £1.9m relating to paramedic re-banding and £0.5m for winter pressures. 2.9 Increase in funding from EASC including inflation uplift £2.8m. 3.3 Additional income received in relation to the costs incurred for the‘111’ 1.8 service. Reduction in funding relating to ring-fenced areas such as -2.6 impairments/ depreciation (-£1.1m) and PIBS (Permanent Injury Benefit Scheme) (-£1.3m), and other minor services.

Total 5.4

Operating Expenses

Operating expenses during 2017/18 totalled £178.0m. This is a net increase of £4.2m from 2016/17. This is mainly a result of:

 An increase in staff costs of £6.3m compared to the previous year. Main changes include £1.9m for the re-grading of paramedics, £1.5m associated with the costs of the 1% pay award / deal, £1.1m for developments within 111 and internal structural reviews, implementation of the apprenticeship levy of £0.5m and £0.3m for winter pressures

 An increase in depreciation/amortisation of £0.9m as a result of a higher base value of tangible/intangible fixed assets, including the implementation of the new CAD system

 An increase in establishment, transport and other areas of £0.9m including £0.3m relating to increased availability and disturbed meal breaks within the EMS area, legal fees of £0.1m and £0.2m as a result of increased fuel pump prices

 Offsetting the above increases are the following reductions in expenditure, demonstrating further delivery of planned savings and cost reductions, through increased efficiency and productivity

 A decrease in impairments of Property, Plant and Equipment of £2.0m. This year’s impairments included the adjustments arising as a result of the District Valuer’s quinquennial review of all land and buildings owned by the Trust. The prior year’s charge, however, was exceptionally high, as £4.6m of this related to the impairment of the new Ambulance and Fire Service Resource Centre (AFSRC) in Wrexham

 A decrease in losses and special payments of £1.1m, predominantly as a result of a reduction in the discount rate applied to the Personal Injury Benefit Scheme provisions (PIBS) in the preceding year

 A decrease in supplies and services of £0.8m as a result of non-recurring investment in this area in 2016/17 predominantly in relation to health and safety and infection control issues

Investment Revenue

Investment revenue has increased slightly because of an increase in interest rates over the course of the year. Interest on deposits was £0.036m in 2017/18 compared to £0.029m in 2016/17.

Other Gains and Losses

The Trust made no disposals of land or buildings during the year, with only vehicles and equipment sold during 2017/18. These sales resulted in an overall profit on sale of £0.218m compared to £1.477m in 2016/17. Of the previous year’s profit on sale of £1.477m, £1.380m related to disposals of three obsolete ambulance stations.

Finance Costs

Finance costs have decreased during the year to £0.155m, a decrease of £0.118m compared to the previous year. Of these costs, £0.137m relates to interest on the Ambulance Radio Replacement Project (ARRP) treated as a finance lease under IFRS.

The result of all the above is that the Trust had a retained surplus of £0.070m for the financial year 2017/18. In 2016/17 the Trust reported a retained surplus of £0.044m.

STATEMENT OF FINANCIAL POSITION AS AT 31 MARCH 2018

Non-current Assets

The net value of the Trust’s non-current Assets increased by £4.735m from 2016/17 to 2017/18.

A total of £18.5m was invested in new and replacement assets. This was financed from the Trust’s Welsh Government funded discretionary capital allocation and funding from the All-Wales Capital Programme.

This expenditure of £18.5m included a total of £9.0m* spent on vehicles, £5.4m* on information technology and intangibles (including over £3.5m on a new EMS CAD ‘Computer Aided Dispatch system’) with the balance being invested in the Trust’s Estate (including £1.0m in respect of acquiring the replacement North Wales Regional Headquarters).

*The amounts quoted for spend on vehicles, ICT and intangibles represent the actual amount spent in-year, rather than the amount capitalised, as per the full accounts.

Current Assets

At year end, the Trust had £9.8m invested with HM Treasury National Loans Fund. This mainly related to Welsh Government funding for committed and expended capital items, for which the actual cash payments are expected to be made early in the 2018/19 financial year.

Trade and other receivables have increased by £5.9m compared to 2016/17. Of this, £3.1m relates to an increase in the Welsh Risk Pool debtor which is reflective of a higher provisions balance at 2017/18.

