Dear Ms Saunders Re: Barbara Young I am writing in response to the Regulation 28 Report that you issued to this Trust, dated 28 January 2022, following the sad death of the late Mrs Barbara Young. In the Regulation 28 Report you raised your concerns in relation to two matters, which I will respond to below:-
1. Confirm the action that will be taken to improve the response times of emergency ambulances. To put this response in some context, you may be aware that during the first wave of the pandemic, we saw a reduction in our normal demand, in addition there were fewer delays in handing over patients at hospital. However, subsequently during 2021 and 2022, activity returned not just too forecasted levels, but above predicted levels. This is further exacerbated by an increase in the acuity of our patients. As a result of this, the Welsh Ambulance Services NHS Trust (The Trust) continues to experience excessive delays in trying to respond to patients in our communities and handing patients over at hospitals for assessment, care and treatment. There have also been other contributory factors why there have been delays in providing a timely response which include, sickness absence, infection prevention and control measures and also delayed transfers of care out of hospital because of a lack of social care packages. This will mean that patients are

2 occupying acute hospital beds as it would be unsafe to discharge home without adequate social care in place.

I can confirm, as with all NHS Organisations, staffing has been significantly affected during the pandemic, with as many as 15% of staff away from work at any one time as a result of sickness absence, a significant proportion linked to Covid-19, whether that be the result of contracting the infection themselves, self-isolation or indeed, during the initial waves, shielding. This inevitably had a bearing, and continues to do so, on our ability to optimise the number of ambulances available to respond.

In addition, for Red calls, crews are required to wear additional personal protective equipment (PPE) which can add crucial minutes to put on, when crews arrive at scene. We recognise this is difficult, but we have a responsibility to safeguard our own crews where there is a risk to them and we follow national guidance on this matter.

During February 2022, the Welsh Government (WG) called a Risk Summit with all NHS providers and Local Authorities to review patient risks in the community and to identify what improvements could and should be made to improve system pressures. This meeting resulted in a mandate from WG for all Health Boards and Local Authority partners to work collaboratively to introduce a system reset during March 2022. In addition, Chief Executives of Health Boards have been asked to urgently provide their plans for how they will reduce hospital handover delays over the coming weeks.

I am able to provide you with absolute assurance that the negative and sometimes catastrophic impact the systems pressures are having on patients in our communities is constantly being reviewed and escalated at the highest level. I can also assure you, that the Trust has already taken many actions to try and mitigate the effects of ambulances being delayed at hospital, which then effects our ability to respond to people in the community. As I am sure you will appreciate, none of these matters sit in isolation but are interlinked. I wish to assure you that the Trust has made several changes and taken actions, over and above those I have listed here. However, I have selected the issues and actions that I hope best demonstrates that the Trust has considered every possible way in which we can react to and mitigate the impact of these pressures, which are fundamentally outside of our control. These include:

Consult and Close

There has been significant investment into the Clinical Contact Centre (CCC), where by the end of the month we have doubled our clinical workforce in this area (Nurses/Paramedics/Mental Health Practitioners), which is already showing some improvement in unnecessary dispatch and conveyance into hospital, where appropriate. The additional clinicians in the CCC are offering patients appropriate alternatives such as for example, signposting to pharmacist, having an up to date Directory of Service to local pathways, and, or giving self-care advice and support. This will release vital resources to respond to patients who need a face to face assessment in the community. We anticipate with this investment that we will be able to consult with our patients and close up to 15% of the calls we receive.

Handover Delays

Unfortunately the Trust continues to see a substantial number of hours lost to hospital handover delays, across NHS Wales, with more than 25,000 hours lost (25% of our on duty fleet) in February 2022. This has a significant impact on our ability to provide timely care and treatment to those in need an emergency community response. The Trust, continues to work closely with our Health Board colleagues across Wales to minimise delays by providing on-site support and,

3 with assistance from nursing and medical staff, prioritising those patients with the greatest clinical need. As an example, a number of Patient Flow Coordinators have been recruited to support the wider system flow pressures at the Grange Hospital, Cwmbran. In addition, we secured support from Private Ambulance Service clinicians over the winter months. The purpose of the approach is to facilitate safe timely transfers for a cohort of patients from the Trust ambulances when there is no capacity within the Emergency Department (ED) or elsewhere in the hospital to facilitate timely off-load. That said, delayed transfer of care remains a significant barrier our ability to respond to calls in the community in a timely fashion with 25% of our on duty fleet capacity lost in this way in February.

