Dear Mr Gittins, RE: Emergency Care Access Performance write in response to the Regulation 28 of 14th March 2017 highlighting performance issues relating to Ambulance handover delays_ Matters of concern: That there were significant delays in the admission of Ms Evans to hospital and the medical treatment was consequently not commenced in a timely manner: 2 That despite changes having been made previously the current practices in place for the handover of patients at an Emergency Department far too often results in wholly unacceptable delays with patients being kept waiting for periods in ambulances and ambulances resources consequently being unavailable for allocation to other calls: Whilst this is a multi-factorial problem, improvements must be made so as to reduce the risk of future deaths: will detail below the improvements we have made or are in the process of making to improve waiting times in our ED but in terms of performance we have made improvements in what is our busiest time of year. Comparing January to March 2017 to the same period last year shows improvements in every indicator (e.g: hours, twelve hours, and response times for Red ambulance calls_ For ambulance handovers taking more than an the number has improved substantially a reduction of 786 instances which is a 23% improvement: Unscheduled Care Plan The latest version of the Unscheduled Care Plan included within our 2017/8 Operational Plan submission is attached_ The plan covers all areas of the Unscheduled Care System and has been developed to ensure improvement in emergency access, as measured by the 4 hour and 12 hour target_ The plan addresses the main causes of Unscheduled Care pressure through reducing admissions (demand) , reducing DTOCs and length of stay (supply) and addressing long hour, flow

at the front of hospitals to protect minors from long waits: It also includes reducing ambulance handover delays_ The overall plan is supported by a set of metrics which will demonstrate improvement on the underlying position which will lead to improved 1Sminute ambulance handover The work in these areas is showing improvement in reducing admissions and DTOC. There is clearly a great deal more to do, but can assure you that these improvements are a priority for the Health Board. Engagement at an Executive Level have taken steps to strengthen the level of visible Executive input to the management of escalation out-of-hours and nominated Morag Olsen as our lead Exec to Iink with the Welsh Government Delivery Unit to explore areas where further improvements. The use of information within Unscheduled Care decision making There is extensive use of predictive tools and modeling within our overall approach to Unscheduled Care. The overall capacity and demand model developed by the planning section has informed the scale of improvement required to achieve a bed occupancy level of 85%. The metrics within the overall plan are calibrated at a level which has been calculated to enable the 4 hour target to be achieved and improve ambulance handover: On daily and weekly operational level, there is extensive use of demand and flow information in Unscheduled Care decision making: In particular, predictive demand analysis is used to drive resourcing decisions within each week. The following is sample, but not a complete list of the information routinely used: Daily and weekly 4 hour/12 hour performance Daily and weekly activity trends Ad ~hoc trends for holidays and peak periods Time spent in ED Heat maps of arrivals and ED occupancy Frequent attenders Review of ambulance performance against quality standards The majority of the above is held on the main information system (IRIS), which is in extracted to support weekly decision making on Unscheduled care_ The following are examples of operational decisions which have been influenced by the above information specifically in relation to improving performanceat YGC and YMH: Medical Rotas; WMH has increased Emergency Department Consultant presence overnight on the shop floor. YGC has a second ED Consultant on the shop floor until 10 pm: These rota changes are set against challenging workforce recruitment and sustainability backdrop 2 key

