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Welsh Ambulance Services NHS Trust

Integrated Medium Term Plan Summary 2018-2021

Published: June 2018

www.ambulance.wales.nhs.uk

www.facebook.com/welshambulanceservice

@WelshAmbulance

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Welcome to our Integrated Medium Term Plan (IMTP) Summary for 2018/19 - 2020/21. The IMTP is vital for us in the Welsh Ambulance Service to ensure there is a clear plan in place for the organisation. Our full IMTP is a detailed technical document that many may not have the time to read, so this summary aims to capture its key messages to ensure that we can reach a wide audience in a reader-friendly way. The IMTP is a requirement of Welsh Government for all Health Boards and Trusts in NHS Wales and it sets out our direction for the next three years, outlining our priorities, challenges and main risks. The plan commits us to delivering 44 actions, more detail can be found in the main IMTP. In their foreword, our Chair and Interim Chief Executive reflect on our place as a global leader in ambulance services, highlighting successes such as our clinical model. They outline the need to look at our strategy for the long term to make a fundamental difference to the landscape of unscheduled and scheduled care in the next 10 years. We will focus on how we shape our services to respond to our changing population, which can be achieved only with support from our partners and by ensuring our teams have the right skills. We hope you find this summary a useful insight into the Trust and the work we are doing to improve the quality of care we deliver to our patients.

Alongside consolidating our achievements in the last two years, we remain a highly ambitious organisation and we have tried to demonstrate this in our plan, whilst recognising the significant challenges that still remain in the ‘here and now’ which we must address. In the immediate term, we intend to:

Realise benefits of investments into the organisation and service such as CAD and Band 6

Address the continued challenges we face around our Amber cohort of patients Make more progress in using the skills of our paramedics in the community Carry out innovative work with patients who fall - another large cohort of

patients we help frequently Deliver a key component of the NEPTS business case through the transfer of

work from local health boards to the Welsh Ambulance Service (WAST) These key programmes, along with many other innovative and transformative actions, are detailed throughout this summary and further information can be found here in the main IMTP document.

1- INTRODUCTION

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2 - STRATEGIC OVERVIEW

Developing a Long Term Strategy

We are proud that we are in our third year of having an approved IMTP. Having this status has not only contributed to stabilising the organisation, but also given us the thinking space to consider what the long-term term strategic plan for the future of ambulance services in Wales needs to be. In 2017/18, we began developing a long term strategy for ambulance services in Wales and we have progressed this by identifying four pillars: (i) Widening our Clinical Offer, (ii) Leadership and Workforce, (iii) Working Together, and (iv) Embracing Technology.

Consequently, we have adopted a collaborative approach to developing what these four pillars mean in detail by engaging with a range of stakeholders including the public, partner organisations and our staff through a range of workshops.

Next Steps Work has already commenced on developing these themes into some more specific statements of ambition and some clear short, medium and long term priorities. Through 2018 we will undertake further targeted engagement on these, both internally and externally, prior to publishing our strategy.

Our Strategic Aims Our document is framed around our strategic aims and is underpinned by five key priorities which are outlined in this section.

We will place quality at the heart of everything we do, whether that is supporting all our leaders to be vibrant and compassionate, ensuring our services are excellent, in developing

strong partnerships or in striving for continued value, excellence and efficiency

• To deliver value, innovation and efficiency across

the organisation.

• To build even stronger partnerships with staff,

patients, the wider public and our full range of

stakeholders.

• To ensure service delivery excellence and further improve the services we provide to patients.

• Our staff are fantastic. We must ensure they are continually able to be their best.

• To ensure all our leaders are vibrant and compassionate and help create a compassionate, caring culture.

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Our Priorities Our five priorities are:

1. We will progress our quality improvement journey – implementing all strands of our quality improvement strategy.

2. We will sustain our Red performance whilst delivering further improvements and efficiencies in our clinical contact centres and our Amber performance.

3. We will continue the transformation of our NEPTS service, placing a significant focus on the successful transfer of work from health boards and implementation of the Quality and Delivery Assurance Framework.

