Dear Mr Knox, Re: Regulation 28 Prevention of Future Deaths report - Joseph Leonard Scott Cattle (deceased) Thank you for your letter of 22 February 2024, in which you enclose a copy of a Regulation 28 Prevention of Future Deaths report ('the report') following the conclusion of the inquest into the death of Mr Cattle. I would like to offer my sincere condolences to Mr Cattle's family on their sad loss. In the report you ask for details of action taken or proposed by the Welsh Government around funding, guidance and targets provided to the Welsh Ambulance Services Trust (WAST), Local Health Boards (LHBs) and Local Authorities to support improvement to ambulance patient handover performance. You also ask about how WAST is funded, and whether this can or should be increased or managed differently. I will respond to your two questions in turn. What funding, guidance and targets are provided to public bodies with a view to reducing ambulance patient handover delays? Overall management strategy to support improvement. Improving ambulance patient handover performance cannot be isolated to a single intervention, process or 'silver bullet' and requires a true whole system effort. This is because long ambulance patient handover delays are intrinsically linked to both difficulties experienced by community-based services to manage people safely in their home or local

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg. Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd gohebu yn Gymraeg yn arwain at oedi. We welcome receiving correspondence in Welsh. Any correspondence received in Welsh will be answered in Welsh and corresponding in Welsh will not lead to a delay in responding.

community, and challenges with supporting timely discharge of patients from hospitals to home. The former has an impact on available ambulance capacity as demand for a response and conveyance to hospital can increase at certain times of day and during weekends in particular; and the latter has an impact on available bed capacity. A lack of available beds can occasionally result in patients waiting longer periods for admission which reduces available space in the emergency department, consequentially causing occasionally long delays for the transfer of patients from ambulances to the care of emergency department clinicians. The overarching Welsh Government strategy towards enabling better outcomes and experience for people who need to access urgent or emergency care services is set out in the Six Goals for Urgent and Emergency Care Policy Handbook. This strategy describes our expectations for LHBs and partners to place greater emphasis on assessing the needs of their local populations who are at greater risk of needing an ambulance response and admission to hospital, and coordinating their care through clear plans and wrap around support. The document also sets out the intention to safely manage people who do not need to access the services of an acute hospital in their local communities, thus freeing up ambulance response and emergency department capacity for those who have an absolute clinical need for them. The handbook also describes expectations of LHBs to improve ambulance patient handover processes and to focus on timely flow of patients through the hospital system and out into the community. We established a national improvement programme ('the Six Goals for Urgent and Emergency Care programme') to enable LHBs to deliver on the objectives set out in our strategy, and have allocated an additional £50m in support over the past two years. The annual Six Goals allocation will increase to £27m in 2024/2025. This programme is complemented by other national programmes including the Strategic Programme for Primary Care and the Regional Integration Fund (RIF) programme which, among other priorities, both focus on supporting safe avoidance of admission to hospital and enabling people to return home from hospital when ready. The RIF allocation of £145m per year is intended to create sustainable system change through the integration of health and social care services. Through the RIF's Home from Hospital model of care activity, Regional Partnership Boards are focussing their efforts on preventing hospital admission alongside expediting a swift discharge from hospital. This is helping people to return home from hospital in a timelier manner with the necessary support in place at discharge. I have directed each LHB to develop a local 'six goals' programme plan that incorporated actions to improve ambulance patient handover performance and patient flow, among other local priorities. This programme plan forms a key part of LHBs' broader Integrated Medium- Term Plans (IMTPs). Welsh Government officials are currently working with the NHS Executive and ambulance commissioners to consider additional focused plans to enable consistent delivery of condition specific pathways that will support better management of frail / older people without the need for conveyance to emergency departments. These plans will also enable action to support people with time critical complaints e.g. stroke and/ or STEMI (a type of