Discharge and Transfer

We also support the discharge and transfer of patients out of hours in order to release beds in hospitals, which in turn supports the improvement of patient flow in the emergency departments.

Reducing Conveyance to ED Departments

Where safe to do so, and where Health Boards have suitable alternative clinical pathways, the Trust aims to support people in the community and to reduce the number of unnecessary admissions to Emergency Departments. We continue to recruit and train Advanced Paramedic Practitioners who have a higher skill level and are trained to treat patients in their own homes, where possible.

Additional Capacity from Military

You may be aware that we have had support from the military on three separate occasions, the latest deployment being scheduled to finish at the end of March 2022. We have asked for military support to help us put out as many ambulances as possible, as well as securing additional support from St John Cymru Wales, other providers and utilising our own staff differently.

Clinical Safety Plan (CSP)

To support the Trust to be able to manage and respond to those patients in greatest need, the Trust has reviewed and enhance the process around the Clinical Safety Plan (CSP). This allows the Trust to manage the demands on the service differently during times of extreme pressure. The introduction of the CSP ensures that patients are advised of the current timeline of delay, and would be encouraged to contact family members, neighbours or friends to help assist with transport to hospital, should this be an option. This provides a framework for Trust Emergency Operations teams to respond dynamically to situations through a set of tactical options that are flexible, immediate and specific to each Health Board area. This ensures that patients with immediately life-threatening conditions such as cardiac arrest and catastrophic hemorrhage, continue to receive services as quickly as possible. The CSP has been approved by Trust executives and the senior management team, and it is accepted that in times of extraordinary pressure, the Trust will be unable to provide the level of response that would be desired. It is therefore appropriate to inform some callers of likely delays and advise them to seek alternative arrangements to ensure that the patient is taken to a facility that can provide appropriate, definitive care.

Demand & Capacity

To ensure that the Trust has the correct number of resources available to respond to the expected demand and maximise the number of resources available to respond to patients, the Trust undertook a Demand and Capacity Review. This review identified a range of efficiencies

4 for the Trust to achieve. This includes a full roster review and some focused improvement work on the management of sickness and absence.

Accordingly, the Trust has increased its workforce by 236 Full Time Equivalent staff, pan-Wales. The staff have been recruited and trained as part of our established Emergency Medical Services Operational Ambulance Programme. Additionally, we will reroster all staff during Q3 22/23 to ensure staff are on duty at the time and in the place that best match patient demand. This will release an internal efficiency equivalent to 72 FTE.

All of the actions above assist by reducing the pressure on busy hospital departments, improve patient flow within the wider NHS system and maximise the availability of our emergency resources for our most critical patients.

2. Confirm whether there are any plans to review the categorisation of elderly patients who suffer falls and are more likely to be affected by the risks associated with lengthy periods of immobility.

Each ambulance service has a response model that supports the categorisation given to each call (irrespective of which prioritisation system is used). That response model and the decisions made will reflect the demographics of the population and the geography being served by that individual ambulance service. In 2015 the Welsh Ambulance Services NHS Trust introduced its current Clinical Response Model (the Model), which removed timed targets for all but those patients with immediately life-threatening illnesses or injuries. The Model underwent a trial period before being approved by the Welsh Government and fully implemented by the Trust.

The appropriateness of the priority given to each category of call is reviewed and changes are considered by the Trust’s Clinical Priority Software Advisory Group (CPAS). In all cases the group will consider the impact any change would have on the volume of each priority of calls received, for example the effect of increasing the number of Red calls would have an impact on all other codes. The CPAS group also sets an “ideal” response for each type of call, in an attempt to maximise efficient use of resources by avoiding “double dispatch” on calls.