4. We will deliver patient and system benefits through effective partnerships with health boards, our blue light partners, the third sector and the people in Wales. There will be a specific focus on estate, fleet, joint training opportunities and the continued rollout of the 111 service.

5. We will continue to develop, re-shape and engage with our workforce. We will place a specific emphasis on the implementing and embedding of the Band 6 paramedic role.

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By bringing together our behaviours, priorities and our strategic aims, we have created a Strategy Map for the next three years, as shown below:

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Overview of Our Performance

We have made good progress in improving key elements of our performance during 2017/18, in particular Red performance, improved hear and treat rates and performance against concerns responses. However, we recognise that we still have areas where performance is fragile, where there is variation or where focused attention is required to demonstrate improvements. A detailed look at our performance is available in the IMTP main document. Key points from the analysis are:

The Demand and Capacity Review In last year’s plan we identified the initial findings of a detailed Demand and Capacity Review. Over the past 12 months we have begun to make use of these opportunities as follows:

Improving the alignment of our rosters Expanding the Clinical Desk Modelling the impact of 20 Community Paramedic Schemes Work is underway to realign internal resource to reduce the relief gap of circa

205 full time equivalents Identifying a way of building modelling software and expertise in house to

become business as usual for the Trust The need for additional staff (circa 60 full time equivalents) by 2020/21

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Our Performance Ambitions

We have set ourselves a number of performance ambitions. These are ambitions which are discrete to the organisation and are not mandated by Welsh Government. It is important to set ourselves these ambitions so that we can measure that the work and actions which we are progressing are having a material impact on the services we provide. A detailed list of our performance ambitions can be found in our full plan. The list below represents just a few examples:

Measurable Ambition

Baseline 2017/18

2018/19

2019/20

2020/21

Percentage Hear and Treat

6.70%

8%

Sustain

10%

Number of NEPTS bookings made by fax/paper

30%

15%

0

0

Improving Infection Prevention & Control - Aseptic training to increase

0%

20%

50%

95%

Percentage of suspected stroke patients who are documented as receiving appropriate stroke care bundle

96.20%

95%

95%

95%

National Policy Context

The Welsh Ambulance Service operates within a complex national picture and, in developing this plan, we have had to take into account a number of external polices, directives and work which we know is progressing. Some of these external factors are shown below.

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Emergency Ambulance Services

Emergency Ambulance Service (EMS) commissioning (this means agreeing what outcomes need to be delivered with which resources) in Wales is a collaborative process underpinned by a national EMS Collaborative Commissioning Quality and Delivery Framework (CQDF). Working with the Chief Ambulance Services Commissioner (CASC) and his office on the development and delivery of the CQDF continues to be critical and core business for WAST. The framework’s overall strategic aim is to move activity towards steps 1 and 2 and away from step 5:

Designed with permission using the CAREMORE® 5 steps. Copyright, 2017 WAST

Non-Emergency Patient Transport Services The Non-Emergency Patient Transport Services (NEPTS) commissioning framework went live (in shadow form) on 1 November 2017. Like the EMS framework there are five steps:

At this stage, the NEPTS commissioning framework includes only WAST delivered services. Over the next three years, local health board (LHB) NEPTS provision will transfer to WAST in a phased manner and is likely to require multiple providers to

Emergency Ambulance Services Committee: Welsh Ambulance commissioning intentions -

we are commissioned by Health Boards through a single committee known as EASC. Our plan is set against what our commissioners are asking

us to focus on.

Parliamentary Review - An expert panel was set up at the direction of the First Minister to

undertake a review of health and social care in Wales. Our plan has to respond to those

recommendations.

Prosperity for All - This is Wales' current programme for government which was

published following the last Assembly elections.

A long term strategy for Health and Social Care - Welsh Government is currently finalising an

overarching strategy for NHS Wales. Clearly all NHS Wales bodies, of which we are one, must

look to realise this wider strategy.

WAST

Step 1 –Help me to

choose

Step 2 –Answer my

request

Step 3 -Coordinate my journey

Step 4 –Pick me up

Step 5 -Take me to

my destination

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deliver the increased workload. As this non-WAST work transfers into the Trust, the commissioning framework will be enacted to cover these services also.

