Imtp 2016-17

CONTENTS

Acronym Table 5 Message from the Chair and Chief Executive 8 Executive Summary 9

Part 1 Delivery of Our 2015/16 Plan 13

1.1 The New Clinical Response Model……………………………………...... 13 1.2 Quality and Operational Performance Trajectories…………………………... 15 1.3 2015/16 Strategic Change Portfolio …………………………………………… 18 1.4 Maturing Commissioning Arrangements and Increased Focus on Financial Strategy…………………………………………………………………………… 22

Part 2 Organisational and Strategic Context 24 This section, coupled with Part 1, serves as a high level diagnostic of the context within which we operate – it answers the “where are we now?” question.

2.1 Profile of the Trust……………………………………………………………….. 24 2.2 Our Demand & Activity………………………………………………………….. 32 2.3 The Five-Step Ambulance Care Pathway, Commissioning Quality & Delivery Framework, Understanding our Populations and Changes………. 33 2.4 National Policy Context………………………………………………………….. 37 2.5 Major Conditions, Older People and Frailty…………………………………… 42 2.6 Becoming a Listening and Learning Organisation………………………….... 43 2.7 NHS Wales Strategic Change Agenda………………………………………… 44 2.8 Service Change with Blue Light Partners……………………………………... 48 2.9 Ensuring Integration with Our Partners’ Three Year Plans………………….. 49 2.10 The Organisation and Prudent Healthcare……………………………………. 50 2.11 Treating People Fairly – Equality, Diversity & Human Rights………………. 51 2.12 Other Strategic Workforce and OD Drivers…………………………………… 54

Part 3 Creating Our Strategic Framework 57 This section sets the strategic framework for the organisation. It sets out our ambition and answers the “where do we want to go?” question.

3.1 Our Vision, Purpose and Behaviours………………………………………….. 57 3.2 Our Strategic Aims………………………………………………………………. 58 3.3 Our Priorities……………………………………………………………………… 59 3.4 Our Strategy Map………………………………………………………………… 63 3.5 Our Performance Ambitions………………………………………………...... 65 3.6 Developing a Frontline-Led Approach to Planning…………………………… 78 3.7 Becoming a Leading Ambulance Organisation: Where Do We Want to be in 5 – 10 years? ...... 84

Part 4 Quality and Prudent Healthcare – the Main Driver of Our Business 86 This section sets out our ambition to put quality at the heart of our plans. It sets out the practical steps we are taking to move towards our vision, any milestones and intended impact of our actions - it answers the “what are we doing and how do we get there?” question.

4.1 Moving Forward 2016/19………………………………………………………... 87 4.2 Quality Themes and Improvements for 2016/17 and Beyond………………. 88 4.3 Quality Improvement, Measures and Assurance System………………...... 89 4.4 Quality Improvement and 1000 Lives Improvement…………………………. 90 4.5 Quality Governance……………………………………………………………… 91

Part 5 Our Strategic Change Programmes – Our Service Focused Priorities 94 This section gives an overview of our service change priorities, the practical steps we are taking to move towards our vision, any milestones and intended impact of our actions - it answers the “what are we doing and how will we make it happen?” question.

 Emergency Medical Services: The Five-Step New Clinical Response 95 Model………………………………………………………………………………  Non-Emergency Patient Transport…………………………………………….. 108

Part 6 Our Enablers – the Building Blocks to Our Success 111 This section gives an overview of the critical deliverables across our enabling functions and sets out how they will develop and strengthen to support service transformation- it answers the “what do we need in place to get there?” question.

6.1 Our People………………………………………………………………………... 111 6.2 Our Finances (Revenue and Capital)………………………………………….. 147 6.3 Our Estate………………………………………………………………………… 163 6.4 Our Fleet…………………………………………………………………...... 166 6.5 Research & Innovation…………………………………………………...... 168 6.6 Service Improvement……………………………………………………………. 169 6.7 Health Informatics and Business Intelligence……………………………...... 170 6.8 Information Communication and Technology……………………………...... 173 6.9 Partnerships and Engagement…………………………………………………. 175 6.10 Corporate Governance and Risk Management………………………………. 179

Part 7 Delivering the Plan 182 This section sets out the delivery framework for our IMTP - it answers the “how do we know what we are delivering?” question.

7.1 Approach to Planning……………………………………………………………. 182 7.2 Plan Delivery……………………………………………………………………… 182 7.3 Risks and Issues to plan delivery………………………………………………. 187 7.4 Engagement and approval arrangements…………………………………….. 190 7.5 Internal Planning model and cycle……………………………………………... 190

APPENDICIES 192

Appendix 1: Emerging Performance Issues Arising from the First Publication of the 193 Ambulance Quality Indicators……………………………………………………….

Appendix 2: CAREMORE® Service Change Ideas Currently Agreed with the Emergency Ambulance Services Committee…………………………………...... 195

Appendix 3: NHS Wales Strategic Change Agenda Milestones………………………………. 197 Appendix 4: Mid Wales Healthcare Collaborative (MWHC) – Key Actions…………………... 198 Appendix 5: Summary of Health Board and Trust IMTPs’ Integration with WAST………... 204 Appendix 6: Supporting Information Relating to Documented Actions……………………..... 207 Appendix 7: WAST 2016/17 Discretionary Capital Plan……………………………………...... 208

Appendix 8: Strategic Change Programme Structures………………………………………… 211

Acronym Description

A&E Accident and Emergency Department ABMU Abertawe Bro Morgannwg University Health Board ACPs Alternative Care Pathways AED Automated External Defibrillator AEMTs Advanced Emergency Medical Technicians AFSRC Ambulance and Fire Services Resource Centre ALS Advanced Life Support ABHB Aneurin Bevan University Health Board AP Advanced Practitioner APP Advanced Paramedic Practitioner AQIs Ambulance Quality Indicators ARC Ambulance Resource Centre ARCH A Regional Collaboration for Health AS Ambulance Station AWW Ageing Well in Wales BAF Board Assurance Framework BCUHB Betsi Cadwaladr University Health Board BME Black and Minority Ethnic BJCs Business Justification Cases CAD Computer Aided Dispatch System CVUHB Cardiff and Vale University Health Board CAS Clinical Assessment System CASC Chief Ambulance Services Commissioner CCA Civil Contingencies Act CCC Clinical Contact Centre CCG Clinical Commissioning Group CCIS Community Care Information System CE Chief Executive CFR Community First Responder CPADs Community Public Access Defibs CPAG Clinical Pathways Advisory Group CPAS Clinical Prioritisation Advisory Software Group CPD Continuing Professional Development CPR Cardiopulmonary Resuscitation CQDF Commissioning & Quality Delivery Framework CR Core Requirements CRM New Clinical Response Model CSD Clinical Support Desk CSPT Call Streaming and Prioritisation Software CTA Clinical Telephone Assessment (Hear & Treat) CTL Clinical Team Leader CW Central and West CTUHB Cwm Taf University Health Board DAV Dedicated Ambulance Vehicle EAs Emergency Ambulances EASC Emergency Ambulance Services Committee EBR Established Based Responders ED Emergency Department EDCIMS Emergency Department Clinical Information Management System 5

EFL External Financing Limit EMS Emergency Medical Services EMT Executive Management Team EMTs Emergency Medical Technicians ENT Ear, Nose and Throat EoL End of Life EoLC End of Life Care EPRR Emergency Preparedness, Resilience and Response ESMCP Emergency Services Mobile Communication Programme ESN Emergency Services Network ESR Electronic Staff Record System FC Frequent Callers FRA Fire and Rescue Authorities FRC Trust Board Finance and Resource Committee GA General Anaesthetic GP General Practitioner GPOOH GP Out of Hours HALO Hospital Ambulance Liaison Officers HART Hazardous Area Response Team HB Health Board HCP Health Care Professional HCSW Health Care Support Worker HEI Higher Education Institute HI Health Informatics HQ Head Quarters HR Human Resources HDUHB Hywel Dda University Health Board ICT Information Communications & Technology IG Information Governance IMTP Integrated Medium Term Plan IPC Infection, Prevention & Control IPR Integrated Performance Report JET Joint Executive Team KD Key Deliverable KPI Key Performance Indicator KSF Knowledge and Skills Framework LDP Local Delivery Plan LHB Local Health Board LRF Local Resilience Forum MBTI Myers Briggs Type Inventory MFR Medical First Responders MIU Minor Injury Unit MPDS Medical Priority Dispatch System MRD Make Ready Depot MWFRS Mid Wales Fire and Rescue Service MWHC Mid Wales Health Collaborative NATC National Ambulance Training College NEPTS Non-Emergency Patient Transport Services NEPTSQIs Non-Emergency Patient Transport Services Quality Indicators NHSDW NHS Direct Wales NICU Neonatal Intensive Care Unit

NWFRS North Wales Fire and Rescue Service NWSSP NHS Wales Shared Services Partnership OD Organisational Development OOH Out of Hours PA Physicians’ Associates PADR Personal Appraisal and Development Review PCR Patient Care Records PCRM Patient Centred Clinical Response Model PCS Patient Care Services PCT Primary Care Trust PERU Pre-hospital Emergency Research Unit PHEM Pre-hospital Emergency Medicine PHW Public Health Wales PIH Partners in Healthcare POW Princess of Wales Hospital PTHB Powys Teaching Health Board PPF Paramedic Pathfinder PPM Planned Preventative Maintenance PTR Putting Things Right QAIP Quality Assurance and Improvement Panel QuESt Quality, Experience and Safety Committee R&I Research & Innovation RAPID Rapid Analgesia for Pre-hospital Hip Disruption RLSS Royal Life Saving Society RNLI Royal National Lifeboat Institution ROSC Return of Spontaneous Circulation RRV Rapid Response Vehicle SCCC Specialist and Critical Care Centre SI Service Improvement SLA Service Level Agreement SMT Senior Management Team SOC Strategic Outline Case SOP Strategic Outline Programme SORT Special Operations response Team TASC The Alliance of Suicide Prevention Charities TIA Transient Ischaemic Attack TK Thomas-Kilmann Conflict Mode Tool TRiM Psychological assessment of risk programme TU Trade Union UCS Urgent Care Services UHP Unit Hour Production UHW University Hospital of Wales VPH Vantage Point House WAST Welsh Ambulance Service NHS Trust WEDS Welsh Education Development Services WFIS Workforce Information System WG Welsh Government WHC Welsh Health Circular WOD Workforce and Organisational Development WTE Whole Time Equivalent

MESSAGE FROM THE CHAIR AND CHIEF EXECUTIVE Welcome to our three-year Integrated Medium Term Plan (IMTP), which sets out our ambition for the Welsh Ambulance Services NHS Trust (WAST) over the period 2016/17-2018/19. The IMTP is the culmination of many months of engagement and planning underpinned by listening to our staff, our patients and our stakeholders to develop our IMTP. We hope our IMTP clearly articulates our purpose, vision, behaviours, strategic aims and priorities and helps everyone understand the role the Ambulance Service plays within NHS Wales and the way we want to develop over the coming years. 2015/16 was a significant year for the Trust, marked notably by the launch of a New Clinical Response Model pilot that focuses on treating those in the most clinical need first and which helps to establish the Welsh Ambulance Service very clearly as one which is clinically led and quality driven. This move towards a sound clinical basis for our services, be they Emergency Medical Services at the forefront of the unscheduled care system; “Hear and Treat” services such as NHS Direct Wales and our Clinical Desk supporting staff in our Clinical Contact Centres; or Non-Emergency Patient Transport Services, which, from April 2016, will be delivered on a new, multi-agency basis, is something that gives us a unique position as a bridge between the NHS in Wales and our blue-light, emergency service partners. The Welsh Ambulance Service is on a rapid improvement journey and the next three years will be critical in ensuring that we are able to provide an ambulance service for people in Wales of which they can be justly proud. This means making bold decisions, reconfiguring our services to best meet the needs of communities and reshaping our workforce to ensure our people can deliver what is needed to move the Welsh Ambulance Service into the top tier of ambulance services, nationally and internationally. Our services are all about people: those we serve and those who deliver care. We hope that this IMTP describes how we all have a role to play in helping us deliver a dynamic and different ambulance service that has a deserved reputation for consistently high standards of care, compassion and performance. We hope you find it an interesting and exciting document and that you will support us in whichever way you can as we work hard to save and improve lives every day. Share your thoughts with us on Twitter @welshambulance, find us on Facebook or email [email protected]

Mick Giannasi Tracy Myhill Chair Chief Executive

EXECUTIVE SUMMARY Our Integrated Medium Term Plan (IMTP) covers a three-year period from 2016/17 to 2018/19. It builds on our 2015/16 one-year plan and provides the framework for the organisation to:

 provide a clear statement of ambition for the benefit of patients, the public of Wales, Trust staff and NHS partners (together with other external stakeholders);  set out how it will deliver the Commissioning and Quality Delivery Framework (CQDF) agreed with the Emergency Ambulance Services Committee (EASC);  outline the next phase of our clinical modernisation journey;  describe the modernisation of non-emergency patient transport services; and  describe the key enabling activities that will support front line staff to deliver good patient care.

We in the Welsh Ambulance Service (WAST) have been through major change over the last 12 months. 2015 saw the introduction of the Commissioning and Quality Delivery Framework and we are now working closely with both the Chief Ambulance Services Commissioner (CASC) and the Emergency Ambulance Service Committee (EASC) to ensure this important framework agreement translates into demonstrable service improvements for people in Wales who need and use our services. The framework saw the introduction of a five-step Ambulance Care Pathway. This is a five-step process for the delivery of emergency ambulance services within NHS Wales. The Ambulance Care Pathway encourages us to focus on the patient journey i.e. patient flow, and a whole systems approach. Figure 1: Five-Step Ambulance Care Pathway

Transformational service changes have also taken place over the last year, including the New Clinical Response Model (CRM) pilot that commenced in October 2015. The new model moves the emergency element of our service from a time-based target system that has its origins in the 1970s, when ambulance services were very different, towards an outcomes-based model. Changes are also evident in the structure of the organisation. A permanent Chief Executive was appointed in August 2015 and, following retirements and other departures, the Executive Team now comprises a Director of Finance & ICT, a Medical Director, a new Director of Workforce & OD, a new Director of Operations (interim), a new Director of Planning and Performance (interim), a new Director of Quality, Safety & Patient Experience and a new Director of Partnership and Engagement. Our ambition is clear, and we have already made significant steps towards becoming a clinically- focussed service rather than just a transport service. In so doing we are building a reputation as a delivery-focused organisation that works through effective partnerships with staff, the public and

9 partner organisations. We want the public of Wales to have confidence in the Ambulance Service. Whether patients are using non-emergency or emergency services, we want them to experience excellent clinical care and customer service, over the telephone or face-to-face. Such changes have meant the organisation has needed to review its purpose, vision, strategic aims and priorities for the coming three years. These have been developed through widespread engagement across the organisation, from the Board to frontline staff and will frame our plans going forward. By the end of year one of this plan we will have:

 successfully transformed our Non-Emergency Patient Transport Services in line with the Minister-approved business case;  implemented, with our partner organisations, the 111 Pathfinders in the Abertawe Bro Morgannwg and Carmarthen areas;  made significant and quantifiable progress in transforming our Clinical Contact Centres, including progressing the procurement of a new Computer Aided Dispatch system, increasing the contribution of the clinical desk and implement learning from external and benchmarking reports;  built on the progress made in 2015/16 and strengthened performance of our New Clinical Response Model for emergency medical services (EMS), using the Five-Step Ambulance Care Pathway, with a focus on reducing variation and moving focus from STEPS 4 and 5 to STEPS 1- 3; and  completed a demand and capacity review and used it to develop strategic resource plans (workforce and fleet) and, where possible, accelerated implementation. These priorities translate into 4 key Change Programmes. Our transformation agenda is underpinned by a robust programme management and delivery mechanism that offers the right level of rigour and scrutiny to assure the Board and partners that change is being delivered effectively. Running through all of this are our refreshed shared behaviours. These too have been developed over the last 12 months with widespread engagement and will provide a compass to guide cultural change across the organisation. By making these changes, we will retain and attract the calibre of staff we need to deliver high quality care to our patients. Our strategy map that articulates this approach can be seen in section 3.4. During years two and three of the plan, we will aim for a further acceleration in our journey of transformation and will:

 demonstrate a step change in demand, evidencing a reduction on current levels and managing the demand which remains more effectively. This will require us to work with the public and our partners across NHS Wales to influence and demonstrate this shift. We will also help more callers with telephone advice and support more patients locally either by referring them to a local health service or by providing all of the care they need at the scene;

 re-shape, support and develop our workforce to reflect an increase in capacity across STEPS 1, 2 and 3 of the New Clinical Response Model, and capability across STEPS 4 and 5, building on the analytical and engagement work we intend to undertake in year one;  implement changes required to our fleet based on our analytical and engagement work in year one;

 implement changes required to our estate based on our analytical and engagement work in year one; and  agree and implement an optimum configuration for our Clinical Contact Centres in line with a revised Estates Strategy (configuration agreed in year 1 with implementation taking place across years 2, 3 and beyond). Clinical Contact Centres are important as they are the first point of contact for all of our callers and patients. This plan will explore the specific and tangible actions being taken within these areas and the quantifiable impact we aspire to make, which you will see clearly articulated throughout this document. For further information on all of our actions you can refer to Appendix 6. The majority of our improvements will be made visible through our performance against the Ambulance Quality Indicators. Our Resources As we move towards 2020, there are a number of risks and opportunities facing the Trust and the health economy in general that have shaped the development of our People Strategy, and our thinking and planning around the future shape of our workforce. Our People Strategy enables us to align our resources and focus our actions over the next three years towards delivery of our organisational vision, strategic priorities and New Clinical Response Model. It builds on the positive progress made in 2015/16, particularly improvements to establishment control, workforce planning, recruitment, PADR and sickness absence rates. It seeks to address current and future risks and challenges, including improving the working lives of our staff, and addressing variability in workforce performance. Delivery of the strategy will be effected through four key workforce and OD enabling plans including a workforce plan, recruitment plan, training and education plan and a ‘Be our Best’ OD plan. More detail of the people strategy model and enabling plans can be found at section 6.1. We recognise that the New Clinical Response Model will require the development and re-profiling of our current workforce to take account of the drive to increase capacity to “Hear and Treat”, and strengthen our capability through the development of the higher level of skills needed to ‘see and treat’ patients who are increasingly frail with complex and chronic conditions. We expect to see an increase in the numbers of specialist paramedics with the skills to better manage patients with long-term chronic conditions at home and in the community, and confidently access alternative pathways to care as appropriate. We will explore and test the impact of creating new roles such as community-based paramedics supporting GP practices and patients within rural areas of Wales, and take steps to maximise the use of our volunteer workforce, including growing our Community First Responder (CFR) workforce and Co-Responder capacity. Our plans also take account of several significant change/transformation programmes, including preparation for the introduction and roll-out of the 111 Pathfinder project and implementation of our Non-Emergency Patient Transport Business Case. We describe this journey in more detail in our workforce plan at section 6.1. This links clearly to our training and education plan at section 6.1 in which we aim to ensure our people are sufficiently trained and skilled to work to the full scope of their practice, and trained to better clinically manage increasing frailty, mental ill health and complexity within the population. Clarity on the exact number of each grade and type of staff needed in the future will be achieved with the support of expert analysts, working with us to undertake a full review of capacity and demand in the first quarter of 2016. In the meantime, we will continue to focus our actions on ensuring timely recruitment, effective rostering and training of all staff to ensure momentum is not lost and our performance and delivery is not adversely affected.

Underpinning this IMTP is a three-year balanced financial plan. To achieve this, the Trust will further improve and deliver on operational efficiencies, meet challenging and ambitious savings plans and further identify opportunities over the planning period to reduce cost. This balanced financial plan is not risk free and is presented on the basis of the key financial planning, resource envelope and funding assumptions fully described in the finance section of this document. Clearly, years 2 and 3 (2017/18 and 2018/19) of this plan will need further refinement once key financial variables are known, including the detailed cost pressures for these financial years, impact of savings delivery between now and then and the opportunities for further efficiencies, but also the outcomes of key pieces of work being described throughout this document, including the demand and capacity review and the outcome of the evaluation of the New Clinical Response Model pilot. In addition, of significance will be the impact of other developments being progressed, including the expected roll- out of 111, investment in “Hear and Treat” services and expected efficiencies to be garnered from the new CAD and other technology developments. The impact all these have on both the staffing and fleet resource requirements of the Trust going forward will see the financial plan further refined. In terms of 2016/17, the balanced financial plan is underpinned by some key planning and resource assumptions, all of which have been shared with the CASC and his team over recent months as this plan has been developed, and all of which have received broad support. These include the resource envelope assumptions, the key ones which are as follows:

 the baseline level of funding via EASC in 2016/17 for EMS services (at 2015/16 prices) will be consistent with that provided in 2015/16, PLUS a net small increase of c£0.8m, being the elements of the additional planned spend incurred in 2015/16 that are currently expected to continue into 2016/17 (£2m), netted off in part by elements of the core spend and funding in 2015/16 that is non-recurring (a net £1.2m);

 what is considered to be a reasonable “fair share” of the additional £200m “general” growth funding being made available in 2016/17 to the NHS in Wales by Welsh Government to cover pay awards and other inflationary and other cost pressures – this is estimated at £5m for WAST;

 the resources in relation to NEPTS are consistent with that included within the recently approved business case for the future delivery of this service;

 other key specific service developments, in particular 111 and the support required for the demand and capacity review, are fully funded;

 the delivery of a challenging and ambitious savings plan for 2016/17 of £6.2m, the full details of which are included within the finance section of this document;

 resources have been modelled on the basis of current performance targets; and

 where Local Health Boards make major service changes, the impact on our services (emergency or non emergency) will be fully resourced via their business case mechanisms and routed through the commissioning arrangements.

The finance section (part 6.2) also summarises the current capital programme over the next few years, which has been developed in parallel with our service, estate and fleet plans.

PART 1: PROGRESS IN DELIVERING OUR 2015/16 PLAN

This section provides an update on progress in implementing the Trust’s one-year plan, both in terms of achievements and challenges.

2015/16 was a pivotal year in the transformation of WAST as the new commissioning arrangements came into force and the new National Collaborative Commissioning and Quality Framework was implemented. For this reason, the Welsh Government recognised that an approvable three-year IMTP for the organisation was unrealistic for 2015/16. Consequently, the organisation was asked to focus on producing a one-year plan.

A one-year plan was produced, approved by Trust Board, endorsed by the Chief Ambulance Services Commissioner (CASC), the Chair of the Emergency Ambulance Services Committee (EASC) and the lead NHS Wales Chief Executive.

We continue to make solid and steady progress in delivering this one-year plan.

Key headlines of our successes are:

 The launch of a pilot of the New Clinical Response Model on 1 October 2015 (see below);  The full roll-out of digital pen technology (Digi-pens), EMS paramedics and ambulance crews in the organisation- the first ambulance service to use such technology;  Being awarded the ‘hosting’ rights for the 111 Pathfinder project in Abertawe Bro Morgannwg University Health Board;  NHS Wales agreement on a new service model for Non-Emergency Patient Transport Services (NEPTS), the implementation of which will form a major component of the organisation’s activities in year one of this plan;  At the time of writing, the Ambulance Resource Centre (ARC) Wrexham remained on schedule to open in March 2016; and  Improvements in delivery against the time-based targets.

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

1.1 The New Clinical Response Model

In October 2015, WAST launched a one-year pilot of a New Clinical Response Model (CRM). The previous CRM (introduced in December 2011) measured the effectiveness of the ambulance service by time-based measures around how long an ambulance took to reach a call. It was well recognised by the organisation itself, and from a number of previous reviews (most recently the McClelland review), that time-based targets are not in themselves a meaningful measure of performance of a clinical service and that, in some circumstances, they may even be detrimental to clinical care, particularly because of the practice of sending multiple resources or the deployment of a less appropriate resource to calls to “stop the clock”, with the intention of meeting a time-based target rather than satisfying a clinical need. The major changes in the 2015 CRM pilot were to:

 categorise emergency calls based on the clinical need of the patient;  remove time-based targets for all calls except highest priority ‘RED’ calls;  measure clinical achievement using clinical indicator data (measuring the quality of the care the patient received) rather than time-based data alone; and

 introduce a new concept of ‘dispatch on code’ for emergency calls other than the highest priority RED calls. Allowing the ambulance service to decide exactly what help is required rather than just dispatching an ambulance to the address. The ‘RED’ code set was examined in detail by a team of senior clinicians. All codes previously in the 2011 CRM ‘RED-1’ (highest priority) code set remained in the new RED codes; in addition to this, a number of other codes previously assigned lower priorities were re-categorised as red. This was based on anticipated clinical need, focusing on those calls where an immediate threat to life was likely to be present, and the nearest possible emergency response should be sent to maximise the chance of survival. Learning from adverse incidents across the UK and the views of the other UK ambulance services were also considered. Such codes include cardiac arrest patients, those not breathing, unconscious or with other very serious conditions. Other calls were then prioritised as AMBER or GREEN depending on clinical urgency. Performance for these calls is measured exclusively using a suite of clinical indicators that have been developed to measure compliance with key aspects of care, identified as those interventions that improve outcomes. Figure 2: Pilot Clinical Response Model

Multiple dispatch RED – BLUE LIGHTS Immediately life-threatening calls Blue light emergency response

AMBER – BLUE LIGHTS Life-threatening / Serious Blue light emergency response calls

Face to face response GREEN 2 and 3– NORMAL All other calls ROAD SPEED Clinical telephone assessment

WAST uses the Medical Priority Dispatch System (MPDS) to prioritise 999 calls. All calls received are accorded a code that shows the main clinical condition of the patient and the urgency of their condition. For each individual MPDS code, the ‘ideal’ response has been identified based upon clinical urgency, anticipated skill mix required at scene, conveyance rates and other historical data. The new CRM trial suggests that, for AMBER and GREEN calls, no ambulance is dispatched until the ‘full MPDS code’ is known (i.e. all clinical information has been obtained to allow a detailed understanding of the presenting problem). This then allows the nearest ‘ideal’ response to be sent, which should be able both to attend in a timely manner, and deal with the patient’s care requirements, including conveyance to hospital where needed. For example, this will ensure that an ambulance is sent to heart attack and stroke patients rather than a paramedic in a response car who cannot get the patient to hospital. The aim of this is to reduce multiple unit dispatch (where a rapid response vehicle is sent to ‘stop the clock’ followed by an emergency ambulance to convey to hospital, for example) in favour of dispatching one resource to provide everything the patient needs.

The Trust is clear that the new model of care will deliver the following benefits:

 the sickest patient will always be treated first;

 the centrality of patient and public safety will maintained at all times;  patients will receive care which meets their clinical needs rather than wants;  delivery of the best clinical outcome for each and every patient on every occasion and optimal patient experience; and  a reduction in overall clinical risk within the ambulance service model by offering a range of treatment options, once the patient’s need has been identified.

EASC is currently undertaking an independent evaluation of the model which we are proactively engaged with and which will be invaluable in testing the extent to which these benefits have been realised.

1.2 Quality and Operational Performance Trajectories

Operational Performance

We recognise that it has been a mixed year for us in terms of operational performance; we have had some achievements and, equally, some areas where we know we need to do more to improve things. Below are just a few of the highlights to represent some of our challenges and successes.

 RED Calls

Improving the operational performance of the organisation was a priority in 2015/16. Figure 3 below shows that, for the final quarter of 2014/15 and the first quarter of 2015/16, there was a month-on - month improvement in performance rising from 43% of category A calls being responded to within eight minutes in December 2014 to 62% in July 2015, when performance peaked.

July and August 2015 saw unfortunate slips in performance: summer months are traditionally challenging when Wales sees an influx of tourists and visitors to the country.

A pilot testing the New Clinical Response Model commenced on 1 October that which included:

 additional capacity – putting more ambulances on duty;  the introduction of robust performance reviews with Heads of Operations; and  working with Health Boards to reduce handover delays.

Figure 3

Figure 4

The New Clinical Response Model pilot reduced the number of RED calls received per day from around 500 under the 2011 model to around 70 per day. This reduced number of RED calls means that we can focus dispatch processes on immediate dispatch of multiple resources to RED calls. The challenge associated with this is that, in some rural and smaller Health Board areas, the daily number of RED calls is small. Our performance improvement against the 65% national target for RED call attendance in eight minutes is a result of the focus applied to these most serious calls. Quality

In our 2015/16 plan we challenged ourselves to become a quality-focussed, clinically-led and clinically-driven ambulance service covering emergency medical services, non-urgent patient care services and our 24-hour health care and advice service.

In pursuit of this ambition, our 2015/16 plan made a number of commitments regarding quality and much has been achieved over the last 12 months as can be seen in the table below.

Figure 5: Quality Improvements 2015/16

Safeguarding Safeguarding changes as a result of the new legislation from the Social Services and Well Being Act 2014. Education & development is on-going; training packages are being updated to reflect the new legislation and guidance. Educational programmes have been delivered using risk-based methodology and the training strategy is currently under review. Plans are in place for practitioner educators to undertake a certified Home Office PREVENT Tutor course and a strategy to deliver the required level of training is being considered. The safeguarding structure review is completed. A new named professional / Head of Safeguarding commenced in post November 2015 with additional supportive posts to be recruited in the 2016/17 financial year. Infection, Prevention & The IPC Code of Practice has been developed and approved with a Control (IPC) supporting operational plan, linking into Health Board areas’ local delivery plans.

A task & finish group has been established to address station and vehicle cleaning. Continued progress in reducing peripheral vascular cannulation rates now 19% (54% in 2010). 2015 data is pending. Mortality Reviews A multidisciplinary WAST group has been established and the Universal Mortality Review (UMR) tool has been amended specifically for WAST purposes. Pilot work with patient care records undertaken and Digi-pen technology will support data collection going forward. This will allow us to review the care of all patients who died in our care. Sadly, some of the patients we encounter are very ill or have severe injuries and will not always survive, but we are committed to reviewing all deaths to make sure any lessons identified are learned. Putting Things Right An internal review of the PTR systems and processes has been (PTR) completed and a 100 day plan to start recovering the position has been implemented. An organisational restructure has been undertaken, moving PTR into the new Director of Quality, Safety and Patient Experience portfolio bringing together risk management, patient safety, patient experience, quality, health & safety, safeguarding, complaints & claims. Service User A new compliments process has been introduced to incorporate them Engagement & Patient within patient experience reporting and learning. Recognition from Welsh Experience Government colleagues on the positive way we handle compliments and present/promote through social media. Targeted community engagement events undertaken; feedback from events built into local delivery plans and informing service developments. Introduced Dignity in Care Programme across the Trust to foster collective responsibility for improving patient experience. We are working towards the Trust becoming a dementia friendly organisation. We have developed a series of self-assessment tools for the NHSDW website as a direct result of service user experience feedback. Feedback captured continues to reflect the positive experiences of patients (professional, reassuring, kind staff and patients being treated with dignity/kindness). Quality Strategy Initial engagement with staff, service users, patients and our communities 2016/19 provided the basis of the initial version of the strategy and, following a wide ranging consultation process during September 2015, the strategy was approved at QuESt in February 2016. Summary and easy read versions will be developed.

1.3 2015/16 Strategic Change Portfolio

Our 2015/16 plan outlined a portfolio of strategic change which the organisation committed to deliver. The portfolio brought together five strategic change programmes. The following table outlines the status of each programme.

What did the programmes set out to deliver? Non- Emergency  Analysis of three prescribed NEPTS delivery models. Patient  Production of business case that identifies a recommended way forward for NEPTS in Wales. Transport  Share the findings with the Minister for Health and Social Care by September 2016. Programme (NEPTS) What has been delivered?

 Business Case produced that contains the preferred model of service delivery, this being WAST managing and co- ordinating all NEPTS in Wales using a mixed economy of providers. The main benefit is that this provides the new organisational arrangements with time (potentially five years rolling agreement) and investment required to truly modernise and improve the quality and performance of NEPTS in Wales.  A recommendation in terms of how NEPTS are to be commissioned in the future, this being through the Emergency Ambulance Services Committee (EASC). The main benefit of this development is a reduction from nine commissioning processes to one, significantly reducing organisational time, allowing this capacity to focus on and deliver the modernisation agenda. In addition, having a single Commissioner assists in the standardisation of NEPTS in Wales, whilst also ensuring any strategies are developed in such a way that they reflect local and national strategies.  A new Service Level Agreement (SLA) that contains generic service standards and requirements for Wales has been produced and agreed, thus ensuring NEPTS provision is delivered equitably across Wales.  Approval from the Minister of Health and Social Care to proceed and deliver with pace the recommendations contained within the business case.

What is outstanding?

 Nothing- full delivery of programme against plan

What are the next steps / phases of work?

 Delivery of the implementation plan – this is explored in Part 5

Clinical The Clinical Modernisation Programme Board (CMPB) was established with a primary objective in 15/16 to deliver the New Modernisation Clinical Response Model and ensure any changes were clinically-led and managed in a systematic way, starting with the Programme identification of core clinical activity which could be standardised across Wales with appropriate supporting performance and clinical indicator information.

The Programme was divided in to five key development project areas using the Five-step New Clinical Response Model, plus an identified Human Resource project to support these developments, each with underpinning workstreams.

Significant change has been achieved in a short time, the most significant being:

 realisation of a New Clinical Response Model which was approved by the Health Minister on 29 July with implementation on 1 October 2015 for a one year pilot; and  the implementation of Digital pen technology across Wales in September 2015 - a first for ambulance services in the UK.

Both changes continue to embed in the organisation and work is ongoing to better understand performance and monitor the impact, including the impact on staff and the public; full benefits, therefore, are still to be realised.

Workforce and The People Programme set out to deliver an ambitious programme of workforce, organisational design and improvement activity, Organisational aligned to existing strategy, to support the Welsh Ambulance Service Trust to achieve its aspiration of becoming a high Development performing organisation and continuing its journey from ‘good’ to ‘great’. Improvement (WODI) The programme set out to deliver the following outcomes: Programme  rosters that are safe, sustainable and aligned to demand, and also ensure staff can utilise their full CPD hours to ensure they are appropriately skilled and able to deliver the highest quality patient care;  a 2% point reduction of the cumulative rate of sickness absence across the Trust by 31 March 2016 and consequent reduction in variable pay expenditure;  a streamlined recruitment process, reduced time to hire and plan that ensures all vacancies are filled in a safe and timely manner and staffing levels are safe and sustainable;  achievement of the Gold Corporate Health Standard; and  WAST as the Employer of Choice and ‘a great place to work’.

Capacity to deliver this programme was assessed to be the greatest risk to delivery within the required timescales. Resource was over-stretched and reactive (as a consequence), and the WOD Directorate was struggling to deliver the agenda with any

pace and impact. As a result, additional HR and OD resource was secured part way through 2015 to support the delivery agenda.

The People Programme made significant progress over the year, and delivered the following headlines:  an operational workforce plan with agreed establishments and identified vacancies, and aligned recruitment and training plans;  successful recruitment to paramedic vacancies resulting in an estimate 6 – 10 vacancies remaining depending on turnover at the start of 2016/17; more paramedic resource available to be deployed as a result and a consequent reduction in demand for variable pay (overtime);  a significant reduction in the time taken to hire staff with an average reduction by 60 days when comparing recruitment timescales in December 2015 / January 2016 with 12 months earlier;  a refreshed annual sickness action plan which reflects learning and best practice from other organisations and ambulance services;  a sustained reduction in the cumulative rate of sickness absence from 8.17% (March 2015) to 6.87% (January 2016);  a set of shared organisational behaviours, approved by the Board, and developed from listening to more than 800 staff, that will assist colleagues to do the right thing in the right way;  establishment of staff long service awards & recognition events;  improved partnership working relationships with staff representatives, including manager and staff representative development sessions #GoTogetherGoFar, lead representative development session, regular meetings with the Chief Executive and Director of Workforce & OD, and engagement in key strategic developments such as the People Programme, Clinical Modernisation Programme, NEPTS;  significant improvement in PADR rates from 10% to 60% during 2015/16;  review of the Clinical Team Leader role and proposed development programme to support CTLs to be the best they can be;  an Executive Team development programme and development of Executive Team Charter; and  a review of the Advanced Paramedic Practitioner role and proposed progression framework.

Following changes to the assessment criteria of the Corporate Health Standard (CHS), it was recommended that the Trust allow more time to develop and embed its well-being framework and activities before seeking to be assessed for the Gold CHS. As a result, we will now seek to achieve Gold status by the end of 2016.

Strategic The Strategic Efficiency Programme constituted a number of workstreams which collectively laid the foundations for work in Efficiency future years in terms of realising efficiencies and supporting the organisation to become more efficient. Delivery of this Programme programme included workstreams set out below.

 Points of Presence: A baseline review of the organisation’s current estate (excluding ambulance stations). This work identified a number of opportunities to progress and these are now woven into this plan.

 Administration Review: A baseline review was successfully completed regarding the organisation’s administrative function. Proposals to carry out a full review of administrative and corporate functions will be developed through 2016/17 and will form part of our plans for year 2.

 CCC re-configuration: During 15/16, this workstream was disaggregated from the strategic efficiency programme. This was done in light of the in-year decision regarding the 111 Pathfinder project WAST will now host and the added complexity this now adds to the CCC re-configuration agenda. Community Engagement This project set out to develop a Community Engagement Strategy and implementation plan that was citizen-centred, to enable the Trust to interact with all stakeholders and promote community ownership of the service. The project has delivered a full scale engagement scoping exercise that has mapped the levels of reported engagement activities across the Trust and the regions. A ‘living’ database showing levels of community engagement/activity is also ‘live’.

The community engagement database has the potential to evolve further and its use broadened. The specification outlined for the database will provide evidence of engagement undertaken and for what purpose. With further development it would be able to highlight where engagement activities will need to be strengthened in order to make certain that engagement activities are representative of all.

The system has the potential to be advocated as a pan Wales system to ensure that learning is shared across other health organisations. This will support the principles of prudent healthcare and co-production.

1.4 Maturing Commissioning Arrangements and Increased Focus on Financial Strategy The National Collaborative Commissioning: Quality & Delivery Framework Agreement is a critical driver of our services (more detail in Part 2). Much progress has been made throughout 2015/16 in terms of strengthening the collaborative approach to commissioning. Some headline achievements are outlined below.

 Support for 14 Service Change initiatives through the CAREMORE approach.  Publication of the Ambulance Quality Indicators (data and supporting narrative) in January 2016.

From a financial perspective, 2015/16 has seen a significant increased focus on the development of our financial strategy and financial planning and integrating this with strategic workforce planning and focussing on the medium as well as short term. Working closely with the commissioning team, this has also seen significant additional detail provided to the Emergency Ambulance Services Committee (EASC) in order to clarify critical areas of spend, including those that linked to past investment in the Trust.

 Two specific amounts within the financial value for 2015/16 agreed at the outset of the financial year, namely:

o £7.5m first provided in 2014/15 predominantly for workforce pressures and recruitment, and the development of the clinical desk within the CCC; and o £8m provided at the end of 2014/15 for service change developments to specifically allow for improvements in operational performance and, in 2015/16, the move towards the New Clinical Response Model.

 The level of additional planned spend in 2015/16, agreed by both the Commissioners and WG, in order to maintain and improve performance delivery, initially estimated to be c£4.4m, this is now forecast to be £3.5m. This further stabilisation of the levels of additional spend required by the Trust to continue its operational performance improvement, whilst delivering within a resource envelope agreed much earlier in the financial year, is key to the confidence the Trust now has, assuming the recovery of fair shares of additional monies being available across NHS Wales, in being able to present, implement and deliver a balanced financial plan and position over the medium term.

 The delivery of significant levels of savings in 2015/16 to achieve financial balance, or even a small surplus, by year end.

 The level of additional detail routinely provided by the Trust to the CASC Team in relation to detailed spend across the Five-Step Ambulance Care Pathway, and in accordance with the National Collaborative Commissioning: Quality & Delivery Framework Agreement (CQDF).

Detailed information was provided to the EASC Joint Committee meetings in September 2015, November 2015 and January 2016 and a summary paper, consolidating these pieces of work, was provided to the office of the Chief Ambulance Services Commissioner in February 2016. The maturing relationship between the Trust and the Commissioning Team has also seen an agreed approach to the basis of the key financial planning assumptions which underpin the three- year financial plan within this IMTP, including the shift of focus away from pockets of previous

22 investment to concentrate on the efficient use of the total resource, especially in relation to EMS, and focus on the overall quantum of spend. The agreed approach has been to set out in detail for the CASC the current expected levels of total spend (including inflationary and other cost pressures) by the Trust, in order for the operational performance improvement trajectory to be maintained and the performance ambitions detailed within this IMTP to be delivered, over the next three years. This includes challenging, ambitious, but deliverable cost improvement, efficiencies and savings targets, and partly driven by reasonable estimates of fair shares of expected additional NHS Wales wide funding over this period; these detailed assumptions have been shared with, and received support from, the CASC, on behalf of the EASC. Further supplementary detail to support this projected level of EMS spend over the medium term, based on the detailed financial planning assumptions within this plan, and the financial modelling that underpins this, have also been provided to the CASC office, including:

 a projected pay spend analysis between core and variable pay over the three years;  total forecast spend over the five-steps of the Ambulance Care Pathway; plus  further detail regarding the Trust’s Cost Improvement Programme / efficiency plan for the coming three years.

PART 2: ORGANISATIONAL AND STRATEGIC CONTEXT

This section outlines the context within which the Trust operates. It covers: - the profile of the Trust, including our people; - demand, activity and population changes; - the National Collaborative Commissioning Quality & Delivery Framework; - national policy context; - major conditions, older people and frailty; - learning from previous events; - NHS Wales strategic change agenda; - blue light partners; - Prudent Healthcare; - Treating People Fairly – equality and diversity; and - Welsh language.

2.1 Profile of the Trust We, the Welsh Ambulance Services NHS Trust (WAST), provide ambulance services for people in Wales, delivering high quality and patient-led clinical care – emergency, urgent, scheduled – wherever and whenever needed. We are changing the focus of our service to establish ourselves as a clinically-led, quality-driven emergency medical service, non-urgent patient care service and a 24-hour health care and advice service that focuses on delivering the best clinical outcomes for patients. We want to (and should) be seen as an integral part of the ‘frontline’ of the integrated healthcare system in Wales, with emergency and urgent care services a fundamental part of the national unscheduled care system. We also work closely with Public Health Wales in our public health messaging and in understanding the changing health demographics that impact on the unscheduled care system. Operations Directorate The Operations Directorate is responsible for all of the ambulance resources provided by the Trust including Emergency Medical Services (EMS), Urgent Care Services (UCS) and Community First Responders (CFRs). Through our EMS workforce, we provide a 999 service responding to emergency calls to the most vulnerable people in Wales. Our paramedics and ambulance crews are trained to manage a wide range of presenting complaints and to administer drugs in line with the UK national ambulance clinical JRCALC Guidelines (Joint Royal Colleges Ambulance Liaison Committee).

Our UCS workforce provides a fundamental back up to our EMS function. Their main objective is to support inter-hospital transfers and respond to a code set of low acuity presentations aligned to their training. These are usually patients who have already been assessed by a doctor, nurse or a paramedic as being suitable to be looked after by a UCS crew.

Both our EMS and UCS services are configured to align with our Health Board partners’ physical boundaries. Each Health Board area has a clinical structure that consists of a cadre of Advanced Practitioners (APs) educated to Master’s level, Clinical Team Leaders (CTLs), Paramedics, Advanced Emergency Medical Technicians (AEMTs), Emergency Medical Technicians (EMTs) and

Urgent Care Services (UCS). There exists a Head of Operations (HoO) who oversees operations in each Health Board area.

Figure 6: Map of our EMS Resource (Funded Establishment)

1. BCU Population – 694,038 Paramedics – 200.8 Clinical Team Leaders – 33 Advanced Practitioners – 5 EMT / AEMTs – 98/7 Urgent Care Staff - 48

2. Powys Population – 132,675 Paramedics – 55 Clinical Team Leaders – 11 Advanced Practitioners – 3 EMT / AEMTs – 42/6 Urgent Care Staff - 14

6. Cwm Taf Population – 295,953

3. Hywel Dda Paramedics – 65 Population – 383,989 Clinical Team Leaders – Paramedics – 138 11 Clinical Team Leaders – Advanced Practitioners 21 – 2 Advanced Practitioners EMT / AEMTs – 22/4 – 6 Urgent Care Staff - 26 EMT / AEMTs – 52/7 Urgent Care Staff - 23

4. ABMU 7. Aneurin Bevan Population – 523,001 5. Cardiff & Vale Population – 580,401 Paramedics – 124.3 Population – 481,979 Paramedics – 118 Clinical Team Leaders – Paramedics – 80.5 Clinical Team Leaders – 19 Clinical Team Leaders – 19 Advanced Practitioners 15 Advanced Practitioners – 4 Advanced Practitioners – 1 EMT / AEMTs – 44/7 – 4 EMT / AEMTs – 63/4 Urgent Care Staff – 33 EMT / AEMTs – 41.9/4 Urgent Care Staff - 31 Urgent Care Staff – 18.9

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

There are currently more than 200 Community First Responder schemes across Wales comprising of approximately 2,200 volunteer members. These responders save lives every year across Wales. There are several different types of Community Response that are set out below.

 Community First Responder schemes - consist of individual volunteers within the community who must be trained to the basic level of a volunteer responder.

 Partner Co-Responding Schemes - across the Central and West areas, they provide an emergency service based response provided by appropriately trained Fire and Rescue Service staff. We are also currently supporting a Fire Service National Joint Council Co- Responder pilot in the North and South East areas until end June 2016.

 Medical First Responders - registered Healthcare Professionals who respond to emergency incidents. These responders have the added benefit of providing additional treatment options over and above those provided by CFR schemes.

 Established Based Responders (EBRs) - static sites e.g. leisure centres, supermarkets equipped with an automated external defibrillator (AED) which a group of people at the site have been trained to use in order to provide basic life support.

 Community Public Access Defibs- automated external defibrillators stored securely in public locations. CPADs can be accessed by members of the public who call 999 in close proximity to the defibrillator and follow the instructions given to them over the phone by an Emergency Medical Dispatcher. Within the Operations Directorate there are several key support teams.

 Fleet Department

A reliable fleet is a pivotal part of providing ambulance services. We have, through the NHS Wales Capital Programme, invested heavily in a modern fleet of ambulances and Rapid Response Vehicles. The national fleet manager and his team are responsible for ensuring that there are sufficient numbers of vehicles available in each operational area of the Trust to match the demand. Employing 38 staff spread across the entirety of Wales, the Administration Department is mainly based at Wrexham and shares the same site as one of the four in-house workshops. The other three in-house workshops are located in Cardiff, Blackwood and Bangor. There is also a management team based at Vantage Point House, Cwmbran. The Fleet Department manages and maintains the vehicles through a rigorous and robust Planned Preventive Maintenance (PPM) schedule. Maintenance is primarily undertaken at the four in-house workshops in the North and South East areas.  Resources Department

Ensuring we have sufficient operational staff in the Clinical Contact Centres and out on field-based operations crewing ambulances and Rapid Response Vehicles is key to providing a safe service.

Operational staff are co-ordinated by four resource centres. Resource managers and their teams ensure that staffing is managed in line with rota patterns. Staffing increases required by special events are co-ordinated by the resource centres.

 NHS Direct Wales Services

NHS Direct Wales provides a one-stop-shop for healthcare information, offering advice and support over the telephone and online, which includes triage from both nurses and dental health advisors. The service presently employs approximately 177 staff (136.51 WTE) including call handlers, nurse advisors, dental advisors and management and administrative support.

Visits to the website continue to rise with users looking for information on particular health conditions or support services, including use of the online symptom checkers.

