Dear Ms Saunders,

Re: Regulation 28 Prevention of Future Deaths report – Marjorie Joyce Michael (deceased)

Thank you for your correspondence of 26 July 2024 sent by email, 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 Marjorie Joyce Michael. I would like to offer my sincere condolences to Ms Michael’s family on their sad loss. In the report you ask for an update on details of action taken or proposed by the Welsh Government to improve ambulance responsiveness and prevent future deaths in the Gwent area. Whilst I have a role to set expectations in terms of a strategic direction for health and care services in Wales, and to hold the NHS to account, local health boards (LHBs) remain responsible for planning and delivering these services at a local level to meet the needs of the communities they serve. I will, therefore, firstly provide an update on action taken or proposed by Welsh Government followed by those actions reported to the Welsh Government being taken by the Aneurin Bevan University Health Board (ABUHB) and the Welsh Ambulance Services University NHS Trust (WAST). Welsh Government actions and support You will be aware the urgent and emergency care system in Wales, as with other parts of the UK, has been under often unrelenting pressure for a number of years as a consequence of a number of well-rehearsed factors. This includes the challenge presented by an ageing population, increasing prevalence of people with multiple chronic conditions and difficulties in supporting timely discharge of patients to local communities caused by social care capacity issues.

2

Overall management strategy to support improvement The NHS Wales Oversight and Escalation Framework sets out Welsh Government’s mechanism and approach for gaining assurance from NHS Wales organisations. The revised framework was published in January 2024 and sets out the Welsh Government's approach for gaining assurance from NHS Wales organisations; and the approach to escalation and intervention where there are matters of concern that need to be addressed.

In line with the arrangements, the process for the escalation of concerns relating to NHS health bodies, including LHBs, is undertaken at a number of levels. Firstly, through the routine performance management mechanisms in place including regular integrated quality, planning and delivery (IQPD) meetings held with each NHS health body and chaired by either the Deputy Chief Executive of NHS Wales or the Welsh Government Director of Operations for NHS Wales. These meetings are used to raise and discuss concerns about the particular health body’s overall quality and safety of services and to undertake deep dives on specific topics.

Joint Executive Team (JET) meetings are held twice a year between the senior teams of health bodies and the Welsh Government Health, Social Care and Early Years Group (HSCEYG). These are formal meetings to hold health bodies to account for performance, quality and safety, workforce and governance including an assessment of the organisation’s performance against national requirements, escalation and accountability conditions I remain concerned about the levels of ambulance patient handover delays reported across Wales, and LHBs must improve the timeliness of handover to release ambulance crews to respond to other patients in the community. We have been clear with LHBs that this is a priority for the Welsh Government in the national planning and performance frameworks, and through the Six Goals for Urgent and Emergency Care (‘six goals’) planning process. To further emphasise how we have prioritised improvement, we have also set LHBs in-year aspirations to reduce ambulance patient handovers over 1 hour by 30% by December 2024. We have put in place additional performance oversight arrangements to enhance scrutiny of LHBs’ delivery against these and other key ministerial targets through the new performance board arrangements. , the Director General of Health, Social Care and Early Years now holding monthly performance board meetings with LHB chief executives. 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 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 the 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.

3

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 handbook 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 the six goals 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 has increased to £27m in 2024/2025. Each LHB has developed a local ‘six goals’ programme plan for 2024/25 that incorporate 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). This six goals 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, the Gwent Regional Partnership Board (RPB) is focusing 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 clearly set out my expectations to ABUHB regarding the quality and timeliness of care to be delivered to people accessing care in the region, including those who are awaiting an ambulance response. This includes a focus on reducing ambulance patient handover waits and the time spent by patients in the emergency department, in addition to optimising quality and safety of care. Support to the Aneurin Bevan University Health Board We have provided an additional £6 million in six goals programme funding over the last two years to drive improvements in urgent and emergency care in Gwent, and the ABUHB will receive a further £2.7m this year. This funding has been used to develop new services and recruit key clinical leadership to oversee the ABUHB’s local programme plan.

Further, national support has enabled the ABUHB to develop and deliver its local six goals programme plan, which includes new interventions to improve patient flow and reduce pressure on its emergency department.

4

This includes development of urgent primary care centres at the Royal Gwent Hospital and Nevill Hall Hospital to better manage urgent care away from the Grange site, and SDEC services at the Grange University Hospital and Ysbyty Ystrad Fawr Hospital to help patients bypass the emergency department entirely.

We have also allocated an extra £300,000 to ABUHB to deliver a new ‘e-triage’ tool, launched in June this year, at the Grange University Hospital which will enable rapid self- triage to improve experience and identification of people who need early assessment.

The Gwent RPB has also been allocated £27.2million in funding this year, and ABUHB will receive a share of Further Faster and Allied Health Professional funding. All these funding streams are intended to either safely support fewer people to need to access services at the Grange University Hospital or improve flow across the system which will help to free capacity in the emergency department and reduce ambulance patient handover delays.

Finally, following consideration of a business case submitted by ABUHB earlier this year, we have also provided £14m capital investment to support the expansion of the emergency department at the Grange University Hospital site. Improvements are expected to be completed by Spring 2025 and will double the current wait capacity (38) to provide 75 seats in total. There will also be an area dedicated to support the e-triage tool referenced above, with the existing waiting area repurposed to provide a rapid assessment area, both of which will help with timeliness of access – providing the right care and treatment more efficiently.