National Wales Strategic Change Agenda

The ambulance service operates as part of a complex health and social care system. There are a number of complicated service changes and developments at various stages of planning and implementation at both a health board and regional level. We are working closely with the four new regional planning fora that the health boards have established at the request of the Cabinet Secretary for Health and Social Services. Such work includes: South East and Central Wales: Supporting health boards in their plans to regionalise some paediatric, obstetric and neonatal services. West Wales: Supporting Hywel Dda UHB and Abertawe Bro Morgannwg UHB to regionalise their stroke services Mid Wales: Working with Powys tHB and other stakeholders to further progress telemedicine. Regional Service Change We have worked closely with the regional planning fora to identify where we are a key stakeholder, and our engagement in the wider range of change programmes is set out within the main document. Health Board Service Change

The map below provides an overview of the strategic change programmes at a Health Board level with which we are engaged.

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Service Change in Collaboration with Blue Light Partners The police, fire and rescue and emergency ambulance services have a statutory duty to keep collaboration opportunities under review and to collaborate where it is in the interests of their efficiency or effectiveness. WAST is represented at the Joint Emergency Services Group (JESG) whose core activities are currently focused on adverse incident escalation and demand management through effective application and sharing of business intelligence. To help us achieve our ambitions, our whole plan is based on effective working with our many partners, both in the NHS and more broadly, including local authorities, the voluntary and private sectors, the wider public and our blue light partners. We have continued to do some innovative work with our blue light partners and the collaborative services we are delivering are shown below:

Fire Service Collaboration

Services

Co-responding

Co-located stations Develop a WAST and FRS Strategic Outline Programme

Police Service Collaboration

Co-locations

Adverse Incident Reporting & Reduction

Demand reduction & Intelligence sharing

Gwent Police Joint Response Unit (JRU)

There is still more to do. Consequently, we will progress the following:

Joint police, fire service & WAST Intelligence Hub Information sharing Foot Intervention Teams (FIT) - A team of ambulance staff responding on foot

with a stretcher and equipment into an area where vehicular access is

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impossible or would endanger crowds. This tactic will be further refined during 18/19.

Joint estate opportunities

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3 – REVIEW OF 2017/18 AND LOOKING FORWARD TO 2018/21

Our achievements in 2017/18 2017/18 was a good year for WAST, with progress made across a number of areas:

Implemented a new Computer Aided Dispatch (CAD) system Development of a new Non-Emergency Patient Transport Delivery Framework Agreed the Band 6 paramedic role – held up as an exemplar of partnership

working Developed our Mental Health Improvement Plan (MHIP) which was approved

by Trust Board and endorsed by our commissioners and Welsh Government. Strengthened our clinical leadership infrastructure with the appointment of

regional and LHB area clinical leads to support operational teams in clinical practice, audit and pathway development.

Delivered our bespoke Team Leaders Development Programme to 67 of our 225 team leaders

Achieved Gold Corporate Health Standard Trained more than 9,000 students through our 160 WAST staff and volunteers

in October 2017 as part of Restart a Heart Day and Shoctober Achieved Accredited Centre of Excellence status in all three EMS Clinical

Contact Centres. Achieved financial balance

Our 2017/18 Strategic Actions Our 2017/18 plan detailed 48 actions which we committed to delivering over the life of the plan. Of those 48 actions;

41 Scheduled to complete

28 Completed

2 Closed mid-year

15 Rolled over to 2018/19

For 2018/19 we have 44 strategic actions, including the 15 rolled over from 2017/18. We continue to monitor the delivery of these actions through the IMTP Delivery Assurance Group (iDAG).

Opportunities and Challenges in 2018 - 2021

There are opportunities and challenges for us, as we operate as part of the wider health system: Political landscape - The life of this plan will be against the backdrop of Brexit

negotiations and both general and Welsh Assembly elections.