In 2014/15

 301,739 telephone contacts were received, a 5% decrease on the previous 12 months, of which 55.3% were directed away from unscheduled care

 4,545,133 website visits were received, a 29.29% increase on the previous 12 months

 42,481 low acuity ambulance calls were transferred for clinical nurse triage, of which 51% were directed away from requiring an ambulance response

 HART (Hazardous Area Response Team)

The Trust also provides and supports a specialist service known as HART (Hazardous Area Response Team). The HART team forms the central plank of what would be the organisation’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) and employs 28 paramedics and 14 EMTs, supported by 2.8 WTE management and administration staff. The HART team ensures the statutory obligations and duties of the Trust are met in relation to its role as a Category One Responder under the Civil Contingencies Act 2004 (CCA), the UK Government’s Counter Terrorism Strategy (CONTEST), and the Security and Counterterrorism Act (2015). Other legislative and guidance documents relating to security and emergency preparedness from both UK and Welsh Government are addressed as part of Trust core business, with the support of the HART team. The Resilience and Specialist Operations department comprises Resilience Managers responsible for specific Health Board areas across Wales, as well as the Hazardous Area Response Team (HART), the Special Operations Response Team (SORT) 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 coterminous with the four Welsh police forces. The department is also engaged in national fora to support the area of operations from Resilience / EPRR, HART and SORT. We are also engaged in the UK Contest Board, 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 the organisation is fully discharging its legal obligations and ensuring that it is in a suitable state of readiness to react to any situation, a number of actions are being progressed by the organisation and lead by the HART team. These are listed in the governance section of our plan (section 6). All of these operational resources, ambulances, HART, rapid response cars and UCS crews are co- ordinated via three Clinical Contact Centres (CCC). Within the Cwmbran CCC is a team of 18 Secondary Triage Clinicians who provide support to the allocators and call takers who receive and dispatch the calls. Our CCC teams answer, prioritise and assess every call that we receive. Most importantly, they give advice to callers on life-saving first aid that can be given in the minutes while the ambulance is travelling to the call. They are an often forgotten vital part of every life we save.  Patient Care Services (PCS) – non emergency/ elective patient transport

Non-Emergency Patient Transport (NEPTS) is delivered by the organisation through the Patient Care Service (PCS) section of the organisation. We employ approximately 590 staff on PCS, with 480 operational, 28 working in ambulance liaison at hospitals and 70 in PCS Control.

The PCS service provides non-emergency transport to the residents of Wales who, for medical reasons, are unable to make their own way to hospital locations and treatment centres. Such journeys include:

 outpatient appointments;  patients for dialysis and cancer treatments;  day centre and psycho-geriatric clinics;  admissions and discharges, including inter-hospital transfers; and  end of life care pathways.

The service acts as a vital link between communities and is an integral part of the overall package of healthcare that the Welsh Ambulance Service provides in Wales.

There are various aspects involved in the service delivery of the PCS.

 Non-Emergency Patient Transport (NEPT) contact centres - where healthcare professionals and/or patients contact the ambulance service to book non-emergency transport  Planning and Day Control teams - who are responsible for the co-ordination of available resources  Operational ambulance staff  Ambulance liaison staff – based at many of the hospital sites  Customer Services Managers

PCS operational staff are trained in the particular needs of the patients we convey, including first aid, oxygen therapy, specialist driving skills, patient moving and handling techniques, basic life support (including automated external defibrillation) and general patient care skills.

The PCS uses specially designed vehicles to provide appropriate levels of clinical care, comfort and safety for patients.

Delivery of these frontline, patient-facing services is supported by a number of corporate directorates employing approximately 9% of our overall workforce. These include:

Directorate Headcount WTE Quality & Patient Experience 39 35.04 Workforce & OD (inc NATC and Occupational Health) 79 73.68 Finance & ICT (inc Health Informatics) 71 67.73 Strategy, Planning & Performance 18* 16.01 Clinical Directorate 53 50.93 Chief Executive & Corporate Secretary 7 6.24 Engagement & Partnerships (including Communications) 6 5.56 Total 273 255.19

*This figure includes staff working in Capital Planning- a function currently being managed by the Director of Finance and ICT Further details of the Directorate portfolios are described below. Quality, Safety & Patient Experience Directorate The Quality and Patient Experience Directorate has three core aims:

 To support front line teams and managers to deliver quality-led services;  Provide the right quality assured information, in a timely manner that allows the Executive Management Team and Trust Board to make informed decisions regarding the quality of care we provide; and  Provide assurances to the Executive Management Team, Board sub-committees and Trust Board in matters relating to quality, safety and experience.

The core functions of the Directorate include the following.

 Patient Experience – Partners in Healthcare  Putting Things Right – complaints, patient safety incidents, claims, inquests  Safeguarding adults and children  Professional standards and practice education  Nursing revalidation  Risk management  Health and safety  Quality assurance  Quality improvement

The Directorate leads the Quality Strategy for the Trust. This embraces the NHS Wales Health and Care Standards (2015) and the All Wales Standards for Accessible Communication and Information for People with Sensory Loss. The Directorate also works in partnership with Health Inspectorate Wales, the Community Health Councils, Commissioner for Older People and Childrens Commissioner.

Workforce and Organisational Development Directorate As a strategic corporate directorate, the Workforce and Organisational Development Team supports the business of the Trust, and are ambassadors for our shared behaviours, health improvement, well-being, equality and diversity encouraging these across the organisation.

The Workforce and OD Directorate comprises the following main portfolios.

 Operational Human Resources, including workforce governance and information  Organisational Design & Development  Training, Education & Development  Employee Well-being and Occupational Health Services

Engagement & Partnerships (including Communications) Directorate The Directorate of Partnership and Engagement is a newly created directorate, the purpose of which is to bring coherence and strategic insight to the Trust’s engagement and partnership agenda, as well as protecting and enhancing the reputation of the Welsh Ambulance Service among its many stakeholders. The Directorate, which is led by the Director of Partnership and Engagement, currently comprises the Office of the Chief Executive and the Communications Team. Finance (revenue and capital), ICT, Health Informatics and Estate Directorate The Trust’s Finance Department forms part of the Finance and ICT Directorate and provides strategic and operational finance leadership and support to the organisation, acts as a key link between the organisation and a range of external stakeholders, including the Welsh Government, the Commissioner of EMS through EASC, LHBs and other Trusts in Wales, NWSSP, internal and external audit. Based across a number of key Trust sites, the finance teams provide specialist input across all finance functions, including financial management and management accounting, financial accounting, financial planning, costing, project accounting and capital support, counter fraud and lease cars. The Trust ICT Department forms part of the Finance Directorate and, along with Health Informatics (HI), provides all information systems and services for the Trust. The ICT Department is made up of a number of specialist teams based at five key Trust sites. These teams provide day-to-day support to existing ICT services but also work to support the strategic aims of the Trust. The Health Informatics functions include information governance, records management, information analysis, business intelligence development and official statistics reporting. The department provides services to all facets of the organisation and has developed an excellent reputation, both internally and externally, for providing a high quality informatics service to its client base.

The Estates and Capital Teams work closely together to provide new capital developments and also maintain the existing estate infrastructure to ensure suitability for operational staff, Clinical Contact Centres, training, resource centres to enable stocking and washing facilities for our fleet, fleet maintenance workshops, as well as providing administration office bases across Wales. The Capital Team ensures that the Trust adheres to the Welsh Government NHS Wales Infrastructure Guidance for all major capital developments and also monitors the progress of the internal capital schemes that are funded via the Trust’s Discretionary Capital Process.

Medical Directorate The Medical and Clinical Services Directorate has responsibility for securing sustainable, consistent, safe and clinically effective care through leading improvements to services and patient care and, in so doing, supporting the Trust in achieving the transformational change necessary. Under the leadership of the Executive Medical Director, the Directorate works collaboratively as a team and with other directorates to ensure that quality and clinical leadership provide the foundations for everything we do. Leading a professional, high-performing team, the Executive Medical Director ensures the identification, maintenance and assurance of agreed clinical standards. He provides the strategic clinical expertise and develops clinical standards that are patient-focused and cost-efficient whilst working together with the Chief Executive and his fellow Directors to shape the future clinical architecture and direction of the Trust.

The remit of the Directorate includes the areas outlined below.  Research and Innovation  Service Improvement  Clinical Audit  Clinical Equipment and Medical Devices  Professional Standards

Planning and Performance Directorate The Planning and Performance Team has responsibility for leading the strategic planning of the organisation and the planning cycle that the organisation has adopted. The Directorate also interfaces with the wider strategic planning community of NHS Wales in order to have visibility of (and influence over) service reconfigurations that may materially impact the organisation. The Directorate retains a specialised project and programme management role and oversees the highly complex programmes of change that the organisation is delivering. The performance arm of the Directorate manages the performance management framework of the organisation and the key relationship with the Chief Ambulance Services Commissioner in regard to ensure delivery of the National Collaborative Commissioning: Quality and Delivery Framework Agreement. Corporate Governance Directorate The role of the team is crucial to the ongoing development and maintenance of a strong governance framework within the Trust. It is a key source of advice and support to the Trust Chair and other Board members and is led by the Corporate Secretary. The team acts as the guardian of good governance within the Trust by:

 providing advice to the Board as a whole and to individual Board members on all aspects of governance;  facilitating the effective conduct of Trust business through meetings of the Board and its Committees;  ensuring that Board members have the right information to enable them to make informed decisions and fulfil their responsibilities;  ensuring that in all its dealings, the Board acts fairly, with integrity, and without prejudice or discrimination;  contributing to the development of an organisational culture that embodies NHS values and standards of behaviour;  monitoring the Trust’s compliance with the law, Standing Orders and the governance and accountability framework set by Ministers; and  providing advice to the Board on implementation of the Trust’s Welsh Language Scheme.

2.2 Our Demand & Activity Long Term Trends Over the last thirty years or so the population of Wales has grown from 2.73 million in 1971 to 2.99 million in 2008, most noticeably in recent years due to net inward migration from the rest of the UK (source PHW). There is considerable variation, however, as some local authorities in Wales have declining populations due to low birth rates and the outward migration of young people. As our planning function further develops we want to ensure that we start to consider even more robustly the clinical, operational and quality impacts of changing population trends by working more closely with Public Health Wales and actively engaging in the Well-Being of Future Generations (Wales) Act 2015, in particular, the Future Trends report and Public Service Boards. Action 1: Actively work with Public Health Wales and engage with the Well-Being of Future Generations (Wales) Act 2015 agenda in order to better develop the Trust’s strategic responses to predicted changes in our population. Local Authority Local Development Plans The Local Delivery Plans developed by each Head of Operations for the seven LHB areas have identified many major business and large housing developments that will impact in future years on the Trust. Under the Town & Country Act (1990), the Trust can make applications for Section 106 contributions towards the costs of healthcare relating to major developments. WAST has recently been successful in making an application for such a contribution. What WAST requires is a comprehensive picture of these planned major developments and a systematic approach to making applications for S106 contributions and modelling and planning the impact of these major developments on response times and the required resource to respond appropriately. Action 2: Engage with local authorities to develop a comprehensive schedule of major development schemes, so that the Trust can apply for S106 contributions, including modelling and planning for the required resource to respond appropriately to these new developments. Health Economy Changes Another key aspect of demand and capacity planning is the portfolio of changes within the health economy. These changes are detailed in 2.13 NHS Wales Strategic Change Agenda. During 2015/16, the Trust procured Optima: software that can simulate the impact of changes in the health economy and assist the Trust with improved planning for performance. Patient Flow The flow of patients through the Trust’s part of the unscheduled care system is shown in Figure 7 below.

Figure 7: EMS Patient Flow (December 2015)

N.B. We will receive multiple calls about the same incident hence the reduction in the number of responses (box 5) compared to the number of calls taken through MPDS (box 4). The recent publication of the Ambulance Quality Indicators, as part of the CQDF, has provided more detailed information on patient flow across the Five-Step Ambulance Care Pathway which will be built on through 2016/17 and will further aid the Trust in developing its approach to effective management of patient flow. The Annual Cycle Patient flow will vary during the year, as a result of seasonal fluctuations in demand, with spikes in demand during the summer holiday period and during the winter. Whilst the basic EMS demand cycle is known, predicting demand with more certainty is much more complicated because of the number of changeable variables. For example, increasingly variable weather patterns and the exact timing of a flu outbreak, which place a greater emphasis on the organisations ability to flex capacity in response to changes in demand. Similarly there are also periods of lower activity for PCS journeys associated with holiday periods, with the reduction in journeys being attributed to stronger application of the eligibility criteria. Demand & Capacity Modelling

In recognising the complexity of understanding demand later in our plan (Section Five, STEP 2) we outline a piece of work to undertake a demand and capacity review of our EMS activity. We are pursuing this collaboratively with the office of the Chief Ambulance Services Commissioner. This is a really important piece of work not only because of what is described above but because, coupled with this, the New Clinical Response Model is currently based on the ideal response to a 999 call. The model makes this ‘decision’ by having a predetermined ideal response to each of the 1800 MPDS codes used to prioritise incoming 999 calls. In addition to the ideal response, a suitable response has also been identified for all codes to inform allocators’ decision-making where there is no ideal response available. We recognise that the model was introduced using our old rosters and staffing grades and thus currently we not as well informed as we could be regarding what resources we need at our disposal to make this new CRM as effective as it possible can be. 2.3 The Five-Step Ambulance Care Pathway, Commissioning Quality & Delivery framework The Commissioning: Quality and Delivery Framework (CQDF) went live in April 2015. The Chief Ambulance Service Commissioner (CASC) has identified the “positive work” that has been undertaken in the first half of 2015/2016 on developing the CQDF.

The Five-Step Ambulance Care Pathway The Ambulance Care Pathway is the five step process for the delivery of emergency ambulance services within NHS Wales. The Ambulance Care Pathway encourages the Trust to focus on the patient journey i.e. patient flow, and a whole systems approach, rather than on functional lines. It acts as a lens for framing all discussions on EMS, is consistent with the Trust’s New Clinical Response Model and has been widely adopted within the Trust. Figure 8: Five-Step Ambulance Care Pathway

STEP 1 (‘Help Me to Choose’) – This step focuses on public education regarding the services provided by WAST and how/when to access them appropriately. This step will include the development of appropriate linkages between WAST and the future 111 service, building on the success of NHSDW and its website as well as the secondary triage clinical desk.

STEP 2 (‘Answer my Call’) – This step focuses on the response to 999 and Health Care Professional (HCP) calls by WAST’s Clinical Contact Centres (CCCs). This step incorporates the provision of adequate time to assess a call and the use of the Medical Priority Dispatch System (MPDS) to identify the priority of the call before offering / sending the most appropriate response.

STEP 3 (‘Come to See Me’) – This step focuses on how WAST makes decisions about what resources to dispatch to assessed/prioritised calls. Broadly, three response options are available:

 Emergency Ambulances (EAs) and solo crewed Rapid Response Vehicles (RRV) and Community First Responders (CFR) will be allocated to RED calls, e.g. cardiac arrest or choking;  Emergency Ambulances (EAs) will be deployed to AMBER calls where the patient requires transfer to hospital (e.g. heart attack or stroke);  solo crewed Rapid Response Vehicles (RRV) will be sent to AMBER calls where the likelihood is that, after assessment, the patient will be referred to another service e.g. GP Out of Hours. (see, treat and refer);  Clinical Telephone Assessment (CTA - ‘hear & treat’) will be offered to all other low acuity AMBER and GREEN calls; and  Urgent Care Service crews (UCS) will be dispatched for low acuity GREEN patients who are assessed by HCPs as requiring admission to hospital.

STEP 4 (‘Give Me Treatment’) – This step focuses on the development and delivery of a range of clinical care services able to offer a variety of treatment options. The selection of the most appropriate treatment will be supported by decision support tools e.g. Paramedic Pathfinder for ‘see & treat’; the Manchester Triage System and the Clinical Assessment System (for ‘hear & treat’). Treatment options will include the use of Alternative Care Pathways or ACPs (set out in a Directory

34 of Services) allowing patients to be referred to primary and community care. WAST will develop a Clinical Hub to coordinate the delivery of care to patients (‘sign – posting’ for clinical advice, managing referrals to alternative care pathways, and arranging non-emergency transportation i.e. managing any element of WAST’s services that is not time critical or an emergency transport to ED).

STEP 5 (‘Take Me To Hospital’) – Patients who require ongoing care and treatment will be transported to hospital or to alternative care settings (e.g. Minor Injury Unit or a primary/community care facility). The clinical acuity of the patient will dictate the level of transport. For critical care patients or patients requiring ongoing treatment, EAs will be utilised. All other patients will be transported by a combination of Urgent Care Services (UCS) and non-emergency patient transport services (NEPTS) or in some cases the use of a taxi. Patients will also in safe circumstances be encouraged to make their own way for treatment. This will usually be after secondary telephone assessment.

Core Requirements The Ambulance Care Pathway is then underpinned by six enablers, which are referred to as Core Requirements (CR). A self-assessment against the Core Requirements was undertaken in December 2015 and reported to the Quality Assurance Improvement Panel (a sub-committee of EASC). It highlighted a number of areas where further focus is required:  CR1 Governance The self-assessment outlined areas for further improvement. Significant progress has been made in 2015/16, for example, the commissioning framework and risk management, but much more remains to be done in 2016/17 to develop these arrangements before they can be established. Our plan sets out how we are going to address this.  CR2 Patient Experience & Satisfaction The self-assessment identified a well-established “Partners in Healthcare” Team which has fully implemented the National User Service Framework and a range of changes e.g. new compliments process, Dignity in Care Programme etc. The “Putting Things Right” (PTR) systems and processes completed a 100 day improvement plan to improve performance, and this remains an area of focus as this moves into the next phase of work. An organisational restructure has moved PTR into the new Directorate of Quality, Safety and Patient Experience portfolio, bringing together risk management, patient safety, patient experience, quality, health and safety, safeguarding, complaints and claims, as well as a new Director having started in February 2016. Updating our datix system will also make a significant impact on the PTR agenda. From April 2016 a quarterly quality assurance report triangulating information will be reported.  CR3 Equity There is variation in RED performance between localities with a variation between the best and worst performers of 32.4% (October 2015). The Trust has developed Strategic Equality Objectives and a Strategic Equality Action Plan; however, there are different levels of maturity of arrangements across Wales which WAST can engage with and it remains an area of focus. Managing variation and addressing inequalities has been identified as a strategic aim of ours and we will use the EASC commissioning NHS Benchmarking toolkit to shine a light on areas where inequity is most severe.

 CR4 Clinical Care A twelve-month pilot of the New Clinical Response Model commenced on 1 October 2015. This has shifted the focus from the previous time based targets to a clinical focus on the right clinical care and patient flow, supported by the AQIs (including new clinical indicators). The pilot will be externally evaluated for Welsh Government and the evaluation procured by EASC. The New Clinical Response Model is a clear priority throughout this plan.  CR5 Staffing The self-assessment identified progress with an emphasis on recruitment, reduced sickness, a review of rosters, an increase in productivity (unit hour production (UHP)) and an increase in PADRs. The key focus for 2016/17 is the implementation of our People Strategy and workforce plan, linked to changes in incidents within the New Clinical Response Model. In our plan we clearly set out our ambition for improving these indicators  CR6 Safety The self-assessment identified a range of safety issues that needed addressing including: safeguarding reporting arrangements and the outcomes of Serious Adverse Incidents. A new professional lead is in place for Safeguarding. QAIP have also been provided with an action plan in support of the issues identified in the self- assessment. A key development in 2016/17 will be the development of a set of core requirement indicators in a similar style to the AQIs. The Trust already reports on a range of enabling activity indicators; however, it recognises that the current approach needs to be improved and is currently actively working with the CASC’s team on developing these. Ambulance Quality Indicators A key part of the developing CQDF is a set of Ambulance Quality Indicators (AQIs) that provide information on patient flow, performance and clinical indicators across the Five-Step Ambulance Care Pathway. The AQIs were published for the first time on 27 January 2016 by EASC (in collaboration with the Trust) and will be published every quarter thereafter with LHB level information from July 2016 onwards. A summary of some of the emerging performance issues arising from the first publication is set out in appendix 1. Service Change Ideas A key part of the CQDF is the identification of service change ideas or the “big ticket items” that the Trust is working on to deliver the shift towards STEPS 1-3. The CQDF requires these service change ideas to be framed using a CAREMORE® template. The CAREMORE® template is a form of project initiation document that helps scope out an idea, its potential impact on the Five-Steps and how we intend to evaluate it. Some 14 service change ideas have been agreed with EASC and these, along with a summary of each, can be found in appendix 2. Each service change idea has key milestones, including an evaluation phase. During 2016/17, the Trust will work with the CASC’s team to ensure the evaluations are discussed with the QAIP i.e. whether there is proof of concept and whether the approach should be embedded and/or expanded. The Chair of QAIP, Professor Siobhan McClelland, has requested a timetable for the 15/16 CAREMORE service change ideas, in particular, when they will return to QAIP for the evaluation phase. This timetable is currently being finalised.

As part of our planning for 2016/17, further service change ideas using the CAREMORE® template will be discussed with QAIP. The Trust has traditionally suffered from initiative overload, so whilst 2016/17 service change ideas will be forthcoming, a balance needs to be struck between completing and evaluating the 2015/16 ones and proposing new ones. Both the 2015/16 service change ideas and emerging 2016/17 service change ideas are covered in Section 5: Our Service Change Plans and denoted by CAREMORE®.

2.4 National Policy Context

Together for Health The Welsh Government has set out the national strategic direction for the NHS in Wales through the overarching “Programme for Government” and the NHS Wales strategy “Together for Health”. This umbrella strategy has been complemented by a suite of additional policy documents or supplementary plans, including:  The Primary Care Plan (2014);  Condition-based national delivery plans; and  Informed Health and Care: A Digital Strategy for Wales (2015).

We recognise that, as an organisation, we are not as effectively plugged into the national delivery or policy groups for all of the delivery plans and the Primary Care plan where we clearly have a role to play. We will work with Welsh Government colleagues and LHBs to ensure that we have access opportunities for joint planning and any ring fenced monies associated with these programmes.

The National Unscheduled Care Programme The National Unscheduled Care Programme gets its mandate following the oral statement of the Minister for Health and Social Services in 2013. It describes how a ‘Framework for Unscheduled Health and Care Services for Wales’ will be established to add value and focus to the quality and efficiency of local unscheduled care delivery. It has recently been re-established and re-framed, following the methodology and systemised approach of the five-step ambulance model. We in WAST welcome this approach and the adoption of a whole system model for the management of unscheduled care. The figure below outlines steps 0 – 10 of the model and is intended to reflect the non-linear nature of the unscheduled care pathway.

Figure 9: 10 Step Unscheduled Care Model

We will use the opportunities that the framework presents to ensure joint approaches and collaborative working on the improvement required to the unscheduled care system. NHS Planning Framework Welsh Government sets out the strategic context and formulates health and social care policy to be implemented by NHS Wales and its partners. The diagram below presents the Framework of National Planning Requirements and identifies the key drivers for change.

Figure 10: National Framework of National Planning Requirements

CENTRAL ORGANISING PRINCIPLES Prudent Healthcare Golden threads running through the entire planning process. They are values and Quality and Safety principles that must underpin plans in the Welsh NHS.

Health Inequalities

SYSTEM SHIFTS Prevention and Health Improvement Relate to the development in new ways of doing things rather than doing things better within existing models. They should be Primary and Community Care evident through all aspects of the plan.

Integration

PATHWAYS Urgent and Emergency Care Whilst there are many, often designed to respond to local circumstances, the advent of national programmes for unscheduled and planned care have and continue to set common requirements that must be evident Planned Care in an organisation.

SPECIFIC NEEDS Maternal and Child Health The diagnostic stage will identify particular populations with higher levels of, or different, needs from services. Meeting Delivery Plans those needs will be common to all services across the NHS and therefore reflected in Mental Health national plans.

NHS OUTCOMES AND DELIVERY FRAMEWORK DELIVERY AND OUTCOMES NHS Older People

Welsh Language

ENABLERS

The key resources and assets that will allow a plan to be delivered.

Finance Governance Innovation Workforce & Infrastructure Service Digital Research & OD Change Health Development

As well as setting out the key planning requirements, the national planning framework sets out:  Roles and responsibilities of NHS organisations within the planning system;  Clarity on benefits of having an approved IMTP;  Planning cycle timetable; and  The monitoring arrangements for delivery of IMTPs.

We will use the planning framework to help develop our local planning model and assure ourselves we are delivering national policy priorities. The Social Services and Well Being (Wales) Act 2014 The Act simplifies the web of legislation that previously regulated social care in Wales and is designed to make access to services easier and more understandable to those who need them. The Act focuses on:  People – putting an individual and their needs at the centre of their care, giving them a voice and control over reaching outcomes that help them achieve well-being;  Well-being – supporting people to achieve their own well-being, building on their own circumstances and capabilities, with better access to information and community support;  Earlier intervention – increasing preventative services within the community to minimise the escalation of critical need;  Collaboration – strengthening duties of collaboration between social services and the NHS as well as strong partnership working with other agencies including Third Sector;  Integration – more effective and better integrated models of care and support which provide a more responsive range of services; and  Workforce – a better qualified workforce with skills that enable people to work across organisational boundaries. Welsh Health Circular (2015) 045 sets out the implications of the Act for Health Boards and Trusts. The direction within the Act is congruent with many of our strategic intentions including, working across the health sector and with blue light partners (collaboration and integration), focusing on working up stream of our five-step pathway (earlier intervention) and many of our existing and emerging workforce models embrace team working. In addition, our strengthened safeguarding teams will ensure that we discharge our renewed accountabilities with respect to safeguarding. The Well Being of Future Generations (Wales) Act 2015 The Act places a statutory duty on Public Service Boards and certain named public bodies to improve the social, economic, environmental and cultural well-being of Wales in accordance with the sustainable development principles. Whilst we are not a “named organisation” who are subjected to the new duties, we will work within the spirit of the legislation and will work with our partners across the public sector in Wales to support delivery of the Well Being Goals as we recognise the contribution we have to make to many of them. We will do this through our membership (where invited) of a number of Public Service Boards bodies in the legislation. The seven well-being goals as well as the five sustainable development principles – long term, prevention, integration, collaboration and involvement – are consistent with the approach of the Ambulance Care Pathway and the New Clinical Response Model which promotes need-led demand. They are also part of the approach we have taken and will continue to take so that we develop our culture. Welsh Language As a result of the Welsh Language Measure 2011, the organisation’s Welsh Language Scheme was replaced in 2015/16 with the new Welsh Language Standards. The Welsh Language Commissioner will expect the Trust to comply with these standards, which cover all aspects of healthcare and public services provided. They will also expect the organisation to increase the opportunities for staff to use the language internally. The Trust is committed to ensuring the services patients receive, policies and initiatives are consistent with the Welsh Language Scheme and, to support this, the Equality Impact Assessment

40 process includes a section to identify how service changes impact on Welsh speakers. The Trust is 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.

We recognise the need to grow our capacity and ability to provide our health services bilingually. A language skills audit is currently underway and will identify any shortfalls that will be met through a combination of recruitment, training and partnership arrangements and is fundamental to delivery of the “Active Offer”. The Trust has a Welsh Language Skills Strategy. The aim of this Strategy is to identify and develop the Trust’s bilingual and skills resources. The following actions have been identified as necessary to achieve this aim:  An audit of existing bilingual skills This has been successfully delivered. Based on data taken from ESR on 30 June 2015: 97% (3095) of Trust staff have recorded their Welsh Language Skills. In addition, a mapping exercise has been undertaken to identify the current situation of Welsh speakers across the Trust involved in service delivery.

 An audit of workplaces and posts In order to determine the Trust’s bilingual skills requirements, each directorate – with the advice and assistance of the Welsh Language Officer – will need to conduct an audit of all workplaces and posts within their service areas. By examining the nature of the service, each post and workplace provides to the public, the audit will establish a set of criteria against which the linguistic requirements of individual posts (the minimum level of bilingual skills needed to ensure the availability of services in both Welsh and English) can be determined.

A Draft Recruitment Guidance to Determine Welsh Language Skills for Vacant Posts has been developed and will need to be approved as part of the Trust’s Recruitment and Selection Policy.

 Training – upskill staff who currently have Welsh language skills and those who do not New members of staff who deal with the public will be encouraged to demonstrate Welsh language skills to Level 1 (basic linguistic courtesy) within their first year of service. Managers will encourage newly appointed staff via local induction/ PADR meetings to achieve Level 1 with the aid of an ‘An Introduction to Welsh – Level 1 CD’ that will be developed by the Trust.

Digital Health and Care Strategy

In developing our Technology and Information Management capability, we are ensuring alignment with both our business aims and priorities and the principles of the Welsh Government Digital Health and Care Strategy. The four principles of the strategy are listed below with links to key deliveries within this IMTP.  Information for you We are committed to developing and delivering digital services and alternative access methods for patients. We are hosts of the 111 Pathfinder that will build on the digital services already in place within NHDSW. We will also look at developing patient self-service where practicable, especially in non-emergency situations such as self-service kiosks for NEPTS services, and will look to further enhance services through tele-health initiatives where practicable.

 Supporting professionals We will develop electronic capability to support operational staff and in doing so will look to utilise greater use of mobile and remote working technologies to enable staff to securely access relevant information at the point of care and away from their base. In carrying out this work we will work with partners across NHS Wales not only to consume information from them but to also provide them with accurate and timely information. The introduction of modern up to date operational system such as the new CAD will only enhance the opportunities for staff yet further.  Improvement and innovation We have already put improvement and innovation at the heart of our change agenda and are committed to continuing with this approach. The availability of high quality and timely information will be key for the future planning of service re-design. We are implementing modelling tools to assist with future development. In addition to introducing new information systems the capability to connect its medical devices to transfer real-time information will prove invaluable in improving patient care.  A planned future We are already working with organisations across Health, Emergency Services and wider public sector and will look for further opportunities to exploit information management and technology to transform services through providing staff with electronic patient-centred view of information in order to support high quality care.

2.5 Major Conditions, Older People and Frailty We recognise that we have a role to play in supporting those with major conditions and those who are older and/or frail. We are working towards being a Dementia Friendly organisation (Action 16) and we will work with the Older People’s Commissioner and Ageing Well in Wales National Programme to ensure we deliver quality care to older people and those with a specific need including dementia, sensory loss, falls, continence care and learning disabilities. Major Conditions In January 2015, the Minister for Health and Social Services announced an extra £70 million for NHS Wales. Of this, £10 million was invested to support the implementation of a set of delivery plans focusing on a range of major conditions. In 2015/16 we were successful in securing £60,000 from the stroke fund for online stroke training for our EMS staff. This has been fully paid for in 15/16, with training being rolled out over 16/17 (action 39, STEP 4; give me treatment). Welsh Government has confirmed that it will be extending the lifecycle of Together for Health Delivery Plans through to March 2020. As a result, we recognise that we need to be looking to take full use of these funds to supplement our other funding streams. As part of our approach to collaborative commissioning we produce CAREMORE® templates. These help us identify and share what we believe to be some of our ‘big ticket’ service change ideas. The CAREMORE® template helps us fully scope out these ideas and gain a greater understanding of what the outcomes and benefits potentially are and also the resources required to progress this work. In the latest round of templates being produced, we have identified opportunities that may potentially fit a delivery plan fund criteria. These include:

 End of life care pathway– End of life delivery plan (currently identified within action 46, STEP 5);  Community paramedic pilot – Primary Care (currently identified within action 38, STEP 3); and  GP Cluster work – Primary Care (currently identified within action 37, service improvement). We will work with our Commissioner to gain support for these service changes ideas before then collaboratively agreeing which is the most appropriate funding stream to access. Older People and Frailty Wales has an ageing population. As a service we are cognisant of the fact that a disproportionate amount of our calls relate to elderly fallers. Consequently, we are looking to implement a range of alternative care pathways so that these patients are not necessarily taken straight to A&E. Actions 45 & 46, STEP 5 outline alternative pathways for fractured neck of femur and end of life care that we are looking to put in place with Health Boards. These will be supported by developments in our training and education for our staff, described in Section 6, to equip them with the skills and knowledge to care for patients with complex, chronic conditions. Our data shows that we also receive a high number of calls from nursing / care homes. Action 19 in STEP 1 commits us to working with this frequent caller category, with the aim of reducing the number of conveyances to hospital. This is not only a positive step for the performance of the organisation but, more importantly, will prove better for the patient as they will be able to remain in their place of residence as opposed to being conveyed to hospital. In addition, as part of developing the Non-Emergency Patient Transport Business Case, we engaged with both the Older People’s Commissioner and patients. These discussions highlighted the following areas where improvements could be made for older people.

 Easier access to book transport. Consequently NEPTS will develop a single access number for all transport requests.  Reassurance and confirmation that transport is booked and on its way. Consequently NEPTS will provide a text alert service and a call-ahead service for patients that will provide a more accurate pick up time.  Reduced waiting time at hospital to go home. Consequently NEPTS will be making our liaison areas at key hospitals more patient-facing with a focus on ensuring delays are minimised.  Improved signposting to social and public transport if not eligible for hospital transport. As a result NEPTS will have a single access number for all transport requests with direct links to Traveline Cymru for elderly patients who are not eligible for NEPTS.  Public transport routes to help support visits to hospital. Consequently NEPTS will progress a working group that is developing an integrated transport hub within North Wales to bring together different providers to improve access to health.

2.6 Becoming a listening and learning organisation We recognise that there are events that we need to learn from. We are committed to doing this and making learning from experience a continual way of moving the organisation forward. An example is learning from serious adverse incidents and the Putting Things Right agenda. In one particular case, the Coroner made some recommendations and these are picked up explicitly in this plan.

 The demand and capacity review (Section 5, STEP 3) will identify if we have the right levels of resources to respond appropriately to the level of demand we experience.

 We have done work on rosters and this will continue when the demand and capacity review is complete.  We are developing the CFR role and looking to increase the contribution it can make to the organisation (Section 5, STEP 3)

2.7 NHS Wales Strategic Change Agenda The Ambulance Service operates as part of a complex health and social care system. It is widely recognised that no organisation can plan or deliver services in isolation due to the critical interdependencies, the joint challenges in terms of workforce, aging population and the shared objectives of improving outcomes and ensuring sustainability. Increasingly, collaborative planning arrangements across regions, or nationally, are developing with each arrangement taking a different form and reflecting different partnerships. It is key that we are engaged appropriately in these change programmes and that we are able to model, and influence, the impact of options or decisions. The capacity to field people to the multitude of service change programmes is challenging but a revised approach will be led by the Planning Directorate. The proposed Business Intelligence Hub will also be key in facilitating better understanding of the impact of proposed changes, specifically the new Optima software. Conversations with the Chief Ambulance Services Commissioner are ongoing to agree how these reconfigurations impact on our services so that any resource implications are understood in a timely way. Below is an overview of those that impact most on our services. Appendix 3 goes into more detail as to the milestones associated with these changes. South Wales Programme The South Wales Programme was formed by the Health Boards of Cwm Taf, Aneurin Bevan, Cardiff and Vale and Abertawe Bro Morgannwg to explore options for sustainable models of service for consultant-led maternity care, paediatrics and emergency medicine. WAST was a partner in the programme arrangements. The decision to consolidate these services on 5 sites (from 8) is being implemented through the three Acute Care Alliances. There will be an impact on our services; these were first mapped out by the WAST led Clinical Conveyance group. As component parts of the South Wales Plan are implemented this impact will need to be reviewed and the impact on WAST services taken into account as LHBs reconfigure their services. This IMPT recommends the establishment of a Business Intelligence Hub and it is anticipated that this group will review this work, using the Optima modelling tool. All Wales Collaborative Following the South Wales programme, the NHS Collaborative was formed and a number of change programmes initiated following the same collaborative model, these include:

 Major Trauma Network;  Neonatal services;  redesign of Vascular Services in Southeast Wales;  redesign of Pathology services;  Sexual Assault referral services;  Emergency Surgery redesign; and  Acute Medicine redesign. This work is driven forward through the Director of the NHS Collaborative and a Collaborative Board comprising the Chief Executive of each NHS organisation. Some of the workstreams have specific project structures.

For WAST the most significant of these changes are outlined below I. Major Trauma Network Development This workstream explores the establishment of a major trauma network (MTN) in South Wales (North Wales are part of a neighbouring MTN). Under the leadership of the NHS Collaborative, a programme of work underway across South Wales to develop a major trauma network. The model will have a single Trauma Centre at UHW, Cardiff or Morriston, Swansea supported by a [yet defined] number of Trauma Units and underpinned by a clear rehabilitation model.

A series of work streams have been established to support the decision making process around this:  baseline assessment of current service provision, to be considered by the Clinical Reference Group;  information - which will consider further information requirements to support the impact assessment of a major trauma centre at either Cardiff or Swansea;  finance and commissioning – which will be asked to estimate the revenue and capital implications of the development of a major trauma centre at either Cardiff or Swansea;  engagement – which will prepare an engagement and communications strategy which will underpin the development work, and which will ensure that stakeholder views are taken into consideration in the decision making process;  workforce - which will confirm the workforce implications of the development of a major trauma centre at either Cardiff or Swansea; and  rehabilitation - A series of three workshops is being planned to take place in November, December and January to confirm the service model. We are well represented across the various workstreams and have recently initiated some work to quantify the impact from an activity and job cycle perspective. As well as impacting on journey times and numbers of transfers, there are likely to be implications for our workforce, namely our EMS crews caring for major trauma patients for potentially longer periods of time as they travel to the Major Trauma Centre. Once implications are known, these will have to be fed into our training requirements. II. Neonatal Services Neonatal intensive care is currently provided from three hospitals in South Wales: University Hospital of Wales, Cardiff; Royal Gwent Hospital, Newport; and Singleton Hospital, Swansea. The clinical workforce at each neonatal intensive care unit (NICU) includes doctors training in neonatal medicine and the allocation and placement of trainees is managed by the Wales Deanery. A phased reduction in trainee numbers is planned and, as a consequence, training will be concentrated in two units from September 2016. The Neonatal Clinical Reference Group and the Collaborative Board have considered the implications and it has been confirmed that the intention would be to maintain three neonatal intensive care units (NICUs), one of which would become a non-training site. A process to determine the location of the non-training unit is being developed and will be a joint approach through the Welsh Health Specialised Services Committee, which is responsible for the commissioning of neonatal intensive care, the Wales Neonatal Network, the Clinical Reference Group and the Wales Deanery.

We continue to be interested and engaged in the outcome of this work as there is a clear impact on our services. The Planning Directorate will lead on this work and engage clinical and medical representatives as appropriate. The Business Intelligence Hub will support the modelling of the options.

III. Acute Medicine and Surgical Services

As part of the legacy from the South Wales Programme, work has been ongoing to further progress the development of service models and recommendations for acute medicine and surgical services across South Wales. The service model for acute medicine and the range of service models for the surgical specialities have identified levels of care across the patient pathway that indicate that care can be differentiated across hospitals, and outline the supporting services required to ensure a safe and sustainable service.

The work on acute medicine and surgery will be further considered to set it within a strategy for the region. We continue to be partners in these change programmes and will analyse via the Business Intelligence Hub the impact of options, as any changes to these services will clearly impact on our emergency services.

Mid Wales Collaborative

In January 2014, the Welsh Government commissioned the Welsh Institute for Health and Social Care (WIHSC) to explore the options for the provision of high quality and sustainable healthcare services in Mid Wales. The Mid Wales Healthcare Study, published in October 2014, highlighted a number of issues and made twelve recommendations to ensure healthcare services in Mid Wales are effective for the population. The first recommendation was that a joint governance mechanism, ‘The Mid Wales Healthcare Collaborative’, should be established in order to implement many of the other recommendations made in the Study.

The Mid Wales Healthcare Collaborative (MWHC) which comprises the four healthcare organisations that cover Mid Wales – Betsi Cadwaladr University Health Board (BCUHB), Hywel Dda University Health Board (HDUHB), Powys Teaching Health Board (PTHB) and the Welsh Ambulance Services NHS Trust (WAST), was formally launched on 12th March 2015 by the Minister for Health and Social Services at the Rural Healthcare Conference. The objectives of the MWHC is to implement the recommendations of the Mid Wales Healthcare Study in order to:

 deliver a single integrated change programme, with full public and professional participation, which addresses the delivery of social care, primary care and specialist care as an integrated continuum, provided as close to home as possible;  address prevention as well as treatment, and promote prudent healthcare; and  deliver a regional plan for Mid Wales.

The Collaborative’s governance arrangements together with a dedicated Project team have now been fully established. Appendix 4 details the actions that are being progressed by each of the Innovation sub-groups in order to ensure delivery of the Study’s recommendations with key priority areas of work identified below.

 Centre for Excellence in Rural Healthcare: The establishment of a Centre for Excellence in Rural Healthcare with a particular focus on research, development and dissemination of evidence in health service research which addresses the particular challenges of Mid Wales.

 Virtual Ward: Roll out the concept of the ‘virtual ward’ to all parts of the Mid Wales area through the establishment of integrated health and social care community teams supporting primary care. This work is being led by the Primary care and Community Services sub- group who will agree the core principles of the ‘virtual ward’ and then allowing for local variation and reflecting local circumstances, ensure the core principles are in place across all parts of the Mid Wales area. The funding requirement is to be identified by Primary Care and Community services sub-group.

 Telehealth: Ensure that there are accessible and appropriate telehealth services available across Mid Wales. The Welsh Government have awarded £250k funding of which £25k has been used to undertake a scoping exercise of telehealth provision across Wales. The report was published in January 2016 and the balance will be used to fund the implementation of the recommendations.

 Mental Health: Ensure that out of hours crisis support is available across Mid Wales.

 Access and Transport: Ensure better alignment between clinic times/Day Surgery and patient transport.

 Engagement and Involvement: Ensure effective communications, engagement and involvement with the public, staff and stakeholders. This work is being led by the Mid Wales Healthcare Collaborative team and includes a series of engagement events and the establishment of a Stakeholder Reference Group. The first round of engagement events involved 4 events Machynlleth, Aberystwyth, Blaenau Ffestiniog and Welshpool. During these events the public were asked for their ideas and comments regarding the Innovation sub-group actions and this feedback will be used to further inform and enhance the work of the Innovation sub-groups. Also the Stakeholder Reference Group (to be established) will provide a pool of interested and motivated individuals on whose expertise and experience the Innovation Sub Groups could draw upon.

Other change programmes

I A Regional Collaboration for Health (ARCH)

The ARCH Programme sets out a vision for an integrated and collaborative medical and life sciences regional economy delivering high quality patient care, developing doctors, healthcare professionals and life scientists to drive excellence for the sustainable benefit of the health, well- being and wealth creation in South West Wales. Key partners are Abertawe Bro Morgannwg UHB, Hywel Dda UHB and Swansea University. The programme sets out to deliver a regional, holistic model of healthcare aimed at transforming healthcare services providing:

 a step change in the care delivered closer to home;  drastic improvements in the wellness of the region and health outcomes for citizens with long term condition;  specialist centres providing excellence in care; and  exemplary patient experience.

This programme represents a system approach to health and well-being and whilst it is still in its formative stages, WAST, will engage to explore opportunities for collaboration as part of that system.

II Aneurin Bevan – Clinical Futures – Taking Better Care

The Clinical Futures – Taking Better Care Programme sets an ambitious vision for increased and better services involving a rebalancing of primary and community care led services across the Gwent health economy. Key areas of working include:

 Community Resource Teams and the Gwent Frailty Programme;  local General Hospitals;  developing Mental Health and Learning Disability Services through partnership; and  Specialist and Critical Care Centre.

The full business case for the Specialist Critical Care Centre is awaiting Welsh Government approval. Our services will be impacted on and we continue to work within WAST and with the Health Board to quantify and model this impact. We will take the outcome of this work back through the EASC commissioning arrangements. III Change for our Powys patients

The NHS Future Fit Programme focuses on the hospital services provided by Shrewsbury and Telford Hospital NHS trust and Shropshire Community Health NHS Trust. Powys Teaching Local Health Board and WAST are partners in this programme.

The decision, including a preferred model for clinical services (that was deferred in October 2015), is now due in mid-2016. WAST is a partner in the Programme Board and will step up its senior visibility and engagement in this programme during 2016/17.

During 2014 Wye Valley NHS Trust was placed in special measures following an inspection by the Care Quality Commission. Powys Health Board is working closely with both the English Trust and the Hereford Clinical Commissioning Group (CCG) to monitor progress against the patient care improvement plan and ensure that Powys patients access safe and effective high quality care. Whilst Powys LHB are involved in taking their transformation programme led by Hereford CCG, further work is required to ensure any implication on WAST are fully understood and modelled.

2.8 Service Change with Blue Light Partners

We are cognisant of the Fire and Rescue National Framework that was published by Welsh Government in November 2015. We are very supportive of this document and recognise that whilst it is not a mandatory function of Fire and Rescue Authorities (FRAs) to provide certain forms of emergency medical response and/or support, nonetheless FRAs should continue to work with WAST and other NHS bodies to develop and implement such initiatives.

Co-responding schemes already operate in South, Mid and West Wales. Most recently a pilot has been launched in North Wales that now see the Fire and Rescue Service working with WAST to respond to some emergency calls. Fire and rescue vehicles have been kitted out with life-saving equipment such as defibrillators, with staff receiving extra training in CPR and other medical skills.

In addition, the Betsi Cadwaladr area of the Trust has embarked on an interesting joint venture with our blue light emergency service partners to develop even closer collaboration and explore new ways of working. In June 2015, the North Wales Emergency Collaboration Board was formulated. This new Board is made up of the three blue light 999 services with a programme of work formally instigated in July 2015.

This programme of work is designed to progress and expand the collaborative working arrangements across the three blue light services. However, this does not preclude other agencies from joining the programme. As the work develops and cross organisational benefits are identified, Betsi Cadwalader University Health Board, local authority professionals or any other professional body as agreed by the Chair of the Board may and should participate. The programme consists of three workstreams each led by one of the 999 services and are:

 Integrated Service Delivery Prevent and Respond;  Multi-Organisational Control Room; and  Integrated Service Delivery Support Services.

In January 2016 we looked to internally second, for a period of six to twelve months, a member of staff to work with colleagues from the police and fire services in developing opportunities identified in the programme above.

Finally, the construction of our new Ambulance and Fire Services Resource Centre (AFSRC) in Wrexham is now complete. The Welsh Ambulance Service and North Wales Fire and Rescue Service (NWFRS) have jointly invested in this purpose-built facility, which will include staff welfare facilities together with meeting and training facilities. The facility becomes operational in the early spring of 2016.

We are working together with Mid and West Wales Fire and Rescue Services, Hywel Dda University Health Board and Dyfed Powys Police on a joint project which is aimed at making homes safer for citizens by reducing the risk from slips, trips and falls. It will also include a security assessment service to cascade crime prevention advice to support the Police Service’s aim of crime reduction and reducing the fear of crime. Each home will be assessed individually to ensure that the most appropriate safety and security device is in place to help elderly, disabled or vulnerable people ensure their property is secure.

Further information regarding how we plan to work even more closely with our blue light partners can be found throughout this plan at section 5 (STEP 2), section 5 (STEP 3), section 6.3 and section 6.10.

2.9 Ensuring Integration with Our Partners’ Three Year Plans

In developing our three year plan and learning from feedback on the plan that was submitted last year, we have been mindful of ensuring effective integration with the strategic plans of our partners. This has been progressed on a number of fronts.

At a local level, WAST Heads of Operations have close working relationships with LHB operational and managerial staff. In the local delivery plans of Heads of Operations, there are joint priorities in terms of patient and system flow, pathway development and, in some cases, collaborative workforce approaches

WAST has been interfacing with the strategic planning agenda in NHS Wales during the development of this plan.

 Revisiting the South Wales Programme plans and timescales  Planning review sessions with Aneurin Bevan UHB to understand more fully the impact of the recently submitted Full Business Case for the Specialist and Critical Care Centre  Engagement with the next stage of the maternity consultation in North Wales  Ongoing and proactive involvement in the Mid Wales Health Collaborative  Engagement in the Future Fit redesign in Shrewsbury and Telford (our Powys patients)

In addition to these activities, discussions were held with all LHBs about alignment of plans, with most opting to use the framing of the five-step model where appropriate. Appendix 4 provides a summary of all the work which both Health Board partners and Trusts are documenting in their IMTPs which we believe will impact on our service, in addition to a summary of all the service developments we are planning which will impact on our partners. These will be agreed with LHBs between January and March 2016 and the document shared with Directors of Planning.

2.10 The Organisation and Prudent Healthcare

WAST is committed to the four principles of prudent healthcare. As an organisation that is making great strides in its ambition to move from a transport-based to a clinically-led, quality-driven service, the principles of prudent health reflect the journey on which we have embarked. They are also reflected in our shared behaviours.

The Trust Board is resolute in its determination to ensure that the organisation delivers a suite of high quality services that are underpinned by a prudent approach to delivery.

Prudent principles also underpin our planning process and are reflected throughout this plan including the three key areas of action within the Securing Health and Well-being for Future Generations document. This aligns to the work already being undertaken in relation to the prevention and management of patients who fall, providing appropriate treatment and care and supporting people to be independent in their homes, avoiding hospital admission wherever possible. Examples are provided in the case studies below.

In working to make a prudent approach to healthcare a standard feature of our operating model and our culture, we are cognisant of the need to ensure our enabling strategies, for example our finance, IT, research, estates and workforce plans, facilitate the change and are informed by what we are learning from the implementation of our New Clinical Response Model during the pilot.