heart attack) to avoid the emergency department entirely, through direct access to the right clinician, first time. I expect this work to commence in quarter 1 2024/2025. Social Care in the Community Welsh Government acknowledges the challenges facing our social care workforce and the need to attract more care workers into the sector to support the work around community discharge and patient flow. Social care is competing with sectors such as retail and hospitality in terms of pay which are offering more pay for less intensive roles, therefore the option for progression and the ability to build a career in social care is our priority. We are committed to raising the profile and status of the workforce through registration of the workforce, promoting and improving pay, terms and conditions, through the work of the Social Care Fair Work Forum. We are moving in to the third financial year of our Programme for Government commitment to pay the real living wage to social care workers in Wales, providing funding circa £113 million across 2022-23 and 2023-24 to support this commitment. In 2024-25, the then Minister for Finance and Local Government confirmed funding within the Local Government's Revenue Support Grant (RSG) to meet the costs of the Real Living Wage of £12 an hour for social care workers alongside recurrent funding to the sector in the form of a £45 million Workforce and Sustainable Social Services grant, to support a range of workforce interventions, including further salary uplifts and to support additional staffing in some areas. We also continue to invest in Social Care Wales recruitment campaign, 'WeCare.Wales', which promotes the variety of roles available in Social Care. All of these measures are aimed at improving experience and outcomes and reducing pressure on emergency care services. The demand for social care will continue to grow and so it's essential we all have effective workforce planning systems in place to meet this demand. We will continue to work in partnership through the Social Care Fair Work Forum with unions and employers on what steps can be taken to further improve terms and conditions for this sector and make social care a more attractive place to work. Quality statement for care in ED I recently published the Quality Statement for Care in Emergency Departments, which sets out the outcomes and standards people should expect to receive when accessing care in high-quality emergency departments across Wales. In 2024-25, LHBs will focus their plans on the delivery of a small number of clinically endorsed priorities, including two actions focussed on patient flow and experience in emergency departments:
• Reduce risk of harm caused by crowding in emergency departments; and
• Improve patient experience by providing better quality facilities and alignment of the right workforce capacity to respond to patient demand. Hospital discharge guidance Hospital discharge is an important part of efficient patient flow, and we are taking forward a number of initiatives to help ensure a person is discharged as appropriately, safely and timely as possible once their treatment has been completed and they no longer need to be in hospital. The Welsh Government has published updated Hospital Discharge Guidance aimed at frontline staff to support their discharge processes. The guidance has also been expanded to include more detailed supporting information for patients, their families and carers, on

discharge practices from admittance to a hospital ward to the point they are ready to be discharged. The guidance includes specific information on support for patient transport as well as the considerations that should be taken to ensure that people are discharged efficiently but safely, either back home or to their usual place of residence, and with the right level of care and support if this is required. In addition, Discharge to Recover then Assess (D2RA) Pathways Guidance is in place to aid patient flow and appropriate discharge. Under D2RA pathways, patients admitted to hospital should be assessed and provisionally allocated to one of four pathways as early as possible following admission. This is to identify what level of support and recovery they will need at the point of discharge. To ensure we have accurate data on delayed discharges, the Pathways of Care Delays {PoCD) Reporting Framework has been implemented. This is a formal reporting mechanism that provides health and social care partners with a comprehensive and vital overview of their regional discharge delays so that relevant interventions and actions can be targeted more appropriately. The monthly PoCD data ensures health and social care teams have a clear position on the areas that have the highest numbers of delays and the most consistent delays. Regions are asked to use this data to draw up coordinated action plans between health and social care partners to establish new or improved working practices aimed at tackling largest delay groups. Further guidance, targets and monitoring. In practice, the Welsh Government monitors the performance of NHS Wales bodies in several different ways. In relation to the monitoring of ambulance patient handovers to emergency departments, a number of specific measures have been put in place in order to ensure the Welsh Government can assess how LHBs and WAST are performing. A Welsh Health Circular ("WHC") was issued in 2016, setting out expectations of LHBs and partners to deliver timely ambulance patient handover through consistent delivery of a range of actions for both pre and post arrival such as: communication, alternative pathways, staffing levels, and booking in processes. It is the expectation of the Welsh Government that these actions are done consistently to meet handover targets. LHBs are expected to take this guidance into account when exercising their functions. Although the WHC includes an objective that patients arriving at an emergency department by ambulance should be handed over to the care of emergency department clinicians within 15 minutes, it accepts that in exceptional cases, patients may have to wait up to 60 minutes. The WHC sets out what the LHB and WAST must do when a handover exceeds 60 minutes. Audits of LHB delivery against the guidance have previously been undertaken on the behalf of Welsh Government by the NHS Wales Delivery Unit. Monitoring and scrutiny of delivery of the policy expectations within the guidance is undertaken through a number of mechanisms. Securing improvements in ambulance patient handover performance was established as one of a small number of Ministerial priorities in the NHS planning framework in 2023/2024 and this has been rolled over in 2024/2025. This requires LHBs to develop plans to achieve the national ambulance handover performance target that no patient will wait longer than one hour for transfer from