The wider unscheduled care system in NHS Wales - We are a vital partner in the unscheduled care system (USC) within Wales and we must work closely with

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all other stakeholders to re-engineer the system. The system is under pressure and, at periodic points throughout the year, escalation levels are such that delivery of our plan will face some risks, as will delivery of LHB plans. This is both a challenge and an opportunity.

Leadership challenge - Identifying, developing and encouraging a change in leadership style from the old “we know best’ to a more collaborative, empowering, courageous and vibrant style of leadership for the future, is seen to be essential in delivering sustainable culture change across the organisation. A further shift in behaviours is needed to transform and deliver our Trust vision.

Specific Challenges for WAST

Our main challenges revolve around our ability to respond (dispatch available resources) in a timely way given the shift and increase in demand.

The Demand and Capacity Review that took place in 2016/17 identified a number of challenges:

Existing capacity Demand projection Performance reduction The impact of system wide pressures

For 2018/19 we will:

Pilot the use of Optima Predict Look at opportunities to reduce the current relief gap Review the rosters across all Local Health Board (LHB) areas Deliver the 30 second reduction in activation times via the new CAD Develop the Clinical Response Model to identify “missed opportunities”

Amber performance remains an area of challenge. Amber calls account for approximately 65% of the Trust’s 999 workload and are made up of a very large cross section of conditions, which range from suspected strokes and breathing difficulties through to suspected broken ankles and elderly patients who have fallen and are injured. Lengthening response times to Amber calls impact on patient care and patient experience with an increase in complaints, concerns, SAIs and near misses when available capacity is insufficient to meet demand. Improving our response times for Amber calls is extremely important for the Trust because of the direct links with patient experience and patient safety. We have a detailed Amber improvement plan which is focused around three core issues:

Resource production Resource availability The clinical model

Actions within these themes can be explored in more detail in our full document.

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Opportunities

Whilst the context may be challenging at times, there are a number of opportunities for the organisation that we must grasp, explore and exploit over the next three years. Some of these relate to realising the benefits of investments made and others relate to strengthening our role in the unscheduled care system and being clearer on our “offer”. Some of the opportunities for us are outlined below.

Further enhancements to our Computer Aided Dispatch (CAD) system Clinical response model Working with primary care Workforce modernisation HCP calls Collaboration and engagement with partners Services for injured and non-injured fallers Implementation of 111 Hear and treat NEPTS commissioning and transfer of work Supporting our volunteers Commissioning arrangements Working more closely Children’s Commissioner and the Older People’s

Commissioner for Wales to achieve better outcomes for these patients

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4 - QUALITY, SAFETY AND PRUDENT HEALTHCARE

During 2017/18, we demonstrated our commitment to putting quality at the heart (see our Strategic Aims) of our service through our Quality Strategy (2016 - 2019). Year three (2018/19) of our Quality Strategy will focus on implementing, monitoring and reviewing actions whilst making appropriate improvements and changes in the areas which matter the most, informed by patients, service users, stakeholders and through staff feedback. Our aim is to continue to develop our focus on quality governance (assurance and improvement) within the Trust so that we may discharge our responsibilities for quality. This means that we will continue to develop our structures and processes at Board level, and across the organisation, to lead on Trust-wide continuous improvement including:

ensuring that standards are achieved and compliance with regulation and legislation

triangulating quality data, information and patient, carer, stakeholder and staff feedback

planning, driving and measuring continuous improvement identifying, sharing and ensuring best practice across NHS Wales

During 2017/18, we made significant progress with developing and strengthening our structure and processes to enhance the quality of outcomes and experiences for our patients, carers and service users and for our staff and key stakeholders. We embedded the changes made to our organisational structures that were established during 2016/17. Next steps for 2018/19 are:

To strengthen our quality governance structures To strengthen our quality assurance and improvement processes Maintaining our focus on improving patient experiences and outcomes to

achieve safe and effective care and achieve excellent patient, carer and staff experience

Our Quality Governance Framework ensures that we continue to implement, monitor and review our strategy, structure and processes, capabilities and culture to drive quality forward across the organisation, measuring compliance and improvements.