Working prudently is at the heart of our future workforce training and modernisation agendas, particularly the application of the principle: “only do what only you can do.” As we develop our ambitious plans for service change, we will consider how roles work together to ensure rigid demarcation is avoided and that patients receive their care from teams that work well together across clinical pathways. We are reviewing the development needs of our staff to enable them to work flexibly and to operate at the top of their competence to be able to meet the needs of patients today, but also anticipating changes to demography and population needs.

Improving the evidence base for our decisions is fundamental to embedding a prudent culture. We are investing in technology like digi-pens to record episodes of care in real time and Optima Predict, an interactive strategic planning solution for emergency services that provides a platform to enable effective planning and the simulation of resource requirements, to ensure we are learning from our experiences and using that intelligence to inform future developments.

Similarly, we are growing our research and development expertise, and working collaboratively with the higher education and commercial sectors, as well as with health partners, to facilitate an environment where the expansion of knowledge in pursuit of better patient care can flourish. Prudent Healthcare Action Plan

In producing this plan, we have been cognisant of the prudent healthcare action plan and the need to ensure alignment and integration with its actions.

Action Number WAST response Cited in IMTP

Action 1: Appropriate tests, Heart Attack – taking patients Section 5 - STEP 5 treatments, and medications direct from the scene to a cardiac catheterisation

laboratory for immediate interventional cardiology treatment. This service is available in all HB areas and

delivers better outcomes and shorter lengths of hospital stay. Stroke – taking stroke patients to a hospital where a CT scan and specialist stroke care is available leading to better clinical outcomes and shorter hospital stays.

Action 2: Changing the model of Non-Emergency Patient Section 5 - NEPTS outpatients Transport

Action 3: Working together to Falls prevention & hospital Section 5 - STEP 1, 2 & 5 improve healthcare avoidance – New Clinical Response Model & alternative care pathways Section 5 - Action 19 Frequent caller management. Putting in place multidisciplinary team plans involving primary and secondary care for frequent callers. This leads to better outcomes and fewer ambulance calls and ED visits. Section 6.9 - Action 138 and Equity: to support people with the work of Partners in learning disabilities access Healthcare healthcare Section 2.4 Welsh Language Standards Section 6.9 - Action 138 Inequalities (sensory loss, learning disabilities)

2.11 Treating People Fairly – Equality, Diversity & Human Rights Our Equality and Human Rights Strategy (2016-20) is called Treating People Fairly. It explains what we intend to do to build upon the progress we have made over the last four years. 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 shift 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 will play 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 ensuring that no-one is excluded.

Our Progress and Learning The Trust has made significant progress since the launch of Treating People Fairly, as described below:

2012-16 Strategic Equality What has gone well Areas for development in 2016-20 Objectives

Increase the number of people Events across Wales with stakeholders Further focus on appropriateness of choosing healthy lifestyles and leading to improved understanding; general public choices when 1 accessing preventative health increased links between Heads of Ops accessing healthcare care services and LHBs

Improve the care of: Older Engagement with specific communities; Increased linkages across WAST People, Disabled people, greater understanding of local and partners; more localised 2 Lesbian, Gay, Bisexual, community needs planning Transsexual & Transgender people by ensuring that they are treated with dignity and respect Increasing the overall diversity of Development and implementation of Maintain focus on developing local WAST workforce-removing any modern apprenticeships; building of and Trust-wide approaches 3 barriers relating to recruitment of relationships with specific groups (e.g. Staff and Volunteers from through Stonewall) protected characteristic groups Reduce gender pay differences Continued research and benchmarking; Further detailed research with 4 through further exploration of some focus on specific identified issues specific data (e.g. training) data

Improve staff awareness, Launch of Treat Me Fairly e-learning Ensure Treat Me Fairly and other understanding and ownership of package; delivery of From Dignity to learning opportunities are available 5 equality and human rights issues Engagement; start of Hear to Be Our and are promoted. through “Treating People Fairly‟ Best; development & launch of shared agenda behaviours

Increase staff awareness of hate Public services partnerships promoting Target specific areas and support 6 crime, harassment and domestic understanding colleague awareness abuse

Improve engagement with people Feedback through PIH networks on the More engagement at local level with 7 from all protected groups in the development of WAST services; use of service plans review and redesign of services patient stories

Improve outcomes for people Improved understanding of access Increased local engagement to 8 from protected groups by issues; information supported services understand local access issues improving access to services to develop

Our Strategic Equality Objectives 2016 - 2020 We have reviewed our 2012-16 Strategic Equality Objectives, as required by law, and considered the lessons we learnt, described above in developing draft objectives for 2016-20. We consulted on these during December 2015 and January 2016. From what our patients, service users, partners and colleagues said, we developed objectives as our focus for 2016-20. As our key learning was that Wales is a series of communities, we have developed broad Strategic Equality Objectives that have been refined and defined locally. Specific local actions have been locally developed and owned and will be delivered to meet the needs of each community in Wales

What are we trying to achieve 2016-20?

 We better understand our local communities by listening to them and finding out what they want  Everyone gets the right service for their needs by providing different things for different people (this may mean taking positive action)  We have a diverse and representative workforce by helping every applicant and colleague feel valued for who they are and what they bring  We tackle unlawful discrimination  We build better relationships between different people and groups

Below are our Strategic Equality Objectives for the next four years.

Our Objectives To Cover 1. Dignity and Respect Ensure both the people we serve and our staff are treated Local priorities for protected groups by linking fairly and with dignity and respect by improving staff with local partners. awareness, understanding and ownership of what this Awareness raising and training. means. 2. Involvement and Engagement Engage with people in the review and redesign of services, Stepping into communities, engaging with and improve access to services to enhance people’s protected groups. Asking. Listening. Feeding experience and care. back.

3. Working for Us Improve employment practices and have our staff better Recruitment practices, local recruitment reflect the diverse population in Wales. initiatives.

4. Being Safe Raise awareness of all forms of harassment and abuse for All colleagues. People in Wales. staff and public including (but not limited to) domestic abuse, abuse of vulnerable individuals and hate crime. 5. Being Healthy and Choosing Well Including Alcohol, Obesity, Smoking, Mental Improve information and awareness about healthy Health Issues. lifestyles and accessing appropriate services.

Our Board will ensure that Treating People Fairly, and our Strategic Equality Objectives are delivered by supporting teams to understand the importance of the plan, and to develop and deliver against their objectives. They will also ensure a prominence in their discussions by receiving and publishing regular reports on our progress (including publishing an Annual Report). Our Executive Management Team will ensure that Treating People Fairly is delivered by also receiving regular updates, and monitoring delivery against objectives through the executive performance review process. Our Equality Group is a cross section of colleagues with responsibility, passion and interest and will provide specific focus, energy and leadership to help us deliver Treating People Fairly. Our aim is to support all colleagues to acknowledge and understand their own and others’ beliefs and to recognise the impact of their behaviours so that they can provide the best services. Our Equality

Group will help to support local teams to embed local equality objectives (in line with the Strategic Equality Objectives) and deliver their local equality actions (as an integral part of their Local Delivery Plans). Action 3: Use every opportunity to promote understanding and valuing of difference such as highlighting and marketing specific Wales and UK campaigns (e.g. events, weeks, days). Action 4: Develop and implement proactive positive action campaigns across the next three years to ensure that our workforce is more diverse and representative of each local community Action 5: To establish a performance framework that enable us to monitor and review the impact of the approaches we have taken and work we have done.

2.12 Other Strategic Workforce and OD Drivers

There are a number of key strategic drivers that influence the development of our People Strategy, and our enabling frameworks and plans. More detail of these can be found at section 6.1. Working Differently, Working Together Within NHS Wales, we have described a set of workforce objectives through the Working Differently, Working Together Framework. Objective 1 - An engaged workforce aligned and committed to the delivery of the vision for NHS Wales. Objective 2 - A sustainable and skilled workforce focussed on helping the people of Wales to improve their health as well as treating sickness. Objective 3 - A redesigned workforce, working together to deliver healthcare for the 21st Century. Objective 4 - A workforce that aims at excellence everywhere within available resources. These objectives, along with the NHS Wales Workforce and OD Directors National Work Programme, national projects, and the challenges posed by the wider health context, provide a reference point and link to the development and implementation our own People Strategy and enabling action plans. Implications of the Francis and Trusted to Care Reports

During 2013 and 2014, an additional understanding of the impact of negative culture and behaviours has emerged in the United Kingdom and more locally in Wales. These reports are still of relevance and importance, and must be taken into account when considering the strategic context of any workforce development objectives. They both highlight the impact of culture linked to behaviours and performance and the importance of having in place robust plans for the ongoing development of the workforce. We will ensure that our OD enabling plans make very clear links to the recommendations of Francis and Trusted to Care. The Leadership Challenge The 2014 report, Williams Commission on Public Services, Commission and Delivery by Welsh Government, noted the future requirement for ‘leaders who can deal with uncertainty and ambiguity and who are able to tackle issues where there is often no simple management solution.’ The

Commission also set out the characteristics of high performing organisations and highlighted the importance of having ‘both effective and progressive leadership and technical excellence in management [are essential] for the provision of high achieving public services.’ Management can be seen as ‘doing things right’ whilst leadership is about ‘doing the right thing’. Leadership development and succession planning is a key strategic priority for the Trust and forms a key part of our OD framework and enabling plans. Prudent Workforce The Minister for Health and Social Services, Mark Drakeford, said: “Our destiny really does lie in the skill, the experience, and the commitment of staff at all levels in the NHS”. Key for the Trust will be the application of the Prudent Healthcare principle “only do what only you can do” as it considers future workforce requirements to deliver new ways of working. We describe our commitment to prudent principles in the design of services and our future workforce earlier in this plan. A Planned Primary Care Workforce for Wales In November 2014 the Welsh Government launched its national plan for a primary care service for Wales up to March 2018. The plan described a set of principles that will underpin the changes required in primary care as:

 prevention, early intervention and improving health, not just treatment;  coordinated care where generalists work closely with specialists and wider support in the community to prevent ill health, reduce dependency and effectively treat illness;  active involvement of the public, patients and their carers in decisions about their care and well-being;  planning services at a community level of 25,000-100,000 people; and  the prudent healthcare principles.

Over the four years of the plan, Welsh Government has articulated the need to see a change in the way services work together, with Health Boards moving their resources towards primary care, supported by hospitals and other services, where needed, rather than continuing the traditional model where hospital-based care has attracted the lion’s share of resources and attention. The drive to provide more care at, or closer to, home requires a system-wide view of health and social care services and a team based approach, which makes the most of the skills of this wide range of professionals. In our IMTP, you will see the ideas we have about the role that our paramedics can play within the primary care team to help tackle demand and provide a potential alternative to traditional roles. These include development of a community based paramedic role, our work with Health Boards to rotate Advanced Paramedic Practitioner staff across GP Out of Hours and the expansion of the variety of roles for paramedics within the Trust such as “Hear and Treat”, paramedics supporting GP home visits and developing research and clinical lead portfolios. Preparing for the Move to Degree-based Paramedicine A change to the educational requirements for paramedics is proposed, with the introduction of a degree level qualification requirement to become a qualified paramedic. This change has potential to impact on the supply of qualified paramedic staff, existing succession planning routes for staff, and the banding of newly qualified paramedics from 2019 onwards. It also presents several practical challenges to be addressed, including the need to identify sufficient hospital and other clinical placements for students and the university and internal resources required to support training additional numbers. Conversations continue with Education Commissioners to inform education provision going forward as part of our workforce planning. This includes preparation for

55 the three-year degree programme expected to commence in September 2017 and a plan to ensure that there is no fallow year in the move from Diploma to Degree. Apprenticeships Developing links with schools, colleges and communities generally, along with offering apprenticeships, is a key part of our IMTP as a whole but particularly linking with Treating People Fairly as it ensures we are reaching ‘harder to get to’ communities.

In April 2017 the UK Government is introducing an Apprenticeship Levy, a result of which we will be required to pay 0.5% of our pay bill. This change presents a future cost pressure for the Trust. Depending on the apprenticeship schemes we operate, and the number and quality of our apprenticeships, we may be able to claim this back if we are providing sufficient suitable apprenticeships.

However, we prefer to see this as a catalyst to improve our career options for our communities as well as our colleagues. We will develop a co-ordinated approach to Work Experience, Apprenticeships and accessing Accredited Learning Funding across the Trust.

We plan to develop our approach to work experience, apprenticeships and accredited learning, ensuring that we have co-ordination between our workforce planning and learning and development approaches. Further information can be found at: https://www.gov.uk/government/consultations/apprenticeships- levy-employer-owned-apprenticeships-training

PART 3: CREATING OUR STRATEGIC FRAMEWORK

In this section we present the work we have developed on our Strategy Map, outline our performance ambitions and articulate our Strategic Statement of Intent on how we envisage our services developing over the next 5 - 10 years.

As part of the initiation of our planning cycle for 2016/17, we reviewed our purpose, vision, behaviours, strategic aims and priorities. This framing was critical as it provided the clarity and steer required for our operational and corporate services teams to plan against.

In future years we would envisage periodic re-visits to our purpose, vision, behaviours and strategic aims to ensure they remain relevant, but we anticipate that these will remain largely static. Future planning cycles would instead focus on recalibrating the priorities of the organisation as work completes and outcomes are realised in order to continually drive forward the organisation.

3.1 Our Vision, Purpose and Behaviours In order to model and demonstrate our commitment to collaborative approaches, all colleagues were encouraged to be involved in developing our shared vision, purpose and behaviours. This has been done in conjunction with the development of Public Services Values and NHS Wales Core Principles.

In order to help all colleagues understand and own these, we have created a visual image of our vision, purpose and behaviours which is striking for both our staff, stakeholders and pateints who access our services.

Figure 11: Visions, Purpose and Behaviours

Importantly, we now have shared behaviours which we will support and challenge each other to live by. This will help ensure that we all do the right thing in the right way, to secure the best possible patient outcomes. We have collaboratively identified the characteristics that would be displayed if the behaviours were fully embedded compared to when not.

Our  I will ask and listen behaviours  I will be honest and open with myself and others  I will be kind, compassionate and caring  I will be my best, together we will be better  I will own my decisions

When it’s going well, When it’s not going so well, we will notice we will notice  More conversations  People being defensive when  Better relationships questioned/ challenged  Happiness!  A lack of respect  ‘‘Hello my name is... How can I help you?’’  Everyone being treated the  Increased empathy same, not as individuals  People being treated fairly  People working in isolation  High levels of trust  People being negative  Seeking support and supporting others  People using time badly  People being friendly, helpful and professional  Blaming others  A sense of pride  People not developing  People making good choices about their well- themselves being  People not wanting feedback  People taking responsibility for their decisions  A lack of empathy & kindness  Prudent decisions

To help us live the behaviours, we have developed an action plan that will help raise awareness, reinforce and hold each other accountable:

Raising Awareness Reinforcing Hold Each Other To Account Create a visual image and Behaviours part of all learning Behaviours measured (using publish widely across the Trust activities 360* feedback) as part of PADRs Encourage use in Email Encourage all teams to use the Signatures behaviours as part of Regular review during meetings developing Team Charters/ to “check and challenge” Use of Siren, emails & other Operating Principles messages Select new colleagues using Within all meetings terms of the behaviours Ensure behaviours in all Job reference; regular review Descriptions and objectives during meetings to “check” Board focus within formal and developmental sessions Report checklist to ensure behaviours are covered Reward and recognise behaviours as part of Trust awards

3.2 Our Strategic Aims Our six strategic aims will support us in realising our vision. They provide a clear framework for our plan and clearly link to the prudent healthcare principles, the Health and Care Standards and the

Commissioning Quality and Delivery Framework. They are applicable to all of our clinical service areas, across all five-steps of the Ambulance Care Pathway and to our corporate and support services. The strategic aims will guide the organisation over the next 3 – 5 years, being used to aid prioritisation, decision-making and in the framing of PADRs

1. To deliver the best possible patient outcomes and experience through transforming our models of care across all of our services, using technology, innovation and research and becoming truly clinically-led and quality-driven

2. To have an engaged and skilled workforce operating within an organisational culture and framework that enables them to work to the top of their skill set to deliver high quality care

3. To effectively manage capacity to meet demand, through aligning resources more effectively, taking more care to the patients and accessing alterative care pathways

4. To reduce unnecessary variation in our services and processes and tackle inequalities

5. To have strong partnerships with our patients, staff, NHS Wales organisations and public sector partners, where their voice is heard and together we improve and shape our services, and

6. To be a highly effective organisation with effective leadership embedded across all levels, robust governance arrangements, financial sustainability and a value for money provider.

In section 3.5, we translate these aims into quantifiable performance ambitions so that we can articulate what successful will look like against each of these aims.

3.3 Our Priorities Our priorities represent the key deliverables that we will realise in the life of this plan. Whilst we anticipate our purpose, vision and strategic aims, remaining constant over the life of this plan, it is conceivable that priorities may change, reflecting any progress made within the course of the planning period and delivery against the priorities demonstrated. Each of the six strategic aims is relevant and applicable to each priority, for example reducing variation applies to ongoing improvements in our New Clinical Response Model as it is in improving management of our fleet.

The five-step ambulance pathway is a key driver for much of our work and so, where relevant, we have also mapped our priorities to the relevant step(s) of the pathway.

Against each priority we have also mapped the sections within the plan where more detail can be found regarding the specific actions that we will take to deliver these priorities.

Our approach to documenting our strategic objectives and priorities, mapped in this way, ensures the organisation is not only being fully transparent in regard to where it is investing its time, resource and focus, but also ensures the organisation is addressing and responding to the Chief Ambulance Service Commissioner’s (CASC) commissioning intentions. Principally:

 To use the M1 Schedule: High Level Description for Model of Care – Five-Step Ambulance Care Pathway –in order to promote and assist in the understanding of the emergency ambulance as a clinical service within the integrated Welsh healthcare system;

 Consider, develop and, where appropriate, deliver service change proposals for more efficient and/or effective healthcare services by shifting the delivery emphasis on earlier steps of the ambulance care pathway without disruption to service capability across all five steps; and  Demonstrating plans that – when clinically safe and appropriate – reduce: o conveyances; o attendances at scene; o calls.

The table below gives an overview of our priorities, how they relate to the Collaborative Commissioning Framework and where they are addressed in the plan.

Priority Description Step on pathway Page which priority Reference in supports document The 12 month pilot runs until September 2016 and will continue to be a Clinical Response Model priority for the organisation throughout 2016/17. The focus will be on supporting the strategic aim of specific cycles of improvement of our performance against RED calls, 1 – 5 95 - 107 best possible patient outcomes the clinical indicators associated with AMBER calls and on effective and experience / manage management of GREEN calls. The five-step ambulance care model will capacity to meet demand / reduce be a key part in framing the actions associated with this priority. unnecessary variation Engagement in, and learning from, the evaluation of the pilot will be a critical activity for WAST in partnership with the Emergency Ambulance Services Committee.

We will also use the outputs of the NHS Benchmarking Toolkit to help focus areas of activity.

Developing a clear understanding of capacity required to deliver the model is key.

Modernisation of our clinical Our clinical contact centres (ccc) are a key part of our service model for contact centres supporting the emergency, non-emergency and telephone assessment services (EMS, 2 96 - 99 strategic aim of best possible NEPTS and NHSDW/111). Key parts of this work programme are: patient outcomes and experience / manage capacity to meet Procure and implement a new Computer Aided Dispatch system – more demand / reduce unnecessary than just an IT system replacement project, this represents significant variation workforce and businesses change for our control centres

111 Pathfinder – working with the all Wales NHS Project, the 111 Project team and ABMU, deliver successful implementation of the pathfinder

Implementation of the outcome of the Non-Emergency Patient Non-Emergency Patient Transport (NEPTs) business case – an NHS wide project, led by WAST NEPTS 108 - 110 Transport (NEPTs) supporting all and aimed at delivering the disaggregation of NEPTS services from commissioning of the organisation’s strategic emergency medical services representing a major change programme framework to be aims for these services, systems and our workforce. developed

Collaborating in the development of a commissioning framework for NEPTS will also form a key part of our business in year one.

Develop robust enabling strategies and plans for workforce, fleet and Plans for workforce, fleet and estate based on the learning from the New Clinical Response Model 1 - 5 111 – 146 estate supporting all of the and a comprehensive and thorough demand and capacity review. & organisation’s strategic aims 163 - 167

Organisational development Much progress has been made in establishing stable and visible and becoming a highly leadership at Board and Executive Director level, developing clinical 111 - 146 effective organisation leadership through the organisation is now beginning to crystallise 1 - 5 supporting strategic aims of through the APP and CTL workstreams, which will continue into engaged and skilled workforce / 2016/17. All of our strategic aims will be delivered only through an strong partnerships / highly active and maturing partnership relationship with our staff and our staff effective organisation representatives and robust corporate governance arrangements. Our People Strategy and enabling frameworks will support this work going forward.

3.4 Our Strategy Map These interdependent elements of purpose, vision, behaviours, strategic aims, and priorities have subsequently all been drawn into a single strategy map to share with staff and stakeholders.

This strategy map is shown below in Figure 12.

Figure 12: Our Strategy Map

3.5 Our Performance Ambitions In order to translate our Strategic Aims into quantifiable ambition, we have set out the levels of performance to which we will aspire over the life of this plan. These can be found in Figure 13 below.

In stating these aspirations, it should be recognised that these represent our ambitions; they are demanding ambitions but ones which remain realistic. They are complementary to the detail in the wider plan and again represent an indicative list of our more quantitative ambitions. These should not be taken in totality or in isolation from the rest of the plan.

This table continues to be tested within the organisation, with our commissioners and, critically, as part of the impending demand and capacity work. As the organisation evolves and new pieces of evidence or benchmarking emerge, it may be necessary to recalibrate these ambitions.

Figure 13: Performance Ambitions

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond Strategic aims 1: The Best Possible Patient Outcomes and Experience Implementing STEPS 1-5 Patient 90% 91% 92% 93% 95% Baseline based on 2015 our Quality Core engagement & National Survey results. In Improvement Requirements: experience: addition a qualitative report Strategy: CR2 Satisfaction with on patient engagement and Quality Health & Care the service experience is produced on Indicators Standards: a quarterly basis for Trust Individual Care Board. Dementia Friendly 30 Dignity Approved Implementati Accreditation Maintain Compliance with the Organisations – champions implementati on of plan by AWW accreditation accreditation process is accreditation. Trust wide on plan by with status monitored by Ageing Well (Ageing Well in Pledged AWW quarterly in Wales, therefore reporting to Wales (AWW) providing some degree of AWW external assurance Bevan Innovators One project Bevan Embedding Exemplar Bevan Commission Advocate Advocate Status Framework implementation Status Status – influencing Trust & Health Board services and plans. Independent assessment process. STEPS 1-5 Concerns: 38% 50% 55% 60% Meet Tier 1 Baseline based on Jan Core Response times targets 2016. 100 day turnaround Requirements improvement plan saw compliance CR1 enabling timely increase from 6% to 38% in CR2 identification of 2015/16.Phase 2 Health & Care quality issues and sustainability plan which Standards implementation of will consider leadership & Governance, improvements / education training plan by Accountability triangulation of April 2016. Note: Concerns & Leadership intelligence. process is under national Individual Care review currently therefore these measures will undergo further review.

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond STEPS 1-5 Patient Safety 2014/15 3% ↑ 3% ↑ 3% ↑ 20%↑ It is recognised that a Core Increase in All clinical healthy reporting and safety Requirements clinical incident incidents culture indicator is a high CR1 reporting with an reporting organisation, with CR6 incremental Baseline incremental reduction in the Health & Care decrease in the data severity of incidents. Standards severity of Approx. Required investment & Safe Care incidents across 1600 resources to enable Datix all grades. incidents to be a fit for purpose per annum system enabling *Coding sets Source triangulation of information require Datix* and analysis of data is development currently under review. External benchmarking & baseline internal data is required to determine severity reduction as coding systems within Datix are very limited currently. A safety culture assessment is planned for 2016/17. STEPS 1-5 Infection , 26% 48% 52% 57% Sustained Key prevention measure Core Prevention & however noted that Requirements Control: Flu ultimately employee CR5&6 vaccinations decision. Health & Care Standards Safe Care

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond STEPS 1-5 Safeguarding One 80% 90% 100% 100% Statutory requirement that Core Adults & Children Board Sustained WAST engage and attend Requirements Appropriate with Adult & Child CR6 attendance at Safeguarding Boards pan Health & Care Adult & Wales. Senior member of Standards Safeguarding the safeguarding team and Safe Care Boards pan clinical representation from Wales. Operations to be in (Currently 11 attendance. Boards) Configuration of the Boards is currently under review and the ambitions will be reviewed in accordance with this once finalised. Safeguarding Amber Amber Amber Green Green Pan Wales internal Quality Outcomes with with assessment process. Rated Framework Incremental Incremental Red, Amber or Green. improvement improvement Implementing NEPTS Baseline performance is currently being established for the developed indicators, yet to be agreed. Performance the Non- Quality indicators are in the initial draft stage and are subject to discussions internally, externally and with the Commissioner. Emergency Indicators Patient (NEPTSQIs) Included below are the ones identified as most important in year one; identified as having the biggest impact in driving Transport are currently down activity and freeing up the resources required to deliver the NEPTS modernisation agenda. service under Business Case: development. Performance Indicators NEPTSQI9 Number of 30% 40% 50% 60% 70% Increasing on-line booking bookings received will free up call taking Indicators being online capacity developed - Section to be NEPTSQI19 % of Enhanced 55% 85% TBC TBC TBC Business Case Deliverable confirmed Service patients (Sept 2016) arriving less than (TBC) 30 min before their appt.

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond NEPTSQI20 % of Enhanced 72% 85% TBC TBC TBC Business Case Deliverable Service patients (Sept 2016) picked up within (TBC) 30 min of time notified as ready NEPTSQI21 % of renal 35% 30% TBC TBC TBC Business Case Deliverable patients travelling (Sept 2016) (TBC) more than 30 minutes Strategic Aim 2: Engaged and Skilled Workforce Workforce WG Scorecard PADR 60% 85% 90% 95% Sustained We will aim for 100% of the Indicators. Core addressable workforce. Requirements Sickness 6.87% 5.87% 5.37% 4.87% Sustained Baseline will be based on end of year position. CPD attendance 68% 100% 100% 100% 100% Baseline based on compliance compliance at end of Jan 16. Staff 43% 48% 55% 65% 65%+ Baseline based on the last Engagement; staff survey. Index Score Percentage of TBD TBD TBD TBD TBD The importance of staff EMS staff who receiving rest breaks on have been offered time and a reduction in their rest breaks overruns is recognised. on time Work to be undertaken to Overruns TBD TBD TBD TBD TBD agree meaningful measures for the organisation and staff. Overruns may have to be expressed in monetary terms to start with as this is the easiest currency to measure.

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond Strategic Aim 3: Manage Capacity to Meet Demand Resource Core Unit Hours >90% 95% TBD TBD TBD Discrete project within Indicators Requirements Production (UHP) resources programme CR5 proposed to make improvements to resource measures e.g. development of Unit Hours Utilisation, developing an aggregate reporting mechanism to include hours, at Health Board level, broken down by EMS, UCS and RRV to provide more detailed assessment. This will be further informed by the planned capacity and demand review. Fleet and Fully kitted and 75% 80% 85% 90% 90% The baseline is based on Estate functional an estimate of the current Indicators ambulance that is situation and total vehicle ready to respond stock, including spare vehicles that may not be fully kitted. All new vehicles come fully kitted. This indicator captures where a piece of equipment fails and is awaiting replacement. The model of make ready depots will, when rolled out across the organisation, significantly reduce the number of hours lost awaiting ordering of specific parts as will be centrally stocked Vehicle Cleaning <20% >30% 40% 50% >50% We will develop a system for deep cleaning

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond ambulances in line with the servicing programme.

The ambition will be that there is 100% compliance with an ambulance being deep cleaned (cab and saloon) as part of the servicing programme.

NHS National Building Cleaning Not 50% 75% 95% 100% High Risk Areas: Sterile Cleaning recorded Storage, Linen Store, Standards Sluice rooms, Medical Audit equipment Store. Assessment Significant Risk Areas: Toolkit include all other areas in an Ambulance Station Low Risk Areas: non-clinical buildings such as admin office and Control Centres. Cleaning contract for the estate to be let 15/16 Performance Planned NWSSP publish an annual of Trust’s Maintenance of report NHS Estate In Wales Estate is Estates: – Estate Condition and measured by 35% 37% 40% 43% 50% Performance Report for all NWSSP  Physical Condition Trusts in Wales.  Statutory and 75% 80% 85% 90% 100% Improvements to the Safety physical condition and Compliance suitability will be  Fire and 40% 60% 80% 100% Maintain determined by levels of Safety investment in the estate as Compliance well partnering  Functional 35% 37% 40% 43% 50% opportunities. Suitability ISO 14001, 30% of the  Space 95% 95% 95% 95% Maintain estate has been accredited Utilisation (northern region complete)

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond  Energy 95% 95% 95% 95% 100% Energy B rating or better Performance (410 kWh/m2 or less) STEP 1- Help Core % of Frequent 4.2% Reduction Reduction Reduction Sustained The data for frequent me choose Requirements Callers – Rolling by by by callers and reporting Indicators CR4 top ten callers by 50% 20% 20% mechanisms is currently Health & Care Health Board under review. Standards area. Effective Care Core Development of 27 30 33 36 40 Through data analysis Requirements Symptom symptom checkers are CR4 Checkers on NHS developed to meet the Health & Care Direct Wales needs of the population. Standards website Use of the checkers is Staying monitored and themed and Healthy can be an early warning system of spikes in conditions. The process is quite lengthy with sign off through WAST CPAG. STEP 2 – Core Hear and Treat 4.32% 5% 7% 8% 10% Acknowledged that Answer my call Requirements percentage improvements Indicators CR4 will need to be revisited in Health and line with any increase in Care demand. Standards 999 calls 89.8% 90% 95% Sustained Sustained Target is 95%. With answered within 6 improvements following the seconds CAD change in Year 2 the ambition could shift to 90% in 5 seconds. However this will require discussion due to financial implications as would require significant increase in staffing. Reduce number 20% 10% N/A N/A N/A Current call taker of calls not recruitment will assist in answered by this metric but a new CAD ‘home’ Clinical when procured will bring a Contact Centre

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond technological change in performance Increased cardiac TBC 60% 65% Sustained Sustained This will be included in the arrest recognition, CCC Modernisation work improving stream. allocation times <45sec STEP 3 – Come Core Red 8 minute 70.6% 65% -70% 65% -70% 65% -70% 65% -70% Baseline based on Oct 15- to see me Requirements performance Jan 16 performance, post Indicators CR4 implementation of New Health and Clinical Response model. Care Target is a minimum of Standards 65% Need to recognise the whole system and the opportunities and challenges within the system that will impact upon the ambitions. There is a need to stabilise and standardise performance across Wales. This ambition will be continually reviewed and developed in light of the demand and capacity review. CFR Contribution 2.3% 4% 5% 6% 7.5% Overall CFR contribution. Current target is 5%.

STEP 4 – Give Core Cardiac arrest 14.6% 14.6% 15.0% 15.5% 20% New indicator. Baseline me treatment Requirements with a return of based on December 2015 Indicators CR4 spontaneous performance only. Health and circulation Care (ROSC) on arrival Standards at hospital. Stroke patients 96.2% 99% 100% Sustained Sustained Baseline based on Oct – documented as Dec 15. Target is 100% receiving appropriate

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond

stroke bundle of care Fracture 83.1% 95% 100% Sustained Sustained Baseline based on Oct – hip/femur who are Dec 15. documented as Target is 100% receiving analgesia Acute coronary 68.5% 95% 100% Sustained Sustained Baseline based on Oct – syndrome Dec 15. Target is 100% patients who are documented as receiving appropriate STEMI care bundle STEP 5– Take Core Conveyance rate 70.5% 70% 68% 65% 60% Baseline based on Oct – me to a place of Requirements following face to Dec 15 performance care Indicators CR4 face assessment Health and Conveyance rate 8% 10% 15% >15% TBD Baseline based on Dec 15. Care not to a major To develop further to Standards A&E Include information on referrals to other pathways. Handover to 81.8% 90% 100% Sustained Sustained Trust to have discussions clear- with Welsh Government regarding the practicality of ever achieving a target of 100%. Strategic Aim 4: Reduce Unnecessary Variation. Operational and STEPS 1-5 RED performance 57.1%- 65% -70% Increasing but dependent on demand Trust maintains an ambition Clinical Core by LHB and 87.5% and capacity modelling work. to get to as many patients Indicators Requirements: localities as quickly as it can. CR3 Equity RED performance 00:16:44 00:15:00 00:10:00 Sustained Sustained Baseline based on Dec 15 within 8 minutes AQI 95th percentile AMBER 00:48:50 00:40:00 00:35:00 00:30:00 00:20:00 Baseline based on Dec15 95th percentile performance, post the New

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond response Clinical Response Model implementation. Conveyance rate TBD TBD TBD TBD TBD Measure to be developed following face to as part of development of face assessment AQIs by Health Board. by LHBs This expands on the previous conveyance measure reviewing by Health Board area. Strategic Aim 5: Strong Partnerships Partnership STEP 1, AQI3 Number of TBD To show a year on year increase in the amount of This AQI under Indicators attendances at appropriate events attended. development. To be confirmed key stakeholder events STEPS 1-5 Time taken to Please see above. Core respond to Requirements concerns CR1 CR2 Health & Care Standards Governance, Accountability & Leadership Individual Care Strategic Aim 6: Highly Effective Organisation Financial and Statutory Breakeven Duty Breakeven Breakeven over rolling three-year To ensure that revenue is Governance Financial Duty accounting period not less than sufficient to Indicators meet outgoings properly chargeable to revenue account in respect of each rolling three-year accounting period

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond Creditor Creditor 98% At least At least At least Target 95% Payments: Payments to non 95% 95% 95% Welsh NHS creditors Of non- Of non- Of non- Government based on the NHS bills NHS bills NHS bills Target number of bills paid within paid within paid within within 30 days of 30 days 30 days 30 days delivery or receipt of a valid invoice whichever is sooner Administrative To remain within Within EFL Within EFL Within EFL Within EFL Financial External Duties Financing Limit (EFL) for the Trust

STEPS: Risk Management Risk Aware Risk Risk Risk External Definitions: Risk aware: STEP 1-5 Strategy & 2015/16 Defined Managed Enabled Audit rates: Scattered silo based Core Framework 16/17 17/18 18/19 Substantial approach to risk Requirements: Movement along Assurance management. Risk CR1 the risk maturity External defined: Strategy and Health & Care pathway. Audit rates: policies in place and Standards: Substantial communicated. Risk Governance, Assurance managed: Trust-wide Accountability approach to risk & Leadership management developed and communicated .Risk enabled: Risk management and internal control fully embedded Trust wide The Wales Audit Office Structured Assessment of WAST (December 2013) concurred with the findings of the internal review and included the 7 key recommendations as part 76

Indicator Type Reference Measure Performance Improvement Ambition Comment Baseline Year 1 Year 2 Year 3 Beyond of the assurances that the Trust was moving forward in terms of governance & risk management. The Strategy is the output of the review.

3.6 Developing a Frontline-Led Approach to Planning As an organisation, we recognised that our approach to planning needed to be stronger. This focus on a more rigorous approach to planning saw the appointment of a new Director of Planning and Performance and the subsequent strengthening of Planning Directorate capacity.

A further facet of taking a more robust approach to planning within the organisation has been the introduction of local planning across the organisation. The requirement is for all aspects of the organisation to develop local delivery plans (LDPs) which clearly articulate what that part of the business will deliver in the coming period and how those key deliverables contribute to the corporate aims and priorities.

An overview of the key deliverables (KD) in each of the service LDPs are shown below in Figure 14. There is variation in these key deliverables to reflect local (e.g. LHB footprint) context, pressures and opportunities. Delivery will largely be tracked through Performance Reviews with organisational delivery units.

FIGURE 14: Operational LHB-WAST Area Key Deliverables Strategic Aims Best Engaged Manage Reduce Strong Highly Possible And Skilled Capacity To Unnecessary Partnerships Effective Patient Workforce Meet Variation Organisation Outcomes Demand And Experience Abertawe Bro Morgannwg WAST operational area KD01 Develop alternative care pathways x x KD02 Improve job cycle efficiencies x x x x x x KD03 Develop staff/community engagement x x x KD04 Patient Care Services (NEPTS project) x x KD05 Develop our teams and staff x x x KD06 Support the wider health community on service x x x x reconfiguration KD07 Ensuring a focus on quality of care x x x x KD08 Workforce planning and capacity x x x KD09 Resilience/business continuity planning x x x Aneurin Bevan WAST operational area KD01 Strengthen approach to communication and x x x engagement KD02 Performance management across and down our x x x x structures KD03 Develop alternative care pathways x x x x KD04 Improve working with Trust support services x x KD05 Ensure effective rosters and workforce capacity x x KD06 Support the wider health community on service re- x x x x configuration KD07 Ensuring a focus on quality of care / demand x x x x management KD08 Resilience/business continuity planning x x x KD09 Develop our teams and staff x x x

FIGURE 14: Operational LHB-WAST Area Key Deliverables Strategic Aims Best Engaged Manage Reduce Strong Highly Possible And Skilled Capacity To Unnecessary Partnerships Effective Patient Workforce Meet Variation Organisation Outcomes Demand And Experience Betsi Cadwaladr WAST operational area KD01 Increase the availability of alternative care x x x x x pathways KD02 Ensuring a focus on quality of care x x x x x x KD03 Improve the delivery of Patient Care Services x x x KD04 Workforce planning and development x x x x KD05 Improve job cycle efficiencies x X x x x x KD06 Further develop Community First Responders and x X x x x Public Access De-Fibs KD07 Supporting sustainable change x x KD08 Staff/staff side and public and community x X x engagement KD09 Resilience and Special Operations X x x KD10 Infrastructure development x X x x x Cardiff & Vale WAST operational area KD01 Clinical Priorities as agreed with the LHB x X x x x x KD02 Workforce planning/HR/Health & Well-being in x X x x x x partnership KD03 Performance management across and down our x X x x x x structures KD04 Financial budgeting/savings x X x x x x KD05 Partnership working/co-production x X x x x KD06 Resilience/business continuity planning x X x x x x KD07 PCS/NEPTS x X x x x x Cwm Taf WAST operational area KD01 Maintain & transition the “Explorer project” x X x x x pending outcome from UHB/WAST Exec Team

FIGURE 14: Operational LHB-WAST Area Key Deliverables Strategic Aims Best Engaged Manage Reduce Strong Highly Possible And Skilled Capacity To Unnecessary Partnerships Effective Patient Workforce Meet Variation Organisation Outcomes Demand And Experience KD02 Developing our workforce x X x KD03 Agree medium term solutions to Cwm Taf x X x infrastructure needs KD04 Clinical governance and quality x X x x x x KD05 Develop, refine & re-launch alternative care x X x x x pathways KD06 Communication & engagement x X x KD06 Performance management across and down our x X x x structures Hywel Dda WAST operational area KD01 Improve job cycle efficiencies x X x X x x KD02 Workforce (planning & development) X x x KD03 Infrastructure (Fleet & Estates) x x KD04 CFR & PADS x x x KD05 Engagement (in partnership with staff / public / x x x Health Board) KD06 Improving the quality of care x x X x x KD07 Business planning x x x x KD08 Patient Care Services x x x KD09 Equality x X x Powys WAST operational area KD01 Reduce lost hours (job cycle efficiencies) x x x X x x KD02 Patient disposition – develop alternative care x x x pathways KD03 Effective utilisation of resources x x x x KD04 Workforce plan x x x x KD05 Community and public engagement x

FIGURE 14: Operational LHB-WAST Area Key Deliverables Strategic Aims Best Engaged Manage Reduce Strong Highly Possible And Skilled Capacity To Unnecessary Partnerships Effective Patient Workforce Meet Variation Organisation Outcomes Demand And Experience KD06 Operational management capacity x x KD07 NEPTS x x x KD08 Estates x x KD09 Business continuity x x x KD10 Equality x x x Resilience KD01 PREVENT training (counter terrorism) x KD02 Tier one multi-agency exercise x KD03 Commander competency training and roll out of x national occupational standards KD04 Reconfigure equipment on national resilience x vehicles KD05 Staff engagement, introduction of TRiM, x continuation of PDR and 1:1 processes and ongoing development of HART 2/ICs KD06 Complete re-write of the Trust’s major incident plan x to meet best practice KD07 Second stage of rolling out the LiD system for x x operational debriefing across the Trust KD08 Substantive resilience manager for South Wales and x Gwent LRF areas Patient Care Services (Non-Emergency Patient Transport) KD01 Full implementation of PCS management structure x x x X x KD02 Workforce development x KD03 Increased flexibility of service x x KD04 Engagement and effective communication x x KD05 Implement enhanced service x x x

These Key Deliverables are complemented by and align to our “Treating People Fairly – Strategic Equality Plan” and the area-specific priorities. They will be tracked as a package of activities through the Performance Management Framework arrangements.

3.7 Becoming a Leading Ambulance Organisation: Where Do We Want to be in 5 – 10 years? Our work on revisiting our purpose and vision exposed a strong appetite for more ambitious and strategic visioning and planning for our services. The discussion has commenced in earnest with the Executive and Non-Executive members of our Board. The culmination of this is anticipated to be a new strategy for ambulance services in Wales that will be developed during the lifetime of this plan. Action 6: The Development of a long-term strategy for ambulance services in Wales Our statement of intent: A “strategic statement of intent” is emerging. The thinking is congruent with the strategic report developed by the Association of Ambulance Chief Executives (AACE) “A Vision for the Ambulance Service 2020 and Beyond”, and further work will be done to explore and test some critical lines of enquiry and a route map, agreed with partners, to develop a new strategy agreed. Our strategic narrative will be further informed by the new NHS Wales strategic publication, expected in the wake of a new Government post May 2016. Notwithstanding the further work required, there are a number of strategic themes where there is emerging consensus and a clear view. We are describing this via our “Strategic Statement of Intent” and a series of statements describing our future state. Our Strategic Statement of Intent: In 5 – 10 years, WAST will have successfully:

 moved away from a response and treatment provider towards an urgent and emergency mobile healthcare service offering a wide range of skills and expertise for clinical decision- making, supported by a range of options and alternatives for referral and/or advice;

 proven ourselves to be an ambulance service employer of choice, with established and respected credentials in our clinical outcomes for patients, our patient experience markers, our responsiveness and our high levels of staff satisfaction. We will be able to recruit, retain and develop our staff, and will have in place a structured career pathway which will include apprenticeships. We will have a flexible workforce that is more representative of the communities we serve;

 proven ourselves to be a great place to work and to belong, with each colleague understanding what they are trying to achieve and able to be themselves as much as possible to achieve their goals; we will have high levels of trust, respect, participation and ownership and will be a role model for public service organisations in Wales and the UK;

 become a technology-enabled workforce and service, expanding the interfaces through which the public can access our services and similarly maximise the benefits of technology in communication with our staff and equipping them in the field (for example apps for training through to diagnostic and care support);

 made progress towards our vision for Clinical Contact Centres delivering an integrated health model (across 111, EMS, non-emergency patient transport and other NHS services) and taken the opportunity to improve and realise benefits from collaboration with our blue light partners in control centres;

 recalibrated and strengthened our offer to the primary care system, working effectively with primary care clusters for both in-hours and the out-of-hours service;

 set and delivered our agenda for collaboration with our blue light partners when it has delivered benefits for patients and the public purse;

 developed a fleet that is responsive and agile to demand, taking more care to patients with vehicles that act as diagnostic hubs, providing a wider range of imaging and testing, either for interpreting locally by paramedic or to enable results to be electronically sent to alternative clinicians;

 created an environment where patients and staff will see themselves as partners, working within Prudent Healthcare principles;

 established effective collaborative relationships with NHS Wales teams, with opportunities for cross-boundary working; and

 have established ourselves as a provider of high quality teaching, research and innovation. We will have strengthened strategic partnerships with academic and teaching institutions and become a Trust with University status.

Where we are less clear on our direction of travel, we will explore the opportunities and benefits, through engagement and a review of the evidence of the following lines of enquiry. These are not exhaustive:

 re-positioned ourselves into a more central role in the urgent and emergency care system, confirmed our “offer” to the management and running of Minor Injuries Units for example – clarified what it means to be system leaders;  explored our role as the navigation route/gateway for urgent and emergency care (in terms of referral to anticipatory or definitive care);  clarity on our role and offer in the prevention agenda;  defined our model for community resilience; and  challenged our thinking and approach to plan for our workforce in its widest sense – our staff, our volunteers, and even the public as co-producers of their care.

Whilst this is exciting and inspiring work, we will not allow it to distract us from our commitment to sustain our current performance and establish some foundations in terms of corporate infrastructure. Through discussion with our staff, our Board, our Commissioners, our partners in the blue light, public and voluntary sector and Welsh Government, we will develop a timeline for unpacking these lines of enquiry. Where this is a clear direction of travel and vision, we will not use the absence of a fully worked up strategy to delay progress. We will work agilely to test, develop and implement improvements to the system.

PART 4: QUALITY AND PRUDENT HEALTHCARE This section sets out our ambition to put quality at the heart of our plans. It sets out the practical steps we are taking to move towards our vision and covers:

 Listening to our patients and the public  Quality themes and improvements for 2016/17 and beyond  Quality improvement, measures and assurance system  Quality governance

Quality underpins all elements of our plan. Providing good quality clinical services is paramount but applying the quality and prudent lens to all of our service, including non-clinical services, is critical. For example, delivering a quality fleet service or ICT provision is essential to the overall delivery of our ambitions. Additionally, we recognise the value to patients and to the healthcare system of adopting a prudent approach to the delivery of our services. By placing better outcomes for patients at the heart of our operating model, the Trust is embedding the principles of prudent healthcare at the very centre of the organisation and is building firm foundations for the future. Our commitment to quality is also central to Treating People Fairly.

We are committed to putting patients, service users and carers at the centre of everything we do, engaging and listening to those who use our services to inform quality improvement. The Health and Care Standards (2015) set the framework of our Quality Strategy 2016/19 and focus on the delivery of safe and effective care, achieving excellent patient/user/carer and staff experience and supporting the implementation of this Plan.

The Quality Strategy 2016/19 was approved at the Trust Board meeting in March 2016 (a priority from our 2015/16 plan). It was developed during 2015/16 from triangulation of local and national data and patient/user/staff feedback and aligns with the requirements set out in Achieving Excellence - Quality Delivery Plan for the NHS in Wales 2012-2016 and Safe Care, Compassionate Care, the National Governance Framework to enable high quality care in NHS Wales (2013).

Following the consultation period during September 2015, the Strategy was revised to reflect feedback themes and was approved at the Quality, Experience and Safety (QuESt) Committee in February 2016. The Strategy incorporates the learning from internal assessments and local/national reports including the Abertawe Bro Morgannwg University Health Board “Trusted to Care” report and the Francis Report (2013) reviewing the care delivered at Mid Staffordshire NHS Foundation Trust. The Francis Report identified five key themes, underpinned by the requirement of a fundamental quality improvement culture and the adoption of common values across organisations focusing on:

 fundamental standards;  openness, transparency and candor;  compassionate, caring and committed staff;  strong, patient-centered healthcare leadership; and  accurate, useful and relevant information.

4.1 Moving Forward 2016/19

Developing through engagement and improving through continuous feedback.

Feedback from staff, service users, patients, stakeholder and communities has been taken into consideration and helped shape our areas for improvement across all of our services for 2016/19 and these will be reviewed and refreshed on at least an annual basis. We are fortunate that, through the work of our Partners in Healthcare Team, we have a significant amount of rich information from service users, patients and communities. Our patients and service users have defined ‘quality’ as:

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

They have told us that, for when they receive good care it can be characterised as:

 Professionalism and caring staff  Excellent service  Kindness of staff  Treated with respect and politeness  Knowledgeable staff  Helpful and reassuring

They have told us they would like improvement in the following areas:

X Hospital handover delays X Longer than expected wait for an ambulance X Waiting times to be picked up for appointments X Long journeys for appointments X Too many asked/repetitive questions on phone X Long wait for a call back

Feedback from staff walkabouts/workshops, staff surveys, engagement events and other discussions identified the following areas on which to focus our quality improvement work:

 handover delays at Emergency Departments and the impact on the quality of care patients receive including delays in treatment, pain relief, continence needs, pressure area care, hydration and warmth and comfort;  Infection Prevention and Control practices with pressures to turn vehicles around quickly;  involvement in shaping the clinical audit programme locally;  time for training and continued professional development including clinical notices, alerts, and new guidance;

 improving organisational learning and sharing improvements;  reducing waiting times in Patient Care Services and improving patient experience;  improving and simplifying the complaints process;  our clinical team leaders who need time to undertake appraisals and support their staff ;  focusing more on the outcomes of the care they deliver, not just time related measures; and  fleet issues.