The Medical Prioritisation Dispatch System (MPDS) does not provide a determinant code based on age within Protocol 17 (falls) which would prevent a specific prioritisation change for elderly patients. The principal role of the Clinical Support Desk (CSD) Clinician is to provide additional clinical triage, advice and support to patients to ensure that they can access the most clinically appropriate care for their urgent and emergency healthcare needs, commonly known as Hear and Treat (H&T). In addition to this principal role, the CSD also undertake a range of other clinical functions in pursuance of maximising patient safety for those awaiting an emergency ambulance. This includes reviewing long waiting patients to maintain patient safety. CSD clinicians have the ability to change the responding priority of an incident based on a secondary clinical assessment, this includes increasing the priority where the patient’s clinical acuity indicates this is appropriate. Dispatch guidelines regarding falls and frailty responders are continually reviewed and updated to ensure maximum utilisation of this valuable resource, part of the CSD role is to provide support to falls assistants following an initial assessment to ensure the correct outcome is reached.

The categorisation of elderly patients who suffer falls and are more likely to be affected by the risks associated with lengthy periods of immobility, will be referred to the Trust’s Clinical Priority Software Advisory Group.

5 Additionally, in 2018, Working in partnership with St John Cymru Wales, the Trust introduced the role of the Falls Assistants (FA). The FA predominately provide a response to patients who have no injuries or where there is a concern for welfare. However, they are able to respond to patients with other medical/frailty presentations, or if there is an injury. This decision will often be supported by a clinical triage and assessment by a clinician, over the phone, prior to allocation. The aim of this new level of response was to ensure those patients often presenting with lower clinical acuity, were provided with a timely response to reduce the risk of further harm.

Within 2021, the Trust successfully awarded a contract to provide a National Falls Assistant Service with one Falls Assistant (for 12 hours per day) in each Health Board area, to St John Cymru Wales. From December 2021 through to January 2022, the Quality Improvement Team are currently working with various stakeholders both internally and externally to further enhance the Falls Assistant provision. This includes the Operations and Clinical/Medical Directorate, along with Health Board Partners. We have introduced a further two vehicles by night (funded by the Trust) which is currently funded up to and including 31st March 2022.

Outside of our contract with St John, one vehicle has been funded by the Cardiff and the Vale Health Board (operational from 19.30-07.30), which is currently funded up to and including 31st March 2022. Additionally, Aneurin Bevan University Health Board continues to fund a Falls Response Service (Paramedic and Therapist) vehicle which operates daily (08.00-20.00hrs) and Betsi Cadwaladr University Health Board are currently funding a trial for a Falls Response Service model which operates 4 days per week. Swansea Bay University Health Board have agreed to fund a Falls Response Service provision for 1 day per week over the winter period, providing ad-hoc cover. In addition to the specialist falls response, the Trust are working with volunteers (community first responders) and Fire and Rescue Services to provide a designated response to patients who have fallen to ensure periods of immobility are reduced. Enhanced Clinical Desk capacity has been introduced with the Clinical Contact Centre, which ensures patients receive targeted advice when waiting for a response including advice in relation to pressure ulcers and reducing the period of immobility. This is provided as part of the telephone triage and assessment.

The Trust continues to work with partners to further expand the model, to ensure patients are able to receive a timely response. In December the Trust undertook a review of the Medical Priority Dispatch System (MPDS) codes for Falls to determine if there were opportunities to improve the timeliness of response. Following a review, four codes were identified as suitable for Falls Assistants (non-registered, in some areas St John Service) to attend without the need for Clinical Triage, thus reducing the requirement to send an Emergency Ambulance. Furthermore, improvements are actively being considered to improve utilisation of resources and support patients who are waiting for a response. A Quality Improvement Workshop has been prioritised for April, with representatives from across the organisation to identify tests of change and prioritise improvements. This includes a review of the advice provided via 999 and a review of the response availability and capacity. The Falls Improvement and Implementation Group (FIIG) will conduct a review of the guidance provided to patients following a fall, consider the risks associated immobility and will suggest possible improvements.

To conclude, and to provide you with absolute assurance, the Trust is aware of the risks and the impact that delays in care and treatment can have on patient outcomes. This is not the level of service that we want to provide for the people in Wales. I hope that this response as provided you with a level of assurance that we, as an organisation, are doing everything in our control to reduce the level of risk, harm and the impact that the system pressures is having on patients in our communities.

6 Whilst writing I would like to extend my sincere condolences to Mrs Young’s family on their sad loss. I would also like to extend the offer to meet with you to discuss our response in more detail and to provide you with any further assurances you may require regarding our commitment to continuance improvement to support the prevention of future deaths.