Positive cash balances were maintained by the Trust throughout 2017/18. As part of the Trust’s financial plans, cash flow for 2018/19 will continue to be carefully monitored.

Financed by Taxpayers’ Equity

The Trust’s capital structure is funded from Public Dividend Capital (PDC) issued by the Welsh Government, a revaluation reserve and a cumulative Income and Expenditure Reserve. The Trust draws down PDC funding as agreed with Welsh Government as and when required to fund anticipated capital expenditure.

During the year, Public Dividend Capital held by the Trust has increased by £0.563m.This is reflected within the increased balance of £66.1m.

The revaluation reserve increased by £2.2m during the year; this was the net result of the District Valuer’s in-year revaluations of £5.0m, with a reduction because of in-year impairments of £0.9. A further reduction of £1.9m was made during the year relating to balances transferred to retained earnings in respect of assets no longer held by the Trust (£0.9m) together with an adjustment for further impairments made (£1.0m).

Pension costs

Details of pension costs are provided on Page 104-108 of the Trust’s financial accounts for 2017/18.

2018/19 and beyond

In common with other public sector bodies across Wales, the Trust is facing a further challenging year.

NHS funding makes only limited provision for inflation, with the Trust expected to receive a 2% funding uplift in 2018/19 for all inflationary and other cost pressures, in line with all other organisations in NHS Wales. When compared to the likely change in cost base (which is based on a number of assumptions, one being a 1% pay award for 2018/19), this results in a c£4.2m savings, cost reduction and cost avoidance target and requirement for the Trust for the coming financial year. It will, therefore, be important that increased efficiency can be delivered whilst continuing to modernise and enhance operational services.

Full details of the Trust’s service, operational, workforce and financial plans are contained within the Integrated Medium Term Plan (IMTP) for the period 2018-19 to 2020-21, which was submitted in accordance with the NHS Wales Planning Framework to WG by 31st March 2018.

2017/18 ACCOUNTS

These accounts for the period ended 31 March 2018 have been prepared to comply with International Financial Reporting Standards (IFRS) adopted by the European Union, in accordance with HM Treasury's FReM by Welsh Ambulance Services NHS Trust under schedule 9 section 178 Para 3 (1) of the National Health Service (Wales) Act 2006 (c.42) in the form in which the Welsh Ministers, with the approval of the Treasury, directed.

The Trust’s external auditor is the Auditor General for Wales and included in “operating expenses”, on page 95 of this document, is the cost of £0.161m for the external audit fee.

The financial information contained within this financial review is a summary of that contained within the final accounts and might not contain sufficient information for a full understanding of the Trust’s financial position and performance. If you would like a copy of the Trust’s full accounts, they are available on request from the following address:

The Director of Finance Welsh Ambulance Services NHS Trust Vantage Point House Ty Coch Way CWMBRAN NP44 7HF Tel: 01633 626262

Governance Statement 2017/18

In accordance with Welsh Government requirements, the Trust’s full accounts for the financial year include a Governance Statement which sets out responsibilities and mechanisms within the Trust for the management of risk. This includes a review of effectiveness and any significant internal control issues arising during the year.

Certificates of Chairman, Chief Executive and Director of Finance

I certify, that the summary of the annual accounts set out on pages 92 to 109 are consistent with the Trust’s full statements for the year ended 31st March 2018.

Related Party Disclosures

The Trust is a body corporate established by order of the Welsh Minister for Health and Social Services. During the year, none of the Board members or members of the key management staff or parties related to them has undertaken any material transactions with the Trust.

The Welsh Government is regarded as a related party. During the year, the Welsh Ambulance Services NHS Trust has had a significant number of material transactions with the Welsh Government and with other entities for which the Welsh Government is regarded as the parent body, namely:

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Receipts Payments to from Amounts owed Amounts due to related from related related party related party party party £000 £000 £000 £000 Welsh Government 1,533 12,706 89 1,595 WHSSC/EASC 0 139,914 0 11 Abertawe Bro Morgannwg UHB 691 3,765 184 11 Aneurin Bevan UHB 155 5,216 23 1,411 Betsi Cadwaladr UHB 396 4,917 94 123 Cardiff & Vale UHB 62 3,621 7 308 Cwm Taf UHB 53 1,301 10 1 Hywel Dda UHB 182 3,007 25 4 Powys Teaching HB 48 1,110 48 46 Public Health Wales NHS Trust 36 44 -1 0 Velindre NHS Trust 1,415 1,609 212 47 Welsh Local Authorities 2,126 112 56 50 Welsh Risk Pool 0 0 0 8,347 TOTAL 6,697 177,322 747 11,954

In addition, the Trust has had a number of material transactions with other Government departments and other central and local Government bodies.