4.2 Quality Themes and Improvements The Trust has adopted the Health and Care Standards (2015) Quality Themes and the NHS Wales Outcomes Framework to form the basis of our Strategy, whilst considering the principles of Prudent Healthcare. Following public and staff consultation, the Trust’s first Quality Strategy 2016/19 was approved by the Trust Board in March 2016 and supports the implementation of the IMTP. The strategy is a detailed document breaking down our aspirations over 2016/19 across the Quality Themes. This document is publicly available on the Trust’s internet site.

Quality and quality improvement is embedded throughout the whole of our plan across all services including the implementation of the new Clinical Response Five-Step Model and Non-Emergency Patient Transport. In addition to the actions included in other elements of this IMTP supporting quality improvement, we have identified the following key areas of action: Infection, Prevention & Control (IPC): Action 7 Strategic oversight of the implementation of the Infection Prevention and Control (IPC) two year operational plan; this will include monitoring of staff immunisation rates with Occupational Health. Action 8 Auditing of peripheral vascular cannulation rates. Action 9 Implement a task & finish group to address vehicle cleaning Trust-wide. Developing quality measures & a quarterly quality assurance report: Action 10 To commence from April 2016, a quarterly quality assurance report triangulating intelligence (qualitative and quantitative) to make sustainable improvements at corporate level 2016/17 including our own locally determined quality measures aligned to the Core Requirements and national mandatory targets and measures. Action 11 Review the capability and development requirements of the Trust’s risk management information system, Datix, to support the development of our monthly and quarterly reporting, heat mapping and early warning systems. Action 12 Undertake an internal assessment against progress with the Health & Care Standards (2015) for 2016/17. Safeguarding adults, children, domestic abuse & PREVENT Action 13 Development of a training strategy to meet legislative requirements including PREVENT. Action 14 Implementation of the safeguarding review outputs. Board to Floor to Board Action 15 Develop programme for walkarounds and feedback mechanisms.

Other key areas We will work with the Older People’s Commissioner and Ageing Well in Wales National Programme to ensure we deliver quality care to older patients and those with a specific need including dementia, sensory loss, falls, continence care and learning disabilities. Partnership working to establish good practice on learning disability care bundles, learning and appropriate training/education of staff across the Trust will also be undertaken. This links with Section 5, STEP 5 of the plan regarding our further development of alternative care pathways. Action 16 Implementation of our accreditation plan to be a Dementia Friendly organisation. Action 17 Work to achieve Bevan Advocate status by August 2016 and Bevan Exemplar status by August 2018.

4.3 Quality Improvement, Measures and Assurance System Quality assurance is provided through our improving compliance with the Health and Care Standards (2015), which have informed our Quality Strategy and key improvement priorities. We will develop our key quality indicators and measures to complement national mandatory targets and these will be at Trust level initially, then Health Board level with the aim of then developing locality / station level measures with staff relevant to the communities they serve across the life of this plan. These will then provide a framework for continuous monitoring and measurement. The image below provides an overview of our whole systems approach to quality, improvement and assurance.

The development of our quality measures will consider the balance of the data to include the structure of key services (number of people accessing our services), how key processes are working (how many people received all of the care they should have received) and the key outcomes that signal safe, effective and efficient services. Data collection at the Trust will be further enabled through the use of Digi-pen technology with the Partners in Healthcare team engaging with patients, service users and communities to obtain feedback on all of our services.

Currently the Trust uses some quality triggers including concerns, patient/service user/staff feedback, clinical audit data and performance and clinical indicators. However, we recognise the need to develop quality measures as detailed above and to use our information more intelligently through triangulation, heat mapping and early warning systems developing this over the life of this plan. Key questions are applied when triangulating the information from a variety of sources to consider the dimensions of quality to demonstrate that we are actively listening and learning.

 Are we providing safe care?  Are we meeting required standards of effective care?  Are we improving user experience?  Are we providing efficient services within our resources?  Are we engaging with the workforce?  Are we providing accessible and equitable services?  Are we improving population health?

4.4 Quality Improvement and 1000 Lives Improvement The 1000 Lives Improvement Service and Health Board/Trusts across Wales have built national improvement priorities into their three year integrated plans. The 1000 Lives Improvement Service

(part of Public Health Wales), Health Boards and NHS Trusts in Wales have agreed a set of national priorities for improvement in their integrated plans:

 improving patient flow;  reducing inequalities (long-term condition management and end-of-life care); and  Improving Quality Together – Model for Improvement.

The Trust is fully engaged with the 1000 Lives Improvement Service and recognises quality improvement draws on a number of approaches and tools and fundamentally means reducing or removing waste and variation in the system. This includes reducing delays and waiting times and ensuring care is equitable across Wales. The Trust has adopted the Model for Improvement and is working with colleagues in 1000 Lives Improvement Service to implement a senior quality improvement team with Silver Improving Quality Together accreditation. The Trust recognises that, in order to implement sustainable quality improvements, firm foundations must be in place including good governance with robust reporting systems and a culture of openness and transparency.

4.5 Quality Governance Quality governance is the combination of structures and processes at and below Board level to identify and act upon Trust-wide quality performance which includes:

 Ensuring required standards are achieved;  Investigating and taking action on sub-standard performance;  Planning and driving continuous improvement;  Identifying, sharing and ensuring delivery of best practice; and  Identifying and managing risks to quality of care.

The Board has overall accountability for the quality of services provided by the organisation. The Quality, Experience and Safety Committee (QuESt), as a sub-committee of the Trust Board, has delegated responsibility for all matters relating to the quality of care we provide. QuESt has a number of sub groups supporting our quality agenda and these are detailed in our quality governance committee structure.

Providing assurances to the public and Trust Board is a fundamental element of this Plan and, to deliver this, we have developed supporting local delivery plans for 2016/17 and an assurance framework which will be monitored at the Quality, Experience and Safety Committee (QuESt) on a quarterly basis. Following each meeting of QuESt, an update will be provided by the chair to the Trust Board through the Trust’s reporting and escalation routes.

Quality Strategy sets out our quality objectives and commitment to quality improvement.

Risk Management Strategy and framework 2016/19 focuses on managing the risk associated with providing our services.

Assurance providing confidence the organisation is delivering the objectives.

 Quality led organisation with foundations for delivering quality Together they put quality at the heart of the Board’s work

What will success look like?

1 We will be a clinically led, quality driven organisation adopting the principles of Prudent Healthcare. 2 We will have effective leaders and our staff will be developed and supported to deliver high quality care, in a high performing organisation that staff are proud to be part of and feel valued. 3 We will have made demonstrable improvements for our service users across all of our services, with sustainable quality improvements aligned to key performance indicators, measures and targets supported by our research & innovation work. 4 There will be clear lines of reporting and escalation routes with the Board receiving the right quality assured information, in a timely manner in a format that allows the Board and Executive Team to make informed decisions about the quality of the services we provide. 5 We will have good governance and risk management foundations in place that provide confidence in our systems to support decision-making, planning and quality delivery. 6 Staff will be engaged and will shape our priorities and know why they are important. We will continue to work in partnership, fostering productive relationships. 7 Quality indicators at station, contact centre and Health Board level will be developed by staff locally, relevant to the local population / service needs. 8 Service users, our communities, partners and stakeholders will be engaged in shaping our goals and priorities on a continual basis.

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

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

PART 5: OUR SERVICE CHANGE PLANS

This section, along with Part 6: Our Enablers, represents the heart of our plan.

Taking our strategic aims, and subsequently our priorities for this plan, we are now able to focus on the key service areas in which we will be investing our change capacity and resources, along with the specific actions that we intend to deliver upon over the next three years.

Further details regarding each action documented can be found in Appendix 6

The organisation is taking forward four major ‘flagship’ service changes as part of transforming the organisation. These can be clearly linked back to our overarching strategic aims.

 Embedding and sustaining the New Clinical Response Model  Transforming and modernising our Clinical Contact Centres (CCCs)  Implementing the agreed new model for Non-Emergency Patient Transport  Supporting the implementation of the 111 Pathfinder Project with NHS Wales partner organisations. Delivering on our priorities and realising our proposed service changes identified above will require the successful execution of a number of related actions and activities. The impact of these actions will be measured through the Ambulance Quality Indicators and show incremental improvement towards our stated performance ambitions as per Figure 13 in Part 3. The remaining section of this plan describes those activities and places them in the context of the five step model. Some of the actions documented have been agreed with (or are being proposed to) our Commissioner to receive specific funding. Where this is the case, a CAREMORE® template has had to be produced and submitted to the CASC’s office as part of the agreed commissioning process. In order to easily identify these actions, they are labelled with the “CAREMORE®” symbol. When settling upon the appropriate actions, consideration was given to the fact that the CRM pilot only runs until September 2016, at which point there will need to be an evaluation. Coupled with the further work required on a demand and capacity model, these two key activities will help to shape the focus and priorities for years two and three. The organisation was cognisant of the fact therefore that it has 6-9 months to provide assurance that this model is working and should continue. Consequently, whilst this is a three-year plan, many actions have a real focus on year 1 to ensure the model’s operational life is extended but also recognising that it is problematic to plan for years two and three with uncertainty surrounding the continuation of the model beyond September 2016.

STEP 1: Help me choose This step focuses on public education regarding the services provided by WAST and how/when to access them appropriately.

To deliver the five-step New Clinical Response Model, there will need to a cultural shift in the way that the public access our services, which will require a change in service user behaviour.

This step is where we address our contribution to the public health agenda, recognising that whilst we have a positive contribution to make, we will need to work across NHS Wales and with partners to deliver a step change. Engineering this shift in behaviour will require a strategy. We intend to engage with Public Health Wales on the development of this strategy. We are not starting from a zero base, we already have work underway that will roll up into this strategy. For example it will reflect the work we are doing to:

 further develop the NHS Direct Wales website in response to feedback form our communities;  closer working with partners organisations to support the Choose Well message and using WAST wisely;  continued development of information through media mediums; and  providing additional symptom checkers to enable people to manage their health and be well informed to choose appropriate services.

In support of this strategy, our Partners In Healthcare team will identify whether service users are accessing any alternative services and pathways before calling 999 and, if not, the reasons why. Through this work, we will take every opportunity to influence the work of and get support from any national work underway or initiated as part of the “Prudent Patient” response to the Prudent Healthcare Action Plan.

Action 18 Develop a longer term ‘Help Me Choose’ strategy.

Improving our response to frequent callers (FC) has demonstrated a reduction in the number of calls received and ambulances dispatched. It is also managing individual patient need better through the partnership work we have undertaken with GPs, specialist services, police and local authority partners. This multidisciplinary approach has, however, identified unmet healthcare needs and patient behaviour via the 999 system, which the wider NHS system was unaware of. Through this work, we are continuing to use our unique position as the only 24-hour national provider of emergency care in Wales, to benefit patients and NHS Wales.

Applying the National Frequent Caller definition, this work will continue to apply to all individuals who regularly call 999 but extending the scope to include callers from:

 residential homes and nursing homes – this work will include working with LHBs to address known problems such as non-injury fallers; and  the Police Service.

Action 19 Demonstrate effective management of Frequent Callers (FC), who impact upon the 999 demand, in each Health Board Area. A 2015/16 CAREMORE® action.

This step also has implications for our workforce planning and development. Achieving a step change in behaviours will require staff to have the necessary skills to be able to educate and inform the public at every appropriate contact. There will be an opportunity to strengthen the management of local Community First Responders so they become the local community experts, particularly in rural areas. It will be important that our staff understand the needs of their communities so that they are able to help people in Wales make the best possible choices. This is likely to mean proactive positive action with some communities to ensure that our workforce is more diverse and representative. In planning for our future workforce, we anticipate opportunities for our more experienced staff to undertake educational roles on a more frequent basis.

STEP 2: Answer my call

This step focuses on the response to 999 and Health Care Professional (HCP) calls by WAST’s Clinical Contact Centres (CCCs). This step incorporates the provision of adequate time to assess a call and the use of the Medical Priority Dispatch System (MPDS) to identify the priority of the call before offering / sending the most appropriate response.

Clinical Contact Centres (CCCs)

CCCs are the centre of the entire WAST operation, making it one of the highest priority areas for improvement, with some of the biggest returns to be made in regard to efficiency and effectiveness of EMS. Performance is dependent on the front end (CCCs) getting it right, and this requires appropriate systems to support staff to deliver the best outcomes for patients.

The long-term success of the new CRM is also in part dependent upon the transformation of the organisation’s CCCs.

This means that there are significant implications and opportunities for our CCC workforce in the future, particularly as we seek to re-profile the workforce to increase our capacity and capability to help respond to a growing demand in activity resulting from the increasing frail and elderly population in Wales.

CCCs deliver a call answering, assessment and triage service and a dispatch of vehicle service to a population of 3.3 million making 1200 “999” calls every day. Two elements of clinical assessment, information and advice services are hosted within CCCs: NHS Direct Wales and Clinical Support Desk (CSD). The CSD reviews more than 2000 patients each month to ensure appropriate utilisation of emergency response vehicles.

CCC staff also work closely with operational colleagues to develop and implement systems-based processes, providing and delivering new guidelines, procedures and policies associated with remote telephone assessment practice. This work is currently prioritised alongside the 111 pathfinder project, for which the team is leading on the clinical development of an updated Clinical Assessment System (CAS). The Emergency Medical Services element of call taking is completed on the MIS Alert 2000 Computer Aided Dispatch system (CAD). Most ambulance services in the UK have moved on from this system and therefore we are not realising the operational effectiveness and productivity benefits

that we could. The key determinants of CCC performance are infrastructure (telephone, CAD etc), capacity, management processes and culture. The plan for our CCCs reflects all of these components, more detail can be found in the CCC Local Delivery plan.

Performance management processes are being tested and realigned to the New Clinical Response Model, utilising “signals from noise” software from Lightfoot, a commercial company.

The demands on the service exceed the available capacity at certain times of the day because of historical working patterns which do not necessarily support the varied, unscheduled nature of the activity presenting to the service i.e. CCCs rely on overtime to bolster up our peaks in demand which is not always possible; the highest risk is currently in Call Taking.

The Clinical Support Desk’s (CSD) function has changed on a number of occasions since inception in December 2014. Since the New Clinical Response Model, the benefits of enhanced triage and Hear and Treat have meant that there is a requirement to review the current system and ensure that governance-led triage processes support staff, along with regular clinical supervision.

CCC is a high risk area in terms of business continuity and resilience. There is a requirement to further train and update all teams on business continuity, whilst maintaining day-to-day operations and continuing to test existing plans.

Risks with the current approach have been identified and the successful mitigation of these risks has, and continues to, allow the EMS element of CCC to operate with minimal operational risk whilst a new CAD is procured and implemented. Changing the culture of EMS to one that is performance and patient-focused has enabled some performance improvement and this journey of development will continue.

Much of the mitigation has focused on increasing the establishment of the CCC workforce. For example, in the clinical desk, the organisation is currently unable to maximise its “Hear and Treat” because of three potential clinical queues and a difficult manual process to accept calls for a clinician. Recruiting an allocator on the clinical desk will allow work flows to be more effectively managed whilst also providing a point of contact for the coordination of inter-CAD incident transfers. The actions detailed below demonstrate a coherent and phased approach to strengthening our CCC function.

2016/17 (Year 1)

With the two major change projects for the organisation completing in year one of this plan (the end of the CRM pilot and the procurement and potential full implementation of a CAD) there will be a major impact on the EMS CCC.

There will be the need to deliver considerable training to all EMS staff and, therefore, abstraction rates will be high.

Any new structure is also highly likely to require changes in rotas for all EMS staff, as well as training with potential role movement with some staff groups.

Consequently, the main drivers and areas of focus for the CCC in year one of this plan will be:

 supporting the procurement and implementation of a new CAD;  restructure of all staff group rotas and roles (in line with organisational change policies);

 embedding the New Clinical Response Model pilot following completion of the pilot;  embedding the national systems delivered into normal practice with a new staff structure fit for purpose;  supporting staff through the journey of change, ensuring frequent communication and support to individuals who need it; and  ensuring a robust framework of engagement of staff representatives within the transformation project.

Action 20: Continue to mitigate current risks associated with CCC service provision.

Action 21: Clinical and functional development of Clinical Assessment Software and supporting processes

Action 22: Undertake a review of the Practice Coach title, role and banding

Action 23: Procurement and Implementation of a new Computer Aided Dispatch (CAD) System Recognising limitations of the current CAD identified but also the importance of improving our “Hear and Treat” rates means that we plan to recruit an allocator to the clinical desk, who will develop and manage a clinical queue for appropriate “Hear and Treat” calls, to include non-injury falls. The potential for expansion of the Clinical Desk, including the clinical support to non-clinical staff in the CCC, will also be reviewed and scoped.

Action 24: Increased Hear and Treat services through the Clinical Desk. A 2016/17 CAREMORE® action.

We want to ensure we allocate an appropriate response for non-injury falls through clinical telephone assessment with appropriate referral and dispatch of ideal ‘Face to Face’ resource, if required. We will link this work to the Aneurin Bevan Health Board and WAST Falls response project Frequent Caller work.

Action 25: Implement appropriate service provision for non-injury falls.

Action 26: Implement the findings of Consultancy “Lightfoot” baseline review of the Clinical Contact Centres patient call cycle 2017/18 (Year 2)

Following the introduction of new CAD and staff structures, year 2 of this plan will entail embedding a performance management framework into the new staff teams to deliver performance improvements.

We recognise that status planning processes in WAST are not yet best practice and that the new CAD will likely go live on the existing methodology but with better technology. Following introduction of the new CAD, we will need to complete a review of all dispatch points, engaging with the operational areas and reviewing zones and priorities. We may also take the opportunity to move to a more appropriate planning system that meets the outcomes of the New Clinical Response Model.

Quality of call handling will be addressed through achieving accreditation to Priority Dispatch ‘ACE’ qualifications. This is an aspiration for the Trust: we will not be able to deliver it until we have completed the main CAD project with its associated training plan.

Main targets and plans for year 2 will thus be:

 performance management embedded in staff structures and aligned to organisational shared behaviours;  status planning; and  ACE accreditation.

We anticipate the plans outlined above will increase our workforce numbers by approximately 23.5 WTE, factored into our financial plan for 2016/17. Any additional resource required will need to be assessed as part of the developing CAD business plan. Our financial plans and templates will reflect year 1 numbers, but not year 2 and 3 at this stage pending further analysis and completion of the demand and capacity work.

Our vision for our service model for CCCs influences our estate plans. We want to create an integrated health model. This will include EMS and NEPTS control, Clinicians, NHSDW (111) and GPOOH services. We will also explore the opportunity to work with Health Boards around the potential to include other jointly beneficial roles within the environment of the CCC, for example specialist mental health practitioners and bed management operations.

Alongside this is the very important aspect of tri-service control rooms across Wales. We remain committed to working with fellow emergency services partners and firmly believes the integrated health model and tri-service are not mutually exclusive; we can achieve both. More information regarding potential CCC estate reconfiguration and how we will deliver this can be found in our estate section, part 6.3 of this plan.

111 Service It is generally recognised that the unscheduled cares system is difficult to navigate and often results in patients taking the easiest and most easily accessible route into our health services. Welsh Government policy over the last few years has reaffirmed the importance of helping people navigate what is often seen as a complex health system. A Welsh 111 Service has the potential to be a vital service to help people with urgent care needs get the right advice in the right place, first time. The Welsh Government’s Manifesto Commitments (2011) were clear that an introduction of a 111 system should:

 build on the success of NHS Direct and offer a single number for accessing out of hours health care in Wales; and  ensure all out of hours services are provided by the local NHS.

The intent is to collectively deliver functionally-integrated urgent care that is the ‘front door’ of the NHS and provides the public with access to urgent care advice, support and treatment.

We were selected as the organisation to host the initial 111 Pathfinder which will incorporate ABMU Health Board and the Carmarthenshire area. The Pathfinder will be evaluated before a decision on further roll out is considered by Welsh Government. An evaluation partner has recently been appointed to support this review and it is anticipated that an interim report will be provided at the mid way point (around October 2016) with a final report due in March 2017.

The 111 Service model has been built up through extensive discussion with key stakeholders. The Welsh model is distinctly different from the model developed in England. In Wales, we want to develop a system that is aligned with prudent health care principles, but also one that can manage complex patients.

The design principles underpinning the model are that:

 all call taking is provided within the NHS and patients access a service through a single, free-to-call 111 telephone number;  the service is delivered by both non clinical call takers and registered professionals, working in a multi-disciplinary team in line with the principles of prudent health care;  GPs are an integral part of the system and in line with prudent health care, maximising their role and utilising their skills and those of other professionals such as Extended Scope Practitioners to manage complex care; and  the model should proactively support the wider urgent care system.

The service model for the pathfinder has 3 key elements:

 call taking – calls will be taken by non-clinical call takers who will be employed within the service. Call takers will use existing call streaming and prioritisation software (called CSPT). Call takers will take initial demographic details and a brief summary of the issue. Call takers will be able to close calls where there is a clear governance framework in place to support this;  clinical telephone assessment – this will be carried out by registered professionals and could include nurses, paramedics, pharmacists, therapists and other staff groups such as dental health advisors. Calls that are assessed as ‘urgent’ during the GPOOH period will continue to be routed for GP triage by the ABMU OOH service. The data demonstrates that up to 2/3rds of calls are classed as ‘less urgent’ and these are the calls where we anticipate other professionals will support these calls in line with prudent health care principles; and  Clinical Support Hub – the clinical support hub will supplement the core clinical telephone service by providing expertise in the management of patients with complex issues. The hub will be staffed by experienced decision makers using their expertise and professional judgement.

Demand and capacity modelling has been undertaken as part of the planning for the pathfinder. The implications from a workforce perspective (i.e. numbers of additional WTE required are outlined below:

Staff Group ABMU Carmarthenshire Total Pathfinder Call Handlers 13.24 4.33 17.57 Nurse 15.07 4.93 20.00 Advisors

These calculations were based on:

 current activity within GPOOH services plus a growth factor of 20% (based on 2014 data);  average call length times : o For call taking 480 seconds (plus 60 seconds hold time for initial six months of pathfinder); and o Nurse call lengths of 900 seconds per call for normal activity and 1500 seconds for GREEN 3 (calls transferred from ambulance service);  priority 1 calls routed to GP OOH service (equating to a third of total call volume) and all other calls progressing through nurse triage or via Clinical Support Hub; and  planned shrinkage levels set at 35.10% for nurse advisors and 32.85% for call takers.

Recruitment to these posts for the initial phase of the pathfinder (ABMU) has been successful.

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Demand and Capacity – All Wales

An initial assessment of the likely demand if the service were to roll out nationally has also been undertaken.

If the pathfinder demonstrates an increase in call volumes as a result of the free telephone number being widely available, the All-Wales service may need to have capacity to handle up to 1m calls when fully rolled out. This would require a significant increase in call centre capacity over and above the current service, which is currently handling circa 250k calls per annum. Given constraints on the physical infrastructure this will require more innovative options to be considered which could include:

 a ‘hub and spoke’ model whereby a central service is supported by regional spokes at a Health Board level. This would offer advantages given that the call profile is distributed unevenly across the 24 hour period, with significant surges in call volume during the early evening period and at the weekend;  further discussion on the New Clinical Response Model and call flow options between 111 and GP OOH services, aligned with the above, where calls are routed to the most appropriate professional (the pathfinder will test elements of this);  remote working to facilitate surge capacity at peak times; and  options that align call flow with other similar services e.g. ambulance delivery – create flexible workforce opportunities.

It is important that this work programme is aligned with the wider strategic modernisation plans that we are considering in regards to our Clinical Contact Centres and their configuration.

The following table provides an indicative assessment of the anticipated workforce requirements using the same methodology as set out above.

Staff NHSDW (core ABMU Carmarth Pembs/ CTU ABHB BCU CVU Powys Total Group 0845 service) WTE enshire Ceredigion HB WTE HB HB WTE WTE Funded WTE WTE WTE WTE WTE Establishment WTE Call 31.78 13.24 4.33 4.89 6.95 11.63 18.89 12.27 5.21 109.19 Takers

Nurse 68.70 15.07 4.93 5.56 7.91 13.24 21.50 13.96 5.39 156.26 Advisors

As part of the continued development of the pathfinder the service model will evolve, in particular to reflect the delivery of new models in line with prudent healthcare principles:

 different skill mix and the introduction of new roles including rotational or joint posts with Health Board (e.g. Band 5 roles and Advanced Practitioners);  stretching the role of call takers to ensure that professionals are being used to their maximum potential;  utilising roles of other professionals such as physiotherapists and pharmacists; and  specialist roles that will help to ensure the delivery of 24/7 service models – some of these will only be possible at scale (e.g. specialist nursing roles, midwives, mental health professionals etc.) which could be delivered through remote working or other innovative options

These opportunities will be enhanced through a new IT system to be procured and available towards the end of 2017/18 which will facilitate improved information sharing across 111 service

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and other services but also will help to facilitate new working models by offering multi-channel access and facilitating remote working options.

Action 27: Work with the 111 Project Board and team to ensure the successful implementation of the 111 Pathfinder project in association with ABMU and subsequently the Carmarthen locality. A 2015/16 CAREMORE® action.

STEP 3: Come to see me

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

Part of the modernisation of our Clinical Contact Centres described in STEP 2 above also spans STEP 3.

Focused effort on improving this step will ensure that we provide a timely response to immediately life-threatening calls (RED calls in 8 minutes), AND an appropriate response to AMBER calls. The actions below highlight some of the key ways we will improve the system. These actions must be considered alongside the relentless and daily focus our operational staff have, both in CCCs and in our geographical teams to improve performance, system flow and efficiencies. The Local Delivery Plans include some detail of EACH area’s specific initiatives.

The demand and capacity review and the NHS Benchmarking toolkit may point to further actions we can take to improve performance against the AQIs within this step and we will remain open to trying and testing new approaches.

Healthcare professional calls are our second highest demand category of call. Following 1 April 2016, and the implementation and embedding of the EASC-funded HCP desk model across all three CCCs, we will work towards rolling this out across Wales so all HCP calls are now captured.

Action 28: Implement HCP desk implementation plan to ensure efficient management of HCP calls at a local and regional level.

It is referenced throughout this plan that the New Clinical Response Model may change the type and level of capacity required. There is also a need to reduce variation (and increase equity) in the five-step model. In recognising this, we have recently produced a 2016/17 CAREMORE® Service Change Idea for sharing with our Commissioner. The aim of the review would be to improve the management of capacity to deliver a sustained level of performance (this level to be agreed) across all LHBs and also help inform our organisational workforce and fleet strategies. This approach of external capacity reviews has been adopted in many ambulance services throughout the UK.

This capacity review would be undertaken in phases and phase 1 of the review would be to establish:

 if we are going to send the ideal response to each incoming 999 call, how many of each type of resource do we need by hour of the day and by location? (This will tell us where we need, who, at what time);

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 given our current WTE by skill grade, what this means for numbers of paramedics, EMTs, UCS staff and CCC clinicians; and  the amount of cover we need per day to meet our A8 target and provide a safe service.

A full specification of this, and future phases of the review, is being drafted. Action 29: To agree a full specification for, and subsequently undertake, a demand and capacity review.

The Demand and Capacity review must deliver an analysis of:

1. Call volumes – current and future. 2. Demographics. 3. The current operational context including handover delays at hospital. 4. Seasonal and special event demand patterns. 5. The ambition to increase the Trust’s A8 performance target to 70% and then 75%. 6. The requirement to release Clinical Team Leader staff from core operational rotas for 20, 50 or 100% of the time. The Trust requires modelling in relation to the type and optimum location of its resources required in light of the findings of 1-6 above. This modelling must advise the Trust on: 1. Optimum dispatch locations - fixed and standby. 2. Optimum crew configuration against the New Clinical Response Model. 3. Staffing numbers for “Hear and Treat” services, solo-crewed rapid response and conveying ambulance resources. 4. Future staffing requirements. 5. The opportunity for use of taxi and non-emergency transport to support EMS. 6. Numbers and locations of Community First Responders. 7. A number of known possible NHS Wales reorganisation scenarios. In section 2 of this plan, we described the important contribution volunteers make to the organisation and, in particular, the types of Community First Responder (CFR) schemes that the organisation utilises. We recognise that CFRs form a very important component of the resources at our disposal and, whilst they make a very valuable contribution to our performance levels, we want this contribution to be even greater. Our work plan on CFRs links directly to recent Coroner reports recommendations, and whilst we encourage CFRs across all of our communities, their role in rural areas is particularly critical. Reviewing the scope of practice for our healthcare professional CFRs will also be looks at.

To help support CFRs to make an even greater contribution we will, in year one of this plan, finalise our CFR strategy. Action 30: To finalise and gain Trust Board sign off of a CFR Strategy

Within the strategy, a number of explicit objectives are emerging; these will be progressed over the life of this plan; Action 31: Explore and expand where possible the provision of co-responding groups across Wales (Fire and Rescue Services, Police Services, RNLI, RLSS etc.)

Action 32: Introduce WAST Medical First Responders and ensure appropriate utilisation and allocation of available equipment

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Action 33: Introduce explicitly clear and unambiguous formal arrangements in the forms of Memoranda of Understanding and Service Level Agreements with all parties responding on behalf of WAST with recruitment, training and clinical governance embedded within the new proposed structure

Action 34: Introduce a standardised support and accredited training package that is delivered to all volunteer groups responding on behalf of WAST

Action 35: Introduce standardised equipment for all groups dependent on skill levels

Action 36: Review CFR dispatch/activation protocols for more effective distribution of resources

Many of the above actions represent 2015/16 CAREMORE® actions.

We recognise the importance of taking learning from other ambulance services around the UK and, where appropriate, further afield. South East Coast Ambulance Service have successfully deployed a community paramedic model which has resulted in a 15% reduction in conveyance to hospital - 35 fewer patients every day; we are committed to more fully exploring this as a potential model of service provision. Examining this model will allow the Trust to build on the successes of the Cwm Taf Explorer pilot. In Wales, with an integrated health system, this model should work well, further aligning emergency and unscheduled care with secondary care only when required.

Action 37: Establish a working relationship with ‘General Practice Clusters’ to ensure that the Trust develops its future services in line with the needs of primary care. Action 38: To explore the potential of a community paramedic model in urban and rural area.

STEP 4: Give me treatment

This step focuses on the development and delivery of a range of clinical care services able to offer a variety of treatment options.

STEP 4 (and 5) requires that the most appropriate clinician attend each incident, whether to deal with a life threatening issue requiring urgent transport to hospital or to treat at home (or in the community) and make decisions on the appropriate alternative pathway to care for their patient.

There is an increasing demand for our paramedic workforce to be able to see and treat the growing number of frail, elderly patients with chronic conditions and / or mental health issues. This requires an overall up-skilling of our staff to be trained in chronic conditions management, and will be addressed through our training and education plans (further described in section 6.1). At page 43, we noted the Trust had received £60,000 from the Stroke Delivery Plan flexible funds money in 2015/16. This was awarded for delivery of standardised stroke-focused online training to all WAST EMS staff in 2016/17.

Action 39: Delivery of standardised stroke focused online training to all WAST emergency medical services (EMS) staff.

This demand driver may also see an increase in the numbers of staff qualified at a higher clinical level as advanced paramedic practitioners, and band 6 “specialist” practitioners. The demand and capacity work described above will assist us in gaining clarity on the actual impact of this on the

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numbers of Band 5, 6 and 7 staff needed to deliver the New Clinical Response Model, and any consequent opportunities to re-profile the overall skill mix in response to any change.

During the life of this plan we will ensure further development of clinical indicators. An improvement plan, aligned with commissioning requirements, will also be developed following each Ambulance Quality Indicator monthly (and quarterly) report. Action 40: To ensure roll out and development of clinical indicators. In recognising this step in the New Clinical Response Model, we have also recently approved an internal clinical equipment business case to ensure our members of staff have the most up-to-date kit necessary to deliver the care and treatment which that patients need. Action 41: Implement Digi-pen phase 2 This is key in ensuring we transform from being perceived as simply a transport-based organisation into being a high quality provider of clinical services, as it enables the development of a suite of clinical indicators which in turn allow WAST to increase its focus on clinical outcomes and be clinically-led. This will also include the digitisation of safeguarding referral forms and the creation of docking facilities at hospitals. Action 42: Develop and modernise the Trust’s existing medicines management arrangements, by supporting the introduction of the Omnicell automated medicines management system.

STEP 5: Take me to hospital

This step refers to patients who require ongoing care and treatment and will be transported to hospital or to alternative care settings (e.g. Minor Injury Unit or a primary/community care facility).

At section 6.1 of this plan we describe the importance we place on clinical leadership and the work we want to undertake during this plan to drive forward clinical leadership across the Trust. This work is critical in our reorientation towards being clinically-led and, quality focused and in particular is relevant to this step. Indeed the work we want to progress around end of life care demonstrates what can be achieved when dedicated leads exist for specific clinical areas.

We have recently produced a CAREMORE® service change idea for our Commissioner for eight dedicated clinical leads for the following portfolios: trauma/PHEM, cardiac arrest, stroke/TIA, clinical modernisation, mental health, end of life care, sepsis and elderly people who have fallen.

The introduction of paramedic leads to cover these eight specialist areas would support our transformation to a clinically-focused service, in particular staff training and development on key clinical developments (cardiac arrest/stroke) and the development of pathways. In addition, the continued development of alternative care pathways will reduce current pressure on emergency departments.

Action 43: Introduce eight dedicated clinical leads for trauma/PHEM, cardiac arrest, stroke/TIA clinical modernisation, mental health, end of life care, sepsis and elderly people who have fallen.

We have also created tools for our paramedic workforce, to support robust clinical decision- making and safe patient care. Paramedic Pathfinder (PPF) has been in clinical practice within the Trust for

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12 months. Notable achievements have been made to train all Trust paramedics, implement reporting tools and develop a series of clinical monitoring indicators. All Health Boards were fully engaged during 2014 on the basis that the Trust was moving to this model of face-to-face paramedic triage. Whilst there has been sporadic interest from some unscheduled care partners and stakeholders across health and social provision, there is no national engagement framework in place to support the necessary progress in order to achieve the full benefits of the PPF model. Strong clinical leadership at the patient interface, robust clinical audit and meaningful feedback are imperative to the safe and effective application of PPF in ambulance clinical practice.

Action 44: Embed and sustain Paramedic Pathfinder as a face-to-face triage tool for paramedics (Paramedic Pathfinder 2) Pressures on the unscheduled care system are huge and, whilst we are working (and continue to work) closely with Health Board partners, handover delays do exist. Consequently, it is vital that all partners look to reduce the pressure on emergency departments and the wider system.. In response to this, a number of alterative care pathways are proposed during the life of this plan. Their successful implementation is dependent on the continued commitment of all partners. A ‘Pathway Development’ workstream within the Clinical Modernisation programme is to be established. This will map pathways currently in place across Health Board areas and use data from Paramedic Pathfinder to identify gaps and develop priority pathways for implementing across Wales. Developed pathways will be presented to the Clinical Pathways Advisory and Approval Group (CPAAG) prior to roll out. This workstream includes roll out of the Mental Health pathway and development and roll out of the End of Life care pathway, across Wales. Local Delivery Plans show a focus of joint working on the following areas.

Action 45 - Implement a range of alternative care pathways

Pathway / Health Board Powys ABMU ABHB CTUHB C&VUHB BCUHB HDHB

Mental Health √ √ √ √

Early Adopters (111) √

Acute GP √

Falls / falls vehicle √ √ √

Alcohol treatment centre / city √ √ help point initiatives

Fractured neck of femur √ √

General hospital admission √ √

Obs & Gynae √ √

Ambulatory Emergency Care √

Community Integrated √ Assessment service

MIU √ √ √

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Chronic obstruction √ pulmonary disease

Stroke √ √

Primary Care Hub √

*Mental health pathways and CCPAG represent 2015/16 CAREMORE® actions.

The choice of proposed pathways to implement has been based on the top reasons for 999 calls and the groups of patients that were identified as regularly being discharged from ED after tests with no treatment. Decisions will also be based on an assessment of local Health Board area need via the close working relationship of our Heads of Operations and their Health Board counterparts. Further details regarding the expected timescale of the implementation of these pathways can be found in appendix 5.

A high volume of End of Life Care (EoLC) patients are conveyed to emergency departments inappropriately. Some 32,000 people die in Wales each year and it is estimated that 75% of those have some form of palliative care need. Data also shows that 56% of the 32,000 will die in a hospital and that there are 65,000 hospital admissions in Wales for people in their last year of life. On average each person will be admitted to hospital 2.16 times in their last year of life. In 2014, emergency admissions in the last year of life accounted for almost 842,000 bed days.

Consequently, we have recently submitted a CAREMORE® service change for 16/17 idea proposal to our Commissioner for EoLC pathway funding. This would allow us to introduce:

 mandatory EoLC training for all WAST Paramedics which includes the recognition of end stages of life and symptom management;  the use of anticipatory medicines;  24 hour access to palliative specialist advice for the paramedic on scene; and  read only access to CaNISC (national electronic palliative patient database) by CCC Clinicians. We would expect the combined benefits of this to be a reduction in inappropriate ED admissions of EoLC patients with patients being able to stay at home or conveyed to a hospice if appropriate. The pathway would help achieve a patient’s wishes for their preferred place of death.

This All Wales EoLC pathway would also facilitate a reduced demand on EAs, reduced lost hours at EDs, reduced demand on EDs and a reduced total amount of EoLC patient bed days.

Action 46: Introduction of an All Wales End of Life Care Pathway

Paramedics and Emergency Medical Technicians were trained in 2015 in the use of the Paramedic Pathfinder (PPF) reductive triage system. PPF allows staff to determine safely the needs of their patients. We will develop a decision support “APP” for our clinical staff to use. This APP will link to the 111 Directory of Service and allow ambulance staff to determine the nearest appropriate service for their patient.

The development of the APP will be linked to the roll-out of a portable communication device for operational staff (more details regarding this initiative can be found in part 6.9 of this plan).

Action 47: Development of a decision support “APP” for our clinical staff to use

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Non-Emergency Patient Transport Services

Our Patient Care Services (PCS) division generates income in excess of £21m and employs approximately 485 staff across Wales. PCS transports patients who would not normally be able to access the care planned for them, some of which can be life determining, if it were not for this support. Unlike EMS, many of the patients who travel with PCS do so a regular basis. This provides frontline crews and volunteers with the opportunity to build rapport with patients that helps to understand and support their care needs whilst also improving overall experience. PCS operates a seven day service (currently limited on weekends) transporting patients to and from outpatient clinics, day centres, renal dialysis units, cancer care or to transfer between, or discharge from, hospital wards. In the 12 months from October 2014 until September 2015, PCS undertook 827,000 patient journeys. Since the McClelland Review of 2013, the future of Non-Emergency Patient Transport Services within WAST has been uncertain. However, this uncertainty has now been addressed since Ministerial approval was received to progress all recommendations contained within a NEPTS business case that was produced in 2015/16. One of these recommendations was that WAST should manage and coordinate NEPTS on behalf of NHS Wales. In Part 1 of this plan, the success of the original NEPTS project (which was the vehicle for producing the business case described above) is highlighted. Representatives from WAST, Welsh Government and the Chief Ambulance Services Commissioner (CASC) have agreed the Emergency Ambulance Services Committee (EASC) will progress the commissioning key deliverables, whilst WAST will focus purely on the service delivery elements of the business case and the establishment of the new NEPTS model.

The key deliverables for the CASC on behalf of EASC are:

 establishing EASC as commissioning body in Wales for NEPTS;  establishing commissioning arrangements;  a national set of NEPTS service standards and requirements; and  creation of a new expert commissioning group to agree KPIs and monitor the same.

The key deliverables for WAST in implementing the recommendations of the business case are summarised in the actions below which will form the core of the NEPTs agenda over years 1 and 2 of this plan. Action 48: Agree and establish a dedicated NEPTS management team within WAST. This will include establishing the NEPTS principles, vision and purpose Action 49: Establish a single point of contact Action 50: Improve discharge and transfer service for all scheduled care Action 51: Extend operating hours of the service. Action 52: Develop an enhanced service for renal, oncology and end of life care.

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Action 53: Engage a range of third party transport providers to help support the delivery of NEPTS Action 54: Creation of a new NEPTS brand. Action 55: Explore how health and social care might work together on transport issues. As an organisation, we have agreed with the CASC that NEPTS will adopt a similar approach to that of our EMS services. A stepped model of service is to be developed that will support and drive the service. In addition to the above implementation programme, there are a number of additional actions that are picked up by other directorates that will support the delivery of NEPTS as part of ‘business as usual’ over the next three years. These include:

 changes to the current configuration of the operational estate. i.e. Cardiff ARC (identified within Section 6.2 Our Estate) and the potential implications for NEPTS;  any changes to the current CCC configuration (identified within Section 6.2 Our Estate), and again the implication for NEPTS; and  the closure of Cefn Coed Divisional Headquarters which would require the relocation of the NEPTS Call Centre (identified within Section 6.2 Our Estate). It is important to note that the operational estate requirements for NEPTS may not always dovetail with the operational requirements of the EMS. This will be reviewed as part of the development of the estates strategy, in particular:

 the use of discretionary capital to support NEPTS Development (identified within the capital part of section 6); and  the procurement of a new NEPTS Planning CAD System (identified within the ICT part of section 6). As the new NEPTS model is implemented during year one, we will require an increase in the use of alternative providers from the voluntary, local authority and community sector. These organisations will focus on the transportation of patients with low-level mobility issues. The more complex mobility patients will continue to be conveyed by ambulance. From a workforce perspective it is likely that, in areas where alternative providers have good geographical coverage, we will not need to recruit to certain positions. We will instead look to allocate regular work to these providers as and when needed. This will add to the flexibility of the NEPTS service: this is likely to commence from year two onwards. In the meantime, we will continue to review and maintain a focus on timely recruitment when required, and to reviewing the employment status of the existing workforce to ensure they are supported and retained as appropriate. When we do recruit to replace existing positions, we will be recruiting more part-time positions to cover peak periods and early or late periods in the day. In year two or three, we will look to develop apprenticeships into the service, and potentially through to other roles within the Trust. As described in the approved NEPTS Business Case, the new model will require the existing WAST PCS service to be internally disaggregated from the WAST EMS service. Fundamentally, this is about creating a new management structure to take forward the service. This will be completed during year one and will enable us to build a robust workforce plan to take us towards 2020. The requirements of the new management structure have been built into the Trust’s workforce and financial plans for 2016/17.

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This structure will introduce PCS Team Leaders who will develop a team approach and ensure each member of the team is supported and undertakes effective PADR. In addition, the PCS Team Leaders will work alongside their team members and undertake observed practice and provide remedial support as necessary. In addition, developmental opportunities will be provided through the PADR process that will provide the PCS workforce with the necessary skills to undertake their role to a high standard and also help them develop skills for the next stage of their career for those who wish to. We will develop a leadership and management plan aimed at identifying, training and developing managers and leaders at all levels to take a proactive role in driving quality and safety, and encouraging innovation throughout the service.

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PART 6: OUR ENABLERS

This section, along with Part 5: Our service change plans, represents the heart of our plan. It describes how a suite of enablers with a suite of actions relating to each enabler will help support us in delivering our ambitions.

Further details regarding each action documented can be found in Appendix 6

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

This section covers the plan for our “building blocks for change”; more detail on some of the technical elements are found in the appendices:

 Our People  Our Finances (revenue and capital)  Our Estate  Our Fleet  Our Partners, Patients and Stakeholders - engagement  Service Improvement and Innovation  Health Informatics/Business Intelligence  Information Management and Technology  Research and Development  Our Governance For each of these areas, we have also continued to be explicit in the actions that we will take.

6.1 Our People

Our people are our biggest asset and it is vital that we use the talents and experience of our whole workforce to provide high quality, safe services to the individuals, families and communities we serve. Changes to our New Clinical Response Model mean the make-up of our existing workforce may need to change. However, effective workforce planning is more than getting the numbers right. It is about getting the staff with the right skills to meet our future demands, performing within the right culture, built with the right staffing model, with the right skills, supported by effective management and clinical leadership that will successfully transform the way we provide care and services to the patients and communities we serve. In this section of our IMTP, we share with you details of our current workforce profile, our People Strategy and enabling frameworks and plans w will support us to deliver against our strategic priorities. More specifically we will:

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 take a closer look at our workforce plan, and how we intend to tackle some of the challenges facing us, including supply of qualified paramedics;

 share our thinking on how we will drive up clinical skills and excellence across the Trust, and how changes to the education and training of paramedic and other staff will support that drive ; and

 outline our OD plans to transform the way we do things and culture of the organisation, and actions we will take to improve the working lives of our staff and their well-being.

Our Workforce Profile The Trust employs approximately 3,030 members of staff (December 2015). The majority of these people are employed within our Operations Directorate, which includes our Clinical Contact Centres, Emergency Medical Service (EMS), Urgent Care Staff (UCS) and Non-Emergency Patient Care Services (PCS) staff. Our frontline teams are supported by colleagues working within our Corporate / Executive functions and teams. Detailed breakdown of staffing numbers by headcount and whole time equivalent by service / directorate can be found in section 2.1. Below are some facts about our workforce

Working Longer Our current workforce profile presents a number of challenges and opportunities. Almost 35% of our workforce is over 50 years of age. There are profession specific challenges and also organisation wide challenges that come from an ageing workforce. It is perhaps helpful to note that, within our front line EMS service, only 29% of our workforce is aged over 50. Changes to retirement provisions mean that predicting potential retirements is harder, with a prospect of staff working beyond a traditional retirement age. As such, it is predicted that the Trust will continue to have an older workforce profile. Retaining our older workforce is multifaceted and involves balancing a number of competing factors, such as awareness of health issues and

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managing absence whilst also managing the changing capabilities of the older workforce. These changes could be a result of a decrease in confidence, the need to work with greater speed and dexterity and the capacity to engage with transformational change. Given the nature of the service changes planned, how we enable this workforce to work differently will also require a specific focus. In addition, an older workforce is likely to have increased family responsibilities and also health concerns and a different perspective on work life balance. This means different strategies will be required to ensure the Trust benefits from their extensive knowledge and experience. This group also has potential to create significant turnover and succession planning will need to be carefully managed to ensure service provision is not jeopardised. The Trust is part of an all-Wales project group looking at the implications of working longer, and opportunities to support staff to remain in work. As a service, we foresee that the shift in workforce capacity to the first three steps of the New Clinical Response Model may provide future opportunities for our older workforce in roles educating the public and school children of the importance of choosing well, and basic life support skills. Opportunities to work within our clinical contact centre and NHSDW / 111 service may also provide an alternative for many paramedic staff nearing the limits of their physical capability to deal with the demands of responding to 999 calls. A more diverse workforce Presently less than 1% of our people identify themselves as from Black & Minority Ethnic (BME) origin. There is some further work to do to ensure our records are as up to date as possible, but we recognise that our workforce is not as diverse as it needs to be. For example, our local community in Cardiff is approximately 10% BME communities; our workforce isn’t. This potentially creates a barrier to providing great care. In our Strategic Equality Plan and Objectives, we state our intention to proactively work with partners to help our BME communities to be want and be able to work in the Trust. This will include encouraging people to become volunteers, working with schools and Swansea University to encourage applications for paramedic training from minority groups, and in developing apprenticeships. Details of our Strategic Equality Plan and Objectives, ‘Treating People Fairly’ are outlined in section 2 of this plan. Our Volunteers

We recognise the important role which volunteering plays in complementing the work of our staff. We support and encourage the efforts of individual volunteers and voluntary organisations for the benefit of patients and their relatives. Community First Responders

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

There are currently more than 200 Community First Responder schemes across Wales comprising approximately 2,200 volunteer members and these schemes contribute more than 3% to RED performance pan Wales. Part 5 of this plan (Our Service Change Plans) explores in more detail the emphasis we will be placing on developing the CFR role over the life of this plan.

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Voluntary Car Drivers The Ambulance Car Service is a vital component of the Patient Care Service and consists of a team of dedicated volunteer drivers who use their own cars and give their time freely to assist in transporting patients to various hospitals and clinics throughout Wales and England. As at January 2016, the Trust had 235 ambulance volunteer car drivers.

Each year, the Ambulance Car Service drivers cover eight million miles providing transport to patients with limited mobility who are able to travel by car.

The Trust’s strategy is to use the Ambulance Car Service volunteers as the service of choice for those patients who fit the criteria. The volunteer drivers transport regular patients and develop strong bonds with them.