ambulance vehicles to the care of emergency department clinicians. This target was also included as an objective for all LHB chairs for 2023/24. I consistently seek assurances from Chairs of LHB on their LHB's commitment to making improvements through regular national meetings. I hold regular meetings with the Chairs, and performance against targets is a recurring topic. Assurance on progress made by LHBs against ambulance patient handover targets is also sought by Welsh Government officials and NHS Executive officers through bi-monthly integrated quality planning and delivery meetings. Performance against this specific target is a standing agenda item at each LHB meeting (with the exception of Powys LHB, as it does not possess a major emergency department within its borders). LHB executives with responsibility for quality, planning and performance
- for example Medical Directors, executive Directors of Nursing, Directors of Planning and Chief Operating Officers - are asked to provide an update on plans to achieve the national target at each meeting, and Welsh Government and NHS Executive officers provide challenge and scrutiny, reinforcing policy expectations. In addition to ambulance patient handover targets and expectations to reduce pathways of care delays, LHBs are also expected to describe in local six goals programme plans how they will reduce the numbers of patients spending longer than seven, 14 and/ or 21 days in hospital beds. These measures are intended to optimise patient experience, reduce risk of deconditioning and reduce bed occupancy; thus enabling timely flow of patients through the hospital system and out into the community. Where there are concerns about progress, the Welsh Government's Quality and Delivery Board is briefed with recommendations for additional action including escalation to Joint Executive Team meetings held between executives of both Welsh Government and the relevant LHB. These meetings are held every six months. Where concern remains about performance, discussions are held at tri-partite meetings with Audit Wales and Health Inspectorate Wales, which inform recommendations made to Cabinet Secretaries on a LHB's escalation status. If potentially serious concerns arise, further steps may be taken. A serious concern arises when the severity, frequency or persistence of problems appears to exceed that which can be dealt with through routine arrangements. The Welsh Government and external review bodies, as appropriate, will work closely with the NHS body to ensure potential serious concerns are explored and their causes understood. If there is no longer any cause for concern, the NHS body will be informed, and routine arrangements will continue. If it is established that there is an issue that requires action, then the Welsh Government and external review bodies will consider the seriousness of the issue, their apparent causes and the capability and capacity of the NHS body to resolve them before making decisions on the form and extent of the action required. However, the Intervention Guidance states that these formal powers are seen as a last resort and will normally only be used if other intervention is unlikely to succeed. How WAST is funded, and whether this can or should be increased or managed differently. LHBs in Wales are provided with an initial revenue allocation on an annual basis. For Hospital and Community Health Services and Prescribing, LHBs are responsible for commissioning services for their resident population from within their core allocation, which would include funding to be provided to WAST under commissioning arrangements for the provision of their service.

Up until the end of 2023/24, WAST received a core funding allocation via the Emergency Ambulance Services Committee. The Committee, made up of the chief executives of LHBs, a chair and the Chief Ambulance Services Commissioner, held statutory responsibility for the planning and securing of sufficient emergency ambulances services for the population of Wales. Discharging this responsibility requires close collaboration between commissioners and WAST, as the provider organisation, to ensure that all available resources are used effectively. These commissioning arrangements were reviewed in 2022-23 as part of a wider independent review of national commissioning of NHS services in Wales. That review recommended establishing a new joint committee of LHBs to hold responsibility for commissioning of specialised services and emergency ambulance services among others. The new NHS Joint Commissioning Committee (JCC) was established on 1 April 2024 and now has responsibility for planning and securing emergency ambulance services for the people of Wales. It is for the committee to consider all relevant factors in determining the quantum of funding allocated to WAST for delivery of emergency ambulance services. I will hold the chair of the NHS JCC to account for effective commissioning of emergency ambulance services and, as described previously in this letter, achievement of the Ministerial priorities I have set of all organisations from 2024/2025 onwards. Additional funding. In terms of procuring ambulance vehicles, WAST submitted a Strategic Outline Programme (SOP) in 2016 that was endorsed by Welsh Cabinet Secretaries for its Vehicle Replacement Programme. The endorsement of the SOP allows WAST to submit Business Justification Cases (BJCs) setting out its vehicle replacement requirements on an annual basis. I will then make a decision on the BJC. Capital funding over the last three years is as follows:­
• 2021-22 - £10.854m
• 2022-23 - £12.230m
• 2023-24-£11.121m The SOP will be refreshed on a regular basis. It is important to recognise that the SOP covers the WAST fleet of vehicles and not only emergency ambulance vehicles. In addition to this core funding, we provided £3m to the WAST in 2022/2023 to enable recruitment of 100 new staff. WAST also has access to national programme funding budgets including the Six Goals for Urgent and Emergency Care programme's innovation and delivery fund.