The Trust Board is the Corporate Trustee of the Welsh Ambulance Services NHS Trust Charity. All voting members of the Trust (marked with an asterisk in the table below) can act as a corporate trustee of the charity. During the year receipts from the Charity amounted to £0.010m (2016-17: £0.010m) with no other transactions being made. Net assets of the charity amount to just under £0.4m.

The Welsh Government income shown above includes £3.733m relating to impairment funding and £0.960m that relates to PDC capital received during 2017-18; of this, £0.397m PDC was repaid resulting in a net position of £0.563m.

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A number of the Trust's members have declared interests in related parties as follows:

Name Position Declaration Director of Poolbank Consulting Ltd. Michael Giannasi * Chairman Honorary Professor School of Human and Health Sciences, Swansea University.

Director of Wales For Europe. Lay Member of the Governing Body of the Church of Wales. Vice Chair of Standing Committee. Helen Birtwhistle * Non-Executive Director Member of the International Advisory Board, Cardiff Business School.

Volunteer with Oasis, an organisation to support asylum seekers/refugees.

Director and Chair of Newport Road Maintenance Ltd. Emrys Davies * Non-Executive Director Retired Member of Unite. Army Reservist. Chair ABF The Soldiers Charity (Glamorgan) Member of the International Medical Panel, Halo Trust. Kevin Davies * Non-Executive Director Emeritus Professor, University of South Wales Independent Trustee St John Cymru Wales. Paton - The Motivation and Learning Trust. Independent Member of Joint Audit Committee for North Wales Police. Chair of Steering Group for the Welsh Government Information Quality Pamela Hall * Non-Executive Director Improvement initiative. Secretary of Llandudno and Area Women’s Group. Head of Customer Service, Principality Building Society, James Mycroft * Non-Executive Director Director of Nemo Personal Finance Ltd (subsidiary of Principality Building Society). Secretary of Llandogo Memorial Green Committee. Martin Woodford * Non-Executive Director Secretary/Team Manager Tintern Sports Club.

Paul Hollard * Non-Executive Director Independent Consultant for NHS Wales.

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Chief Executive (1/4/17 to Director of Omnimark Ltd. (Company does not trade and never commenced Tracy Myhill * 31/1/18) trading). Board Member, Trivallis Housing Association (Interim Chair September 2017 to January 2018). Honorary Colonel Welsh Field Hospital 203. Executive Director Quality,

Claire Bevan * Safety and Patient Honorary Contract Swansea University Lecturing. Experience

Richard Lee Director of Operations Examiner for Royal College of Surgeons.

Treasurer of Thrive – Local Charity, Keith Cox Board Secretary Magistrate Cardiff and Vale.

(* Voting members of the Trust) No other Trust members provided declarations of interest in related parties during the period.

Material transactions between the Trust and related parties disclosed on page 100 during 2017-18 were as follows

Material transactions between the Trust Payments to Receipts from Amounts owed Amounts due and related parties disclosed on page 61 during 2017-18 were as follows (unless related party related party to related party from related already reported on page 60) : party £000 £000 £000 £000

North Wales Police 0 2 0 0 St John Ambulance 1,597 0 110 0 Swansea University 199 209 0 17

TOTAL 1,796 211 110 17

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Salary and Pension Entitlements of Senior Managers