2 Nursing Rotas; Since YGC opened the new Emergency Department in June 2014 the nursing staff have been significantly increased to ensure staffing meets demand especially in the evening, weekend and over night: WMH have increased twilight shifts to meet evening demand. Both WMH and YGC Emergency Departments have increased their Health Care Support Workers capacity and increased Physician Assistant roles to meet demand and improve timeliness_ 3_ GP Out of Hours; both YGC and WMH have worked to create an integrated platform to deliver services that support patients moving from ED to GP Out of Hours to reduce demand on the minors ED streams. This redirection continues to evolve with further work supporting satellite GP Out of Hours facilities co-located with Minor Injury units for example at Llandudno Hospital. Emergency Departments and WAST; WAST locality Leads are engaged on both sites supporting non-conveyance options for EMS activity. This includes the formal Minor Injuries Units Stand Operating Procedure to redirect suitable clinical cases to MIUs: 5_ Alternative Healthcare Professional provision; Both Emergency departments have responded to the Musculo-skeletal demand attending the departments by appointing Extended Scope Physiotherapists: YGC has also employed through seasonal plan funding GP support to ED to stream suitable patients away from the main emergency department pathways. 6 Emergency department Capacity; both EDs have reviewed the demand profiles and commissioned additional clinical capacity: WMH have opened two additional examination rooms for minor attendances to protect the minors stream. YGC have converted one minors trolley space to a four chair ambulatory area to increase minors stream capacity. Operational site management; WMH have employed twilight site managers to support evening bed pressures: AIl three acute hospitals in the Health Board are moving towards a new out of hours site management clinical rota to support flow and response to escalation. This includes additional night sisters to support core site management_ WMH also provide a Senior Manager of the day who works till 8pm to support decompression of acute problems affecting flow _ 8 Ambulance Conveyances; YGC has engaged with Public Health Wales to understand the higher 999 demand experienced at YGC. This work is informing number of plans including the development of a minor injuries unit within the north Denbighshire project at the Royal Alexandra hospital site 9_ Frequent service Users; data on both Emergency Department attendances and acute admission into medicine from frequent service users (more than attendances admissions in rolling 12 months) has resulted in resources being

allocated to clinical Psychology to lead multi-disciplinary response to the most frequent service users. This results in a multi-agency action plan. Benefits are felt within the acute hospitals, WAEDT and north Wales police_ 10_ Senior Manager Bronze and Silver on call arrangements; a formal review of Bronze and Silver on call manager rotas in recognition of the demands of unscheduled care pressures has informed the development of a new model. This includes Dedicated Silver on call for 24 hours b Development of complimentary clinical rota to support sites de-escalation and risk management Strengthened site management resilience with additional night Sisters to support flow
11. Evening / Overnight Capacity; all sites have developed surge capacity options to meet periods of peak demand during the evening and overnight: This utilizes physical capacity that would not normally be staffed overnight, therefore increasing capacity and utilization of core clinical estate. 12 Development of Medical Fit to Discharge data; WMH and YGC have used data extracted specifically from WPAS and local data collection to identify patients fit for discharge but delayed due to factors outside of the acute hospital control. This has resulted in the development of new escalation pathways and teams, such as the Step Down Team at YGC to secure alternative discharge transfers options for MFDs contributing to bed blockages and bed turn over: 13_ Patient Navigators at YGC Emergency Department; learning from Salford Hospital has been implemented at YGC through using patient navigators to help redirect and expedite patient care of walk in attenders:
14. Roll out of treatment escalation plans (TEP's); a completed pilot of treatment escalation plans for palliativelterminally ill patients in Nursing and residential homes has resulted in a 50% reduction to referral to the emergency department and is now being rolled out across BCU. 15_ Regular Review of Patient delayed in Ambulances; to help prevent recurrence of the issues you raised relating to Rebecca Evans system of regular checks_ diagnostics and treatment; has been in place to ensure patients experience the minimum delay:
16. Ambulance Red Release; in partnership with the Welsh Ambulance Trust (WAST) they co-ordinate with emergency department to ensure that ambulances can be released to respond to potentially life threatening calls through immediate offload into any available in ED_ put

The above are just examples, but are offered to illustrate the level of daily and weekly scrutiny of demand and Unscheduled pressures: The Health Board fully accepts that its current unscheduled care performance, though demonstrating an improvement on this period last year, must improve both in terms of giving our patients and our staff the experience should be receiving: expect the move to position of improvement rather than deterioration to be an important turning point which acts as a springboard to build on. hope this letter offers the required level of assurance that we are focused on taking action to address the performance issues raised in your letter. Please let me know if you would like further detail on any of the areas within my response_