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5 – OUR SIGNIFICANT SERVICE CHANGE

Emergency Medical Services

The delivery of our EMS services is captured in the following five steps. These steps

are used to frame our key improvement initiatives.

Step1: Help Me Choose

This step focuses on helping the public chose the right part of the NHS, including the services provided by us and how and when they should be accessed appropriately. Last year we:

Successfully introduced a national approach to individual frequent callers, which has produced significant reductions in the number of such calls.

Piloted a multi-disciplinary response to frequent caller care homes in Cardiff and the Vale, working with the LHB. As part of its 2018/19 plans, the Trust will expand this approach across Wales.

Looking forward, we will develop our Public Health Plan (Choose Well and Making Every Contact Count).

111 Implementation

The 111 Pathfinder launched on 4 October 2016 and, up to the end of October 2017, received more than 175,000 calls from patients living in the Abertawe Bro Morgannwg University Health Board (ABMU) area and Carmarthenshire (where the service was launched on 2 May 2017). The 111 Strategic Plan for 2018/19 - 2019/20 paints a picture of a future service vision for 111 with much closer alignment between the clinical desk in the EMS service and the clinical support hub in 111. We will work with the national 111 programme and local health boards to deliver the high level milestones set out below:

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Step 2: Answer My Call

This step focuses on continuing to improve our Clinical Contact Centres (CCCs), acknowledging that these are at the centre of the entire WAST operation. We have made significant progress over the last 12 months in Step 2:

The implementation of the new CAD (Computer Aided Dispatch) system In November 2017 we successfully implemented a new Computer Aided Dispatch (CAD) system.

Improved ‘Hear and Treat’ rates In 2017/18 we further strengthened the Clinical Desk which now employs 30 whole

time equivalent staff, including two senior clinicians. We have also extended our responsiveness to fallers and CCC clinicians are now operating out of police control rooms in North Wales, Dyfed Powys and South Wales force areas most evenings.

Looking forward into 2018/19, we are establishing a phase two CAD project board which will drive through many of the new benefits and efficiencies which the new CAD offers.

Step 3: Come to See Me

As part of Step 3 we will continue to focus on ensuring the correct clinical response is provided to match the need of the person contacting the Welsh Ambulance Service. The new CAD and efficiencies in the CCC should enable the Trust to reduce multiple vehicle arrivals at scene for Amber and Green Incidents, which should free up resources to respond to other incidents.

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Red performance will be maintained within the performance ambition of 65% to 75% of Red incidents being responded to within eight minutes, with continued monitoring of the 95th Red percentile.

Development of an Electronic Patient Clinical Record (ePCR)

The Trust currently uses ‘digi-pen’ technology to compile clinical records for the patients that we attend. This system has delivered considerable benefits. Looking to the future, and in line with the emerging ideas from developing our Long Term Strategic Framework, we will develop a more innovative and effective electronic solution to capture and record clinical information that will improve the quality of care we provide to our patients. Moving forward, we will establish a Project Board to oversee the development of a business case to secure the investment required to implement a solution.

Step 4: Give Me Treatment This step focuses on the development and delivery of a range of clinical care services able to offer a variety of treatment options. We have developed and will report against seven key clinical indicators; cardiac arrests, strokes, heart attacks (called STEMI), fractured hips (known as neck of femur injuries), febrile convulsion, sepsis and hypoglycaemia. Some of the clinical initiatives which we will continue to progress in the lifetime of this plan include:

The Telemetry project The Omnicell project The Out of Hospital Cardiac Arrest Survival Plan The Clinical Indicator Improvement Plan Pilot of advanced paramedics in North Wales

Step 5: Take Me To… This step refers to patients who are not appropriate for ‘hear and treat’ or ‘see and treat’ services and require hospitalisation. Our aim is to support those patients who trigger this part of the 5 Step Care Pathway and we recognise that, as a Trust, we will need to support our staff with appropriate training and technology in order to improve performance in this area. We will continue to work closely with our Emergency Medical Retrieval and Transfer Service (EMRTS) colleagues on the following priority areas;

Improving the safety of critical care transfers across Wales Training for WAST staff in the use of trauma triage tools and other trauma skills The switch on of the CAD Aeromedical Module which will allow improved

management of EMRTS resources To ensure the most appropriate care and treatment and mode of conveyance

to or between hospitals are provided for patients.