Workforce Key Performance Indicators (KPIs)

Below in Figure 15 are some of our workforce and OD KPIs that we currently monitor on a monthly basis within the Trust: Figure 15

Figures are correct as at 31 January 2016 with exception of staff engagement, which is taken from most recent NHS Wales Staff Survey in 2013. A new survey will be run later in 2016.

Note that Statutory and Mandatory Training figures are not currently available as the ESR report and data is currently under review. However, this will be reported and monitored across the Trust as soon as available.

Monitoring of these key performance indicators takes place on a monthly basis through Executive Performance Review meetings with each Head of Operations, and also through production of the Trust’s monthly IPR, which is received at Executive Management Team, Finance & Resource Committee and also Trust Board.

Our People Strategy ‘Being our Best’

One of our key strategic priorities as a Trust is the need to have an engaged and skilled workforce operating within an organisational culture and framework that enables them to work to the top of their skill set to deliver high quality care. Our People Strategy is designed to enable us to build on the positives of the last 12 months and respond to the challenges ahead by providing focus and opportunity to align our resources accordingly. Below in Figure 16 is a simple SWOT analysis that has assisted in developing our strategy and action plans.

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Figure 16: SWOT Analysis

Strengths Weaknesses More robust operational workforce planning ESR system set up requires further work and data capacity and clarity of vacant posts cleanse to ensure workforce and financial data is aligned Improved establishment control and monitoring of recruitment activity Limitations of an ‘out of date’ CAD system Aligned recruitment and training plans Low levels of engagement of staff and morale More frontline EMS staff in post, and increased High expectations of change and improvements UHP available brought about by New Clinical response Model Improved sickness absence rates, plus lower Resourcing levels at peak times and in rural areas number of vacant posts and less requirement for Absence of a clear clinical leadership strategy and overtime limited effective use of the paramedic pathfinder Pilot New Clinical Response Model and positive Limited access to alternative pathways and GPs / impact on outcomes (AQI) and performance Third Sector services to support patients at home Improved partnership working with Trade Unions Need for changes in behaviours

Significant increase in number of PADRs for staff Limited availability / access to workforce

Introduction of CPD hours into rosters benchmarking information for ambulance services New Executive leadership team, clear strategic direction Agreed shared behaviours and vision – built from bottom up

Threats / Risks ….. Opportunities

Financial risk posed by introduction of Band 6 for Potential benefits offered by new models such as paramedics in some English Ambulance Services the ‘community based paramedic’ in rural areas and discussions of grading reviews of paramedics and critical care paramedic nationally Development of a modular approach to disease Service developments within Health Boards and specific training to increase clinical skills and

Trusts attracting Advanced Paramedic Practitioners decision making into GP Out of Hours and multi-disciplinary teams Increase use of the clinical desk to assess non injury within the hospital and community setting. falls, option to employ specialist mental health Impact of continuing pressures across USC system, nurses and midwives on the desk and impact on patients and also staff working lives Volunteer car drivers instead of taxis or one step through overruns and inability to take timely meal further and employ staff similar to the those in breaks local authorities 'man (person) in a van' who does High levels of abstractions / variation across CCCs this. and Health Board teams Expanded use of the CFRs and Co-responder Overall affordability of potential developments models Capacity and/ or capability in management and Review of the staffing model (crews) of EMS supervisory infrastructures, inc. corporate teams Vehicles Development of the CTL role and APP role

From this we have developed a simple four-step model (Figure 17) with key activity areas which will be our focus for the next three years and from which our enabling frameworks flow. The model also identifies the core ‘golden threads’ that run through the whole strategy and everything we do as a Workforce & OD Directorate and organisation.

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Figure 17: Four-Step Model

Key Enabling Frameworks There are four key enabling frameworks of activity linked to the model. They are:  Workforce Planning (Plan)

We know that robust and effective workforce and resource planning is key to our future success and to ensuring a resilient, safe and sustainable future workforce.

We will know we have been successfully in our workforce and resource planning when we have  a resilient, flexible and sustainable workforce with low turnover and low sickness;  increased paramedic hours available to be rostered and a consequent reduction in our reliance on overtime and private ambulance usage;  the most appropriate response clinical staff attending calls that make best use of their skill sets, and the lowest acuity healthcare professional (HCP) calls are being managed by the Urgent Care Service rather than paramedic staff;  improved performance and, most importantly; and  improved quality of care and positive patient experiences.

 Recruitment (Recruit)

The opportunity for paramedic staff to move into roles in the ambulance and wider NHS setting, including GP OOHs, is growing and, like many other ambulance services in the United Kingdom, we are experiencing difficulties in attracting qualified paramedics to our vacancies. We want to be seen as the employer of choice among ambulance services.

We will know that we have successfully achieved our recruitment plan objectives when:  we have recruited to all our vacancies in a timely manner;  the time taken to hire new staff and the process is as efficient as possible and candidates have a positive experience;  WAST is seen as the employer of choice, and Wales as the place to live and work;

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 our workforce profile better reflects the communities we serve, and our patients (continue to) receive care and support in their preferred language of Welsh or English.

 Training and Education (Train)

Our people have a fantastic appetite for personal and professional development. Ambulance training and education is evolving in terms of developments to degree level education, driver training and our staff need the skills and confidence to deliver high quality care adapting to increasing pressure of demographic changes and an ageing population (and an ageing workforce). Strong clinical leadership and direction in this area will help make our plans to deliver the highest standards of training and education for staff a reality.

We will know that we have successfully achieved our training and education plan objectives when:

 we can show evidence of improved clinical decision-making across the Trust and lower conveyance rates;  we see improved clinical outcomes for patients and receive stories of positive patient and staff experience;  we experience a reduction in complaints and concerns related to treatment and care;  our workforce is well trained and keeping up with the latest clinical and technological advances;  we meet our CPD and mandatory training target; and  we have transformed our National Training Centre into a flagship training facility, recognised as a centre of excellence with state of the art training facilities

 Organisational Development (OD) (Retain)

We have a dedicated and skilled workforce, committed to delivering the highest quality of patient care for the people of Wales. We are on a journey of transformation over the next three years – transforming our services, culture and workforce. The OD framework and plans will help underpin this transformation by focusing on leadership and management capacity and capability, health and well-being, engagement and appreciation of staff, and creating personal responsibility and accountability, and ultimately ensuring we retain a skilled, dedicated and motivated workforce.

We will know that we have successfully achieved our OD plans when:

 our people are more resilient and better able to deal with the day to day emotional challenges of the job, and stress-related absence falls;  we have achieved Gold Corporate Health Standard (2016) and then Platinum (2019);  all staff receive regular, high quality feedback on performance and care & undertake a quality PADR with their line manager;  levels of colleague participation and ownership will be much higher, reflected in an improved employee engagement score from staff surveys;  we have in place a sustainable model of clinical supervision and appraisal, with a network of skilled clinical mentors to support staff and students;  levels of turnover will be low; and  diversity and inclusivity among our workforce improves and we are recognised as a Stonewall Top 100 Employer. A number of core ‘golden threads’ run through our strategy and are integral to what we do and the outcomes we seek. They are:  leadership (including clinical leadership);  behaviours;

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 quality; and  staff well-being. The development of our new set of organisational shared behaviours and plans to embed these are outlined in section 3 of this IMTP. Similarly, details of our Quality Strategy and commitment to being a quality driven, clinically-led organisation are described in Section 5 of this document. Leadership We define leadership as “the ability to positively impact and influence others”. Therefore, vibrant, empowering and effective leadership is a key enabler for us to deliver our strategic priorities and plans described further on in this section. Good leadership is also key to enabling our staff to be their best.

To help us develop and grow our leaders, we have developed principles of effective leadership in the Trust. These are outlined below:

 to create high levels of humility and self-inquiry, and listening/ questioning and trust towards others;  all development needs to be chosen by the learner and not forced: we always work with the willing and want leaders to be the best they can be in their own way;  each leader is unique and will have unique needs: we try to avoid set programmes for any group unless it is absolutely required;  we are part of Public Services Wales; we take every opportunity to develop leadership with partners;  we focus on transformation rather than transaction; our activities are facilitated and not “trained”; and  leadership can be shown by anyone; all our opportunities are available to all of our colleagues.

Leadership development is a cornerstone of our OD plan, further details of which can be found later in this section.

Clinical Leadership

Driving forward clinical leadership across the Trust is a vital part of our overall leadership and management development plan. It is a key part of a developing, integrated agenda, working closely with Heads of Operations, Workforce Development and the Medical and Clinical Services Directorate. Rising unscheduled care demand for individuals with long-term conditions is a major challenge for the NHS in Wales. This has resulted in a call for more care to be delivered closer to home in the community setting and the modernisation of NHS clinical roles and delivery systems. Similarly, the concept of prudent healthcare strongly promotes clinical role substitution and adaptation in order to achieve similar or, better outcomes for patients, albeit using less expensive human and technical resources. In this IMTP, we outline a significant programme of clinical change to modernise ambulance practice and clinical service delivery. Ensuring the quality and consistency of ambulance clinical practice during this period of change is a challenge. Effective high quality clinical leadership is, therefore, pivotal to achieving any benefits predicated by this change and remains a key priority.

Our clinical leadership development plans will ensure an appropriate structure is in place to encourage clinical leadership throughout the Trust, made more important because of increasing

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levels of clinical decision-making at the patient interface. We aim to further support and challenge all clinicians to understand and develop their own and others’ clinical practice. This will be based on a range of indicators, evidence and feedback across multi-professional teams and groups.

We have already made progress towards improving clinical leadership within the Trust by:

 reviewing the Advanced Paramedic Practitioner (APP) role;  exploring options to improve access to clinical supervision for frontline staff;  strengthening links between training and education, with operations and clinical and medical directorate;  reviewing of the role of the Clinical Team Leader (CTL) and the development and support required to be able to deliver their role effectively;  development of the Organisational Learning Group; and  developing clinical pathways and clinical lead roles (described earlier in this plan).

As part of our plans, existing and future clinical team leaders will be developed in the underpinning theories of leadership and management of change within a clinical setting. We will do this through the development and implementation of a structured development programme and action learning workshops across the Trust. We expect this to result in a greater understanding of clinical leadership across a wider range of clinical disciplines, grades and groups in the Trust.

We will also review our existing Clinical Services Strategy, which is nearing the end of its term, with a view to developing and consulting upon a refreshed strategy linked to a Clinical Leadership Plan. Having a clear clinical leadership and supervision infrastructure across the Trust will help serve as a quality assurance function and work closely with Research and Clinical Audit departments to provide the ability and systems to identify best practice. This will have a key impact on both individual and organisational learning and performance improvement.

As part of this developing infrastructure, the Trust will consider the role and benefit of introducing consultant paramedics in the future. There is a clear need to ‘do things differently’ to provide safe, high quality care to patients, relieve pressures on the clinical workforce and ensure prudent use of NHS Wales resources and finance. The key benefits of introducing a consultant paramedic role include ensuring contribution to the wider NHS health economy by improving patient safety and clinical quality at both ‘advanced’ and ‘core’ levels of paramedic practice within the Hear & Treat and “See & Treat” domains; assistance in the implementation and monitoring of organisational learning into clinical practice though expert clinical supervision and mentorship; and support of the development and delivery of national clinical strategy through system thinking, developing shared visions and supporting the internal/external clinical education and research agenda. Well-being The health and well-being of our staff will remain a core focus for us in terms of the realisation of our vision of valuing staff. Continuing development of our in-house Occupational Health and Well-being Service to ensure a range of services, advice and guidance to promote and improve the well-being of staff is a key objective for us. In 2015/16 we developed the following services for our staff to help promote their health and well- being:

 immediate access to telephone counselling for all staff, with opportunity for face to face counselling if required;

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 display of posters and leaflets with technology enabled QR codes with direct links to dedicated support services to signpost staff to resources for advice; and  launch of two occupational health and well-being vehicles across Wales. This provides local services that are tailored to WAST needs. They have been used for flu awareness campaign including vaccinations and health screenings.

The Trust’s Health and Well-being Steering Group will continue to develop and promote initiatives within the Trust which support and encourage improved health and well-being through engagement with staff and in line with the NHS Wales Health and Well-being Charter.

Through the development of a network of well-being advocates, health promotion activities can be targeted to local need and demand and facilitate support local to where staff live and work.

We will continue to work with our partners in charities like The Ambulance Services Charity (TASC), MIND and Time To Change Wales to ensure that staff can access specialist support services and treatment if appropriate.

Recently, the Trust has launched a new employee assistance programme which includes many interactive and online tools to help inform and influence individuals to take positive steps towards improving their lifestyle; diet and exercise, sleep and debt management for example. These tools will continue to be promoted and encouraged. Our People Strategy map (Figure 18 below) provides an overview of the strategy, the context and challenges, enabling frameworks and plans with key dependencies and outcomes.

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Figure 18: Our People Strategy

Our People Strategy 2016/17 – 2018/19

Our Vision A leading ambulance service providing the best possible care through a skilled, professional and healthy workforce

Our Strategic Strategy will underpin delivery of all Trust strategic priorities but particularly aligned to priorities 2, 5 and 6 Priorities

National Policy The Social Services and Well Being (Wales) Act 2014 – a better qualified workforce with skills that enable people to work across organisational boundaries & Strategy (Workforce & Prudent Healthcare – working prudently to ensure you do only what only you can do. OD) NHS Wales Working Differently, Working Together Framework – engaged workforce, a sustainable and skilled workforce, a redesigned workforce, a workforce that aims at excellence within available resources

Implications of Francis and Trusted to Care Reports - impact of culture and behaviours upon performance and care

2014 Williams Commission on Public Services – articulates the leadership challenge, importance of leadership development and succession planning

Primary Care Workforce Plan

Equality Act (2010), Welsh Language Measure (Wales) 2011 and standards

Enabling WORKFORCE PLANNING (PLAN) RECRUITMENT (RECRUIT) TRAINING & EDUCATION (TRAIN) ORGANISATION DEVELOPMENT Frameworks (RETAIN)

What National move towards a degree based Competition for qualified paramedics in Changes to Clinical Response Model Increasing numbers of volunteers opportunities paramedic profession face of national shortages and differences Ageing population and increase in need including CFRs to support, engage and and challenges in terms and conditions to English for skills to manage chronic conditions retain face us in the Potential for a ‘fallow’ year on move to Ambulance Services and support patients to remain at home next three to degree (so that they can be treated on an Challenge to engage staff and improve five years? Long lead in times for recruitment individual basis for their needs) against 2013 NHS Staff Survey response Impact of degree requirement on internal rate (30%) and engagement score (43%) succession routes Challenge to attract and recruit to rural Opportunity to positively contribute to which benchmarked significantly lower areas and retain staff there Financial affordability of re-banding of flow across the system through increased than the average for NHS Wales (55%) clinical decision making to support paramedic staff to B6 Lack of diversity and poor representation Turnover rates of 11% in 2015 from visible BME groups among the patients at home or access alternative Increased demand for Advanced workforce at all levels (including Board) pathways Need to develop vibrant, authentic and Paramedics to work within HBs and empowering leaders at all levels Primary Care Launch of Trust refreshed shared Changes to the Driving Qualifications / behaviours and need to embed into Improving management capability and 121

Delivery of New Clinical response Model selection processes to ensure right person, Standards capacity at scale, across Wales and changes to demand / ideal response right place and right time Strengthening of infrastructure to deliver History of bullying and harassment, Opportunity to develop community Increasing role for Community First clinical leadership and supervision across learning from experience of others such paramedic role in rural areas, Specialist Responders and Co-Responders with Fire clinical staff to support PADR and as London Ambulance Service Paramedic and APP roles Service reflective practice Lack of structured succession planning to Review of Clinical Team Leaders role & Minimum levels of bilingual skills to ensure Poor physical infrastructure within NATC middle and senior management roles rosters services can be delivered to patients in and need to maximise use of technology both Welsh and English as part of to deliver training Improving TU relationships but challenge Implementation of NEPTS and 111 recruitment plans to embed strong partnership working Pathfinder Expectations of staff /graduates / with Trade Unions at middle millennials management level Increasingly ageing workforce – a third of EMS workforce over the age of 50 Up-skilling and maintenance of trainer Staff experiencing long shifts due to competences lengthy overruns and delays at hospital Potential to integrate and participate in multi-disciplinary teams within primary Challenge to ‘professionalise’ the Low compliance with meal break care paramedic workforce requirements

Delays to hospital handovers and high Ability to transfer skills such as nursing National statistics of 1 in 4 people suffer levels of abstractions qualifications within paramedic training with mental health problems – increasing prevalence of stress, anxiety and 2015/16 a 1.5 percentage point reduction depression as a reason for absence (approx) in sickness absence, with a further one percentage point reduction would Flu vaccinations for front line staff a place WAST among majority of Ambulance Ministerial priority Services

Resourcing levels and policy, particularly at peak demand times (e.g. Christmas) and in rural areas at night

Enabling Plans Workforce Plan Recruitment Steering Group Action Plan Workforce Education Development Being Our Best – OD Plan Group Action Plan

Inter- Demand & Capacity Review Strategic Equality Plan Clinical Leadership Task & Finish Group Strategic Equality Plan dependencies / Action Plan linked action Workforce Education Development Group CFR and Co-Responder Strategy Health & Well-being Steering Group NATC Training & CPD Plan plans Sickness Action Plan Communication & Engagement Plan Corporate Health Standard Action Plan Quality Improvement Strategy Local Delivery Plans NHS Wales Workforce & OD Directors Improving our Staff Working Lives – Work Programme Clinical Strategy (Development) problem solving test beds

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Education Commissioning Communication & Engagement Plan

WiFIS Quality Improvement Strategy

Staff Recognition and Appreciation Plan

How will we Resilient and sustainable workforce – low Workforce profile will better reflect the Positive patient and staff experience Sickness absence targets will be met know we have vacancies, low sickness, increased UHP and communities we serve been improved quality and performance Reduction in complaints and concerns We will have achieved Gold Corporate successful? No / minimal vacancies in EMS Health Standard and then Platinum Decreased cost of overtime and private Strengthened clinical leadership and ambulance usage Trust is seen as Employer of Choice improved clinical decision making across We will be a Stonewall Top 100 Employer the Trust Positive patient experience Less disciplinary cases All staff will receive regular, high quality Lower conveyance rates feedback on performance and care & Reduced time to hire PADR Improved clinical outcomes for patients Patients will (continue to) receive care and Levels of colleague participation and support in their preferred language of ownership will be much higher Welsh or English Workforce profile will better reflect the communities we serve

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Workforce Plan In 2015/16, we took action to build a solid foundation for future workforce planning by improving establishment control, confirming budgeted and actual establishments (particularly for Emergency Medical Service- EMS- staff), and aligning recruitment and training plans. Developing the skills, capacity and capability to workforce plan continues to be a priority. Working closely with finance and operations colleagues, we have also taken action to improve data quality with the ESR system and align this with our financial data. We have trained a number of HR staff in workforce planning, and begun to develop closer links between our workforce and resource planning teams. Our ability to workforce plan depends upon an understanding of current and future demand for 999 and other services and what that means for the workforce, and of the supply chain of paramedics and other staff. Our EMS workforce is our biggest resource and, therefore, remains a focus for our workforce planning. As a result of our planning work:  we have been able to demonstrate an increase in the number of staff and production hours available to our Health Board operational teams and a consequent reduction in the need for overtime during 2015/16;  we know how many paramedic staff we currently need up to 2019 based on existing requirements if there is no change to our current skill mix or establishments, and how many we students are currently in the supply chain. We know that if we do nothing to change our existing skill mix, there is sufficient supply to meet demand based on average turnover among the workforce but this may be significantly impacted by our ability to recruit from among the student workforce;  we have taken action in our education commissioning of paramedic students to avoid the potential for a fallow year as a result of the potential introduction of a degree requirement for all paramedic students. This is described in further detail below;  we expect that demand for 999 services will continue to grow, and is linked to an increase in the frail elderly population of Wales. The graph below demonstrates that an increasing number of our patients are now over 65. This change in demographic will also result in a change of case mix. Our staff will require an increasing focus on health issues associated with frailty and chronic illness as well as injury patterns associated with old age;  we recognise the need to plan for increasing competition for paramedic staff to other ambulance services, but also to new roles in the wider NHS unscheduled care system and also outside the NHS;  future demand and workforce requirements will be driven by the ideal response under the New Clinical Response Model; and  we expect to drive a re-profiling of our workforce over the next three years to increase capacity and capability across STEP 2 (Answer my call) and STEP 4 (Give me Treatment) of the New Clinical Response Model.

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Figure 19: Ambulance Demand (999 + Verified Incidents)

The Supply Chain – Paramedic Education Commissioning Paramedic education has gone through significant change since 2008 with the introduction of the Diploma in Paramedic Science at Swansea University. Given the evolving nature of the service and the preparation required to equip paramedics with the knowledge and skills necessary, further change will be required. Paramedics have traditionally been trained to deal with life-threatening conditions; however, this forms only a small part of their work and they are increasingly being called upon to deal with non-life threatening conditions and complete an episode of care or refer on to other staff rather than transport everyone to the local Emergency Department. It is proposed that paramedic education in Wales be extended to a three-year undergraduate degree programme. Although Welsh Government has given no official confirmation, it is expected that this will be supported and confirmed at some point in 2016/17. It is likely that, in the other parts of the UK, this will be introduced at a later date.

With a change from a two-year programme to a three-year programme, there is the risk of a fallow year. To mitigate this risk, the Trust is taking forward discussions with Swansea University, with the support of the Welsh Education Development Service (WEDS) on the following recommendations:

a. the one year EMT conversion programme is continued for the next 5 years (2015-2020) at diploma level. This will enable current EMTs to work within that timescale to progress to a paramedic role; and b. the diploma and degree programmes are run simultaneously for one year (the year the degree is introduced). This would have the effect of ensuring an output of Paramedics each year from the EMT conversion programme and the diploma/degree programme. Critically, there would be no fallow year.

The following tables in Figure 20 demonstrate the required number of paramedics over the five-year period (depending upon when the degree requirement is introduced). Note that current education commissioning numbers have been increased in 2017 to mitigate against the potential for a ‘fallow year’ if degree requirement is introduced in 2017.

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Figure 20: Paramedic Recruitment Plan Original Plan (Introduction of Degree in Amended Plan (Degree in 2017) 2016) Start Output Start Output Diploma Degree Diploma Degree Diploma Degree Diploma Degree 2014 17 2014 17 2015 64 2015 64 2016 32 17 2016 32 32 17 2017 32 32 64 2017 32 64 2018 39 32 2018 39 32 2019 32 2019 32 2020 39 2020 39 Total output over 5 years = 184 Total output over 5 years = 184 In addition to Diploma / Degree candidates, WAST will also be provided with 30 places in September each year on the EMT Conversion Programme, which is an 18 month process - 6 month bridging module and 1 year academic programme, with a March outturn of paramedics. Our assessment indicates that our basic paramedic replacements required to 2019 based on no change to our future skill mix will be just about met based on:

 Current paramedic workforce 765.04 WTE;  Average paramedic turnover circa 48 WTE per annum;  Estimated number of newly trained paramedics required simply to replace average staff turnover (inc Turnover and Internal Promotion) c.186 WTE;  Estimated number of new paramedics coming out of training (including EMT) to 2019 = c205; and  This will result in a narrow surplus by 2019. It should be noted however that this surplus provides a very narrow buffer in terms of supply given potential increases in turnover that could result from increased competition for paramedic and APP staff, and recruitment rates of the student workforce into posts with WAST. In the 2015/16 WAST secured only c.50% of the student outturn, which if repeated would result in a deficit of newly qualified paramedics. This highlights the importance of our recruitment plans, details of which follow further on in this section. Demand and Current / Future Capacity Our demand will be driven by the New Clinical Response Model, which was launched as a 12 month pilot in October 2015. This pilot will be evaluated later in 2016. However, in order to understand what the new response model means for our current configuration of workforce, a detailed analysis of demand and capacity is planned for the first quarter of 2016/17. This exercise will assist us to understand the picture of demand by hour, by day in each area and the ideal response under the new model. It will tell us how many of each type of resource we need by hour and by location if we are going to send the ideal response, and what this means for the number of paramedics, EMTs and UCS staff and CCC clinicians in order to meet our A8 target and provide a safe service. This work will also enable us to model and understand the impact of different scenarios and growth drivers, including demographic changes and changes to Health Board service models. We will be able to model the impact of crewing ambulances with a UCS member or staff and a paramedic, the impact of releasing all Clinical Team Leaders from rosters (whether for 20, 50 or 100% of the time),

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and how many WTE we would need if we were to introduce new roles such as community-based paramedics, critical care paramedics and specialist paramedics. This work is too complex for the analysis tools and skills currently available to us, and we will work with an expert provider (yet to be agreed) to develop our capacity demand and workforce model through April, May and June 2016. As a result, we have not reflected any change to our workforce numbers and skills mix for years two and three at this stage of planning, but expect the detail to be available to us for August / September 2016. We know that, in addition to the implications of the capacity and demand work, there will be other developments over the planning period that are likely to impact on workforce numbers and the cost base of the Trust, for example, linked to the replacement of the Trust’s CAD. The impact of these will need to be modelled and assessed, including consideration and identification of funding sources to support any developments. The numbers in our workforce and finance plans do, however, take account of the following developments described in Section 5:

 development of the 111 Pathfinder in 2016/17 and estimated numbers if rolled out pan Wales in 2017/18 and 2018/19;  development of the NEPTS service, and specifically the need for a more resilient management infrastructure in 2016/17; and  known developments with the CCC as part of its Transformation programme.

Future Workforce Modernisation Opportunities We have referenced at different points in this plan a number of potential future roles and opportunities that the Trust plans to develop and progress over the next three years. These include:  opportunities to collaborate on expanded roles for paramedics across NHS Wales unscheduled care services, GP Out of Hours services and the potential for paramedics to undertake GP home visits and also with education providers;  development of specialist roles such as community-based paramedics in rural areas and critical care paramedics;  reviewing the evidence base and potential benefits of the specialist paramedic role within the Trust;  expanding the expert knowledge base of staff working on the CCC clinical desk by collaborating with Health Boards to extend opportunities to midwives and mental health nurses; and  introduction of consultant paramedic roles into the Trust.

We will be exploring these opportunities in year one of our plan. We will also seek to develop the career pathways for staff using, where appropriate, the College of Paramedics career framework in Figure 21 pictured below.

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Figure 21 We will be exploring the following :  The potential to create ‘ambulance paramedic’ roles suitable for newly qualified staff in the first 5 years of their career;  progression routes for band 5 paramedics into a band 6 role through competency based assessment supported by modular training on, for example, chronic conditions management;  Progression into roles such as specialist and advanced paramedics providing supervision or advanced care; and  Apprentice opportunities for PCS staff and UCS through to paramedic.

Workforce Efficiency and Productivity As we plan and develop our future workforce, we recognise the need to ensure we do not lose focus on opportunities to increase workforce efficiency and productivity. Our main areas of opportunity to reduce variable pay spend and spend on private ambulance providers are:

 Effective resource planning and efficient rostering of resources, with a drive to tackle variability in abstractions and performance  Improving attendance at work, reducing cumulative sickness absence rates by a further 2% over the next three years  Improving the working lives of staff by reducing overruns and improving meal break compliance  Maximising the benefits of a technology enabled workforce  Streamlining recruitment and reducing time to hire

Resource Planning – Efficient Rostering

Over the past 24 months, we have been reviewing existing EMS operational rosters with colleagues and staff side representatives, the purpose being to accommodate changes and developments to staffing levels, growth in demand, changes to the job cycle and re-configuration of hospital services over recent years. The project team worked in partnership to realign rosters to the funded establishment and to predicted demand in order to achieve the best possible fit. The opportunity was also taken to incorporate a set number of training hours and to determine the existing level of variable capacity. This process highlighted a number of issues, which are yet to be addressed:

 some areas are under resourced and have insufficient variable capacity;  unfunded local initiatives which have been introduced over time have resulted in a reduction of planned unit hours; and

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 approach being taken regarding the allocation and management of Clinical Team Leader "protected" time is inconsistent.

These are significant contributing factors to our high reliance on overtime during the 2015/16 period despite a reduction in absence and a general increase in the EMS funded establishment. Our existing rosters provide circa 20% variable cover capacity that varies from 7% to circa 30%. This is low in comparison to the generally accepted best practice for ambulance services, where the benchmark is 34%. Our current abstraction rate is approximately 35 – 40% which excludes hours uncovered because of vacancies or the 3% reduction in available hours as a result of introducing the Learning and Development hours. The deficit in variable cover capacity therefore results in our heavy reliance on overtime to produce a robust level of resourcing and must be addressed as part of our demand and capacity planning exercise.

Action 56: Address the variable relief capacity as part of the capacity and demand work and workforce planning exercise

Going forward, the Roster Review project in its current form will be closed and the Demand and Capacity work will commence. Through this work we will review current working practices to identify opportunities that allow us to increase productivity. These include:

 learning and development hours (CPD) – a review of the current allocation of hours, how these are utilised, what % is currently being utilised, how the unused hours are being recouped by the Trust. We are discussing with our trade union colleagues a proposal to realign a % of existing CPD hours to enable a working shift where ‘on the job’ development and reflective practice with either a CTL or APP can take place. It is important to create opportunity for all clinical staff to reflect on the care they provide to patients. As registrants, it is a requirement under the HCPC fitness to practice guidance that reflection is a facility that all registrants should embrace. There are a number of benefits to being able to critically and clinically evaluate practice for both the practitioner and the patient;  review of CTL position/management time – work is on-going to review the role and management time, recommendations should be available by the end of May 2016;  skill mix of Emergency Ambulance – Review of crew skill mix to identify where we can do more within the same resource envelope;  abstractions – a performance framework will be developed to demonstrate the flow of recruitment into operational hours. This will allow us to understand the implications of high abstraction rates on the workforce and manage them more effectively;  variable relief capacity within rosters where appropriate to further reduce reliance on overtime, and ensuring appropriate control of overtime usage. (flexibility); and  the potential positive benefits of ‘over-recruitment’, and appointment of staff on a more flexible basis on a Health Board or regional pool basis.

The financial impact of some of these proposals has been modelled and is described at section 6.2 of this plan.

Improving Attendance at Work WAST considers reducing sickness absence the number one priority and in 2015/16 we developed a comprehensive Sickness Action Plan to deliver the 1% point target reduction set by Welsh Government and the 2% point stretch target we set ourselves. This internal stretch target was an ambitious target and we have made good progress in reducing absence across the Trust.

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Trust Absence Rates - Effective Date: 31/01/16

We believe there is still more we can do to further reduce sickness absence and we have set ourselves a target of 1% point reduction of the cumulative sickness rate by the 31 March 2017, with a further reduction of 0.5% point to be delivered in 2017/18 and again in 2018/19. A holistic approach to our employee health and well-being is instrumental in being able to deliver against our target reduction and we have described the importance of this agenda earlier. There are further details of some of our wider health and well-being planned actions later in this section. We already have a sickness action plan in place that will be refreshed and rolled over into 2016/17. This plan reflects learning from our own success and that of other organisations including West Midlands Ambulance Service. There are 6 key things that we believe we need to maintain a focus on in 2016/17:

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

In order to deliver a 1% point reduction in our sickness levels, we have modelled the minimum rates of sickness that each LHB area needs to achieve by the end of 2016/17. Progress against the target will be discussed at our monthly Executive Performance Review meetings. Areas that had already reached their target are assumed to remain at the current level and we have reduced other areas based on the percentage required against the current rates to achieve the reduction Action 57: Develop action plan to reduce sickness absence by 1% point by 31st March 2017, and a further 0.5% point in 2017/18 and in 2018/19. Further detail of the financial impact of reducing sickness is described later in this plan.

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Improving the working lives of our staff

In 2016/17 the Operations Directorate’s key objectives are designed to start the process of ensuring staff are supported to begin working in new ways to deliver the benefits the New Clinical Response Model offers. These changes will increase the efficiency of the EMS as well as improving the working lives of staff.

Reducing shift overruns is one of these key priorities.

There are a number of actions to consider, but among the main ones are:

 maximising the contribution of the clinical desk;  increasing the use of HCP referrals by EMS staff. This will reduce overruns caused by conveyance to hospital;  maximising the use of safe, alternative transport solutions by the EMS staff;  developing agreement with Health Board colleagues about the release of crews delayed awaiting handover at shift end; and  tackling variation in conveyance rates.

This will be supported and enabled by:

 using clinical information via the digipen system to allow CTL staff to discuss alternatives to conveyance with colleagues;  our training and education plans to improve access to educational modules which staff can take using their KSF hours which will increase staff confidence in using alternative pathways;  the development of a decision making support app which staff can use to support their clinical decision making; and  ensuring staff feel supported when cases go wrong providing there are good records of decisions made and the rationale behind them.

In addition to these priorities it is vital that staff are given opportunity to take rest breaks during their shifts. In Q1 of 2016/17 we will develop a series of test bed projects with staff and staff representatives to provide local solutions to this issue.

Workforce Enabled Technology We aim to standardise and streamline workforce processes, maximise the potential benefits of the whole ESR system and enhance the quality of workforce information available to managers. ESR is a programme providing a dual payroll and HR package that works together and is integrated as a national system used in the NHS throughout Wales and most of England. The roll out of ESR Manager Self Service is enabling us to ensure that managers are taking the necessary accountability and responsibility for the staff they manage. In order to realise the full benefits of ESR, we will encourage all staff and managers to use ESR. We believe that in doing so, there is the potential to lead to a more engaged, skilled, competent and safe workforce with improved efficiencies, processes and productivity. It is difficult to quantify the financial impact of this at present. However, it will also assist us to be compliant with safety standards, and maintain up-to-date records of appraisal/ PADR, registrations, CRB/DBS, etc. Moving to a fully electronic solution in the future will result in a reduction in waste as we remove paper and duplication. The system also offers the functionality to support talent management processes.

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We will continue our roll out programme throughout 2016/17, with a particular focus on raising awareness and the use of the business intelligence elements of ESR to enable line managers to access comparative management data and reports from their desktops. We have refreshed our project arrangements for the roll out of ESR and associated systems to accelerate implementation. With the recruitment of a dedicated WFIS team, this work will be progressed during 2016/17. This will significantly enhance individuals’ and line managers’ ability to ‘live report’ and provide intelligent data to drive managerial decisions.

This work will be monitored by our local WFIS Programme Board.

In the near future, we expect the introduction of ESR Enhance, which is being developed to meet improvements requirements as determined with user groups and through communications to HR Directors. There are 16 areas for improvement. The first release will introduce a new more intuitive and engaging homepage that provides key information for Self-Service users regarding their compliance with mandatory training and appraisals and their absence record. It will provide far greater accessibility as it will be available through the internet, on mobile devices and via Apps, giving both online and offline capability. Employees will have full or view-only self-service access which includes access to national e-learning, easy access to their payslips and information on training and professional registration. Future developments will cover payroll admin improvements, data management, expenses management, reporting, workforce data, finance, data validation and medical revalidation. Our ability to maximise the true benefits of this depends on accessibility for our staff, particularly those based across Wales in the many ambulance stations we have with limited numbers of computers.

Recruitment Plan We recognise our employees are fundamental to our success. The main aim of the recruitment plan is therefore to ensure we have timely and safe recruitment processes that ensure the right calibre of staff with the appropriate qualifications, skills, experience, competencies and personal qualities to meet both present and future requirements of the Trust.

Promoting the Trust as an employer of choice is also a key objective of this plan, with an emphasis placed on the kind of employment experience the Trust can offer potential candidates and a clear understanding of why people stay within the organisation and are prepared to go the extra mile. This will be our ‘employee value proposition,’ and will be developed over the next few months.

As part of our recruitment campaigns, we want to show potential candidates just how much Wales has to offer as a place to work and live and the benefits of working with us at WAST. We will ensure we link our work to that being undertaking on an all-Wales basis, led by the NHS Wales Directors of Workforce and OD, specifically in relation to developing an ‘NHS Wales Recruitment Brand’.

Action 58: To progress the Trust’s corporate recruitment branding and development of new promotional boards and materials. Action 59: To develop targeted recruitment events and a positive action recruitment plan to increase applications from members of ethnic groups currently under-represented in the workforce.

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In 2015/16, we set ourselves a clear ambition to ensure we have no EMS vacancies by April 2016. Good progress has been made towards this; however, challenges continue to face our EMS workforce and current vacancy projections for April 2016 estimate we will have:

 approximately 7 WTE paramedic vacancies;  an over-establishment of approximately 2 WTE Advanced / Emergency Medical Technicians;  approximately 4 WTE Urgent Care staff vacancies; and  approximately 9 WTE Advanced Paramedic Practitioner vacancies.

Recruitment of Qualified Paramedics Our workforce plan illustrates that, over the course of the three years, we have commissioned sufficient student placements to meet demand for paramedic staff within our current staffing model. However, on an annual basis, demand is likely to exceed supply at different points of the year because of natural turnover. This is at least until October each year when we will see the paramedic degree course student outturn. One of our key aims is to retain the majority (if not all) of those students who train and qualify in Wales, and take swift action to employ them. Recruitment to paramedic posts continues to be a challenge nationally, and action is needed to get us to full establishment and ensure we stay ahead of the recruitment curve. Changes to terms and conditions and changes to paramedic banding in some ambulance services in England also present a recruitment and retention challenge to us.

Over the next three years, we aim to ensure we are able to move to a place where we can confidently make a contingent offer of employment to all HEI students on commencement of their diploma or degree subject to successful completion of their studies and practice placement training. Our ability to do this is dependent upon robust workforce planning. We will work closely with our colleagues in Swansea University over the HEI intake and ensure we maintain close contact and communication with the student cohort at regular points in the year, taking the opportunity to promote the Trust as a great place to work, including our preceptorship programme and clinical support mechanisms.

In the future, we hope to create opportunity for our Practice Placement Manager to sit on student course interviews, which in effect becomes a WAST job interview too.

Action 60: Ensure focus on ongoing recruitment activity to fill vacant posts whilst work in progress to complete the demand / capacity work and future workforce requirements.

Action 61: Continue to develop links with the military careers services and other potential partners.

Advanced Paramedic Practitioners Our workforce planning has also highlighted a growing problem with the retention of Advanced Paramedic Practitioners (APPs), as a result of them leaving to take up posts in Health Boards and universities in 2015/16. Filling the APP vacancies from our existing staff will place an additional drain on our paramedic workforce.

Our current APP educational programmes will deliver the following qualified staff over the next three years: July 2016 – 7 WTE; July 2017 – 13 WTE; July 2018 – 15 WTE. We have commenced work with our APPs and staff representatives to review the APP role and remit as senior clinical leaders, the reporting arrangements and explored how we can systematically support them to meet the four pillars of advanced practice.

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We will take a proactive stance with Health Board colleagues in a prudent approach to identify opportunities to place our APPs, and paramedics at the very heart of the urgent unscheduled care system. This could provide a sustainable solution to some of the challenges facing Health Boards, and an important opportunity for APPs to diversify in their practice by rotating across EMS, primary and other community-based areas of care, thereby supporting CPD and potentially addressing retention issues.

Action 62: Review the number of APPs in training for future years, scope proposal to develop workforce modelling tool with WEDS to facilitate this action.

Action 63: Progress proposal for the development of a structured approach for newly qualified APP’s to make the transition from novice to expert.

At present, we do not experience or foresee any future difficulties in recruiting to our Advanced / Emergency Medical Technician, Urgent Care, Call Taker, Patient Care Services or nursing workforce. Recent recruitment of call takers and nurses to NHS Direct Wales in advance of the 111 Pathfinder was successful. However, this does have a potentially negative impact on Health Boards losing qualified nursing staff to WAST. As the Pathfinder progresses, we will need to consider the broader impact of 111 recruitment activities.

Reducing Time to Hire In 2015/16 our recruitment task and finish group was tasked to identify opportunities to streamline recruitment processes, reduce time to hire and ensuring safe hire of new staff. The group has supported the work to confirm vacancy requirements and successfully developed a recruitment plan aligned to a training plan. This group also facilitated a process mapping workshop to identify opportunities to streamline recruitment processes, organised targeted recruitment training sessions (supported by NWSSP), introduced a recruitment link advisor role into the WOD structure and piloted a new approach to bulk recruitment, a “One Stop Shop” approach for Paramedic, EMT and UCS. As a result there has been a significant improvement on the average time to recruit – and an improving downward trend shown in the table below, which compares performance in December 2014 and then 2015, and January 2015 and then 2016. Average time to recruit (in days)

Date All Wales average WAST

December 2014 69.9 119.4

December 2015 65.2 90

Date All Wales average WAST

January 2015 83.2 169

January 2016 70.5 82.8

However, we believe there is more we can do to further reduce time to hire, particularly by reviewing the process map and targeting constraints experienced within our Occupational Health service.

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Action 64: To work in partnership with NWSSP and Occupational Health to review the recruitment process map to identify opportunities to further reduce time to hire to achieve the average all Wales target. There are a number of risks and sensitivities within the Trust’s workforce plan which we continue to work to mitigate. These are described further in section 7.3.

Education, Training and Development of Our People

Rising unscheduled care demand for individuals with long term conditions has been identified as a major challenge for the NHS in Wales, resulting in a call for more care to be delivered closer to home in an out-of-hospital community setting. Redesigning new clinical roles and patient pathways, driving up the quality of clinical care and decision-making is taking on an increasing importance and presents a challenge and opportunity for the Trust.

Ambulance education is also evolving in terms of developments to degree level education (registrant – Paramedic) and a change to the accrediting body (pre-registrant education - EMT). Additionally, there are imminent legislative and accrediting body changes in relation to driver education.

The importance of ensuring effective high quality clinical leadership, education and development therefore cannot be understated and remains a key priority for us in 2016/17 and beyond. We recognise that, to safely and effectively clinically modernise service delivery and implement programmes of change, we need to ensure any improvements predicted by these initiatives are fully supported by an informed, innovative and professional clinical workforce. Clinical leadership in this context is best facilitated by those clinicians who deliver patient care so they can positively support and influence others to change whilst continually improving the quality of care delivered.

National Ambulance Training College (NATC) Training and education for the bulk of our staff is delivered through our National Ambulance Training College (NATC). To support the education and development of our staff, it is imperative that we work with our partners such as Swansea University to ensure we have an education function that is ‘future-proof’ and clinically excellent, through which we can deliver the range of education and learning interventions required in light of the changing educational models and increasing clinical standards. We are considering the potential for a consultant paramedic post within our Training and Education team to lead development of a training and education strategy, in response to the changing educational requirements of the New Clinical Response Model and demographic drivers. This would also support us to ensure we create a fit for purpose collaborative HEI curriculum and readiness for introduction of a Paramedic Science degree programme requirements for all new paramedics. Action 65: Scope the proposal to create a consultant paramedic role with a lead for clinical training and education The NATC provides leadership to all educational programmes to equip Ambulance Service personnel with the essential knowledge, skills and behaviours to allow them to respond safely and deliver evidence-based high quality, safe care to our patients. With growing expectation placed upon the delivery of pre-hospital care, there has been a commitment to develop and deliver expanding educational and training programmes to meet the continued education and development needs of the Trust and its staff. NATC also provides induction and CPD for all clinical and non-

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clinical staff in-house, through our National Ambulance Training College facilities in Swansea and associated regional training centres, which are IHCD and Future Quals accredited. At present, the NATC Team consists of 11 Learning & Development Managers, who cater for the educational needs of circa 2,500 members of staff. A benchmarking exercise against other UK ambulance trusts has identified a deficit in terms of existing tutor: student ratio, and goes some way to understanding some of the constraints in capacity to deliver training courses to meet ad hoc demand experience. This exercise points to a requirement for an additional circa 13 Learning & Development Managers to match national ratios. Over the next three years, we will be working with colleagues in the Clinical Directorate and National Ambulance Training Centre to address capacity constraints and ensure our education, training and development facilities and programmes are fit for future purpose. Future estates changes also indicate that Central and West Headquarters at our Cefn Coed site (National Ambulance Training College) will be required to relocate by 2018. Our ambition is to develop our National Ambulance Training College into a flagship training facility, recognised as a centre of excellence with state of the art training facilities by 2019. During 2016/17, we will scope and develop a business case and plan that will seek to address the capacity constraints, estate challenge and opportunities presented by technology, ensuring we also seek collaborative solutions with partners such as Swansea University. Action 66: Develop the business case and plan for the transformation of the NATC

The NATC continues to progress its proposals for the provision of a Virtual Learning Environment for staff and a fully functional and effective e-learning platform that will provide students and tutors with state of the art, innovative learning and reference materials and tools. A business case for the purchase of tablet devices has been approved for 2016/17, which will not only improve the learning experience for students and lead the way in terms of ambulance education, but will also reduce costs associated with purchase and issue of key reading materials for WAST education programmes. These technological advances will ensure WAST is equipped to embed the principles of the NHS Wales Technology Enabled Learning (TEL) strategy. Action 67: Develop eLearning portfolio for all WAST staff Action 68: Introduce bespoke eLearning platform for Driver Education Action 69: Expand and develop bespoke eLearning platform to include clinical education The NHS Direct Wales Practice and Service Development Team also works independently to provide education, training and professional development for all disciplines of NHSDW Clinical Contact Centre staff, as well as in collaboration with the NATC to schedule programmes of mandatory and statutory training through the Team’s annual CPD plan. Continuing Professional Development We have already touched on the opportunity for the Trust to make a significant contribution to patient flow across the unscheduled care system, and that demand for ambulance clinicians and managers to take highly complex decisions on patient care and management is increasing. It is therefore imperative that any future CPD programmes address the professional, legal and ethical dimensions of decision-making, including duty of care, to ensure the Trust delivers safe and effective patient-centred clinical services.

Embracing the notion of a shared ‘decision making framework’ for both clinicians and operational managers, the Trust’s CPD programmes must be aimed at increasing clinician confidence in

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professional reasoning, increasing their influencing and negotiating skills and foster individual and team understanding of collaborative practice and how clinical decisions are effectively communicated. Central to this approach will be to enable clinicians and managers to reflect ‘in’ and ‘on’ both clinical and managerial practice using a recognised model to achieve safe and effective care. The subject matter of CPD will be informed by lessons learnt from SAIs, research and audit, changes to clinical practice guidelines and will be informed by trends and themes recorded in staff PADRs, for all staff groups.

Our workforce has a fantastic appetite for learning. The Workforce Development Team has recently devised a ‘Voluntary CPD Programme’ that will be rolled out from 1 April 2016. These sessions will be delivered by our operational tutors across the country and will cover a range of topics.

It is also planned to introduce a modular approach to training and education for the development of the existing paramedic workforce. This requires consideration of available HEI modules pan Wales and identification of supporting funding streams (WEDS). It is anticipated that this will enhance skills such as chronic disease management and clinical decision-making.

We have revised our Study Leave Policy to ensure managers can provide equitable support to all staff groups who wish to undertake formalised education and development. In addition to this, there are various funding streams available to our staff to support specific career development e.g. Bespoke EMT to Paramedic Conversion programme, MSc in Advanced Practice (for both paramedic and nurse registrants), NVQ and vocational funding for all staff groups e.g. ILM, NVQs. In 2016, we will also launch a new Staff Bursary Scheme to create opportunity for staff to apply for financial support for their professional research and / or development. However, there is a need to consider a centralised training budget within the Trust to further support all staff development opportunities, and this will be considered as part of our budget setting discussions. Based upon internal evaluation and external quality assurance mechanisms, the NHSDW Team delivers high quality education in the classroom setting, as well as developing excellence in the clinical practice environment, through coaching and performance support activities. Induction courses for all disciplines of call-taking staff are academically accredited. Additionally, the Team developed an accredited mentorship course for HCSW level staff, which has now been rolled out across other areas of the Trust by the NATC. Currently, the Team is working alongside external experts to develop a series of e-learning modules to support mental health learning for all CCC staff on the Learning@NHSWales platform. The Team’s approach to NHSDW induction and CPD activities strives to equip staff with excellence in their practical skills, with an underpinning emphasis upon compassion, respect and dignity for patients and callers and a sound understanding of prudent healthcare principles. These elements of clinical practice are run as themes through all learning.

The Team works closely with operational colleagues to ensure that NHSDW appropriately invests in workplace and HEI education and training. Our strategy provides staff with an opportunity to constantly evaluate their practice against evidence based healthcare guidelines and research. This approach evolves alongside developments in the sphere of adult education by identifying opportunities to innovatively embed supported, self-directed learning for our staff. By taking this approach, we aim to teach our staff how to learn independently, as well as providing them with new skills and knowledge.