REMUNERATION 2017-18 2016-17 Salary Benefits Pension Total Salary Benefits Pension Total Name and Title (bands in Kind benefits (bands (bands in Kind benefits (bands of (rounde (£'000 of of (rounde (£'000 of £5000) d to the (to £5000) £5000) d to the (to £5000) nearest nearest nearest nearest £100) £1000) £100) £1000) Michael Giannasi (Chairman) 50-55 50-55 50-55 50-55 David G Scott (Non-Executive 5-10 5-10 Director) (Note 1) Kevin Davies (Non-Executive 5-10 5-10 5-10 5-10 Director) Pamela J Hall (Non-Executive 5-10 5-10 5-10 5-10 Director) James Mycroft (Non- 5-10 5-10 5-10 5-10 Executive Director) Emrys Davies (Non-Executive 5-10 5-10 5-10 5-10 Director) Martin Woodford (Non- 15-20 15-20 20-25 20-25 Executive Director) Paul Hollard (Non-Executive 5-10 5-10 5-10 5-10 Director) Helen Birtwhistle (Non- 5-10 5-10 Executive Director) (Note 2) Tracy Myhill (Chief Executive) 130- 2,600 105 235-240 150-155 2,700 76 225-230 (Note 3) 135 Elwyn Price-Morris (Chief 45-50 - 45-50 Executive) (Note 4)

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2017-18 2016-17 Salary Benefits Pension Total Salary Benefits Pension Total Name and Title (bands in Kind benefits (bands (bands in Kind benefits (bands of (rounde (£'000 of of (rounde (£'000 of £5000) d to the (to £5000) £5000) d to the (to £5000) nearest nearest nearest nearest £100) £1000) £100) £1000) Sara Jones (Clinical Director) 90-95 3 95-100 (Note 5) Patricia Roseblade (Interim 110- 6,200 48 165-170 105-110 2,400 49 155-160 Chief Executive) (Note 6) 115 Christopher Turley (Interim Director of Finance & ICT) 15-20 600 5 20-25 (Note 7) Dr Brendan Lloyd (Interim 135- Deputy Chief Executive / 2,500 0 140-145 135-140 1,100 10 145-150 140 Medical Director) (Note 8) Claire Vaughan (Director of 90-95 22 110-115 85-90 43 130-135 Workforce & OD) Claire Bevan (Director of 110- Quality, Safety & Patient 2,800 198 310-315 90-95 1,900 70 160-165 115 Experience) (Note 9) Estelle Hitchon (Director of 85-90 21 105-110 85-90 93 175-180 Partnerships & Engagement) Hannah Evans (Director of Strategy Planning & 90-95 36 125-130 85-90 38 120-125 Performance) Richard Lee (Director of 100- 27 125-130 95-100 228 325-330 Operations) 105 Keith Cox (Board Secretary) 80-85 0 80-85 85-90 12 95-100 (Note 10)

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Notes:

Note 1 - David G Scott left the Trust on 31 March 2017 Note 2 - Helen Birtwhistle joined the Trust on 1 April 2017 Note 3 - Tracy Myhill left the Trust on 31 January 2018 Note 4 - Elwyn Price-Morris left the Trust on 16 May 2016 Note 5 - Sara Jones left the Trust on 10 November 2016 Note 6 - Patsy Roseblade was appointed Interim Chief Executive from 1 February 2018 Note 7 - Christopher Turley was appointed Interim Director of Finance & ICT from 1 February 2018 Note 8 - Dr Brendan Lloyd was appointed Interim Deputy Chief Executive from 1 February 2018 Note 9 - Claire Bevan was awarded a retrospective pay increase from 1 April 2016 Note 10 - Keith Cox retired and returned to the Trust during the financial year in line with the Trust’s Retire and Return Policy

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PENSION BENEFITS

Name and Title Real Real Total Lump sum Cash Cash Real Employer’s increase increase in accrued at age 60 Equivalent Equivalent increase in contribution in Lump sum pension at related to Transfer Transfer Cash to pension at aged 60 age 60 at accrued Value at 31 Value at 31 Equivalent stakeholder at age related to 31 March pension at March 2018 March 2017 Transfer pension 60 real 2018 31 March Value (bands increase in (bands of 2018 of pension £5,000) (bands of £2,500) (bands of £5,000) £2,500)

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Tracy Myhill (Chief Executive) 5-7.5 2.5-5 60-65 170-175 1,178 1,021 123 19

Patricia Roseblade (Interim Chief 2.5-5 7.5-10 20-25 70-75 506 421 80 17 Executive)

Christopher Turley (Interim Director of 0-2.5 0-2.5 30-35 80-85 513 471 6 2 Finance & ICT)

Dr Brendan Lloyd (Interim Deputy 0 0 0 0 - - - - Chief Executive / Medical Director) * Claire Vaughan (Director of 0-2.5 0-2.5 15-20 40-45 283 247 34 13 Workforce & OD)

