Written Statement: Update on unscheduled care pressures over winter 2019/20 and next steps to improve ambulance services

Further to my statement in October regarding preparations for winter 2019/20, I am making this statement to provide Members with an update on the current position in relation to winter pressures across the health and care system.

I would like to take this opportunity to reiterate my thanks to staff across NHS Wales and the social care sector who are working hard to provide care to the people of Wales. Winter is always a challenging period, but this year - more than any other - has seen relentless pressures across the system, which has made for an extremely challenging working environment for frontline staff.

Planning began in early 2019, informed by a review of health and social care resilience over winter 2018/19.

I made £30 million available to health boards and local authorities earlier in the year than ever before to support plans for the winter. For the first time this year, I deliberately allocated a significant part of this funding to Regional Partnership Boards. This was intended to ensure health boards and local authority partners worked together and with other partners to collaboratively plan services across their health and social care community.

Integrated health and social care winter plans were finalised in October 2019 and examples of service enhancements include:

• The Welsh Ambulance Service has introduced a number of schemes to increase capacity over the winter period, including additional clinicians in its clinical contact centre to support, signpost and discharge patients over the telephone
• Increasing OOH primary care capacity and extending GP access over weekends and evenings through pilot schemes in parts of Wales;
• The 'Emergency Department Well-being and Home Safe' service, delivered by British Red Cross, has been extended for a further 6 months at 8 emergency departments and expanded to 3 additional sites to support staff and improve patient experience
• Integrated services such as the Stay Well@home programme in Cwm Taf Morgannwg University Health Board and the 'Hospital to Home' programme in Swansea Bay University Health Board, which are designed to support people at home and in the community, prevent unnecessary hospital admissions and ensure timely discharge for those people that require admission to hospital, and
• An additional 400 beds or bed equivalents will be made available at sites across Wales over the winter. That is the size of a large district general hospital of additional capacity available in the system.

Pressures across the whole health and social care system increase over the winter months, due to a number of factors including the presentation of people with norovirus and ‘flu like symptoms and the number of older and sicker patients attending emergency departments.

While we are currently experiencing a relatively mild winter, we have seen exceptional pressures across our system throughout the festive period and into the start of January 2020. Data published today, covering the period from 18th December 2019-5th January 2020, highlight a number of spikes in activity for ambulance, telephone advice line and emergency department services, which placed significant demands on services from which it will take time to recover. There has also been a tangible difference in the level and the nature of demand across urgent and emergency care services.

For example:

• The Welsh Ambulance Service experienced a 23% increase in the number of immediately life-threatening or ‘Red’ calls when compared to the same period last winter [Footnote 1]. There was also an 8.4% increase in Amber calls over the same period.
• Within this period, the Welsh Ambulance Service received over 100 Red calls per day on 8 out of these 17 days, peaking at 119 calls on 20 December.
• Emergency departments saw the highest number of attendances over a festive period, with considerable spikes of activity that caused extreme pressure on certain days [Footnote 2].
• Within this broader increase in attendances, there was an 8.4% increase in attendances for over 75s compared to last year and an 8.6% increase on 5 years ago.
• There was a 5.2% increase in emergency admissions of people aged over 75 when compared with last year.

This level of increased pressure brings significant challenges and, as a result, some patients have unfortunately waited longer for access to care. This pressure also has consequences for staff well-being, and it is testament to the commitment and skill of frontline teams that they continue to deliver timely care to the majority of people.

Over recent days, we have seen the wider implications of these increased pressures across other parts of the system, with some planned procedures postponed at sites across Wales to accommodate the increased demand from emergency cases.

Organisations generally reduce the number of operations planned over the winter period, particularly the first 2 weeks of the New Year. This is to ensure there is sufficient capacity for patients who require emergency admission. I would reiterate that these procedures are postponed rather than cancelled, and will take place at a later date.

Looking ahead, I have reflected on progress made against recommendations from the review of calls to the Welsh Ambulance Service categorised as Amber (the ‘Amber Review’), published in November 2018.

The Amber Review found that 'ambulance availability' was the single main determinant for the timeliness of Amber response. The review identified a range of issues that reduce the availability of ambulance resources and detailed a number of recommendations to enable improvement. Progress has been made against these recommendations, but I believe more work is needed to realise the necessary improvements in ambulance delivery.

It is clear that given the changing operational environment, improvements to Amber response cannot be delivered in isolation from the wider issues surrounding ambulance availability.

I have decided to establish a Ministerial Ambulance Availability Taskforce to lead:

• implementation of recommendations from a recently commissioned independent “Demand and Capacity” review
• rapid delivery of alternative pathways and community-based solutions to prevent avoidable conveyance to emergency departments
• optimisation of the ambulance patient handover process
• improvement in Red performance, and
• build on progress made by the Amber Review Implementation Programme.

The taskforce will be jointly chaired by the Stephen Harrhy, Chief Ambulance Services Commissioner and Professor David Lockey, EMRTS Cymru National Director, with membership from relevant leaders from across the health and social care system.

This approach will focus not only on Amber responsiveness, but also on the need for wider improvements to reflect and respond to the changing environment, such as the changing picture of demand and performance for Red calls, increasing handover delays and the wider health and social care landscape.

Finally, Members will be aware of the impact ambulance patient handover delays can have on patient experience and clinical outcomes through limiting available ambulance capacity.

I am concerned about the deterioration in ambulance patient handover performance over recent months. As an immediate step, I have asked officials to develop proposals for a system of incentives to achieve desired improvements. I expect to take a decision within the next couple of weeks to enable the new system to be introduced in time to impact on performance this winter.

This will be one element of a broader approach to incentives that will in due course focus on other parts of the urgent and emergency care system to drive improved performance

[1] As part of the continual review of the clinical response model, the Welsh Ambulance Service regularly reviews call handling practices and the categorisation of incidents. An update to call handling practices this summer appears to have resulted in an increased Red incident volume. Further work is being undertaken to understand this change. Therefore, it is not possible to compare red incident volumes in recent months at present.

[2] Comparisons with 5 years ago have been made against the official statistics for the period rather than NHS management information. NHS management information prior to 2018/19 has a high number of records with no age specified. As the management information and official statistics differ, the actual change could be different to the 8.6% shown.