Action 70: Compilation of an extensive CPD directory for all staff groups with regard to learning and funding opportunities and a CPD Programme that reflects current and future

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changes to clinical practice, learning from adverse incidents and development needs identified through the PADR process

Action 71: Benchmark skills development for existing, vocationally trained paramedic staff e.g. commissioning of HEI educational modules We currently receive funding from the Workforce, Education & Development Services (WEDS) on an annual basis, for the release and backfill (single time) of Paramedic staff to attend annual CPD refresher training. This funding is accounted for by the Trust’s Finance Department as income for the year and as such, there are significant financial, as well as patient safety and legislative implications if the Trust does not ensure that every paramedic attends the annual refresher programme. Action 72: Seek support to create an appropriate education and development budget to support staff in achieving their professional development needs. The following chart (Figure 22) illustrates Trust-wide CPD Compliance by directorate and discipline as at 31st January 2016: Figure 22: Trust Wide CPD Compliance

Attendance at CPD sessions is reported on a monthly basis and shared with relevant managers, with a regular review by the Senior Management Team (SMT) and Executive Management Team (EMT). Statutory and Mandatory Training Completion of statutory and mandatory training is a legal requirement of every member of staff and the importance of this cannot be overstated. Failure to comply with Statutory& Mandatory training requirements could pose a significant risk to the Trust with regard to patient safety, litigation, legislative requirements, staff competence and confidence. We have identified a number of constraints affecting compliance rates, including reluctance of staff and managers to adhere to the agreed KSF Hours CPD allocation process and restrictions on staff release because of operational demands. The statutory and mandatory training programme for corporate areas has been rolled out via eLearning across the Trust for the last two years. Significant focus is being paid to improving compliance rates for this group of staff, with key performance figures shared with managers on a regular basis.

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The WD Team plans and delivers all statutory and mandatory training requirements for NHSDW and CCC staff, in conjunction with the Quality and Nursing Directorate. The remit for systems and clinical updates for this group of staff remain with the respective Heads of Operations. At present, we are unable to report against our statutory and mandatory training compliance targets because of system difficulties in the set-up of ESR and OLM. This is currently under review to re- establish the link and ensure we can implement reporting and monitoring arrangements. Action 73: Work with the operations teams to improve CPD and Statutory Mandatory Training Compliance to ensure targets are met Action 74: Strengthen the link role of Learning & Development Managers with Operational teams to discuss compliance at locality level during briefings Action 75: Maximise use of the business intelligence reporting mechanism of OLM. HCSW Framework & Development Needs The Trust has appointed a project lead and small team, sponsored by WEDS, to fully implement and integrate the Framework and its associated agenda in WAST. This is being driven through WEDG and consists of three phases delivered over three years, to ensure compliance by the mandated deadline of 2018. Post year one, consideration will need to be given to acquisition of funding for the continuation of this team. Action 76: Progress the WEDG HCSW Development Agenda workstream.

Action 77: Develop apprenticeship opportunities within WAST in line with Government mandate and to mirror best practice in other UK ambulance Trusts

Organisational Development Plan We are part way into a longer term OD plan that started several years ago to transform the Trust. So far we have redesigned the structure of the Trust, developed overarching principles/approaches and focused on leadership behaviours to help the transformation. In this time, we have seen a change to the Executive Team and Board members, and many new faces join the Trust. This has brought fresh thinking, new ideas and a new drive for culture change across the organisation. Our Approach to OD The underpinning principles are based on the very best practices and NHS Wales policies (e.g. Prudent Healthcare). They are:  use evidence-based approaches: e.g. neuro-science, psychology, team-based working etc.;  “power is where decisions are made”; the safest and highest quality decisions are made by those close to the issues; limited number of core parameters with as much choice for individuals/teams as possible;  the Trust needs to rebalance quantity and quality so overt focus on behaviours;  transformation requires disruption by breaking the norm; and  continuously reinforce.

The Francis Report (2013) highlighted the importance of setting and embedding a culture of openness, candour and good care as fundamental to the delivery of high quality safe services to our

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population. For WAST, this is set out in Being Our Best, which clearly articulates the actions we believe are needed to achieve the transformational change required to deliver both the outcomes of the Francis report and the Trusted to Care report to support the step change in culture, systems and leadership we need. There is an increasing knowledge base about effective OD, with NHS Employers suggesting that there are High Impact Changes that organisations need to focus on to deliver great services. These are intertwined throughout Being Our Best as they focus on: developing local evidence-based solutions; trusting and empowering visible leadership at all levels; sufficient management capacity and capability; excellent health and well-being support services; colleagues having as much personal responsibility as possible.

Our Approach to Colleague Participation, Engagement & Empowerment Why this is essential for WAST:  patient safety is determined by how engaged people are in their work (West);  clinician behaviour determines quality of care; this is underpinned by how they feel about work;  community/primary care is the unknown: clinicians can only give their best healthcare if they are trusted to do their best within as loose parameters as possible; and  high levels of participation and engagement lead to less conflict and, therefore, a more productive workplace.

Our Evidence-Based Principles:

 “power is where decisions are made”: the best decisions are made closest to the issue;  we each need as much as choice as possible about what we do and how we do it;  we each need to be very clear and know what we’re trying to achieve and how we need to do it;  listening is the single most dignified thing that someone can do; dignity builds respect with respect building trust;  many colleagues work remotely and have little contact with each other; human relationships and interactions create warmth and belonging, so every opportunity needs to be taken to get people together and build relationships to strengthen belonging;  strong employee engagement is a positive indicator for employee well-being and will have a positive impact on our sickness absence rates.

The OD challenge and opportunity for leadership is to lead, model and support a move from processes to people. This will be done through:

 taking every opportunity to have clear parameters (outcomes and rules) and encouraging colleagues to be themselves so that they fully participate and own their actions and behaviours;  taking every opportunity to support every individual and team to develop their OD capacity so that they can do the right things in the right way; and  creating Trust-wide systems, processes and approaches to help individuals and teams to perform to their best.

During 2016-17, we will implement our action plan to assist colleagues to understand and live the shared behaviours, vision and purpose including selection processes, PADRs, team meetings, performance frameworks, award systems and Board focus. This action plan is described in Section 3 of this document.

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During 2017-18, we will take the opportunity to review the impact of our approaches as well as reviewing the shared behaviours. We will collaboratively update the behaviours and approaches as appropriate. Action 78: To develop an appropriate evaluation framework and mechanism to enable assessment of the impact of communicating shared behaviours and culture change How we help people to be involved, participate and take real ownership Welcoming New Colleagues

All colleagues should expect to be warmly welcomed into the Trust both corporately and locally with their team. Both welcomes should emphasise the importance of each individual being their unique best within the Trust/local parameters. In 2015/16, 71% of new starters were released to attend our colleague welcome days. We aim to ensure 100% of all new starters receive an induction to the Trust. We will support all teams and managers to understand the importance of welcoming new colleagues and the focus on recognising their unique individuality.

Action 79: Review local induction arrangements to ensure the Trust’s expectations of shared behaviours are reinforced and 100% of new starters receive induction.

Personal Appraisal and Development Reviews Every member of staff has a right to receive an annual appraisal, and we have been working hard to ensure robust measures are in place to monitor and report Personnel Annual Development Review (PADR) compliance on a monthly basis. In 2015/16, we set a challenging target of 85% compliance by 31st March 2016. Significant improvement has been made since early 2015 when reported rate on ESR was less than 10%. As at 1st March 2016, we are reporting a completion rate of nearly 60%.

Our focus during 2015/16 has been to ensure that not only do we achieve our compliance target, but that the quality of the PADR is also improved. There has been significant focus on supporting colleagues with both the quality and quantity of PADRs as ‘career conversations’ and this work will continue in 2016/17. The work to continue improvement in this area includes:

 supporting Team Leaders and Middle Managers with understanding their role and developing their skills and behaviours. This has included listening skills and using appreciative inquiry;  supporting colleagues to want to participate and take ownership of their PADR. This has included a “marketing” plan; and  using pulse surveys to review the quality of PADRs and testing “user-friendly” ways of inputting PADR information onto ESR, including the production of a video for managers. The feedback from many colleagues is that currently PADRs have not been of sufficiently high quality to be beneficial, as the balance has been on managing performance rather than being supportive.

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Therefore, the Trust will focus its actions on developing improved qualitative approaches during the course of the IMTP.

As a result of both improved quantity and quality of relationship and focus, individuals will become more engaged, increasingly effective in delivering appropriate patient care and will experience and encourage high levels of trust with patients and colleagues. These will be measured through a range of measures including quantitative and qualitative patient and colleague experience measures (e.g. pulse surveys, patient outcomes, patient stories, accolades/complaints). Further evaluation of this will be undertaken following the staff survey in 2016.

Action 80: Achieve a PADR target of 85% by 31st March 2017 through vigorous focus on the importance, quality and quantity of PADRs with managers and their team members. Pulse/Staff Surveys

Giving and receiving feedback provides a common theme throughout our IMTP. In order to improve, it is essential to know how we are doing. The knowledge gained from the feedback helps us make better decisions. The act of taking part in surveys, receiving and using immediate feedback and being part of making decisions about improvements are known to be an excellent way of improving participation and ownership. Importantly, the evidence-based actions will become integral to each team’s Local Delivery Plans and not stand-alone actions. To help improve our knowledge of colleagues’ experiences of the workplace, we have used a series of pulse surveys so that the information can be used to inform groups, teams and individuals to make decisions with a better understanding of their colleagues’ perspectives. Additionally, we have actively encouraged groups and teams to run their own surveys. Preparations are being made for the roll-out of the next NHS Wales Staff Survey in June 2016. We will work in partnership with TU colleagues to help raise participation and engagement levels through supporting colleagues to actively take part. We aim to improve on the participation rates from the baseline of 30% in 2013 to 50% in 2016. During 2016-17, we will:

Action 81: Work in partnership with TU colleagues to use the data from the survey to help support development of local and organisational action plans as part of each team’s LDP. Action 82: Implement a monthly pulse survey using the engagement index to provide ongoing assessment During 2017-19, we will:

Action 83: Implement a system to provide real time feedback on colleagues’ experiences of work; this will provide information to enable proactive decisions to be made to improve day to day experiences of the workplace, linked to annual PADR

Team and Identity We recognise how important it is for our staff to know and feel connected to their closest work colleagues. For most of us, this takes place within a team setting. We will continue to ensure that every team has sufficient time to understand, plan and deliver its requirements, including making sure that the team focuses on its own development. Action 84: Support leaders and develop systems to value team meetings, and apply principles of team development to achieve improved team performance and success. Staff Appreciation and Recognition

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We have collaboratively developed a shared vision, purpose and set of behaviours. Along with the annual priorities, these will be widely publicised to support colleagues. In particular, the Trust will reward and award colleagues who live the behaviours as these will be accessible and within the circle of control for every colleague.

Highlighting and rewarding excellence is an important way of reinforcing the actions and behaviours we expect from colleagues. As we have collaboratively developed a shared vision, purpose and set of behaviours and these are a crucial focus for us because they are measurable, they will be the focus for our Staff Appreciation Awards.

Other actions that we will actively model and encourage are:

 always find a positive first; smile (it’s contagious); say “thank you”; give someone a thank you note;  use Twitter and Siren to publish a “kudos” or ‘thank you’ column;  recognise people who show initiative by creating opportunities for them to get involved with or lead specific projects or pieces of work as part of development;  arrange for teams or individuals to present their ideas or the results of their efforts to others at learning events, team meetings and the Executive Team and create colleague story boards;  senior leaders (Heads of Operations, Execs etc) to meet colleagues in person to thank individuals and teams;  write a letter of praise recognising specific contributions and achievements; send a copy to senior management and the employee’s personnel file;  share positive feedback with an individual when you hear something positive about them as soon as possible (face-to-face is best); create and share your own positives about someone with others;  create a ‘hall of fame’ wall with photos of outstanding employees in reception at VPH but also at stations;  develop a colleague of the month scheme in directorates (e.g. Health Board level) based on feedback from colleagues and the public; and  create an employee recognition event to publically celebrate success and achievements.

Therefore, our key action for 2016-17 is to:

Action 85: Review and expand our opportunities to recognise staff for their broader contribution, celebrate success and recognise excellence through development of our ‘Appreciating our People’ Awards Ceremony Mentors and Coaches

Helping each colleague understand the choices that they have in their work can be a vital role for a coach or mentor. We will continue to actively support all colleagues to access a coach or mentor (either from within WAST or from the broader public services). Colleagues can also expect to access internal or external mentoring support via their manager or teams to help coach them but also provide appropriate advice.

Action 86: Build links with partners across the public sector with a renewed focus on supporting colleagues to “ask and listen” including refreshing the coaching and mentoring plan to ensure everyone can access coaching and mentoring and there is sufficient capacity.

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Personal Development

Research-based evidence of levels of engagement within UK healthcare highlights the importance of developmental development – i.e. development that is over and above the requirements to meet the job. This is highlighted as the second most important factor in determining engagement and participation levels. Therefore, the Trust corporately, and each manager, should always support individuals to develop to know and achieve their ambition so that they achieve their full potential.

Action 87: Develop the Trust’s approach to succession planning, career planning and career pathways from April 2016 with an ongoing focus of supporting individuals to fulfil their potential. Management and Leadership Development

The relationship each of us has with our manager is the single biggest determinant as to how we feel about work and, therefore, our levels of engagement and participation. Many of the approaches identified in this IMTP rest on good leadership and management practices. In particular, the ability to ‘actively listen’ has not been a visible part of the management culture. Therefore, a key part of our approach to supporting colleagues to be involved and participate is developing managers and leaders with their knowledge, skills, behaviours and, above all, beliefs.

Action 88: Create and market leadership development opportunities through the development of a prospectus for all staff Action 89: Develop and implement a management passport to support managers to have appropriate capability and confidence to manage their teams and services. Action 90: Undertake a review of where decisions are made across the Trust and the impact of these; highlight adverse consequences and implement system changes to improve its organisational effectiveness

Driving Forward Clinical Leadership

Driving forward clinical leadership across the Trust is a vital part of our overall leadership development plan. Traditionally, within the ambulance service, clinical leadership has been seen to come from senior clinicians with management responsibility i.e. Medical, Paramedic and Nursing Directors. More recently, however, the increasing levels of clinical decision-making responsibility that ambulance clinicians are asked to take when assessing and managing patients at home, suggests there is a far greater need for clinical leadership through all levels of the service.

Our Clinical Leadership Development Plan will ensure an appropriate structure is in place to encourage clinical leadership throughout WAST, made more important because of increasing levels of clinical decision-making at the patient interface. We have already made progress towards improving clinical leadership within the Trust – reviewing the importance of the Advanced Paramedic Practitioner role, proposing a clinical leadership structure and also taking steps to improve access to clinical supervision.

We aim to further support and challenge all clinicians to understand and develop their own and others’ clinical practice. This will be based on a range of indicators, evidence and feedback across multi-professional teams and groups. Additionally, existing and potential clinical team leaders will also need to be developed in the underpinning theories of leadership and management of change within the clinical practice setting. We will do this through the development and implementation of

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action learning workshops across the Trust, to facilitate a greater understanding of clinical leadership across a wider range of clinical disciplines, grades and groups in the Trust. Executive and Board Development

A programme of development for the Executive Team has been established to explore and develop how this new team is going to provide leadership for the Trust. The sessions have included the opportunity to explore what type of Director is required and to open up discussions regarding Director portfolios.

A team profile has been produced using Myers Briggs Type Inventory (MBTI) and Thomas – Kilmann Conflict Mode Tool (TK); although neither of these tools was new to the Executive Team, the production of the team profile has proved helpful to explore in the context of:

 MBTI: the impact preferences and behaviours can have on team effectiveness.  TK: an indication of individual’s preferences for dealing with conflict and the effectiveness and appropriateness of the use of each.

Further development sessions, including some joint sessions with the Heads of Operations, on a quarterly basis are scheduled for the next 18 months. This will further strengthen the team to provide effective leadership for the Trust. An integral part of the Executive Team development to date has been the development of an Executive Team Charter as a statement of intent and commitment to a set of behaviours and operating principles in their interactions as a team, and also their leadership and management of the Trust.

A Board Development Programme has also been established, to support the Board in understanding its accountabilities, and also to develop as a team together. A series of ‘two at the top’ development sessions have been run for the Chair and Chief Executive, and will now be run for individual pairings of Director and Non-Executive Directors with common portfolios.

Effective Partnerships

Working collaboratively for the greater good is at the heart of the Trust’s redesign. The evidence of the “wisdom of crowds”, “nothing about me without me” and that “two heads are better than one” underpin the Prudent Healthcare principles. Involving everyone in developing the future and making decisions about how to get there not only prevents avoidable conflict but it promotes ownership. Where people own things, they are significantly more likely to happen.

Our external partnerships have flourished through realigning our management structures with partner organisations (particularly Health Boards). This has enabled collaborative teams to identify local issues and create local solutions to meet local needs. These partnerships need further support and development as together teams understand the needs of local communities and plan and deliver services to meet these.

Internally, we will continue to support colleagues to understand the importance of trusting each other, collaboration and working together. This is at all levels of the Trust and includes the relationship between managers and their teams, within teams and across teams (both internal and external). We have seen significant improvements with our partnership working between trade union representatives and managers through our Go Together Go Far programme. During 2016-19, the ongoing actions we will take are:

Action 91: Develop planned activities that support individuals and teams to understand the benefits of trusting each other and working together; support individuals to develop their partnership capabilities including skills and approaches through our leadership development plans

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Action 92: Support and encourage individuals and local teams to develop relationships across the Public Services in Wales Health and Well-being

Our continuing commitment to improving the health and well-being of all our staff has been described earlier in this section. In terms of our plans for this, in 2016/17 we will continue our efforts to embed employee health and well-being into the culture of the organisation by ensuring a robust action plan and that appropriate systems and processes are in place to encourage and enable staff to be responsible for their own well-being.

Our overall aim is to achieve Gold Corporate Health Standard status by the end of 2016, and Platinum by 2018. An action plan is in place to support the ambition to achieve Gold status. The Trust has refreshed and re-launched its Health and Well-being Steering Group, chaired by the Director of Workforce and OD, and a full range of actions are planned to develop our services to staff. We will also ensure we make links to work ongoing at an all Wales level, led by the NHS Wales Directors of Workforce and OD.

In 2016/17, our primary focus will be on supporting good mental health and the management of pressure.

 We will work with partners to seek ways to reduce mental health stigma in the workplace, building a proposal to introduce a system of psychological assessment of risk programme (TRiM), roll out of Mental Health First Aid training and developing a focused stress recognition and awareness training programme. We will also roll out across the Trust o the ‘Looking after your Well-being and Managing Stress’ leaflets.

 We will champion lifestyle improvements through the promotion of workplace challenges and team events and promotion of healthy options i.e. mindfulness, standing desks, take the stairs campaign etc.

 We plan to further develop our in-house health-screening services to incorporate night workers screening, bi-annual health screening and voluntary health checks.

 Our flu vaccination programme failed to deliver the expected levels of frontline staff vaccinations to meet the Welsh Government target in 2015/16. We therefore plan to review our delivery plan and capacity, with a view to commencing our planning at a much earlier stage of the year in 2016.

 We will continue to develop proposals for staff benefits which include the launch of car lease and computer salary sacrifice schemes alongside, cycle scheme, and childcare vouchers.

Action 93: We will sign the Welsh Government ‘Time to Change Wales’ campaign pledge in April/ May 2016 Action 94: Pending successful achievement of Gold status, prepare action plan to help us gain the Corporate Health Standard Platinum accreditation

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6.2 Our Finances

Overview

WAST has recently implemented a number of service developments that are focused on delivering the best outcomes for patients and improving performance. At this stage, some of these developments have been introduced on a pilot basis. The full service, activity, performance and subsequent financial impact of these significant developments will continue to be assessed and refined in line with emerging evidence and evaluation and, where appropriate, factored into the financial plan. The implementation of the New Clinical Response Model is very likely to have a significant impact on the resources required to deliver the service. There will be a fundamental review of the skill mix of staff required to maximise the benefit of the new model along with the potential change in fleet requirements. Similarly, there are further key service developments planned for implementation over the immediate and medium term that will increase productivity and efficiency and enhance services. On top of this, WAST has been selected as the host provider for the 111 pathfinder project. A strategic approach has been taken to the development of a Medium Term Financial Plan that will address both immediate financial requirements, but will also need to remain flexible to adapt to service change. As part of this approach it is vital that the effects of service change and the resultant financial impacts are considered at a system wide level and that resource and investment plans reflect the principles that underpin prudent healthcare. This includes working in conjunction with the Trust’s commissioners. Similarly, there is a drive to further increase efficiency, to ensure value for money and to maximise the benefits of the resources available. This will be a key focus in the IMTP, with the scrutiny of costs and financial governance central to the delivery of our vision for a caring and responsive ambulance service for people in Wales. To achieve this, we will work both internally within the organisation to ensure that there is cohesion between financial, workforce and service planning to support decision making and to optimise service delivery and also with our partners, including the Chief Ambulance Services Commissioner (CASC) and the Emergency Ambulance Services Committee (EASC). This will include exploring opportunities for further collaborative working, such as estates, but also the potential to establish joint posts that could provide both financial and service benefits across health and emergency service partners. Whilst the Integrated Medium Term Plan looks forward over the next three years, it is evident that, for WAST, there are a number of significant service changes which will impact during this period. This financial plan is being developed based on a number of current assumptions, but also recognises the need for a level of agility to be able to respond to service change. The finance resources have been modelled on the basis of current performance targets, no change to the targets have been accounted for. The sensitivity of our plan to any changes will be scenario tested via the demand and capacity work.

Similarly, we have assumed that where Local Health Boards make major service changes, the impact on our services (emergency or non emergency) will be fully resourced via their business case mechanisms and routed through the commissioning arrangements

The current revenue financial position – 2015/16 At the end of February (month 11), the Trust continues to forecast a small surplus (£0.150m) for the financial year 2015/16. This position is inclusive of additional planned costs associated with specific actions agreed to increase operational capacity, which have delivered performance improvements

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in 2015/16, and have enabled schemes such as the Cwm Taf Explorer pilot. Additional non- recurring income of £3.5m has been provided by Welsh Government to offset these costs. On this basis, the Trust is on target to meet each of the statutory financial duties in 2015/16. Figure 23 below presents a summary of the Trust’s financial position for the year to date at 29 February and the forecast year end outturn for 2015/16. Figure 23: Financial Position at 29th February 2016 Plan Actual Variance Annual Annual Annual Financial position at 29 February 2016 YTD YTD YTD Plan Forecast Variance £000s £000s £000s £000s £000s £000s INCOME Welsh NHS Local Health Boards 16,273 16,317 44 17,756 19,161 1,405 Welsh NHS Trusts 728 729 1 794 811 17 WHSSC 116,987 117,037 50 128,066 129,384 1,318 Welsh Government 787 4,019 3,232 4,281 4,281 0 English NHS Organisations 174 199 25 190 217 27 Other Operating income 2,666 2,775 109 2,905 3,027 122 Other Income 6,200 6,950 750 3,046 4,624 1,578 Total Income 143,815 148,026 4,211 157,038 161,505 4,467 EXPENDITURE Pay - Sub Total 102,615 104,877 2,262 111,806 114,449 2,643 Non Pay - sub total 29,624 31,310 1,686 32,535 34,181 1,646 Total Expenditure 132,239 136,187 3,948 144,341 148,630 4,289 Non allocated contingency 118 0 -118 283 0 -283 Unidentified Savings target -131 0 131 -173 0 173 Profit / Loss on asset disposal -217 -87 130 -237 -87 150 DEL - Depreciation, Accelerated Depreciation & Impairments 11,008 11,008 0 12,009 12,009 0 AME - Depreciation & Impairments 606 606 0 606 606 0 Total Interest Receivable -29 -35 -6 -32 -37 -5 Total Interest Payable 221 214 -7 241 234 -7 Net Surplus / (Deficit) 0 133 133 0 150 150

It is anticipated that to maintain capacity and performance improvement, elements of the planned additional costs in relation to EMS will continue into 2016/17. This is an assumption that has been fully recognised by the commissioners.

Future year revenue financial planning assumptions

WAST receives the vast majority (more than 80%) of its income through a commissioning arrangement, led by the Chief Ambulance Services Commissioner, who acts on behalf of all Welsh Health Boards on the commissioning of Emergency Ambulance Services. This arrangement is conducted through the Emergency Ambulance Services Committee (EASC), which is responsible

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for developing collective commissioning intentions and plans. Welsh Government incorporates funding for ambulance services as part of the allocations made to NHS organisations. It is expected that national, NHS-wide, planning assumptions, including funding uplifts, will be equally relevant to commissioning agreements and financial plans for WAST have been developed on this basis. The key financial assumptions within the Trust’s three-year financial plan are:  National position The UK Government spending review announced an increase in NHS revenue expenditure over the next five years. The Welsh Government draft budget similarly provided for an increase in 2016/17. The headline figures indicate plans for an additional £293.5m for the NHS in Wales.

This increase is against the 2015/16 baseline and consists of £260m revenue to support:  core NHS delivery £200m;  intermediate Care Fund £30m;  older people and mental health services £30m; plus  an additional £33.5m capital.

Of the additional £260m revenue funding, £60m is targeted to specific programme areas. The increase of £200m to core NHS delivery represents an increase of 3.2% on health budgets.

WHC (2015) 059 provides detail in relation to the initial 2016/17 Health Board Revenue Allocations and whist the allocations at this stage are incomplete in that they do not include the £200m additional funding, it is indicated that for planning purposes that this funding will be available to support the costs of inflation and other cost pressures, by way of the following paragraph: “For planning purposes Health Boards can plan on the basis that the £200 million funding will be allocated to NHS organisations to meet these pressures, including the costs of 2016/17 pay awards, and will be distributed primarily using population shares.” It is assumed that once this uplift is reflected in LHB Allocations, there will be a corresponding increase to the commissioning agreements with WAST. For 2016/17, a “fair share” of this £200m has been estimated at £5m within the Trust’s financial plan, and this IMTP therefore. Similarly assumptions have been made in relation to the levels of uplift to be applied for 2017/18 and 2018/19 and that these will be applied on a fair shares basis across all NHS organisations in Wales. On this basis the expected share for the Trust has been estimated based on a 3.2% uplift in 2016/17 providing for a fair share of the £200m additional NHS core funding of £5.0m, and for the years 2017/18 and 2018/19 uplifts of £4.0m and £4.5m respectively.

 Inflation and unavoidable costs Figure 24 below presents the costs that have been calculated demonstrating how inflation is likely to impact on the current cost base and which have been provided by WAST as part of national modelling work.

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Figure 24: Inflationary Pressures

Inflationary Pressures 2016/17 2017/18 2018/19 £m £m £m Pay 1% Pay award 1.16 1.17 1.18 Cost of increments 1.25 1.41 1.27 National Insurance and Pensions – Impact of 2.00 0.27 0.27 contracting out arrangements (2016/17 only) and auto enrolment (2017/18 and 2018/19) Total Pay 4.41 2.85 2.72

Other statutory compliance issues 0.40 0.40 0.40 Non-pay inflation 0.70 0.70 0.70

Total 5.51 3.95 3.82

 Apprenticeship levy During 2015, the UK Government consulted on the intention to apply an Apprenticeship Levy from 2017/18. NHS Employers responded to the consultation, indicating the NHS would be the major contributor but would not benefit significantly. The UK Government Spending Review and Autumn Statement 2015 confirmed the apprenticeship levy will come into effect in April 2017 which will require employers to make a payment of 0.5% of their pay costs. The Apprenticeship Levy will be collected by HMRC from employers via PAYE; however, skills policy and arrangements, including apprenticeships, are devolved matters. The level to which WAST, as an employer, might receive financial benefits from the scheme are as yet unquantified. On this basis our plans have assumed the costs associated with the payment of the apprenticeship levy as c£0.4m for each of the years 2017/18 and 2018/19. The net financial impact of expected uplifts, inflation and unavoidable costs (including apprenticeship levy) are summarised in the figure 25 below.

Figure 25 Summary of Financial Implications 2016/17 2017/18 2018/19 £m £m £m Assumed fair share of additional funding 5.00 4.00 4.25 Less: Inflation and unavoidable costs 5.51 3.95 3.82 Apprenticeship Levy 0 0.40 0.43 Estimated Financial Impact Shortfall Shortfall Balance £0.51m £0.35m

Inflationary increases and unavoidable costs exceed the expected share of additional funding, presenting a cost pressure to the Trust of £0.51m in 2016/17 and £0.35m in 2017/18.

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 2016/17 baseline position In developing our financial plans, the following assumptions have been made to provide a planning baseline for income for 2016/17, and future years.

 Emergency Medical Services (EMS) Additional funding has been made available through EASC during each of the last two financial years totalling £15.5m (£7.5m + £8m). Based on the agreed approach with the CASC to determine the reasonable resource envelope for EMS over the next three years which will underpin this financial plan, it has been agreed to look to move away from pockets of previous incremental investment in the Trust to much more focus on the increasingly efficient use of the whole quantum of spend. This has seen significant additional detail provided to the CASC office by the Trust over recent months, to fully support the previous recurring investments in the Trust, and with which to agree this expected reasonable level of spend and resulting resource envelope, against which the Trust has developed its financial plans. Through this process, it has been assumed that £14.3m of the above £15.5m funding will be recurrent within the baseline for future years. It has been recognised that £1.2m of the original £15.5m supported elements of variable pay spend in 2015/16. In addition, during 2015/16, further non-recurring funding of £3.5m was provided by Welsh Government to support the planned costs of increased capacity. Figure 26 below summarises this.

Figure 26

Planned Funded Additional EMS Capacity Costs Funding 2015/16 £m £m Source Variable Pay 1.7 Additional Non- 3.5 Recurring Use of other providers 1.8 WG funding Within EASC Variable costs to support additional 1.2 1.2 capacity included within EASC agreement baseline

Total 4.7 4.7

During 2015/16 there have been a number of initiatives that have been implemented which will require recurrent funding. Many of these have system-wide benefits and their continuation is contingent upon the availability of continuing financial resource and funding. This includes increasing operational capacity and providing additional resources to include support for the Explorer Project in Cwm Taf. The associated costs within the Trust’s financial plan for all this have been estimated as a minimum of £2m in 2016/17, for which it is assumed that this will now be funded via its commissioning agreement with EASC, and which has also been included as such in the above process to determine the reasonable resource envelope on which this Trust is building its financial plan. Other examples of local initiatives which will need to be considered for funding in 2016/17, including the Alcohol Treatment Centre in Cardiff (for which the current funding stream is due to cease in 2016/17) and establishment of similar centres elsewhere in Wales, will require further discussion with commissioners to determine their financial sustainability. On this basis, the Trust’s financial plans have, therefore, included the following income assumptions in relation to baseline EMS funding:

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Baseline EMS funding at 2015/16 funding levels: Estimated spend on EMS 2016/17 - @ 2015/16 prices £m Current forecast of EMS spend 2015/16:- Baseline spend 129.8 Additional planned spend 2015/16 3.5 Total forecast spend 2015/16 133.3

Less net non-recurring spend 2015/16 within above baseline spend -1.2

Less additional planned spend 2015/16 (initially planned to be non- -3.5 recurring) Plus capacity and performance enhancing schemes 2016/17 2.0 Total estimated spend on EMS 2016/17 - @ 2015/16 prices 130.6

This baseline position results in a real terms reduction of income of £2.7m against current levels.

 Impact of assumed share of additional £200m funding: The apportionment of the fair share of additional funding (£5m) could be disaggregated on the basis of income distribution that would result in a split of around £4.1m attributed to EMS with the balance attributed to other activity, e.g. PCS. However, for consistency, it has been assumed the full value, £5m, will be facilitated in total through the EMS element of the EASC agreement (on a similar basis to the 2015/16 pay award). On the basis that the additional funding is fully facilitated through EASC the baseline funding expected for EMS from EASC for 2016/17 is £135.6m

 Transitional cost pressures linked to EMS performance: Versatility and responsiveness of services has been a critical feature of the improvement in performance and at times this has required a premium in terms of the costs incurred. Consistent with the further development of the Trust’s financial strategy and fully integrating this with the strategic workforce plan and People Strategy, the further continuation of such variable costs is currently under review, both to establish how greater efficiency can be achieved, yet still maintain a level of agility that would allow the flexibility that is required to respond most effectively to demand. Whilst some of the costs incurred to increase capacity in 2015/16 (£4.7m) are expected to immediately reduce, by up to £1.5m, there will continue to be a reliance on elements of variable pay and alternative providers to maintain performance levels.

Our plan has assumed an initial cost pressure associated with maintaining levels of EMS capacity for 2016/17 in the region of £3.2m, for which savings and other efficiencies will be required to offset such costs, should they continue, and based on the funding assumptions previously described, in the context of a balanced financial plan

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 Renal Transport Funded Through WHSSC It is assumed that income for renal services will remain, as a minimum, constant in real terms with 2015/16 levels. On this basis, at least £1.1m will continued to be funded, separate to EMS, through WHSSC.

 Patient Transport Services The Deputy Minister for Health announced the implementation of the Non-Emergency Patient Transport Services (NEPTS) business case on 22 January 2016. The financial case included a commitment to fund service developments through increasing efficiency in this service and is predicated on an assumption that future funding streams will reflect current levels. This is in line with the assumptions included as part of the business case developed in partnership with all Health Boards and Trusts. Following this recent announcement a detailed implementation plan is being developed which will include refining the profile of the financial plan.

It is assumed that income for PCS for 2016/17 will, as a minimum, remain constant in real terms with 2015/16 levels.

 111 The direct financial impact of the 111 pathfinder is assumed to be cost neutral, with corresponding income (initially via ABMU) and expenditure assumptions of £1.775m for 2016/17, made up as follows:

Additional Costs for 111 Service Delivery 2016/17 £000 Core staffing costs 1,461 Telephony Costs 62 IT costs 150 Subtotal 111 service delivery 1,673 Plus Project costs via WAST 102 Total expected income and expenditure 2016/17 1,775

It is also assumed within this IMTP and financial plan that the implementation of 111 will not lead to a direct increase in 999 calls, and it is on this basis that both the operational and financial plans for the Trust have been constructed within this IMTP.

 ESMCP It is also assumed within this financial plan that any additional revenue costs falling to the Trust as a result of the ESMCP (Emergency Services Mobile Communications Programme) and associated business cases will be financially neutral, i.e. funding will be made available to offset any additional costs.

 Demand / capacity review Finally, as detailed elsewhere within this IMTP, the Trust is looking to complete a comprehensive demand and capacity analysis in early part of 2016/17, linked to the ongoing evaluation of the New Clinical Response Model. It is assumed that any additional costs incurred in delivering this (expected to be c£100k) will be funded.

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2017/18 and 2018/19  Funding uplifts Whilst the Welsh Government draft budget provides only for 2016/17, the UK spending review provided indicative budgets for the next four financial years. These figures present plans for further increases for the NHS in England, and, consistent with other NHS Wales health organisations, it is on this basis that WAST financial plans have been developed, which assume that additional funding will be provided for each of these years resulting in further uplifts of a minimum of £4.0m and £4.25m respectively.  111 The financial implications of an extended roll-out of the 111 pathfinder have also been considered and estimated within years two and three of the financial plan, building on those expected above in year one (2016/17). Initial estimates suggest this could potentially increase our workforce over the following two years by a further 59.84 WTE call takers, and 67.56 WTE Nurse Advisors. However, it must be noted that these figures are subject to change and would require further investment. Again, the working assumption within the Trust is that any additional cost impacts of the implementation of 111 throughout this planning period will be financially neutral to the Trust, i.e. will be externally funded. Assuming full roll-out of 111 by the beginning of year three of this planning period (2018/19) would see a further increase in the Trust’s costs of c£5.8m (including estimated telephony and IT costs); the planning assumption within this plan for year two (2017/18) is a half roll-out of this over and above that already committed for 2016/17. In each year, additional funding via ABMU has also been assumed to offset these additional costs.

 Other developments There is a significant range of further developments over the planning period that are likely to be implemented leading to changes in the cost base and profile of the Trust, in terms of type of spend across the Five-Step Ambulance Care Pathway. Work continues to assess the impact of such changes, many of which will be clearer following the outcomes of the demand and capacity review and the implications of other developments, e.g. the replacement of the Trust’s CAD. Whilst the detailed impact on service, workforce and finance of these developments cannot yet be fully quantified and included within this three-year financial plan, it expected that the impact will commence through years two and three (2017/18 and 2018/19) with the planning work being completed through 2016/17. It is also assumed within this financial plan that the costs of any such developments will either be separately funded, release spend elsewhere within the Trust to offset such costs (including across other steps of the pathway) or will only be implemented when further additional savings and efficiencies have been identified. Examples of these include:  further developments in CCCs, in addition to 111. This includes the further investment in staff and the clinical desk resource to increase “Hear and Treat” rates in line with other ambulance services across the UK. The implementation of a new CAD system will also see operational efficiencies within CCCs, as will the further review of the configuration of CCCs as part of the wider estates review and rationalisation. This may see the number of dispatch desks required reduce because of greater automation, especially during the night, alongside reviewing shift patterns;

 furthering the ICT strategy of the Trust to develop a technically enabled workforce, especially in relation to front line operational staff, which will provide for even more treatment at scene and resulting impact on hospital conveyances; and

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 working with Health Board colleagues and others to further develop the availability of alternative care pathways, ability to access direct to speciality, etc, releasing resources and further enabling the proportion of the Trust’s spend to move towards STEPS 1 and 2 of the ACP.

As part of the financial modelling that underpins this IMTP, some initial preliminary analysis has been conducted which starts to consider how EMS costs can be attributed across each of the five steps of the ACP over the planning period being considered. The table below presents the initial results of this and provides indicative detail of how costs might shift between steps during the next three years. This information includes the assumed full roll-out of the 111 pathfinder.

Further future refinements of this analysis will need to reflect the outcomes of the demand and capacity review, the evaluation of the New Clinical Response Model and the future resources (staffing, fleet, etc) required to deliver this, and take account of the implications of developments above (as appropriate). Therefore, at this stage, this information must be viewed purely as an early indication that will be developed throughout 2016/17 in conjunction with the Commissioner.

Estimated costs across STEPS Steps Estimated Year STEP 1 STEP 2 STEP 3 STEPS 2 & 3 STEPS 4 & 5 split Help me Answer Come Answer my call Give me between Total choose my call and see & Come and treatment & STEPS me see me Take me to... 2015/ £ £0.7m £7.0m £13.3m £1.6m £110.7m £133.3m 16 % 0.52% 5.27% 9.92% 1.23% 83.07% 100.0% 2016/ £ £0.7m £9.1m £13.8m £1.7m £112.0m £137.4m 17 % 0.52% 6.65% 10.0% 1.24% 81.5% 100.0% 2017/ £ £0.7m £11.4m £14.2m £1.8m £115.3m £143.4m 18 % 0.52% 7.92% 9.92% 1.23% 80.4% 100.0% 2018/ £ £0.8m £13.7 £14.7m £1.8m £118.8 £149.8m 19 % 0.52% 9.14% 9.79% 1.23% 79.4% 100.0%

Other initial supporting analyses to further describe other shifts in spend within the planned EMS resource envelope over the next three years have also been initially estimated and shared with the CASC and his team. A key example is the level of pay costs over this period and, in turn, how this is expected to break down into core costs and variable pay. Clearly, this is a key area that will need some significant further refinement once the current key outstanding pieces of work previously described have been concluded. Based on the known plans being progressed by the Trust, including recruitment, workforce efficiencies, and savings plans (see below), this suggests a reduction in the levels of variable pay by 2018/19 of in the region of £4m pa (a drop from c9% of total pay spend to just over 4%, or a nearly 50% reduction in the levels of variable pay itself) when compared with current levels.

Summary of financial changes Figure 27 below sets out a summary of the assumed in year, material revenue cost changes described for each of the years 2016/17 to 2018/19. Figure 27

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2016-17 2017-18 2018-19 Summary of assumed financial changes R NR Total R NR Total R NR Total £m £m £m £m £m £m £m £m £m Brought forward recurring deficit/-surplus 0.00 0.00 0.0 0.0 0.0 0.0 Income changes Share of £200m -5.0 -5.0 0.0 0.0 Future years inflation 0.0 -4.0 -4.0 -4.3 -4.3 Additional Funding 2015-16 3.5 3.5 0.0 0.0 Variable element of EASC 1.2 1.2 0.0 0.0 Assumed funding for continuuation of capacity -2.0 -2.0 0.0 0.0 Assumed funding for 111 (via ABUHB) -1.8 -1.8 -2.0 -2.0 -2.1 -2.1 Total income changes -4.1 0.0 -4.1 -6.0 0.0 -6.0 -6.4 0.0 -6.4 Expenditure changes Unavoidable costs - Inflation, pension, statutory compliance etc 5.5 5.5 4.0 4.0 3.8 3.8 Apprenticeship levy 0.0 0.4 0.4 0.0 0.0 Continued capacity 2.0 2.0 0.0 0.0 0.0 0.0 Reduction of non recurring costs -1.5 -1.5 0.0 0.0 0.0 0.0 Non-recurring savings delivery / gains 2.5 2.5 1.4 1.4 0.5 0.5 Assumed 111 costs 1.8 1.8 2.0 2.0 2.1 2.1 Total expenditure changes 10.3 0.0 10.3 7.7 0.0 7.7 6.4 0.0 6.4

Sub total deficit / -surplus (inc bfwd) 6.2 0.0 6.2 1.7 0.0 1.7 0.1 0.0 0.1 Efficiencies / service re-design / gains Planned accountancy gains (profit on disposal) -1.0 -1.0 Potential savings -4.9 -4.9 -1.2 -1.2 -0.1 -0.1 Non recurring savings -0.4 -0.4 -0.5 -0.5 0.0 0.0 Total efficiencies / service re-design / gain -4.9 -1.4 -6.2 -1.2 -0.5 -1.7 -0.1 0.0 -0.1 Total deficit / -surplus 0.0 0.0 0.0 Recurring deficit/-surplus carried forward 0.0 0.0 0.0

Savings and efficiency The scale of the financial challenge for future years is significant. Whilst it is expected that a fair share of additional funding will be provided to support the majority of the forecast inflationary and unavoidable costs, it is clear that the achievement of financial balance will require further efficiencies and the financial plan has been developed on this basis. The Trust’s financial position for 2015/16 includes a savings target of £4.5m (3%). Of this, a number of the schemes implemented are non-recurring and will require additional savings of £2.5m to be re- provided in future years. This adds to the potential shortfall against inflation and unavoidable costs of £0.5m (in 2016/17) and initial cost pressures of £3.2m associated with continuing current levels of capacity to maintain performance. The financial plan therefore presents a savings requirement for 2016/17 of £6.2m increasing, to cover the costs of the apprenticeship levy, to £6.5m in 2017/18.

Significant progress has been made to establish a range of cost reduction, cost avoidance and savings schemes to deliver financial balance both for 2016/17 and in the longer term, which includes a reduction of costs through a range of initiatives set out below.

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 Further reducing sickness rates – significant financial savings have been delivered in 2015/16, as a result of a reduction in sickness rates during the year. Our plans are to reduce sickness rates further, by 1% point in 2016/17 and 0.5% point in each of the following two years which will provide additional savings over the next three financial years, increasing from £0.6m in 2016/17 to £0.8m in 2018/19.

 Other variable pay initiatives – this includes a range of schemes which will improve efficiency, benefit staff and reduce spend, such as increasing job cycle efficiencies (including reducing the time from handover to clear), reductions in overruns, reviewing meal breaks, a proposed re-alignment of some operational CPD and further reducing the time to recruit operational staff. These will all reduce the variable costs associated with overtime hours. Together with service modernisation, it is anticipated that further variable costs (overtime) of over £1m can be saved.

 Management of (non-operational) vacancies – is expected to save a minimum of £0.2m.

 Through reducing reliance on other providers – such as St John and other private providers will plan to reduce costs over this planning period by up to £1.3m.

 Fleet maintenance and fuel - the review and rationalisation of these costs is planned to save up to £1m. This will include a detailed review of current contracts for maintenance and repairs, assessing the potential threshold for such repairs in the future, looking at innovative ways in which some elements of routine maintenance can be provided, and a prudent assumption in relation to the potential continuation of current low fuel prices.

 Consumables, Drugs and Medical Gases – through a combination of Trust-wide and local schemes we will reduce costs by up £0.5m.

 Procurement – Our continued drive towards cost effective procurement, and working to maximise this with colleagues in NWSSP, will result in additional savings being delivered in 2016/17.

 Reviewing and minimising expenses – will provide a source of additional savings both in the immediate and medium term. This will include further exploring the pool car policy within the Trust with a view to creating a number of points around Wales where staff can access pool cars, thus reducing travelling expenses costs. Other areas of spend also being further reviewed and considered for savings opportunities include:

o further exploring salary sacrifice schemes, including those in relation to vehicle purchases and the impact on cost per mile expenses paid; o using the introduction of telemetry to facilitate the ability to better challenge certain claims against the Trust, potentially reducing losses and compensation costs as well as further protecting our staff; o assessing the cost / fuel impact of reducing conveyance rates in some areas; o review of use of taxi policies, especially for EMS, and the potential use of voluntary car users; o reviewing future uniform replacement polices; and o reviewing other local practices.

Further financial benefits are anticipated including through estates realisation, which will provide non-recurring gains of more than £1.0m in 2016/17.

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Ambitious plans that will deliver a balanced financial position for each of the next three financial years are in place.

However, it must be recognised that, whilst efficiencies will in some cases result in cash releasing savings, other actions will instead enable improvements in productivity and performance. The balance of efficiency gains between performance and cash releasing savings will be an important element of the on-going discussions with our commissioners. A key example is the implementation of the NEPTS business case, where efficiency savings have been reprioritised to fund agreed service developments. Whilst this is welcomed in terms of the improvement to patient care, it presents limitations in relation to the potential to provide additional cash releasing savings. In developing the financial plan for 2016/17 to 2018/19, there is emphasis both on the identification of immediate efficiencies, either in terms of performance or cost, but also exploring potential longer term opportunities, which will be further developed and enhanced throughout this planning period. Part of this approach includes the scrutiny and comparison of costs through internal and external benchmarking, including working with the Commissioner-led development of a benchmarking toolkit, in conjunction with the NHS Benchmarking Network. Whilst our plans for the delivery of savings are at both local and corporate levels, there are clear lines of accountability and progress of delivery will be closely monitored. Savings plans are being progressed towards implementation via robust project plans, being very clear in terms of ownership of the actions required to deliver, key milestones, deadlines, and monitoring arrangements, which have further informed the current expected profile of such savings delivery over the lifetime of this financial plan. Similarly, how we look to describe, quantify and evidence the likely shift in the Trust’s spend on EMS from STEPS 4 and 5 more towards STEPS 1 and 2 of the Ambulance Care Pathway will form an important part of our financial plans for the future. It is recognised that an important part of this will be to develop a fuller understanding of how these shifts influence costs across the whole system and the financial impacts both for the Trust and our partners.

Summary of Financial Risks: No financial plan is risk free. Financial risk management forms a key element of the project plans that underpin both our ambitions and savings targets. We have strengthened our financial capacity and corporate focus on finance and, as an organisation, have structures in place to drive through the delivery of our financial plan.

A summary of the key risks to the delivery of the Medium Term Financial Plan includes:

 funding assumptions in relation to pay and non-pay inflation;  financial impact of New Clinical Response Model and the transition of any changes to workforce and fleet requirements;  implementation of the NEPTS business case, specifically matching the profile of efficiency with service development;  availability of capital funding to support the infrastructure investment required to implement service change;  financial impact of EASC commissioning intentions, and confirmation of the EMS financial resource envelope as assumed within our financial plan;  outcomes of demand and capacity work; and  delivery of cash-releasing savings and efficiencies.

Scenario planning will help to mitigate these risks, highlighting the levels of financial risk but also indicating the service and performance impact. However, the extent of service change that the Trust

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is implementing is extensive, with key developments such as the NEPTS business case at an early stage but with the potential to transform the quality and efficiency of services.

Impact on Workforce Co-ordination between financial and workforce plans is vital to both financial and service delivery. This alignment is a critical element of our future plans as WAST implements service developments and includes both immediate and longer term planning, both in terms of existing workforce and recruiting and training the workforce required for the future. As part of this our workforce plans reflect a commitment to:  reduce sickness absence;  streamline recruitment processes to reduce the reliance on more costly forms of cover for operational staff; and  minimise the costs of relief cover, whilst maintaining a level of flexibility that will enable the most efficient use of staff resources.

The current funded establishment is presented within the table below. This represents the contracted establishment and does not reflect levels of variable resource.