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Estelle Hitchon (Director of 0-2.5 0-2.5 20-25 60-65 397 353 40 12 Partnerships & Engagement) Claire Bevan (Director of Quality, 7.5-10 27.5-30 40-45 130-135 904 670 228 16 Safety & Patient Experience) Hannah Evans (Director of Strategy 0-2.5 0-2.5 15-20 40-45 251 215 34 13 Planning & Performance) Richard Lee (Director of 0-2.5 0-2.5 35-40 95-100 598 558 34 14 Operations) Keith Cox 0-2.5 0-2.5 40-45 130-135 - 987 -997 4 (Board Secretary)**

*Brendan Lloyd chose not to be covered by the NHS pension arrangements during the reporting year **Keith Cox left the pension scheme on 16 July 2017

HUTTON REPORT INFORMATION

2017-2018 2016-2017

Band of Highest paid Director's Total 147.5 152.5 Remuneration £000 Median Total Remuneration £000 30 30

Ratio 4.99 5.15

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Remuneration Relationship

Reporting bodies are required to disclose the relationship between the midpoint of the banded remuneration of the highest-paid director/employee in their organisation and the median remuneration of the organisation’s workforce.

The banded remuneration of the highest-paid director in post at 31 March 2018 in the Welsh Ambulance Services NHS Trust in the financial year 2017-18 was £147,500 (2016-17, £152,500). This was 4.99 times (2016-17, 5.15) the median remuneration of the workforce, which was £29,536 (2016-17, £29,603).

In 2017-18, 0 (2016-17, 0) employees received remuneration in excess of the highest-paid director. Remuneration ranged from £16,523 to £147,500 (2016-17 £16,132 to £152,500).

The reason for both the reduction in remuneration together with the downturn in ratio compared to 2016-17 is the result of a change of Chief Executive. This has resulted in the Chief Executive no longer being the highest-paid director within the organisation.

The annualised banded remuneration of the Chief Executive is £140k to £145k (2016-17, £150k to £155k). This is 4.82 times (2016-17, 5.15) the median remuneration of the workforce.

Total remuneration includes salary, non-consolidated performance-related pay and benefits-in-kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.

Sustainability Report 2017/18

BACKGROUND

HM Treasury’s Government Financial Reporting Manual FReM requires that entities falling within the scope of reporting under the commitments of Greening Government and which are not exempted by de minimis limit or other exemption under Greening Government (or other successor policy), shall produce a sustainability report to be included within the Management Commentary in accordance with HM Treasury issued Sustainability Reporting in the Public Sector guidance. This requirement is not applicable to Wales as a Devolved Government. However, Wales is unique in the UK in having sustainable development as a central organising principle. Sustainable reporting is an essential part of organisational governance in the public sector in Wales and the Welsh Government’s aim is to enable integrated reporting.

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ENVIRONMENTAL, SOCIAL AND COMMUNITY ISSUES

The Trust is aware of the potential impact its operation has on the environment and it is committed to wherever possible:

 ensuring compliance with all relevant legislation and Welsh Government Directives  working in a manner that protects the environment for future generations by ensuring that long term and short term environmental issues are considered  preventing pollution and reducing potential environmental impact; and  maintaining for the foreseeable future its ISO 14001 environmental management accreditation

The Board’s Sustainability Report provides greater detail in relation to the environmental, social and community issues facing the Trust. It also details some of the steps being taken by the Trust to tackle sustainability, these include:

 integrating the principles of sustainable development into every day decision making;  focusing on reducing the consumption of finite resources and minimising waste where possible; and  adopting a carbon based management approach specifically aimed at reducing CO2 and meeting the Welsh Government target objective of a 3% year on year reduction in our carbon footprint

During 2017-18 the Trust has completed roll out of its Environmental Governance System to cover the South East Region and the whole of the Trust has now been successfully assessed.

More environmental coordinators and environmental auditors have been trained and environmental awareness has been added to our continuous professional development (CPD) programme.

BSI has again successfully audited the organisation as ISO 14001 compliant, as well as achieving transition to the ISO14001:2015 standard. The Welsh Ambulance Service remains the only ambulance service in the UK to be accredited under ISO14001.

You can read more in our Sustainability Report here 2017/18

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