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Our Non-Emergency Patient Transport Service (NEPTS)

Developments

A vital part of what we do involves taking people to and from routine and specialist outpatient appointments at clinics, hospitals and day centres. NEPTS makes over 700,000 journeys every year for patients across Wales and enables them to be on time without the use of an emergency ambulance.

In line with the NEPTS Business Case, the commissioning of NEPTS services is changing significantly over the three year period of the plan. We continue to work in close collaboration with health boards, and the CASC, to support us in delivering the service that patients need.

The NEPTS commissioning framework went live (in shadow form) on 1 November 2017. Like the EMS framework, there are five steps:

The aim of the five step model is to focus on patient flow and to provide a clear framework for the delivery of the service in line with patient need. We will use various service improvement methodologies to improve the patient experience over all five steps.

STEP 1: Help Me to Choose We recognise that we need to increase our engagement with both existing and future users of NEPTS and health care professionals to ensure that accessing the NEPTS service is simple, and eligibility is easily understood. We also understand the importance of working closely with health boards around their service change and the impact it may have on NEPTS service across Wales. The valuable NEPTS resource should be focussed on patients who have no other means of accessing appropriate transport to care. Over the term of this plan we will continually work with other transport providers to increase the alternatives to NEPTS for non-eligible patients, as well as reviewing the existing eligibility criteria with our commissioners, Welsh Government and other stakeholders.

STEP 2: Answer My Request

Call taking: During 2017/18, NEPTS introduced a national call taking model with a single 0300 number to simplify access for patients and HCPs. This national model is in place across the three WAST managed journey booking centres, taking calls directly from patients and HCPs across all areas of Wales. However, there are currently two Health Board managed booking centres taking patients calls from the Ceredigion and South East Wales areas, which creates confusion for users and it will be a priority for 2018/19 to simplify this by full integration of all centres across Wales. We also want to reduce risk associated with HCP bookings by stopping fax bookings from HCPs and extending the provision of online and telephone capability.

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Eligibility: Our Patient Needs Assessment (PNA) tool will be continually developed to ensure that our patients get the most appropriate service to meet their needs. We will develop our service to meet specific user needs such as a complex handling service, end of life transport and a planned paramedic service that will help reduce EMS pressures. We recognise that person to person conversations are the most effective way of gathering valuable information from our patients about their individual need.

STEP 3: Coordinate My Journey Our NEPTS Journey Coordination Centres (JCCs) are key to ensuring we provide a responsive and prompt service to meet their needs, and improvements here will provide some of the biggest returns in regard to efficiency and effectiveness of NEPTS. Use of technology: integrating our staff skills and experience with proven technology will significantly improve the way we provide our services. To achieve this we will review the functionality of our existing systems, specifically our Computer Aided Despatch (CAD) system and assess its suitability and flexibility to support our changing needs. Plan efficiently: during 2018/19 we will continue to focus on developing an effective forecasting model to accurately identify demand to help secure resource, shifting the balance from user to system planning to reduce workload and reduce variation in approach. We recognise that increasing the use of alternative transport providers without the ability to improve the way we use the resource will lead to increased cost of delivery. Therefore, we will continue to introduce our new Journey Coordination Model, which will increase the use of tried and tested technology such as mobile devices that allow our journey coordinators to know the location of all our resources at all times across Wales. Transfer of NEPTS work from health boards: from the first quarter of 2018/19, in line with the business case recommendations and subsequent Commissioning Quality and Delivery Framework, WAST will start to become responsible for the provision of all NEPTS provision within NHS Wales. The transfer of NEPTS work currently commissioned directly by health boards with external providers will transfer into WAST management arrangements using a phased approach, on a health board by health board basis. This would see the enactment of a plurality model, or mixed economy of providers, overseen by WAST to ensure high quality, consistent and fit-for-purpose services are provided to all our non-emergency patients.