Funded Establishment as at 31st March 2016 Board Finance Quality & CE Office Secretary Operations & ICT Strat Dev Nursing W&OD Clinical Total Funded Funded Funded Funded Funded Funded Funded Funded Funded WTE WTE WTE WTE WTE WTE WTE WTE WTE Chairman & Non Execs 8.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 Executive Board 7.00 0.00 0.00 0.00 0.00 0.00 0.00 0.40 7.40 Senior Manager 1.00 4.00 60.91 30.30 6.80 8.81 26.80 22.00 160.62 Admin & Clerical 1.00 7.67 186.82 51.60 2.00 17.68 37.18 21.09 325.04 Other Staff 0.00 0.00 131.81 0.00 0.00 16.48 7.60 1.00 156.89 Ambulance Staff 0.00 0.00 2,359.12 0.00 0.00 0.00 0.00 3.00 2,362.12

Total 17.00 11.67 2,738.66 81.90 8.80 42.97 71.58 47.49 3,020.07

Our financial plans are being developed to reflect both the planned workforce investment and the potential to reduce variable costs. These will also be influenced by the longer term workforce requirements arising from the New Clinical Response Model and the implementation of NEPTS.

Our workforce plans have identified a number of areas where there is expected to be investment in contracted workforce during 2016/17, including:

 recruitment within our Clinical Contact Centres (CCC);  implementation of the NEPTS business case (i.e. strengthening of the NEPTS management and supervisory structure); and  the implementation of 111 Pathfinder will increase our workforce, with the following additional workforce assumptions included in our current plans for 2016/17.

Increase in WTE Staff Group ABMU Carmarthenshire Total Call Handlers 13.24 4.33 17.57 Nurse Advisors 15.07 4.93 20.00

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The table below indicates how these changes might initially impact on our contracted workforce in 2016/17.

Potential Funded Establishment as at 31st March 2017 Quality CE Board Finance Strat & Office Secretary Operations & ICT Dev Nursing W&OD Clinical Total Funded Funded Funded Funded Funded Funded Funded Funded Funded WTE WTE WTE WTE WTE WTE WTE WTE WTE Chairman & Non Execs 8.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 Executive Board 7.00 0.00 0.00 0.00 0.00 0.00 0.00 0.40 7.40 Senior Manager 1.00 4.00 60.91 31.30 6.80 8.81 26.80 22.00 161.62 Admin & Clerical 1.00 7.67 228.31 56.10 2.00 17.68 39.18 21.09 373.03 Other Staff 0.00 0.00 151.81 0.00 0.00 16.48 7.60 1.00 176.89 Ambulance Staff 0.00 0.00 2,366.52 0.00 0.00 0.00 0.00 3.00 2,369.52

Total 17.00 11.67 2,807.55 87.40 8.80 42.97 73.58 47.49 3,096.46

Capital The capital programme has been developed in parallel with our service, estate and fleet plans. The Trust’s current Capital Plan includes schemes with a gross investment value of more than £226m profiled over the next five years. This includes new estate developments and the replacement of the CAD system, as well as a rolling vehicle replacement programme.

We will build on the current organisational processes for the management and prioritisation of capital planning and, in parallel with our commitment to allocate our revenue expenditure across the five steps of the ambulance care pathway, we will seek to align our capital planning processes on the same basis.

There are two elements to our capital plans:

1. Discretionary Capital

2015/16 The Welsh Ambulance Services NHS Trust Discretionary Capital Programme allocation is funded from the Welsh Government All Wales Capital Programme (AWCP). WAST has been allocated a total of £3.884m discretionary capital for 2015/16. This is an increase of £0.826m from 2014/15, where the initial allocation was £3.058m (although an additional £3m was allocated later in the year, bringing the total allocation to £6.058m for 2014/15). 2015/16 discretionary capital spend included (but was not limited to);

 £961,000 on 85 Corpuls Defibrillators;  £29,755 on Advanced life support (ALS) mannequins;  £175,000 on a rolling IT hardware replacement programme; and  £917,000 maintaining and improving estate.

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Recognising that demand for discretionary capital monies always outstrips funds available, the organisation recognises the importance of taking greater advantage of other funding opportunities or routes, such as the Health Technology Fund, ‘Invest to Save’ and Integration Funds.

Future Years It has been confirmed that WAST has been allocated a total of £5.826m discretionary capital for 2016/17. This is an increase of £1.942m from 2015/16, subject to the approval of this IMTP. The organisation has an Internal Capital Planning Group that meets monthly and oversees all aspects of discretionary capital planning. A robust assessment and prioritisation process has been undertaken to determine how funding will be prioritised and allocated to schemes, with final approval by the Trust Board, ensuring that the Discretionary Capital allocation is utilised effectively to support the Trust in achieving its strategic goals which are aligned to this plan.

All of the bids received for funding from the Discretionary Capital allocation for 2016/17 have been recorded and verified by the Finance Department and the Internal Capital Planning Group (ICPG) using agreed criteria and scoring matrix that includes the following considerations:  improved quality and safety;  statutory compliance requirements;  affordability in terms of capital and revenue;  transformation aligned to the IMTP; and  invest to save.

The results of this exercise, which form the Trust’s Discretionary Capital Programme for 2016/17, has be to the Trust Board’s Finance and Resources (FRC) Committee, and Trust Board for approval.

On this basis, the draft plan has assumed discretionary capital funding of £5.826m for 2016/17, reflecting a baseline at the 2015/16 level of funding with a non-recurring increase of £1.942m, subject to the approval of this IMTP.

2. Capital Investment Awarded for Major Capital Schemes Based on the Submission of Five Case Model Business Cases to Welsh Government.

Our capital programme also supports a number of major capital schemes that facilitate the implementation of our plans, and underpin our strategic aims and priorities. Capital investment will unlock quality and efficiency improvements/gains through the purchase of the most up-to-date vehicles, along with clinical equipment. In addition, this investment will provide our staff with the most appropriate buildings that allow vehicles to be cleaned and stocked, with suitable rest facilities to ensure they are ready for the next call of the day. 2015/16 For 2015/16, the Trust’s Capital Expenditure Limit is £19.682m, which will fund:  discretionary capital £3.9m (above);  Joint Ambulance/Fire Development ARC Wrexham £4.9m;  vehicle replacement 2015-16: further EMS vehicles £8.3m;  Blackweir business case costs £0.15m;  “Hear and Treat” function - planning & dispatching £0.39m;  Omnicell- £0.42m;  communication devices to more than 400 community first responders £0.47m; and

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 EMS equipment £1.2m.

A high level summary of current progress is indicated in Figure 28 below.

Figure 28 Scheme Status Timescales Wrexham Ambulance and Fire On target / on budget Handed over mid Service Resource Centre February 2016 Cardiff Ambulance Resource Centre Strategic Outline Case approved by Welsh OBC under Government; currently development undertaking development of the Outline Business Case Vehicle Replacement 2015/16 On target Complete end March 2016 Computer Aided Dispatch System Business Case submitted Currently going to WG – Planned through the Tender implementation summer Process 2016 Non-Emergency Patient Transport Business Case submitted Approved Relocation of Trust HQ St Asaph Options Appraisal Ambition to be complete, BJC to be completed by April developed 2017

All Wales Capital: Future Years A high level overview of our current capital plan includes:

 continued investment in vehicle replacement and fleet that will align with the requirements of changing service delivery models including the New Clinical Response Model and Patient Transport;  Clinical Contact Centre configuration to support service developments;  Blackweir ARC together with Bangor ARC and Newport MRD;  ICT infrastructure development;  replacement of operational systems including the Control and Despatch and 111;  Community First Responders;  ESMCP & ARP; and  estates review.

The details of the capital programme for 2016/17 are currently under discussion both internally and externally with officials within Welsh Government. As part of this, consideration is being given to potential schemes that can be accommodated within year, as well as the progress of existing capital schemes which currently include a number of strategically important initiatives including vehicle replacement, Cardiff Ambulance Resource Centre (ARC), Bangor ARC, and Newport Make Ready Depot (MRD), each of which is vital to increase efficiency. Our current plans present schemes for additional investment with a total value in the region of £200m over the next five years, of which £27m relates to 2016/17.

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The Welsh Government final budget published on 1st March 2016 provided for £10m of capital funding in 2016/17 to support the replacement of vehicles across Emergency Medical Services and Non-Emergency Patient Transport Services as well as some Specialist National Resilience Vehicles.

Costs of Capital The costs of capital have been included as £12.728m in accordance with the allocation value presented within WHC (2015) 059. Our initial calculations have indicated that depreciation charges will increase over the next five years and it is assumed that these costs of capital will be fully funded by Welsh Government.

6.3 Our Estate

The Estates Department forms part of the Finance, ICT & Estates Directorate and reports directly to the Director of Finance and ICT. Our estate currently comprises some 43,548m2 (gross internal) floor area in 110 buildings located throughout Wales. The revised estates Strategic Outline Programme (SOP), if fully completed, will eradicate all issues of less than ideal building functionally; it will also address a significant element of the backlog maintenance which currently stands at c£13.4m. In the interim, this is being addressed through the internal discretionary programme. Our Frontline Operational Sites Our organisation has an Estates Strategy that was written in 2011. It aimed to deliver:

 Ambulance Resource Centres to provide office and welfare facilities for staff with workshops to maintain, wash, clean and restock our fleet vehicles;  Make Ready Depots to provide office and welfare facilities for staff with vehicle washing, cleaning and restocking; and  Social Standby Points (SDPs): places where staff can rest and recuperate and have access to office facilities usually through sharing other buildings such as fire stations.

We recognise that lots has happened and that many things have changed since 2011 and that subsequently this strategy needs updating. MRD Dobshill was constructed in 2012 and has been operating successfully since then. ARC Wrexham is in the final stages of being constructed and will be operational in March 2016. It is envisaged that, moving forward, Ambulance Resource Centres (ARC) and Make Ready Depots (MRD) will form the core of the Trust’s operational estate as they will be underpinned by an integrated network of deployment points strategically located in areas of peak patient demand, ensuring we are best serving people in Wales. We also recognise, however, that the current Estates SOP now also needs to be reviewed and updated, in line with the proposed ‘direction of travel’ along with any other changes to operational requirements and to ascertain whether there are any estates priorities emerging, which may need to be reprioritised.

It is important to ensure that the review of the SOP is operationally led. The SOP review will thus commence with a series of 1:1 meetings between with the Director of Operations and each of the

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Heads of Operations. Each Health Board area will be reviewed, comparing the original SOP proposals against what may have changed or be deemed to be a more urgent requirement now.

Once the meetings are completed, an exercise will be undertaken to map the findings, which will be applied on a national basis across Wales against what was planned initially in the original SOP.

Our Control Centres and Administrative Bases Our Clinical Contact Centre (CCC) function is currently provided from five separate premises across Wales. This configuration is a legacy from the merger of five former ambulance services into a single Trust for Wales, along with the integration of the NHS Direct Wales service.

The current configuration of CCCs is detailed in Figure 29 below.

Figure 29 No of CCC Region Services Workstations Central & Llangunnor, Carmarthen West PCS & 999 29 Central & Thanet House, Swansea West NHSDW 44 Bangor North NHSDW 20 Llanfairfechan North PCS & 999 28 NHSDW, PCS & VPH, Cwmbran South East 999 68

In 2014/15, we had an opportunity to join South Wales Police, Mid and West Fire & Rescue Service and South Wales Fire & Rescue Service in the development of a joint control room facility located in Bridgend, South Wales. Although this was presented to the Trust Board in March 2015 as an option, it was felt that there was insufficient information and evidence to support the option at that time. There was an added issue regarding the outstanding decision on the hosting of the 111 service in Wales, as this was recognised as having a significant impact on the capacity required in any CCC configuration.

Whilst the development at the Bridgend facility has progressed with Police and Fire Service, we have committed to a minimum of a single desk, thus making the control centre ‘tri-service’.

In North Wales the CCC situation is slightly different. The Trust Board approved the development of a Strategic Outline Case (SOC) in partnership with North Wales Police and North Wales Fire and Rescue Service for a joint emergency control centre based in North Wales.

The decision to move towards the development of the SOC for North Wales was predicated on a review of CCCs across Wales that was completed by Consultants ORH and finalised in December 2014. Whilst this report is still considered accurate, it started from the assumption that an integrated health model i.e. EMS, PCS NHSDW (111) and GPOOH, all located in the same CCC, was the preferred service model option.

We subsequently recognise that we need to be clear what our preferred service model is before we can progress to considering our optimum and desired configuration of our CCC estate.

Our Research and Development Team have committed to a piece of work to explore and consider the evidence for an integrated health service model, whilst we have also held workshops to begin scoping out what the full range of options (and what they ‘look like’) are. Combined, these two

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exercises will allow us to agree our preferred service model and subsequently fully initiate any estate reconfiguration work.

Sites We Share with Health Board Partners

We will work with all LHBs in Wales to ensure our individual plans are dovetailed together. This is particularly important where this Trust shares LHB sites such as at Cefn Coed, Swansea. ABMU has plans to redevelop the Cefn Coed site, which will require us to relocate our Regional Headquarters and Training School (this is likely to be in years 2 or 3 of the plan). Our model for future service delivery will be considered in the context of the lease opportunities and options to further rationalise the administrative estate, such as at Vantage Point House, will be considered during the term of this plan. Our Estate and Our Blue Light Partners In addition to the tri-service control centres which are documented above, we are also working with the Mid and West Fire and Rescue Service (MWFRS) to design and develop a model for a shared vehicle maintenance facility. Currently, a fleet of 45 PCS vehicles in the Abertawe Bro Morgannwg (ABM) Health Board area is repaired and maintained by three local dealers based in Swansea and Llanelli. The vehicles operate from various stations including Bryncethin, Glynneath, Gorseinon, Neath, Pontardawe, Port Talbot and Swansea. A one-year pilot project will provide the opportunity for MWFRS and WAST to work together to establish if effective and efficient use of publicly funded assets through a joint vehicle maintaince site can be achieved. More widely, it is also proposed to engage with other emergency services within Wales to jointly review the estates proposals for all of the emergency services. This will enable strategic estates planning for collaborative working for the future.

Year 1: Action 95: Commence the process of establishing the organisations next ARC in Cardiff. Action 96: Review and update the Trust’s National Estate Strategy 2011 to include all Trust Estate. Action 97: Review joint WAST / Mid and West Wales Fire and rescue Service (MWFRS) vehicle maintenance pilot. Years 2 & 3 Action 98: Relocate the organisation’s Trust HQ from its current site at St Asaph to another site in North Wales. Action 99: Relocate the organisation’s regional West Wales HQ from Cefn Coed Action 100: Progress any CCC estate reconfiguration that may result from earlier work

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6.4 Our Fleet

We operate 706 vehicles:

 273 Accident and Emergency Ambulances (EMS);  143 Rapid Response Vehicles (RRV);  260 Patient Care Services (PCS); and  30 specialist and auxiliary vehicles encompassing the Hazardous Area Response Team (HART).

Our Fleet covered in excess of 20 million miles in 2015/16, used £5 million of fuel and was serviced and inspected circa 5,000 times by the Fleet Department. The accident and emergency ambulance fleet is a modern range of coach built, box body vehicles. The average age is 3.1 years; rapid response cars have an average age of 2.4 years. The ambulances are equipped with all the latest clinical technology and labour-saving devices such as electrically operated tail lifts and stretchers that help to reduce manual effort and improve the patient experience. The design of all vehicles has been undertaken in partnership to maximise user contribution. The Fleet Department employs 38 staff spread across Wales; the Administration Department and one of the four in-house workshops at Wrexham are in the process of relocating to a new purpose- built site that will be shared premises with North Wales Fire and Rescue Service. The other three in-house workshops are located in Cardiff, Blackwood and Bangor. There is also a management team based at Vantage Point House, Cwmbran.

Ambulance reliability is a key priority for us. The Fleet Department manages and maintains the vehicles through a rigorous and robust Planned Preventive Maintenance (PPM) schedule. In the North and South East areas maintenance is undertaken at the four in-house workshops; Central and West areas are predominantly maintained by third party suppliers.

We are moving from the current PPM system to a time-based service interval system. This will assist in increasing reliability and the release of vehicles for servicing.

As a result of the New Clinical Response Model the CCC has the opportunity to dispatch the most appropriate resource to a 999 call rather than simply the closest resource. Each incident outcome code contains details of the ‘ideal response’; this, by default, will identify the most appropriate vehicle to send to an incident. This will inevitably lead to a change in the current vehicle mix. This will be thoroughly tested through the analysis of historical demand as part of the demand and capacity work described earlier in this plan. The historical activity will be aligned to the New Clinical Response Model which will provide information on the fleet requirements to deliver the most appropriate resource. This information will be compared to the current fleet available and a plan developed to move towards the ‘best fit’ fleet mix. We are in the process of developing a three- year vehicle Strategic Outline Programme (SOP); this will include migration to the optimal fleet mix that will be derived from the analysis described above. The SOP will also smooth out the procurement process by removing some of the peaks and troughs in the current replacement cycle. The SOP will outline the new/replacement vehicle requirements over the next three years and, once approved, will enable funding to be allocated by WG on a systematic basis without the need for lengthy annual Business Justification Cases (BJCs).

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The Fleet Department currently provides CCC with a schedule of planned maintenance; arrangements are then made for the vehicles to be taken out of service at the appropriate time. This is not a robust process, with many vehicles not being available on the exact day for scheduled service.

Localities and CCC are also responsible for arranging repair for unplanned breakdown; this is time consuming and unproductive in terms of use of resources. The solution, in-conjunction with time- based scheduling, is to implement a virtual fleet and logistics help desk in CCC to take much of this work away from CCC staff.

Action 101: Implement a Virtual Fleet and Logistics Help Desk in CCC

In 2015, the Trust invested in on-board vehicle telematics, and aims to roll it out to the entire fleet. Before the information can be used to create improvements, an agreed policy must be in place to provide both guidelines to management and assurances to staff that the systems are there only to help protect them and to provide additional information to the fleet department.

During 2015/16, we invested in a replacement computerised fleet management system. This is a state-of-the-art system that will be a keystone for the modernisation of the Fleet Department and further developments of the Make Ready Operation in that it will:

 reduce manual effort (less manual inputting of data);  increase efficiencies of both administration and maintenance processes;  improve accountability for vehicle compliance;  improve stock control;  provide greater visibility of vehicles for all key stakeholders (internal and external);  provide greater control of maintenance budgets through uniformity and consistency across all suppliers; and  provide up to the minute status for all vehicles that are off the road and not operational.

Consequently, we want to fully install and embed this system in year one.

Action 102: Install and fully utilise a new computerised Fleet Management System

There is an industry-wide shortage of skilled motor vehicle technicians as there has been a reduction in companies taking on apprentices in recent times. We have a vision to introduce an apprentice training scheme and now need to ensure that there is a return from the time and money invested in the scheme to date.

Last year, we conducted a trial of “vehicle movers” in North Wales using agency personnel. This proved very successful and is now funded annually as part of the fleet core budget. A business case for rolling out vehicle movers in the South and East has been approved and recurring monies made available to fund the employment of a small team of driver/cleaners. The next part of the solution is to employ the North drivers directly on Trust contracts.

The fleet age profile is inconsistent owing to large number of vehicles being procured some years and very few in other years. This inconsistency creates challenges with regard to managing maintenance revenue budgets. Challenges also arise when funding is not available to replace large numbers of vehicles in one financial year. We know this age profile needs to be addressed through a smoother and more manageable replacement programme.

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6.5 Research and Innovation

We have highlighted that one of our six strategic aims is to deliver the best possible patient outcomes and experience through transforming models of care across all of the Trusts services, using technology, innovation, research and best practice to become truly quality driven.

We recognise that both research and innovation along with service improvement (Section 6.6 below) are not mutually exclusive. We recognise that these functions support the Trust to develop an integrated approach towards innovative and sustainable change. We do, however, also appreciate that innovation and service improvement shouldn’t happen in silos or pockets of the organisation-owned and driven by the few. Both should be a core principle of the organisation and fostered within a culture that encourages innovation and continuous improvement. We therefore want to develop an innovation strategy that clearly outlines what innovation means to WAST and how we plan to embed it in the organisation.

Action 103: Develop a Research and Innovation Strategy for WAST Significant innovation is already embedded throughout the organisation through its systems, structures, the nature of the business, and its need to develop strategic partnerships to deliver future sustainable services with partner Health Boards.

The implementation of the New Clinical Response Model as a one-year pilot demonstrates the significant innovative change programme underway within the Trust. The New Clinical Response Model is regarded as innovative by other UK ambulance services, and is also attracting interest worldwide. The Clinical Modernisation Programme Board (CMPB), chaired by the Medical Director, oversees its implementation, with work streams based around each step of the model (see Appendix 9: Structure Diagram).

This programme is one of four transformational programmes going forward and the Programme Board structure is outlined in Appendix 8. Oversight of the delivery of the programmes is through the Delivery and Assurance Group (DAG). The Programmes have also embraced technological change; e.g. the implementation of digi-pen, the new CAD, embedded within the modernisation of the Clinical Contact Centres.

We are proud of the Research and Innovation that we conduct, and recognise the pivotal role that Research and Innovation (R&I) has to play in the organisation. The R&I functions for the Trust are delivered by the Pre-Hospital Emergency Research Unit (PERU), which is part of the Health and Care Research Wales arm of Welsh Government. The Trust is widely recognised as having a strong research focus and as an attractive place to undertake pre-hospital research, mainly because of our exemplary track record in delivering on trials, but also in relation to the geography of Wales, which encompasses both rural and sparsely populated areas. The Trust is, therefore, strategically well placed to take advantage of this environment to improve health through developments in the pre-hospital phase of care.

In order to optimise grant capture from research funders, the Trust needs to work with academic, clinical and industry partners. In 2015-2016, the RS&PD allocation was used to good effect on the two projects:

 Rapid Analgesia for Pre-hospital Hip Disruption (RAPID): a feasibility study for a randomised controlled trial; and  Transient Ischaemic Attack 999 Emergency Referral (TIER): feasibility trial

Some of our highlights include;

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 Two Clinical Trials of Medicinal Product: o (CTIMP); RIGHT 2; and o Paramedic 2. Rapid Intervention with GlycerylTrinitrate in Hypertensive stroke Trial 2 RIGHT-2.

High quality research can be costly and time consuming, which relies on collaborations across many stakeholders. Consequently, the Trust’s R&I team engages in and contributes to high level fora such as the:

 South West Wales Regional Academic Health Sciences Hub;  South East Wales Academic Health Science Partnership; and  UK National Ambulance Services Research Group.

Planned Research activities for Year One of this plan include: Action 104: Delivery of RAPID / TIER / PARAMEDIC-2 / RIGHT-2 trials Action 105: Develop a work plan to support the R&I Strategy Action 106: Develop Intellectual Property Rights and revenue Sharing Agreements

6.6 Service Improvement

Our Service Improvement (SI) Team has an overall aim of supporting the Trust to spread good practice, and to increase its capacity for sustainable change.

The SI Team works alongside Public Health Wales, and in particular, the 1000 Lives Plus Programme, to improve patient care through the adoption of standardised methodology. The SI Team has consistently had two primary corporate objectives recurring annually. These are:

 to provide direct expert SI support to the organisation to improve certain systems of patient care; and  to establish a learning centre to support all staff in developing their own SI skills / knowledge, which will enable WAST to run numerous programmes of improvement.

The Service Improvement Team provides support within the context of the four underpinning principles of Prudent Healthcare and it supports WAST to change how services are designed and delivered so that patients are always put first. As a result of this ‘patient-centred approach’, the SI Team is part of the Medical and Clinical Services Directorate as outlined above. This enables the team to benefit from the clinical leadership of the Executive Medical Director, and engage in team working with other lead clinicians.

The focus for 2015/16 of this specialist resource was to:

 design a model for the demand generated by Card 35 processes (STEP 3 deliverable);  prepare CCC staff with the necessary skills and knowledge to adopt the revised response model – ‘go – live’ with the new response model from 01 /10/15 (STEP 3 deliverable);  design and create an ICT framework to enable staff to submit innovative ideas and receive timely feedback;  undertake a monitoring plan to constantly review the testing period of the new response model 01/10/ 15 – ongoing through to 01/10/16 (STEP 3 deliverable);  launch the ‘Sense Maker APP’ to test a method of capturing ideas from staff in real time – testing period until 31/03/16;

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 falls pathway for all paramedics to access community services on behalf of patients who are not injured / ill as a result of a fall;  referral process for all paramedics to inform a patient’s General Practitioner (GP) of resolved epileptic seizures and hypoglycaemia events;  Mental Health Pathway (tested in the Cardiff and Vale Health Board area);  development of a specific dispatch and transport service for the predictable demand of Health Care Professional (HCP) low acuity patient admissions to hospital; and  testing of a dedicated ‘Falls Response Service’ with a joint team of paramedics and community healthcare professionals (e.g. physiotherapists and occupational therapists).

Importantly, all frontline-led developments have been captured through the planning process for the IMTP with developments throughout local delivery plans for each Health Board area and directorates.

A governance process for supporting innovation for the Trust’s Five-Step New Clinical Response Model (or Patient Pathway) has been established. A structured approach has been created through the work of the Clinical Prioritisation Advisory Software (CPAS) Group, and the Clinical Pathways Advisory Group (CPAG).

Both groups are medically / clinically-led, and are the main fora for considering, supporting and developing new ideas / ways of working in relation to call handling and dispatching to calls (CPAS), and to delivering patient treatment and care (CPAG).

The principle objectives for the service improvement team for the period of this plan include: Action 107: Support the production of an external evaluation report on the new Patient-Centred Clinical Response Model (PCRM), by being the main point of contact for the organisation that is awarded the successful tender by EASC. Providing an independent and objective report that measures key elements of the innovative PCRM, which is likely to attract both national and international interest. Action 108: Design a web-based Ideas Portal to enable staff to develop ideas/innovations to improve Trust core business. The system design will ensure that all ideas are aligned to the Trust’s strategic objective of highlighting the importance of innovation across the Trust.

6.7 Health Informatics and Business Intelligence

Health Informatics provide information services to all facets of the organisation and are broadly arranged under the following functions: 1. Information services and business intelligence 2. Information governance & records management

As the Trust has re-orientated itself as a clinically-led quality-driven service, rapid transformation is reflected in the Trust’s business information assets as there is an increased dependency to continuously increase the access to, and analysis of, clinical and non-clinical information to improve and optimize decisions and improve patient care. We are already on a development pathway to better manage the Trust’s information assets - a best of breed data warehouse (Microsoft and Data Academy) has been in development over the past 6 years which includes data from mission critical systems such as CAD, Cleric and Clinical Solutions as well as CCC telephony and elements of information streams from Datix. A data warehouse-based clinical indicator monitoring system has been introduced since the digitalisation of the Trust’s patient care record in 2015, which is shown in

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the literature to have both clinical effectiveness and efficiency benefits as well as improved systems operating experience. Building on this work, the department will stabilise the existing information asset management in year 1 through improved governance structures and procedures, including setting up an information governance steering group. A key dependency will be on ensuring that data quality is a top priority for business units as well as clearly linking information outputs with the business processes underpinning them. A key work programme this year will be to support the Quality Improvement, Measures and Assurance system. Improving the organisation’s ability to realise the benefits of its information assets will include a review and investment in business intelligence tools as legacy information portals such as Launchpad are outdated and no longer reflect the business requirements. As such a business intelligence strategy will be developed which includes an immediate requirement to continue to develop the data warehouse. In addition to these requirements is the production of our organisation’s commissioning dataset for unscheduled care and non-emergency patient services to support the new commissioning agenda. As the roll-out of national and local commissioning arrangements continue, how we share information with our partners and regulators is rapidly changing. The department will continue to support internal and external capacity and service reviews such as the outcome of the New Clinical Response Model evaluation. The implementation of information tools such as Optima, CAD and the Signalsfornoise pilot will require resourcing from the department, the demand for which is unknown at this time. An important scheme of work has been to develop an information portal for how we locally engage with our communities which supports the benefits of prudent healthcare and coproduction. It is expected that this service will continue to develop over the lifetime of this 3-year plan.

Building on the foundations of year one, key features of year two and three will be:

 to support the clinical leadership structure with new information for clinicians to understand and develop their own and others’ clinical practice;

 to support better management and reduction of demand through new streams for health information to be delivered to support the self-care agenda in NHS Wales;

 to support CCC to embed a performance management framework into the new staff teams to deliver performance improvements which may require a rework of the existing information landscape and indicators;

 to supply information analyses to review of all dispatch points, engaging with the operational areas and reviewing zones and priorities will be key to ensuring the Trust is efficient and effective in its service operations;

 continue to support the strategic planning agenda, including modelling of options and scenarios, and

 ongoing support of the performance management framework, the reporting of performance information in quantitative forms and creating new information lenses through which to view initiatives such as clinical pathways and public access defibrillator sites.

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As such, key actions include: Action 109: Develop a long-term plan for new streams for health information to be delivered to support the self-care agenda in NHS Wales. Action 110: Develop a business intelligence strategy and associated programme of work for a long term roadmap of the management of information assets in the Trust. Action 111: Document a long-term plan to incorporate additional data streams into the data warehouse such as clinical data and risk management information. Action 112: Develop a data quality strategy that will maximise the completeness, accuracy and timeliness of clinical and non-clinical data within the Trust. Action 113: Develop a data dictionary coterminous, where relevant, to national data descriptors. Information Governance and Records Management We will strengthen the Trust’s Information Governance standards to maintain our clinical and corporate information’s confidentiality, integrity and availability. On an annual basis, every Health Board and Trust in Wales must complete the Caldicott Principles Into Practice (C-PIP) assessment in relation to Information Governance. The organisation is then provided with an outturn report that highlights areas of improvement for the following year. Whilst it is recognised that the Trust has increased its performance of this assessment from 34% to 82% over the past seven years, areas for improvement arising from this assessment and Standards for Health assessments include information governance management, information governance training and records management. In response to this, an Information Governance Steering Group has been established to formalise the management arrangements of information governance. Going forward, there will be a need to develop an Information Governance strategy and associated policies to ensure the Trust has a long term plan for delivery. In order to address the information governance training gap, the IG team has worked with the Trust’s education and training department to strengthen the arrangements for IG training at induction for clinicians and as part of mandatory ongoing training. In order to address the records management gap, a records and archives manager has been employed encapsulating the totality of the Trust’s records management resource. This work area is historically fragile and the scale of this programme is substantial. Work this year has delivered against a project to centrally store historical patient care records (PCR’s) of which there are circa 1 million. With minimal investment, the department has resolved a quarter of a million records to date and is forecast to double this figure during the first half of 2016/17. Building on this will be the need for a robust records management strategy and associated policies since there has been no corporate ownership or investment in records management previously. As an immediate priority, work to develop a Trust wide information classification system for the security marking and handling of information assets will be complete. A larger programme of work is to develop the Trust’s information asset register and to identify and take forward information asset owners for all facets of the organisation where electronic or paper records are stored. Priorities for this area include: Action 114: Develop an information classification system for the security marking and handling of information assets. Action 115: Develop an Information Governance Strategy and policy directory to strengthen Information Governance Management. Action 116: A baseline review of the Trust’s records through inventory and information asset owner’s directory to create a central register of records.

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Action 117: Implement at Trust wide Records Management (RM) policy and framework, which complies with the legislation and regulatory standards (ISO 15489).

6.8 Information Communication & Technology (ICT)

Over the life of this plan, the vision of the ICT department will be to support the Trust’s strategic transformation and modernisation agenda through providing Trust staff with an electronic, patient- centred view of information in order to support high quality care. The high level strategic priorities for the ICT department are as follows:  Maintaining and improving the ICT Infrastructure To support the transformation of the Trust, a robust and resilient ICT infrastructure will be required as a greater reliance is placed on electronic information and the ability to access such information by increasing numbers of staff. Future plans must be in place to ensure we have sufficient flexibility within the ICT Infrastructure to scale up to meet this demand.

Action 118: Improve and enhance the ICT infrastructure to provide a basis to support the implementation of new systems and solutions including the greater use of mobile and remote working technologies which will enable staff to access relevant information at the point of care and away from their ‘base’. (Years 1, 2 & 3).

The Trust’s ambition to ensure all staff have easy access to an electronic device will lead to a significant improvement in two-way communications. This will enable greater and quicker compliance with information such as clinical notices, but will also enable provision of support through, for example, a health and well-being App. Mobile devices will also support clinical decision-making when caring for patients by providing electronic access to tools like the Paramedic Pathfinder and alternative care pathways for treatment. Action 119: As reliance on ICT systems and electronic information increases, there will be a need to review and revise business continuity and disaster recovery procedures to ensure robust safeguards are in place (Years 1, 2 & 3).

 Working with corporate departments to improve operational information systems We will work across all areas and programmes within the Trust to improve current operational information systems while ensuring they meet the needs of the Trust and, as far as possible, comply with national standards. In conducting this work, we will ensure that data quality is critical as the information needs to be up-to-date, accurate, and available wherever care is being delivered. Making this a practical reality is a significant challenge in light of the continued reliance on paper records, the number and variation in IT systems in use across the Trust and the level of investment in technology required to enable and sustain change and modernisation

Action 120: Work with colleagues within the Trust on implementation of operational and business solutions and to enhance the capability of current systems. o implementation of the new CAD (year 1) o Implementation of a NEPTS planning and coordination system to replace the existing CLERIC system (year 2).

Action 121: Delivery of the Emergency Services Mobile Communication Programme (ESMCP) having started will see a need to mobilise a Trust project to support implementation

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of the Emergency Services Network (ESN) and associated works for the Trust.(Years 1, 2, 3)

Action 122: We will also look to commence work on a potential replacement roster solution (Year 3)

 Improve information sharing and collaboration by working with partners across health and other sectors We will work with other Health Boards, Trusts and NWIS to share patient and clinical information. In the short to medium term, the approach will be to identify opportunities that maximise the benefits of investment in existing information and technology in order to provide more joined-up clinical information to Trust staff at the point of service delivery. Action 123: Work with colleagues in ABM and the wider NHS along with key suppliers to deliver and support the introduction of 111 pathfinder project (Year 1) and to implement a new patient management system to support the national 111 service to replace the existing CAS system (year 2& 3).

Action 124: Work with NWIS to provide access to national information resources, such as the Master Patient Index (eMPI) and Individual Health Records (IHR) as well as investigating options to provide Trust information into national repositories, such as Welsh Clinical Records Service (WCRS) and national systems such as EDCIMS and CCIS. (Years 1 and 2)

 Improve staff access and patient engagement and access Considerable technological advances and mobile coverage improvements over recent years have presented an opportunity to promote and develop a greater use of mobile and remote working technologies which will enable staff to access relevant information at the point of care. We will need to ensure that systems are capable to supporting mobile and agile working within the Trust and similarly ensure appropriate choice of end user devices to carry out routine tasks. Opportunities will arise to investigate options around ePCR as ESMCP will improve mobile coverage and the initial three-year Digi-Pen contract will be due to expire.

Action 125: As Microsoft support for Office 2007 is due to end we will need to be upgrade Office in order to mitigate any security risks and capitalise on modern functionality which will support the provision of remote and mobile working for operational staff.

Action 126: Review options around ePCR as the initial 3-year Digi-Pen contract will be due to expire (Year 3) Similarly, we will also look at leveraging these technological advances to improve patient accessibility to Trust services through deploying a wider range of services securely via the internet to better direct patients and the public to the care they need at the right time, thus supporting the prudent healthcare agenda. Action 127: We will work with colleagues across the Trust to look for opportunities to maximise the benefits of patient self-service (Years 1, 2, 3).

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 Develop the skills and professionalism of ICT staff In order to achieve this ambitious programme of work, it will be essential that ICT staff are given the appropriate skills to ensure they are equipped to play their part in supporting future developments and technologies. Action 128: Conduct a baseline of the current skills and abilities of ICT staff and identify any gaps in key technology areas. Develop a structured development programme for each member of staff (Years 1, 2)

6.9 Partnerships and Engagement

Our recently refreshed purpose and vision statements emphasise our values, which involve caring for our patients and staff and securing improved outcomes for those who use our services.

Achieving improvement is not just a function of process, organisational or system change. It is predicated as much on working with our employees, our patients, the wider public and our stakeholders to shape change, to help us understand what’s important to our staff, the people we serve and our partners and to develop our services in a way that genuinely reflects the needs of our population.

It is only by working in this way that we will begin to move away from a culture predicated on today’s issues, to one where we are focused on tomorrow. We now need to move forward this agenda with pace, discipline and cohesion if we are to realise the substantial organisational gains which effective partnership and collaboration offer.

This means looking at how we work together to build mutual understanding and support to create better, more productive relationships and more resilient communities: ultimately, to, deliver better services for the people we serve.

We have a unique role in the Welsh NHS as a bridge between two significant elements of our public services, the NHS community and the emergency service, blue light family.

We are committed to working with our emergency service partners (and our current activities are outlined in section 5 (STEP 2), section 5 (STEP 3), section 6.3 and section 6.10.). We want to do this in an even more collaborative and integrated way, identifying shared opportunities to learn and work together. How we do this in a way that adds value for the people we serve, and for our respective employees, remains an important debate for us that we will need to conclude and deliver on within the lifetime of this IMTP.

Wrapped around this whole agenda is our wish to be a more open, communicative organisation that tells its story better through our employees, our patients, the media and to politicians. We hope that, in so doing, we can develop a shared understanding of the improvement journey we have embarked upon, what it means, why it's important and how everyone can support us to deliver an ambulance service of which everyone in Wales can be proud.

During the last 12 months, we've started to redefine our future, but there's still much work to do.

While our engagement activities straddle a number of Director level functions, for example Quality, Safety and Patient Experience and Workforce and Organisational Development, the Trust has also established a new Directorate of Partnerships and Engagement, the purpose of which is to bring coherence and strategic insight to the Trust’s engagement and partnership agenda, as well as protecting and enhancing the reputation of the Welsh Ambulance Service among its many stakeholders.

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This agenda, for the first time, now has prominence at Board level through the Director of Partnerships and Engagement and demonstrates the Trust’s commitment to working more effectively and collaboratively with stakeholders to deliver tangible organisational and service benefits.

Analysis As an organisation, we have recognised that the risks of not engaging better outweigh the risks of maintaining the status quo, but this does not mean that the engagement journey will be smooth. Financial pressure across the public services, coupled with increasing demand for healthcare, including ambulance services, means that, while the need for collaboration has never been greater, the risk of organisational retrenchment poses a real threat, both by WAST and our partners. Strong leadership and organisational courage will be needed to ensure that we deliver what is needed to move us away from an organisation focused on the problems of today, to one which is redefining its purpose as a clinically-led service on the frontline of emergency, pre-hospital and scheduled care. Similarly, the organisation’s tendency towards silo working is a risk in engagement terms, which is why the development, delivery and evaluation of an engagement strategy which has a broad base of support across the organisation, and from stakeholders, will be so critical to the success of this work. Feedback from patients and the public provides a rich seam of organisational insight that is currently underutilised in the decision-making process. There is a huge opportunity to triangulate data from patient experience, including concerns, staff, stakeholders and others to give the organisation an insight into its strengths and weaknesses and to identify opportunities for further development and collaboration. Partnership and Engagement Priorities for 2016/17 – 18/19

Our objectives in delivering a refreshed approach to partnership and engagement are:

 To deliver better services to the people we serve  To position the Welsh Ambulance Service at the forefront of public service collaboration  To add operational capacity within the organisation and reduce demand on services through better public engagement and education  To improve our reputation and restore public/political confidence in our ability to deliver

Given the all-Wales nature of the organisation, and the elevated temperature that often surrounds the wider unscheduled care system and the performance of the Welsh Ambulance Service particularly, the significance of positive engagement with our staff and partners cannot be overstated.

One of our primary goals over the lifetime of this IMTP will be to develop an integrated approach to engagement that allows the organisation to systemise its engagement more effectively, identifying clearly the outcomes it is seeking to achieve through partnership and collaboration.

Part of this will be to ensure that the principles of effective partnership and engagement underpin organisational priorities and that the organisation actively seeks opportunities to optimise its delivery through identifying appropriate and realistic opportunities to work collaboratively with partners.

Similarly, in galvanizing staff around new ways of working and developing the organisation into one that is genuinely clinically-led, the involvement of colleagues will be key. This must be

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complemented by a robust and comprehensive approach to listening to our patients and wider stakeholders, providing mechanisms for their experiences and ambitions to be heard and keeping them involved in our improvement journey in order that they understand what needs to change, why and how they can help.

Importantly, the Trust will develop mechanisms to source, triangulate and interrogate stakeholder intelligence in order that the organisation has its finger very firmly on the pulse.

While the challenges we face are not necessarily easily segmented by stakeholder, they centre on a number of key areas. Detailed below are some indicative actions that we will be taking in the partnership and engagement realm over the life of this plan. Please note that this summary section of our engagement priorities set out below should be read in tandem with the relevant more detail sections, e.g. Workforce (section 6.1) and Quality (section 4).

Workforce  Listening to our staff using a variety of face-to-face, digital and other tools and working with them to develop new models of care/ways of working which are supported  Ensuring our people are advocates for the service and feel confident in advising patients and the wider public on lifestyle choices and use of NHS services, using the “Making Every Contact Count” model. This means ensuring colleagues understand the priorities and ambition of the Welsh Ambulance Service as one which is clinically-led and has a public health remit. This approach will support the Service’s demand management activities  Ensuring our staff understand their contribution to delivering our objectives through a robust process of PADR and that they are involved in shaping our services and the way in which they are delivered  Ensuring that staff understand the importance of listening to patients, that it is everyone’s business and that we provide them with the right tools and training to do so  Ensuring the experiences and views of patients are fed back to staff, good and bad, so that staff have an opportunity to reflect on and understand what it feels like to be a Welsh Ambulance Service patient, helping to inform their clinical practice and communication skills  Ensuring our policy development agenda is informed by feedback from staff  Ensuring our relationships with recognised trade unions and professional organisations are predicated on mutual respect and understanding and are underpinned by a culture of partnership

Patients  Listening to the experiences of our patients and learning from them in a way that actively influences service delivery, including those from seldom heard groups. This will include reporting patient experience feedback in the right format and fora to influence decision- making  Ensuring that the tools we use to measure patient feedback are sufficiently robust and diverse and that we analyse feedback data in a systematic way. This will involve a review of how this is currently undertaken and any necessary changes made  Ensuring that we are triangulating all the patient feedback we receive, be that via concerns, compliments, serious incidents, media coverage or other sources to ensure we understand what our patients are telling us and sharing that across and beyond the organisation in a systematic way  Ensuring that the Board and leadership team review patient feedback regularly and that it is reported in an open and transparent way  Ensuring we publicise to patients, staff and the wider public what we have done in response to the feedback we have received. We will undertake a review of current practice to ensure we are doing this well  We will analyse how well our online tools work by reviewing how patients use the NHSDW website and analysing its potential and use as a call attendance/avoidance mechanism (i.e.

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does it serve a preventive purpose?). We will do this by working in partnership with colleagues across the unscheduled care system to understand the journey of our NHSDW patients across the unscheduled care pathway

Public  Supporting members of the public to understand our ambition and our New Clinical Response Model, as well as the wider unscheduled care system, so that they understand when and how to use the services we provide by reviewing and refreshing our approach to communicating our New Clinical Response Model and ambition  Engaging the public in widespread and varied conversations, embracing the full range of groups, ethnicities, ages and genders, to stimulate debate and mutual understanding on the role of the Welsh Ambulance Service in the wider health system by seeking opportunities to collaborate with partners on appropriate opportunities,  Ensuring our engagement methods are diverse and robust, embracing social media, face-to- face and more traditional methods to seek and provide feedback  Ensuring that our engagement activities are aligned with organisational objective and support the needs of operational staff by regularly reviewing work programmes and sense checking against organisational requirement

Stakeholders  Optimise the use of our resources for the benefit of the people we serve by identifying and exploring opportunities to work more collaboratively with partners to deliver better services for people in Wales  Build trust and confidence in the Welsh Ambulance Service as a respected and dependable partner that is innovative and open to collaborative opportunities. We will do this by delivering on our commitments and being a visible and present partner in key public service arena  We will work with our political and media stakeholders to uphold the reputation of the Trust by celebrating our successes and being open and transparent where improvements are needed, and by responding in a timely fashion to requests for information, data, concerns, media enquiries etc  We will map our engagement activities using an engagement database to ensure we are working in an equitable fashion across Wales and that we are capturing the feedback from stakeholders in a way which informs future interactions

Evaluation In adopting a revised approach to collaboration and engagement, it is important that the impact of these changes is understood and kept under regular review. In this respect, the planned Engagement Strategy will set out how, and at what intervals, work in this area will be reviewed so that outcomes are evaluated and any issues identified at an emerging, rather than at a potentially critical, stage. As the IMTP is a living document, so its various iterations will continue to refine what and how we “do” engagement, so that it keeps pace with organisational and stakeholder requirements. Action Plan Action 129: Agree a definition of engagement internally to avoid ambiguity and to provide organisational clarity (2016/17) Action 130: Review engagement activities taking on board the views of stakeholders as to their effectiveness (2016/17)

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Action 131: Review organisational structures to ensure that the organisation is set up to deliver its engagement agenda effectively (2016/17) Action 132: Agree at Board level its collaborative priorities for the period 2016/17 to 2018/19 (2016/17) Action 133: Introduce a system of stakeholder account management to ensure consistency of approach and contact at Director level (2016/17) Action 134: Develop and deliver an engagement strategy which outlines our partnership and engagement priorities and identifies a system for collating feedback and feeding this into the decision-making process at Executive and Board level (2016/17) Action 135: Agree and deliver one key priority with its top 6-10 stakeholders in 2016/17 and repeat in 2017/18 and 2018/19 Action 136: Undertake a baseline stakeholder assessment in 2016/17 and subsequently in 2017/18 and 2018/19 to track progress against objectives Action 137: The Board to agree the introduction of collaboration as a fundamental operating principle against which organisational developments will be measured (2017/18) Action 138: Continue the work in progress measuring Patient Experience to inform us what it is like to be a user of Welsh Ambulance Services (and identifying issues affecting all communities within Wales)

Action 139: Real time capture of patient experiences o reporting themes o working with colleagues to identify and implement learning o identify services changes/benefits o feedback to patients/service users of changes

Action 140: Work with other emergency response organisations such as the fire service and police force to consider how we better interface to streamline response and meet community needs

Action 141: Collaboration with NHS colleagues and voluntary/3rd sector organisations on shared capture of patient experience; learning and actions to improve experiences of the NHS care/treatment pathways

Action 142: Integrated reporting of all methods of patient/service user feedback. Action 143: Develop a Patient Experience Diagnostic Tool to measure where the Trust is against best practice in patient experience, engagement and learning.

6.10 Corporate Governance and Risk Management

In simple terms, governance refers to the way in which organisations ensure that they are doing the right thing, in the right way, for the right people, in a manner that upholds the values set for the Welsh public sector. The Board has overall responsibility for ensuring good governance within the Trust. The Board is responsible for setting strategic direction and satisfying itself that there is a good system of

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governance and internal control in place, underpinned by an effective risk management system. The Board will oversee the delivery of the Trust’s Strategic priorities and the non-executive members of the Board will hold the Executive Team to account for performance and delivery. We recognise that the effectiveness of our governance arrangements has a significant impact on how well we meet our aims and objectives. We also recognise that, as the Trust evolves and grows, so too must our governance systems and processes. As a consequence, during 2016/17, a great deal of emphasis will be placed on ensuring that our governance and risk management systems are fit for purpose and have or are adapting to meet the considerable strategic and operational changes taking place within the Trust. Such changes include the New Clinical Response Model, the new 111 non-emergency helpline and the revised management arrangements around the Non-Emergency Patient Transport System (NEPTS). Work has already begun to strengthen the governance and risk management frameworks. This includes the delivery of a Board Assurance Framework, a review of the groups and sub-committee structures that support the Board and Board Committees, and a review of the risk management arrangements, including the corporate risk register. The outcome of this work will be seen and introduced during 2016/17. Additionally, in October 2015, the Trust Board commissioned an internal review of the governance processes and in November 2015, agreed seven key areas of improvement. The Board agreed to implement a revised Board assurance and risk management framework over the lifespan of this plan aiming to form an integral part of the successful delivery and sustainability of the following set out below.

 Integrated Medium Term Plan (IMTP) & programmes of change  Organisational Development Strategy  Planning & performance management framework  Quality Improvement Strategy 2016-19  Research & Development Strategy 2015-19  Clinical Audit Programme  Meeting Commissioners requirements through the Commissioning Quality & Delivery Framework (CQDF) – CAREMORE® Framework Patient Care Pathways and Core Requirements and  Inform the Annual Governance Statement.