Escalation of ABUHB to enhanced monitoring (Level 3) Performance particularly related to the Grange University Hospital emergency department is not where it should be. In line with our revised oversight and escalation framework, the LHB was, escalated to level 3 (enhanced monitoring) in January 2024.

Welsh Government officials have agreed with the ABUHB an escalation framework that clearly identifies where improvements are expected to be seen for both performance and outcomes towards improvement in delivery of care at the Grange University Hospital emergency department.

Whilst in escalation, ABUHB is held to account by Welsh Government through normal performance management arrangements such as IQPD and JET meetings. Further oversight is also in place through enhanced monitoring touchpoint meetings chaired by either the Deputy Chief Executive of NHS Wales or the Welsh Government Director of Operations for NHS Wales, as well as quarterly escalation meetings with LHB leads and chaired by the Chief Executive of NHS Wales. This includes a focus on progress made by LHBs on delivering the in-year aspiration to reduce ambulance patient handover delays over an hour in length by 30% by the end of December.

Following the escalation of ABUHB to enhanced monitoring, and with specific regards to ambulance patient handover, we have observed gradual improvement. For example, each month of 2024 has seen a reduction in the number of handover delays over 1-hour in length at all ABUHB sites when compared to the corresponding month in 2023. In July 2024, there was a 27% reduction when compared to July 2023. However, there is more to do to continue this downwards trend and to support the timely release of patients and crews, and we will continue to monitor the position closely.

5

Support to the Welsh Ambulance service The new NHS Joint Commissioning Committee (NHS JCC) was established on 1 April 2024 and 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 achievement of the Ministerial priorities I have set of all organisations from 2024/2025 onwards. 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 core funding, we provided £3m to the WAST in 2022/2023 to enable recruitment of 100 new staff. Since December 2021, there has been a 4.6% increase in WAST’s emergency medical services workforce in the ABUHB area. WAST also has access to national programme funding budgets including the six goals for programme’s innovation and delivery fund. We have targeted investment in 999 ambulance clinical triage resources and technology. This includes the use of video consultation technology which is helping to support around 4,500 (10-15%) patients without needing ambulance transport to an emergency department per month (in 2024/2025) to date. As described previously, plans to improve ambulance responsiveness in the ABUHB area are characterised by actions within the gift of WAST and ABUHB’s six goals programme plan; and joint plans with local authorities to improve patient flow. I note you have not requested an updated response to your report from WAST or ABUHB. You may wish to write to both organisations directly for further details on specific actions they are taking to improve ambulance responsiveness and prevent future deaths linked to delayed ambulance response, as they are responsible for delivery of services on the ground. I have provided a summary of the actions undertaken by ABUHB and WAST for information below, as reported to us by both organisations through ongoing monitoring arrangements undertaken by Welsh Government officials and the NHS Executive.

Aneurin Bevan University Health Board actions Through delivery of its local six goals programme plan, ABUHB has interventions underway to reduce pressure on the emergency department at the Grange University Hospital and improve patient experience and outcomes. ABUHB provides quarterly updates on progress in delivering its six goals programme plan to the NHS Executive and specific elements of this plan to improve emergency care pathways at the Grange University Hospital are

6

reported to the Welsh Government at monthly enhanced monitoring meetings. ABUHB has reported to us the following actions are in train:

• Implementing a 24/7 urgent care service which includes minor injuries units and integrates the front door at the local general hospital sites – ensuring a seamless transition from in and out of hours services.

• Maximising the use of specialist advice and guidance lines with further integration of the frailty and ‘flow centre’ navigation system. The ‘flow centre’ is staffed by clinicians who are able to provide specialist remote advice to clinicians in the community who are at scene with patients helping to reduce unnecessary emergency department attendances and ambulance conveyances.

• A new hub comprised of clinical professionals is providing Community Resource Team (CRT) clinician capacity at the Flow Centre to support clinician to clinician conversations and triage of identified frail/older patients, including care home residents, to offer an appropriate alternative to acute admission.

• Early interventions to increase the number of elderly or frail patients supported at home and further development of SDEC frailty services to help patients bypass the emergency department entirely if they do need to attend hospital.

• Embedding of new falls pathway and development of fracture liaison services – reducing the future risk of falls and re-fracture.

Welsh Ambulance Services University NHS Trust actions Our policy expectation, and the commissioning intent of the NHS JCC, is that WAST prioritises response to those in most need and aims to provide the right response, first time to optimise outcomes and experience. We expect WAST to work in partnership with LHBs to design and deliver consistent alternatives to ambulance despatch and conveyance to hospital. This is set out in our six goals policy handbook referenced earlier in this response. WAST has developed improvement plans for 2024/25 to help manage more people in the community, reduce conveyance to hospital and protect valuable resources for those most in need of an urgent response. Immediate actions include:
• Optimising use of its ‘Clinical Support Desk’, to manage up to 17% of patients remotely where clinically safe to do so and reduce the number of patients conveyed by ambulance to hospital;
• A targeted workforce plan to reduce sickness absence rates and increase available capacity;
• Additional volunteer capacity through WAST’s Connected Support Cymru initiative to aid decision making and support more patients to remain at home;
• A focus, with LHBs, on improving direct access into SDEC pathways, particularly for frail and elderly patients, to reduce conveyance to emergency departments and patient length of stay; and

7

• Full rollout of the Cymru High Acuity Response Units (CHARU) which provide specialised emergency responses to people with high acuity needs and is improving clinical outcomes for people who have suffered a cardiac arrest. Optimal utilisation of CHARU vehicles and practitioners will help preserve other urgent ambulance resources for other patients.