Action 144: Implement and embed the Risk Management Strategy & Framework 2016/19 approved at Trust Board in March 2016 and assess maturity in 2017/18

Action 145: Develop a Board Assurance Framework (BAF) document mapped to the strategic aims and priorities

Action 146: Development & embedding of the content and breadth of the new Corporate Risk Register (CRR) and Local Risk Registers (LRR) with central oversight, monitoring and reporting

Action 147: Review the effectiveness, reporting and monitoring arrangements of groups sitting below sub-committee level.

Action 148: Implement a document management system with supporting policy and guidance.

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Action 149: Undertake a Trust-wide safety culture assessment

Action 150: Development of Datix as the supporting infrastructure for the management of risk and concerns, monitoring of improvement plans and sustainable organisational learning.

Risk Management and Risk Appetite

The Risk Management Strategy & Framework 2016/19 was approved by the Trust Board in March 2016. This document describes the approach the Board will take in developing its risk appetite and tolerances in relation to the strategic aims and priorities for 2016/17. This will link to the development of the Board Assurance Framework document. Whilst risk is inherent in many of our activities, the Trust will not accept risks that materially impair the ability to deliver services to a high standard of safety and quality. As such, the Trust will not accept risks that materially impair its reputation or cause any disrepute with stakeholders.

In common with other NHS providers, the Trust is limited in the extent to which it is permitted to use public funds to reduce/eliminate risks. This is a major influence in determining the risk appetite of the Trust.

Meeting our Statutory Obligations: As an organisation we have a rage of statutory obligations many of which are documented in our standing orders. Under the Civil Contingencies Act 2004 (CCA) Category One responders (such as WAST) are also subject to the following set of legal civil protection duties:

 risk assessment;  emergency planning;  business continuity planning;  warning and informing;  information sharing; and  co-operation.

As part of discharging these duties during the life of this plan we will undertake the following actions; Action 151: PREVENT training (counter terrorism) Action 152: Tier One Multi-Agency Exercise Action 153: Re-write of the Trust’s Major Incident Plan to meet best practice Action 154: Commander Competency training and roll out of National Occupational Standards

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PART 7: DELIVERING OUR PLAN

This section describes our localised approach to planning and how we will deliver our plan, including scrutiny and performance management.

7.1 Approach to Planning The Trust has adopted an integrated planning approach for development of this and future IMTPs. This approach recognises that the Trust will be able to better develop clear medium and long term strategic objectives which in turn frame the development of short, medium and long-term service improvement plans. The trust is fundamentally changing the way in which it has “done planning” over recent years and is guided by the following key principles:

 ensuring a clarity of purpose, vision and priorities to shape the plan and Local Delivery Plan (LDP) process;  board engagement through all stages of plan development;  prudent healthcare and the new Quality Strategy as a golden thread throughout the plan;  a multi-disciplinary group overseeing the planning cycle;  using a wide stakeholder group to explore action against the five-step model;  early and detailed work on the financial baseline position, exploring opportunities for further efficiencies, using benchmarking, analysis and peer review to challenge the organisation;  improved alignment across the service, workforce and financial elements of the plan through the IMTP delivery group and senior planning, workforce and financial input from the outset and throughout;  built on improved modelling of activity and demand;  informed by and aligned to the strategic planning agenda across wider NHS Wales (for example the Mid Wales Collaborative, South Wales Programme, joint work with Fire and Police service);  consolidation of the critical national policy and legislative drivers that will impact on WAST over the three year period, the impact of the Well Being and Future Generations Act, the Well Being and Social Services Act and the outcome of the Green paper consultation;  early and ongoing engagement with key partners and stakeholders;  early and ongoing engagement with our Partnership forums;  building on the benefits and credibility of having a clear New Clinical Response Model whilst demonstrating ambition in terms of future opportunities; and  reflecting the strengthening relationship with and influence of the collaborative Commissioning Quality and Delivery Framework.

This is a maturing approach, an approach that the organisation remains committed to however recognises that it will be a number of “cycles” before the organisation is entirely comfortable with the nuances of this sort of approach. Nevertheless significant strides have been made.

7.2 Plan Delivery

The organisation has developed a very strong delivery focus, which has been developing year on year since the Strategic Transformation Programme in 2014.

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Over the course of the last two years the organisation has sharpened its focus on a number of key principles:

 a programme and project management model that tracks performance/delivery against plans;  a reinforced approach to managing all activities with robust governance and focused performance management; and  an overarching delivery framework that supports delivery by specialist advice and a programme infrastructure and support.

We have identified four strategic change programmes that will support and drive delivery, in a co- ordinated way, of a number of the actions contained within this plan. These programmes have previously been identified in section 5 but for clarity are;

 Clinical Modernisation  Clinical Contact Centre Modernisation  Non-Emergency Patient Transport  111 Pathfinder Project

We have also created a Planning and Business Intelligence group that is intended to be a permanent business structure and an Executive Finance Group. An overview of the structure we are putting in place can be seen in Figure 30 below. A deep dive into the individual programme structures can then be seen in appendix 8. Finally Figure 31 below offers a little more detail on each of the programmes and group we have put in place. This structure does not abandon the delivery mechanism that currently exists, which has been driving strategic change within the organisation. Rather it has taken lessons and built on the existing structures to ensure focus is retained, bureaucracy is minimised and the chances of success are maximised. We have taken direct scrutiny of change management out of the Executive Team forum. This scrutiny is now undertaken by a Delivery Assurance Group. We nevertheless recognise the importance of the Executive Team retaining a line of sight of the holistic delivery of change thus this assurance group will report on a monthly basis to the Executive Team. The Trust Board will also receive strategic change updates (and wider IMTP implementation updates) in line with NHS Wales planning guidance. The delivery assurance group will be chaired by the Director of Planning and Performance. Membership will constitute the senior responsible owner (SRO) and programme manager for each programme of work along with representatives from other key areas across the organisation. The high level purpose of the group will be to:

 Ensure programmes deliver within agreed parameters (time, resource and scope)  Resolves strategic issues between programmes  Makes resource decisions in regards to delivery  Give approval (or not) of key milestone outputs and authorisation to proceed to next phases.

We have been careful to build a delivery structure that offers assurance and rigour to the complex process of change management; however we have balanced this with a structure that is capable of managing and adapting to the dynamic environment within which we, and the wider NHS in Wales, operate within. Consequently this structure might evolve further overtime.

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Figure 30

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Figure 31

Clinical Modernisation Programme

Purpose

The purpose of the Clinical Modernisation Programme is to drive and ensure performance of the New Clinical Response Model during the 12-month pilot, which started on 1 October 2015. The impact of the New Clinical Response Model will be monitored and managed using a revised set of performance measures and clinical indicators; this will include the impact on service users to ensure delivery of high quality care and a positive service user experience. The Clinical Modernisation Programme Board will oversee implementation of the New Clinical Response Model, ensuring it is clinically-led and managed in a systematic way, including monitoring progress against agreed milestones.

The Programme is designed to support the recommendations of the McClelland Strategic Review of Welsh Ambulance Services (2013) and is aligned to the NHS Wales agenda; Our Plan for a Primary Care Service for Wales up to March 2018 (2015), Health and Care Standards (2015) and Prudent Healthcare Principles.

Actions which the programme will own Actions 18, 19, 24, 25, 28, 30, 31, 32, 33, 34, 35, 36, 37, 38, 40, 44, 45, 47, 62, 126

The programme will be structured to mirror that of the New Clinical Response Model, i.e. STEP 1 help me choose project, STEP 2 answer my call project….. The programme will own a range of actions across the New Clinical Response Model.

Clinical Contact Centre Modernisation Programme

Purpose Clinical Contact Centres are at the heart of the organisations operations. This programme has been designed to oversee the vast transformation and modernisation of processes, infrastructure and practices that currently exist within the function. There are many inter-dependencies associated with modernising our CCCs and this programme Board will have a key role to play in managing both internal programme dependencies and also the dependencies which exist with other change programme. Actions which the programme will own Action 23, 26, 100

Non-Emergency Patient Transport Programme

Purpose A NEPTS implementation programme board has been created to directly oversee the recommendations of the NEPTS business case which was approved by the minister in January 2016. It will have direct oversight for a number of work streams that will each individually focus on a number of the recommendations.

Actions which the programme will own Action 48, 49, 50, 51, 52, 53, 54, 55

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111 Pathfinder

Purpose

This programme represents the pre-existing Joint Implementation Group (JIG) which exists between the Trust and the 111 Pathfinder project team. Actions which the programme will own Action 27, 123

Executive Finance Committee

Purpose To lead and oversee the delivery of the Trust’s financial plan.

Planning and Business Intelligence

Purpose To ensure all work associated with demand prediction/capacity assessment, strategic development intelligence etc. is captured by a focal point within the organisation and can be reviewed, examined, challenged and shared with the result of the organisation in a coordinated and coherent manner. This group will both;  Act as an enabling function to the four change programmes  Represent a permanent business structure to support management of core business

Those actions we have committed to in this plan that do not map to one of these strategic change programmes are being managed ‘internally’ by the relevant Directorate as part of their business as usual activities. Scrutiny of delivery will be managed via renewed Performance Management arrangements that aim to embed a culture of performance improvement. An overview of the performance hierarchy and escalation process within which all these actions are to be managed is shown below in Figure 32.

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Figure 32

Annual Report

6 Month JET Review

Quarterly Assurance Reports

Integrated Performance Report & Programme Reports (monthly)

Directorate Performance Reviews (inc Heads of Operations)

In month reports

1:1s and PADRs

Assurance- Performance and Management

From the 1 April 2016 we will be implementing a set of core performance management principles that over the course of Q1 and Q2 of year one will be formalised into a fully agreed Planning and Performance management framework for the organisation. The purpose of the framework will be to support the delivery of the right clinical care at the right time through good planning and performance improvement, in particular, improved patient flow and effective resource utilization. A good Planning and Performance Improvement Framework should help front line staff do their jobs and help remove barriers that are preventing them from giving their best.

7.3 Risks and Issues to plan delivery

It is recognised that every action identified in this plan has risks and issues attached to delivery and these are highlighted at a high level in appendix 5. Action owners will be actively managing these risks/issues and mitigating them to a tolerable level. The performance management arrangements identified above will then ensure the appropriate escalation where necessary. However there are a number of overarching risks and issues that exist in relation to plan delivery. These are documented below.

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 Political Landscape. The life of this plan will see both a Welsh Assembly election and a referendum on the UKs membership of the European Union. Both could have consequences for the organisation, the targets to which we are expected to perform and our strategic direction.

 The wider unscheduled care system in NHS Wales. We are a vital partner in the unscheduled care system within Wales and we must work closely with all other stakeholders to re-engineer the system. The system is under pressure and at periodic points throughout the year escalation levels are such that delivery of our plan will face some risks, as will delivery of LHB plans. We are committed to working with our LHB partners and WG to better plan for these peak times (through the Seasonal planning process). Our plan will be sensitive to these risks and we will work agilely and proactively to mitigate.

 A commissioned service. We recognise that we are a commissioned service and must be responsive to the collaborative commissioning arrangements, including any decisions regarding performance and funding levels. We have a good relationship with the Commissioner and will endeavour to maintain this, however planned delivery is dependent on being commissioned to the level that we have assumed.

 Planning assumptions. In developing our plan we have had to make some explicit assumptions (section 6.2 details our financial assumption for example). These assumptions have been in relation to our finances, performance targets, availability of capital, no significant changes to demand etc. Should these assumptions not prove to be accurate, we will have to revisit sections of the plan. The sensitivity if each assumption may vary. We will use the demand and capacity modelling exercise to test the sensitivity of the assumptions through what if scenarios. Our financial planning assumptions have been shared with our Commissioner repeatedly and the advice has been that these were reasonable and in line with what other NHS Wales organisations are assuming. Many of the risks and sensitivities to our workforce and other plans have been referenced throughout this plan. These include:  Recruitment of sufficient numbers of EMS staff.

We have already described our intent to maintain a focus on the recruitment of qualified paramedic and other frontline staff whilst further work is done to understand the true picture of demand and capacity of our services across Wales. There is a national challenge to the recruitment of qualified paramedic staff, and our education commissioning numbers are just about sufficient to ensure adequate supply of qualified staff provided we are able to secure employment of the graduate paramedics. The move to a degree requirement for future paramedics may also impact on our current career pathways and supply channels of EMTs converting to paramedics. Failure to recruit in sufficient numbers will result in the continued use of overtime and external providers at premium costs to support operational delivery.

However, to date we have been successful in our recruitment plans, and we will continue to target our recruitment activities and plan our training courses appropriately. This work is supported by the work of the recruitment task and finish group plans to further streamline the recruitment process reducing time to hire, and to develop a national recruitment/advertising campaign, promoting the advantages of our New Clinical Response Model and of joining #TeamWAST, to ensure sufficient numbers of high quality applicants into the future.

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 Band 6 for paramedics

At UK level there is a push by Trade Unions to gain a band 6 grading for qualified paramedic staff. Whilst this may result as an introduction of a degree requirement in the future, we are increasingly seeing different UK ambulance services introducing Band 6 roles and/or career pathways into their existing structures. For some English ambulance services who have Foundation Trust status, this is easier to do as they have increased flexibility to manage and make changes to A4C terms and conditions.

In WAST we are committed to working with our trade union colleagues through 2016/17 to explore the possibilities of new roles described in section 6 of our plan, and will be seeking to develop the career pathway and create more opportunities for our paramedic staff to work at a Band 6 level. There is clearly a cost implication to any potential development, and this will need to be modelled and assessed, including consideration and identification of funding sources to support any developments in discussion with our Commissioners and any increased flexibility that may be needed to address constraints offered by existing terms and conditions structures.

 Constraints on capacity within the National Ambulance Training Centre (NATC)

There is a regular review of training timetables and constraints to delivery within the National Ambulance Training Centre (NATC) as part of the ongoing workforce planning process. This enables us to ensure capacity to deliver training courses can be matched with demand going forward and there is sufficient flexibility within the resource to accelerate timetables where required in the future. However, our current staffing levels do not benchmark favourably against other Ambulance Services, and there is a need to review current staffing ratios and potential alternative models to delivery. This is described further in section 6 of our plan.

 Further work to ensure robust vacancy and establishment control at locality level

A process of quarterly review and monitoring of establishments takes place through the workforce and finance teams. At present this is still reliant upon manual intervention which increases the risk of error. The data used and ease of process has already been significantly improved upon following commencement of the new Workforce Information Systems Manager. However there is still much work to do to improve the quality of the data within the ESR system and systems of control and reporting of workforce data required for planning and performance management purposes. We expect this work to be completed by September 2016.

 Whole System pressures and impact on workforce and workforce target

We are listening to our staff who tell us of the impact that the pressure across the whole USC system is having upon their work-life balance, morale and heath. As a result, there is a risk that continued and sustained demand across the system will impact on our ability to recruit and retain qualified staff, and spikes in demand and increased pressure also impact our ability to meet our sickness targets.

Our Risk Management Strategy, approved in the Trust Board of March 2016 (a priority from our 2015.16 Plan) will be key in helping us to manage these risks and continuously review their impact.

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7.4 Engagement and approval arrangements

The Chief Ambulance Services Commissioner was provided with a copy of the first formal IMTP submission to Welsh Government at the end of January 2016.

Discussions then took place through January and February with both the Chief Ambulance Services Commissioner (CASC) and the chair of EASC to agree a mechanism by which this plan would gain both parties support. It was agreed that the final plan would not go before a full EASC committee. The following roadmap though was agreed so that assurance on the plan would still be achieved:

 through February and March regular fortnightly meetings were arranged between the Director of Planning and Performance, the Assistant Director of Finance and the CASC to apprise the Commissioner on the development of the plan and to take, and respond to, feedback;  a further copy of the full plan to be shared with the Commissioner’s office on the 10 March inviting any further comments; and  subject to the CASCs views a letter of support of the plan to be received from the Commissioner that can be shared with Trust Board at the open meeting where they will discuss, and agree, the plan and subsequently Welsh Government as part of final plan submission. 7.5 Internal Planning model and cycle

Planning the re-fresh of the 2017/18 – 2019/20 IMTP is a critical element of the continued transformation of WAST and will signal the continued shift towards a front line lead, creative approach to strategic planning and delivery rather than a “top-down” executive level document. Recognising that the organisation needs to change its approach to planning; moving from the more centralised approach in 2015/16 to an approach that fully engages internal and external stakeholders a planning timetable for 2016/17 has been agreed, this takes learning from the 2016/17 cycle and recognises that WAST still has a maturing approach to planning.

The planning cycle will commence with an Executive Team away day in May and provide the forum for Executive team to consider:

 feedback on the refined purpose, vision, aims & behaviours;  strategic context;  organisational context – financial, workforce; and  the organisation’s eight priorities.

An Integrated Planning team will be re-convened to drive the day to day delivery of a robust and approvable refreshed IMTP. The team will include representatives from:

 Strategy, Planning and Performance;  Quality;  Operations;  Health Informatics;  ICT;  Workforce and OD; and  Finance.

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The high level milestones for plan development are outlined below and will be underpinned by a more detailed development plan.

The timetable for developing the 2017/20 IMTP:

Date Forum Purpose June / July 2016 Executive Team Away Day  Lessons learnt  Review of strategic priorities  Finance  Workforce  Emerging wider NHS Wales / blue light services planning issues Beginning June/July 2016 Establish IMTP Delivery To lead development of Group IMTP August – October 2016 Development of organisation To begin the ‘front line lead’ Local Delivery Plans (LDPs) approach to planning in the organisation which will WAST Interdependency inform the subsequent re- workshop fresh of the IMTP.

September – October 2016 Initial plan development To begin the re-fresh of the IMTP October 2016 NHS Wales Peer Review To share, learn, challenge, scrutinise plan development with other Health Boards and Trusts. October – March 2016/17 Plan refinement to include To progress the production of- development of the IMTP

 1st draft for sharing with Trust Board and Welsh Government.

 Final draft for Trust Board and Welsh Government approval.

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WAST IMTP 2016/17 – 2018/19 APPENDICIES

Appendix 1: Emerging performance issues arising from the first publication of the AQIs Appendix 2: CAREMORE® service change ideas currently agreed with EASC Appendix 3: NHS Wales Strategic Change agenda milestones Appendix 4: Mid Wales Healthcare Collaborative (MWHC) – Key actions Appendix 5: Summary of Health Board and Trusts IMTPs integration with Appendix 6: Supporting information relating to documented actions Appendix 7: WAST 2016/17 Discretionary Capital Plan Appendix 8: Strategic Change Programme structures

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APPENDIX 1 Summary of some of the emerging performance issues arising from the first publication of the AQIs.  STEP 1 – Help me choose WAST has a good Partners In Health Team who undertake a good number and range of community engagement events, but consideration needs to be given to a public education programme regarding the whole unscheduled care system. A more systematic approach to STEP 1 must include consideration of how the NHS direct Website is used for conveying our message – NHSDW has around 300,000 unique hits a month. The Trust has made good progress in establishing a frequent caller team and actively managing this cohort of patients, many of who are vulnerable adults. Further work will need to be undertaken in 2016/17 on expanding this approach. Across NHS Wales our collective aim must be to reduce calls through a clear and effective education and engagement approach.  STEP 2 – Answer my call “Hear and Treat” rates (NHSDW and Clinical Desk) are improving, from a low base and are now just over 5% and expected to hit 5/6% in the first half of 2016/17; however the UK average is circa. 10%, so there is room for improvement. We should be aiming to increase “Hear and Treat” rates and thus reduce (unnecessary) attendance at scene. Future iterations of the AQIs and Benchmarking Toolkit are likely to highlight variation in terms of time to answer call and call abandonment rates that we will seek to improve.  STEP 3 – Come to see me In the January AQIs release RED performance for the first three months of the New Clinical Response Model was 70.6%; however the 95th percentile (for December 2015) was 16.44 minutes, which is twice the 8 minute target. RED calls are immediately life threatening where every minute counts, so moving the distribution curve towards a bell shape (and less of a curve) is a key area of focus, as previously detailed. Similarly, the AMBER 95th percentile (for December 2015) was 48.50 minutes, compared to an internal guidance of 20 minutes. AQI14: Number of responded incidents that received at least 1 resource allocation, is an important indicator for the New Clinical Response Model, as the old A8 target encouraged multiple dispatch, which was inefficient. AQI14 details the percentages for 1 vehicle through to 4 or more vehicles allocated and will be important to monitor over time. During 2015/16 the Trust invested in a new structure to support the recruitment, training, deployment and retention of Community First Responders (CFRs). AQI15 measures the effectiveness of our CFRs. For the period October 2015 to December 2015, CFRs were the first response on scene (when deployed) in 79.6% of responses.  STEP 4 – Give me treatment The AQIs provided information on four clinical indicators, including one new one: the number of patients suffering cardiac arrest with a return to spontaneous circulation (ROSC). Performance on these indicators is comparable with other UK ambulance services with the expectation that our future plans will include improvement trajectories.

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We would expect AQI17: number of incidents that resulted in non-conveyance to hospital, to increase overtime as the Trust works on improved clinical leadership and key pathways e.g. mental health, end of life. Whilst not published in the January iteration AQI18 will provide information on the dispatch of ideal/suitable responses, which is a key indicator for the New Clinical Response Model.  STEP 5 – Take me to... The AQIs in STEP 5 provide information very similar to that detailed in 1.1 Quality and Performance Trajectories; however, AQI19ii Number of patients conveyed to hospital by type is of particular interest as it clearly demonstrates the high level of conveyance into Major A&E Units which the “shift left” is seeking to reduce where it is clinically safe and appropriate to do so:- Figure 33: Number of Patients Conveyed to Hospital by Type

AQI19ii Number of patients conveyed by hospital Oct 15 Nov 15 Dec 15 Total type

Total Number of patients conveyed 23,208 22,551 23,927 69,686

Tier 1 Major A&E Units 21,111 20,645 21,938 63,694

Tier 2 Minor A&E Units 473 455 466 1,394

Tier 3 Medical Admissions Unit 558 532 602 1,692

Other (all other units such as Maternity or 1,066 919 921 2,906 Mental Health)

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Appendix 2 CAREMORE® service change ideas currently agreed with EASC

Ref. Service Change Summary Idea

The aim is for the 111 service to become a trusted, easy to use resource for 1. 111 Pathfinder urgent advice and clinical assessment which integrates the current contact services within NHSDW together with GPOOHs call handling and nurse triage services across Wales.

Digi-pens to record patient care records. Paper copy is left with the patient and a digital copy stored in data warehouse (improved data security). The digital 2. Digi-Pen record is then validated and a report can be produced. Enables much greater focus on reporting and improving clinical outcome, in particular, the reporting of 10 clinical indicators (with further sub-indicators) compared the previous four. A key project related to the New Clinical Response Model.

The effective deployment and utilization of first responders e.g. community first 3. Community First responders or uniformed first responders, through a single management team Responders for Wales.

To improve the quality and clinical appropriateness of care provided to mental 4. Mental Health health patients accessing WAST by involving a mental health professional at Pathway the earliest opportunity. This is done via a phone call between the Paramedic on scene and a crisis team worker. A decision can then be made as to the most appropriate course of action. The options are; direct admission to a mental health facility. For the patient to stay at home for follow up from G.P or mental health services. For the patient to be taken to the ED

Health Care A dedicated HCP calls service desk within the CCC function designed to 5. Professionals manage the UCS provision and plan admissions with hospitals from HCP non- (HCP) emergency calls, who are requesting transport for patients within an agreed - Dedicated timeframe of 1 to 4 hours (HCP GREEN 3 calls). Additional dedicated UCS desk resource to exclusively manage this demand. - Urgent Care Staff (UCS) provision Ensuring any clinical innovation or alternative pathway of care is based on 6. Clinical Pathway patient need, has a current or emerging evidence base and has an associated Appraisal and clinical audit and evaluation plan to assess its effects on patients and the Approval Group overall service delivery in term of patient flow and clinical outcomes.

Training costs associated with the development and roll out of a reductive 7. Paramedic triage model for paramedics to better enable them to conduct face to face Pathfinder triage of patients when they arrive at scene, using a flow chart of presenting signs and symptoms, to determine the most appropriate clinical pathway for the patient’s needs e.g. community care, self-care or patient specific pathways to, which should also help reduce conveyance rates to A&E

A pan-Wales manager to ensure a standardised approach to improving clinical 8. Frequent Callers outcomes and reducing ambulance activations to 999 calls for frequent callers, working partnership with other health providers, the Police and social care.

Initiative set up as part of the cardiac arrest survival plan. 3RU team set up to 9. Resuscitation

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Rapid Response support and lead resuscitation efforts at cardiac arrest/peri arrest calls. A Unit dedicated team specialising in managing cardiac arrest patients with skills including clinical decision-making and crew resource management.

The initiative was to provide the concept (accepted) and potential benefits of 10. GP/Paramedic Advanced Paramedic Practitioners and Training Advanced Paramedic Out of Hours Practitioners supporting GPOOHs with home visits. Based on best practice and much quoted report from Everden et al in 2003 that Band 5 Paramedics “can handle most of the likely GPOOHs home visits.”

The New Clinical Response Model 1 year pilot was driven by clinicians and the 11. Clinical Response new 2015 Policy is clinically led. It recognises that getting to patients with life Model threatening symptoms requires an 8 minute emergency response (or less) and the organisation will continue to be performance measured against this. It also recognises that for the majority of callers, an 8 minute emergency response will not impact on the patient’s outcome. This model allows call takers up to two minutes extra time to identify the patient’s need and to send, or refer to, a clinically appropriate care provider e.g. an APP, refer to Hear & Treat/Direct, refer to GP, take the patient to the right hospital or facility. This model also monitors and measures the clinical care provided to the patient on scene.

CCCs are the lynchpin to the EMS service. The effectiveness of them is a key 12. Transformation of determinant of the effectiveness of the rest of our service. They are integral to CCC STEPS 2 and 3, Answer my Call and Come to See Me. The modernisation of CCCs (including the new Computer Aided Dispatch system) has been identified as a priority for the 2016/17 IMTP; however, there are a number of immediate actions that have been undertaken to mitigate identified risks around the CCC, staffing structure and ICT pending the new CAD and restructure.

The initiative aims to boost WAST’s capacity to respond to demand through 13. Overtime/Private increased unit hours production delivered through either incentivized overtime Providers 7days a week or the use of private providers.

To improve the ambulance response times for immediately life threatening 14. Cwm Taf Explorer calls for patients in Cwm Taf. The initiative includes: 1) the delivery of a shared programme of public education to ensure residents of Cwm Taf understand the full range of services available 2) a communication strategy to support the work of Explorer 3) the commencement of the development of a clinical culture that encourages and supports clinicians to operate fully within their scope of practice 4) the geographic ring fencing of emergency ambulance resources within the boundaries of Cwm Taf 5) The implementation of a system to appropriately convey patients where the request originates from our HealthCare Professional colleagues (HCP) within the appropriate timescale

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Appendix 3 NHS Wales Strategic Change agenda milestones This table gives a high level overview of the major service changes planned for NHS Wales and, where clear, the critical milestones. Only those changes that will impact on WAST services have been included. For some, for example the Mid Wales Health Collaborative, only as the programme progresses will milestones for change become clearer. This work will be routed through the Business intelligence Hub

NHS WALES STRATEGIC SERVICE CHANGE (where impact on WAST) MILESTONE

CWM TAF (SOUTH WALES PLAN) Transfer of obstetrics, paediatrics from Royal Glam Hospital Summer 2017 Transfer of ED activity from Royal Glam To be determined Development of Royal Glam as diagnostic hub ? ENT service reconfiguration (emergencies to UHW) Qtr 1 2016/17

ANEURIN BEVAN Specialist and Critical Care Centre (SCCC) Dec 2015 SCCC Full Business Case submitted to WG Spring 2019 SCCC operational To be determined Potential changes to GI bleeds To be determined Potential changes to ENT

CARDIFF AND VALE ENT service reconfiguration (emergencies to UHW – from RGlam and POW) Qtr 1 2016/17

ABERTAWE BRO MORGANNWG ENT service reconfiguration (emergencies to UHW – from RGlam and POW) Qtr 1 2016/17 A Regional Collaboration for Health (ARCH) Programme Key milestones TBD

POWYS Future Fit – Redesign of services across Shrewsbury and Telford To be determined

MID WALES COLLABORATIVE As service planning and engagement work development – milestones will emerge

MAJOR TRAUMA NETWORK (South) Establishment of Major Trauma Network (MTC plus MTUs plus rehab model) To be determined

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Appendix 4 Mid Wales Healthcare Collaborative (MWHC) – Key actions

Priority Action Expected outcome Service, workforce and Target financial implications date 1. MWHC team Secure required resources for Secure the required funding and resources. Implementation the recommendations of the Funding requirement is Mar 16 2016/17 to continue the work of Mid Wales Healthcare Study. £200k with £50k contribution the MWHC. from WG on the basis that of match funding of £50k from the three HBs. Plus Resources required from collaborative healthcare organisations to support the Innovation sub-groups. 2. Centre for Excellence in Rural Healthcare Establish a Centre for Excellence Scope the innovative approaches needed to The establishment of critical mass of applied Funding requirement is Mar 16 in Rural Healthcare, with a address education, research and development research excellence, conducting new work on £133,500 per annum for the particular focus on research, for healthcare in Mid Wales. the healthcare challenges of Mid Wales, and first 2 years (total £267,000) development and dissemination of working closely with local clinicians, managers to be funded equitably by the evidence in health service Scope appropriate models for the Centre of and others to apply the lessons from three collaborative Health research which addresses the Excellence in Rural Healthcare. experience elsewhere. Boards and WAST. particular challenges of Mid Wales. Develop a Business Case for the establishment Generate a new level of credibility in Mid a Centre for Excellence in Rural Healthcare. Wales to help to recruit strong candidates for local clinical posts. 2. Primary Care and Community Services Establish the role of Physician Introduce a 4-year PA development programme Up to 6 qualified and experienced PAs working Funding through WG 2016 - Associates (PA) across Mid which supports the student PA through training across Mid Wales. allocation for developing the 2020 Wales. and offers a 2-year fixed term internship primary care workforce, with following graduation costs to be shared equally between the three HBs. Total costs as follows: Year 1 = £60,000 Year 2 = £60,000 Year 3 = £282,000 Year 4 = £293,000 Total = £695,000 198

Priority Action Expected outcome Service, workforce and Target financial implications date Up-skill the rural primary care Produce a skills and competencies framework Completed skills and competencies framework Funding requirement to be 2016 workforce. for the practice nurses and health care delivered. identified by Primary Care assistants (and other non-GPs involved at and Community services primary care level in the delivery of long-term sub-group. conditions management.

Following the delivery of a skills and competencies framework deliver a programme Programme of training and development Funding requirement to be 2018 of training and development opportunities for available and offered to all appropriate primary identified by Primary Care appropriate primary care staff to help each care staff in the MWHC area and Community services achieve their maximum potential within the sub-group. framework Establish an enhanced Identify current ‘blockages’ and strategies for All medically fit patients are discharged or Funding requirement to will 2018 community-focused service that over-coming them. transferred from Bronglais Hospital in a timely be the cost of recruiting a supports the timely discharge/ manner and to safe and appropriate alternative Discharge Liaison post. transfer of ‘medically fit’ patients forms of care. from Bronglais Hospital. Establish an integrated Develop an integrated service that involves the Regular, readily accessible GA dental sessions Funding requirement to be 2016 community focused dental service development of an intermediate oral surgery operating at Bronglais Hospital. identified by Primary Care in Mid Wales. service for complex extractions. and Community services sub-group. Develop an integrated service that involves the Regular, readily accessible GA dental sessions development of a joint GA list (involving CDS operating at Bronglais Hospital. Funding requirement to be 2016 staff) in Bronglais Hospital using existing identified by Primary Care facilities not fully utilised due to lack of suitably and Community services trained staff. sub-group.

Develop an integrated service that involves the Ready access to a clinically appropriate locally future development of a maxillofacial service based maxillofacial service that avoids which avoids the unnecessary use of secondary unnecessary travel to more distant hospitals Funding requirement to be 2017 care services and patient travel to South Wales. outside the Mid Wales area. identified by Primary Care and Community services sub-group.

Rolling out the concept of the Agree the core principles of the ‘virtual ward’ Core principles of the ‘virtual ward’ are in place Funding requirement to be 2016 ‘virtual ward’ to all parts of the and then allowing for local variation, reflecting and being worked to in all parts of the MWHC identified by Primary Care MWHC area. local circumstances, ensure the core principles area and Community services are in place across all parts of the MWHC area. sub-group.

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Priority Action Expected outcome Service, workforce and Target financial implications date

3. Mental Health and Learning Disabilities Ensuring out of hours crisis support is available when needed. Alternatives to admission, with in- patient access when needed. Developing integrated services for people with Dementia.

Extending access to psychological therapies. Child and adolescent mental health services. 4. Telehealth and Innovation Re-establish a Tele-Dermatology Develop a Business Case for the re- Re-establishment of the Tele-Dermatology Six month pilot to commence Apr 16 service for Mid Wales. establishment of the Tele-Dermatology service service for Mid Wales thereby reducing the April 2016. Cost of approx for Mid Wales. need for patients to travel to more distant £25,000 to be funded by hospitals/clinics outside the Mid Wales area. HDUHB. Review telehealth, telemedicine Undertake an All Wales Scoping exercise to An understanding of the provision of Tele- WG have awarded grant Jan 16 and telecare across Wales to establish a baseline of all Tele-health equipment health equipment that is currently available or funding of £25k to undertake identify activities that present that is currently available or in use within Tele- in use within Tele-health, Tele-care and Tele- this exercise. opportunities for adoption or health, Tele-care and Tele-medicine. medicine across Wales. expansion across Mid Wales. Implement the recommendations Use the final report from the Scoping exercise to Accessible and appropriate telehealth services WG have awarded grant Dec 16 of the review of telehealth, draft a specification to determine where available across Mid Wales. funding of £225k for telemedicine and telecare across equipment is needed. equipment and training. Mid Wales. Use the final report from the Scoping exercise to Appropriate infrastructure in place to support determine where extra support is required (staff, the operation of telehealth equipment across estates and IT infrastructure) to deliver services Mid Wales. via tele-health.

Use the final report from the Scoping exercise to draft a specification to determine where training All relevant staff provided with a programme of is needed. training in the use of equipment. 5. Palliative Care and End of Life Identify and assess the range and Carry out a scoping exercise to map the range An understanding of the provision of palliative WH have awarded the End of May 16 scope of end of life and palliative of services provided. and end of life care across health, local Life Board grant funding of 200

Priority Action Expected outcome Service, workforce and Target financial implications date care services in rural mid-Wales. authority and third sector provision in rural Mid £44k to undertake this Identify: Wales. exercise.  service demand by the take up of services, occupancy levels, effectiveness / Improved ability to develop co-ordinated outcomes, working hours and waiting pathways. times;  geographical location / accessibility of Improved ability to ensure any proposed services; service improvements / new developments  gaps in service provision; reflect identified gaps in current provision and  duplication of services; improve the experience and outcomes for  ‘what works well’ patients and their families. Understand the public perception  Identify ‘key messages’ relating to end of Targeted stakeholder engagement included as Costs of public, staff and Mar 17 for end of life and palliative care life / palliative care from the public an integral aspect of the project. stakeholder engagement services of patients, families and engagement meetings facilitated by the covered by MWHC budget. their carers living in rural mid- Mid-Wales Healthcare Collaborative. Recommendations for service improvements Wales  ‘Targeted’ stakeholder engagement with and / or service change informed by support from members of the Innovation stakeholder views and opinions. Sub Group / Working Group  Liaison with service providers Understand the demographic and Identify and analyse relevant data sources in Recommendations for service improvements health profile of rural mid-Wales order to establish an estimate of the level and and / or service change informed by an location of need. enhanced understanding of the characteristics of the local population. Provide an overview of key Research examples of best practice / service Evidence based examples of best practice Feb 16 messages from research, national models for end of life and palliative care services service models for EoL / palliative care guidance and good practice in rural areas - including legislation, national services (cancer and non-cancer). relating to end of life and palliative guidance and local commitments. care services in rural areas. Evidence based examples of new technology (tele-health, tele-rehab, telemedicine) in enhancing EoL / palliative care services in rural settings.

Successful EoL / palliative care services in rural areas from the perspective of patients, families and their carers.

Successful EoL / palliative care services in rural areas from the perspective of the workforce. 201

Priority Action Expected outcome Service, workforce and Target financial implications date

Underpinning evidence, policy and national guidance. Identify service improvements / Make recommendations for service Proposals for service improvements / service Jun 16 service change where appropriate improvements / service change with particular change with particular emphasis on new with particular emphasis on new emphasis on new technology and Hospice at technology and Hospice at Home. technology. Home. 6. Bronglais General Hospital Actively engage clinical staff in all Create/strengthen professional networks to A robust professional support network to share On-going discussions about how services provide a robust support unit and to share good innovations and good practice. should be developed. practice. Active recruitment to medical and On-going recruitment to vacant posts. All specialties have a full complement of staff Funding requirements On-going nursing vacancies. (all clinical staff) in order to provide efficient included in HDUHB IMTP. and effective service to its population. Jan 16 Specific Bronglais General Hospital recruitment campaign. Sufficient nurse complement to reduce the need for agency staff Increase bed capacity to restore Introduce an additional 12 beds at Bronglais Improve patient flow in and out of Bronglais Funding requirements Jan 16 surgical throughput, reduce General Hospital. Hospital. included in HDUHB IMTP. waiting lists and avoid accident and emergency delays for medical patients. Work innovatively to increase Develop and agree a surgical service model. To create a safe, sustainable surgical service Funding requirement to be May 16 surgical capacity. at Bronglais Hospital for the people of Mid identified by Bronglais Wales. General Hospital sub-group Establish a new closed MRI Develop a Business Plan for the proposed A new, fit for purpose MRI scanner, serving all Funding requirements Dec 16 scanner servicing all specialties. acquisition of a new MRI scanner with specialties including colorectal and paediatric included in HDUHB IMTP. Anaesthetic Kit that will service all specialities. services thereby reducing the need for patients to travel out of the area. 7. Access and Transport Better alignment between clinic Undertake pilot on subsection of outpatients in Reduce “wasted” time for patients To be tested as part of pilot July 16 times/Day Surgery and public Bronglais to test approach to improved transport. alignment Improve patient experience Implementation of mixed service Implementation of the all Wales NEPTS Better quality of NETPS service Full detail in the NEPTS April – provision to meet new service Business Case Improved arrangement for renal patients business case Dec 2016 specification for Non-Emergency Extended hours of operating Patients Transport Service (NEPTS). Implement the New Clinical Pilot launched 1 Oct 2015. 65% RED performance across all MWHC Delivered through current Pilot to 202

Priority Action Expected outcome Service, workforce and Target financial implications date Response Model. areas resources Sept 16 Focused action plan for Hywel Dda area Improving performance against clinical Demand and capacity review indicators

Evaluation of New Clinical Response Model Reducing variation of performance

Improved patient experience

Strengthen models of community CFR action plan 65% RED performance across all MWHC CFR funded through EASC Ongoing resilience, including Community areas First responders, co-responding Co-responder pilots Implications of community and alternative models (e.g. Improving performance against clinical paramedic to be developed Community Paramedics) Explore pilot for community paramedics with indicators MWHC Cluster Reducing variation of performance

Improved patient experience

8. Communications and Engagement Ensure effective communications, Develop, implement and evaluate a Mid Wales Effective engagement with: Costs of public, staff and Dec 17 engagement and involvement. Healthcare Collaborative Engagement Plan.  Public; stakeholder engagement  Staff; covered by MWHC budget.  Health and social care staff and senior clinicians;  Local Authorities, including officers and elected members;  Third Sector;  Community Health Councils

Support for dialogue with the community through a programme of media relations based on the development of good relationships with local media.

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Appendix 5 Summary of Health Board and Trust IMTPs integration with WAST

Organisation Joint Priorities Health Board/Trust actively engaged on priority

e.g. WAST’s priorities which require collaborative work with Local Health Boards and Detail degree of engagement, e.g. Health Board aware of other NHS Wales Trusts scheme, conversations taken place, etc.

ABMU 1) 111 pathfinder, including Pre-pathfinder initiatives 1) 111 ongoing engagement with the HB 2) Working together to improve hospital handover (in line with guidance) 2) Handover ongoing engagement 3) NEPTS BC implementation 3) NEPTS minimal engagement Pathways implementation: Mental Health / Early Adopters / Acute GP (Swansea) 4) Pathways ongoing engagement except for End / Falls vehicle (Swansea) / help point plus (Swansea) / end of life (all wales work) of Life

Hywel Dda 1) Collaborative AP development pilot with primary care partners and GPOOH 1) Joint interviews with two APs appointed - target services date of go live early April 16 2) Mid Wales Health Collaborative 2) WAST supporting the collaborative at both 3) Joint Performance action plan public events and through the work streams 4) 111 Pathfinder - Carmarthen 3) Action plan agreed, implemented and kept 5) NEPTS BC implementation under regular review and refinement. 6) Pathways implementation: Stroke / end of life (all wales work) 4) Locality Manager part of implementation group 7) Retention of dedicated ambulance vehicle (DAV) Withybush 5) Engagement 6) Stroke pathway agreed 7) Ongoing discussions with HB to make this service part of core business.

Aneurin Bevan 1) Working together to improve hospital handover (in line with guidance) 1) Joint WAST and AB weekly meeting and 2) Development of new model for unplanned care - Code Zero RED AMBER partnership work with HALO Release of EA’s to support patients in community when delays impact 2) SOP shared with AB and control, request 3) SCCC Joint partnership project (hyper acute stroke, ENT, etc.) implemented as required with DGH’s. 4) NEPTS BC implementation 3) Continued WAST engagement with AB 5) Pathways implementation: Mental Health / neck of femur / Falls / end of life 4) Active engagement – proposed pilot live for AB (all wales work) / Community Nursing 24 hour project early April. 5) Joint Falls service working well with weekly

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conference with Almanac, Community nurse 24/7 live 29th Feb.

BCU 1) Alcohol treatment centre in Wrexham 1) Project completed in partnership with HB and 2) NEPTS BC implementation others 3) Pathways implementation: Mental Health / district nurse / MIU / Falls / end 2) Engagement of life (all wales work) / interface with GPOOH and clinical support CCC (local 3) Pathways ongoing engagement to BCU area) 4) Actively engaged on project teams/board 4) BCU acute service re-configuration 5) Actively engaged 5) Working together to improve hospital handover and patient experience through improved performance (in line with guidance)

Cardiff & Vale 1) Alcohol treatment centre 1) Joint working with external budget removed 2) Development of new model for unplanned care - Code Zero RED AMBER 2) Joint meetings in process Release of EA’s to support patients in community when delays impact 3) Joint Process Mapping 3) Working together to improve hospital handover (in line with guidance) 4) Regular joint meetings ongoing 4) NEPTS BC implementation also PCS transition from Whitchurch to Lansdowne 5) Some pathways already in place or being 5) Pathways implementation: Falls / end of life (all wales work) / emergency obs developed and Gynae / Ambulatory care / Barry MIU Pathway / Cardiac stemi 6) Joint engagement with ARC development 6) Strategic estates Planning pending substantial road network potential changes at UHW

Cwm Taf 1) Implementation of South Wales plan inc. diagnostic centre, paeds, obs &neo 1) WAST attends all meetings 2) Optimising use of paramedic pathfinder 2) MD and P Care lead involved 3) Evaluation of Cwm Taf Explorer 3) Equal partners 4) NEPTS BC implementation 4) Engagement 5) Pathways implementation: Mental Health / MIU / fractured neck of femur / 5) Ongoing work – regular meets to develop and Falls / end of life (all wales work) / community integrated assessment service improve/tweak 6) Acute medicine model whereby pathways have been developed and agreed 6) Ongoing monthly clinical meetings with WAST for patients going to Royal Glamorgan Hospital.

Powys 1) Meaningful and joint engagement in Future Fit Programme 1) Option appraisal being reconsidered, assistant 2) Mid Wales Collaborative – focus on exploring modes for community, new head of Ops in discussion. model for Bronglais 2) Supporting public meetings and work streams 3) NEPTS BC implementation 3) Minimal involvement

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4) MIU acceptance criteria 4) Locality team meeting with Health Board leads March 16 to take this forward. Public Health 1) Development of Help me choose strategy 1) Engagement Wales

Velindre NHS 1) Engaging with the Velindre cancer programme – link with NEPTS 1) Engagement Trust 2) NEPTS BC implementation 2) Engagement

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Appendix 6 Supporting information relating to documented actions

See separate excel spreadsheet.

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Appendix 7: WAST 2016/17 Discretionary Capital Plan as at February 2016

Total Remaining Capital Cumulative Discretionary Total Bid Code Title Directorate Rank Notes Cost (yr1) Cost Capital Score (inc VAT) (£5.826m) The signal strength for hand portable radios is extremely poor at Bargoed, and indeed within some rooms in the station there is no Bargoed Enhancement BID1035 Ops 18,000 18,000 5,808,000 25 1 signal at all. Clearly this poses a Signal significant risk to the organisation and patients where crews cannot be contacted to respond to the next emergency call. Replacement of 1. Revenue cost already in place for Hazardous Area Response existing equipment 2. price only BID1004 Ops 49,161 67,161 5,758,839 24 2 Team (HART) Breathing indicative as tender process next Apparatus Equipment year

BID1002 Training School Tablet Spend to save modernisation Training 57,311 124,472 5,701,528 21 3 Computers initiative

Llanfyllin station – Boiler BID1013 Estates 10,000 134,472 5,691,528 21 3 Essential remedial work replacement works Pwllheli AS – Boiler BID1022 Estates 15,000 149,472 5,676,528 21 3 Essential remedial work replacement works Essential remedial work

Rhyl AS –

BID1023 Boiler/Control/Pipework Estates 84,810 234,282 5,591,718 21 3

replacement works

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Total Remaining Capital Cumulative Discretionary Total Bid Code Title Directorate Rank Notes Cost (yr1) Cost Capital Score (inc VAT) (£5.826m

Essential remedial building work, Colwyn Bay AS – BID1017 Estates 187,000 421,282 5,404,718 20 4 costs may be less (£147,000) if replacement roof planning permission agreed Holyhead AS – roof BID1019 Estates 145,920 567,202 5,258,798 20 4 Essential remedial building work covering renewal Pembroke Dock – roof BID1016 Estates 20,000 587,202 5,238,798 19 5 Essential remedial building work repairs Pontypool station – roof BID1028 Estates 20,000 607,202 5,218,798 19 5 Essential remedial building work covering Essential remedial building work, Tredegar Ambulance asbestos in structure, building BID1029 Station – Internal and Estates 260,000 867,202 4,958,798 19 5 owned and retained as reporting External refurbishment station, price includes temp accommodation Aberystwyth station – structural repairs to BID1011 Estates 18,000 885,202 4,940,798 18 6 Essential remedial building work concrete frame and masonry Haverfordwest station – Essential remedial building work, BID1012 Estates 65,000 950,202 4,875,798 18 6 roof covering renewal required because of terms of lease Various station – Drainage BID1020 Estates 50,160 1,000,362 4,825,638 16 7 Statutory Requirement remedial works Aberdare station – roof BID1024 Estates 25,000 1,025,362 4,800,638 16 7 Essential remedial building work light renewal Total Remaining Capital Cumulative Discretionary Total Bid Code Title Directorate Rank Notes Cost (yr1) Cost Capital Score (inc VAT) (£5.826m 209

Actual net cost after savings £7K Monmouth Ambulance Capital and annual Revenue £4K but Station – Provisions of only until station sold. alternative BID1027 Estates 82,000 1,107,362 4,718,638 16 7 accommodation to enable DJ to provide a Business Case for the disposal of dilapidated whole project, confirming the former station approval process and final outcome.

Costs halved (from £10,399). Only SmartBoard ICT need one smartboard – moved one BID1003 requirements for Training 5,199 1,112,561 4,713,439 15 8 board to Carmarthen. Technology, Equitable Staff Education enabled learning – most out of dolls etc link to these boards £5k

To be combined with BID1001 for Sit-Stand Desk Provision – Workforce BID1008 71,471 1,184,032 4,641,968 15 8 CCC furniture. It was suggested that Get WAST Standing and OD this bid would be piloted. Porthmadog-Llandudno- BID1021 Holyhead Kitchen Estates 31,680 1,215,712 4,610,288 15 8 H&S/improvement replacements

Major Incident Response BID1038 Ops £53,918 1,269,630 4,556,370 25 1 Specialist Major Incident Equipment Equipment

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Appendix 8: Strategic change programme structures Clinical Modernisation Programme

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Clinical Contact Centre Modernisation Programme

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Non-Emergency Patient Transport

213