STEP 4: Pick Me Up Service improvements: Our ambition is to be the leading provider of NEPTS within the UK and, to do this, we need to constantly look at innovative ways of improving our service whilst at the same time becoming more efficient. We will consider the whole end to end system as this will require working closely with our Health Board colleagues. We will develop a continuous improvement methodology during the life of this plan that will identify, plan, test, check and implement initiatives that will resolve inefficiencies and quality issues as they are identified. Improving the information we

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provide to our patients will be a priority for us and we will be building on our trials of vehicle based and hospital based information screens to ensure our patients know the best ways of using our services. Third Sector providers: A key aspect of the NEPTS Business Case was the need for the service to be delivered through a plurality of providers. To achieve this, WAST will develop partnerships with the third sector, especially community transport schemes and voluntary ambulance services across Wales. Enhanced services: The NEPTS Business Case clearly identified the need to invest in and improve the transport service provided to renal dialysis, oncology and end of life patients. This was achieved during 2016 and maintained during 2017, and we are proud of what has been achieved. The subsequent improvements in patient safety have been significant. Discharge: Patient flow is a critical part of the delivery of healthcare within Wales. NEPTS can play a key role in improving flow through the effective discharge of patients from hospital in a timely and effective way. NEPTS will focus on areas where further improvements can be made as a priority during the period of this plan and will work alongside the Health Boards to improve the flow out of hospital. Support for patients waiting: During 2018 we will be changing the focus of our hospital liaison roles away from being a desk based role to a front of house, concierge type role. This will improve the patient experience while patients wait, and improve the turnaround times of NEPTS crews at hospital. We will also be putting in processes to improve the level of information our patients receive to make them aware of how long they will have to wait and other information they will find helpful.

STEP 5: Take Me to My Destination Collection of information: We have now rolled out a system of capturing this data in real time. As we increase the number of providers working as part of NEPTS, we will ensure we are able to capture high quality reliable data around timeliness. Patient feedback: NEPTS has the opportunity to learn significantly more from feedback from its service users. During 2018 we will continue to develop innovative ideas to capture this feedback and learn from it. ESMCP: NEPTS will work with the Emergency Services Mobile Communication Programme team to define how NEPTS is best served by the new radio replacement programme. NEPTS is a valuable part of the NHS Wales civil contingency response process. Aborted journeys: Up to 10% of all NEPTS journeys are aborted (i.e. cancelled after allocated to a vehicle). This is an expensive waste of resource, both in terms of money

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and in capacity that could be re-allocated to provide a more timely service for patients. We understand that nearly 70% of all our aborted journeys are down to just five causes, and four of these can be mitigated by contacting patients prior to setting off, or developing IT links to share information. We will work with health boards to do this in the coming year.

Appointment times: Prudency is a key part of delivering NHS services and we see scheduled appointment times as an area where better use of valuable resource could be achieved. Through working closely with each health board to clarify true appointment times, and other practical arrangements, we can be more efficient and improve the patient experience.

Welsh Government Together for Health National Delivery Plans

There are five Welsh Government “Together for Health National Delivery Plans” to which the organisation contributes. These are:

We have also identified a lead for each area and our support and contribution to these agenda are tracked through a newly formed internal group called the National Delivery Plan Forum.

We explain in greater detail what we will offer as an organisation across these plans in our full IMTP.

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Responding to Elderly People Who Have Fallen Older patients who have fallen are the most common reason for a 999 call in the UK. Approximately 30% of people living at home aged 65 years or older fall every year, and about half of those who fall do so repeatedly. 999 calls to the ambulance service for patients who have fallen can be divided into two groups – those who are injured and need treatment and those who have fallen, are uninjured but need assistance to get up. A Falls Improvement Plan has been developed to focus on:

Prevention of falls. Avoidance of inappropriate demand on WAST (in particular from residential and

nursing homes). Responding to people who have fallen but are uninjured. Responding to people who have fallen and are injured.

Our emerging thinking to date is represented in the diagram below and is subject to further testing and refinement through 2018/19.

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6 – OUR ENABLERS

Our ambitious plan to improve the breadth and quality of services needs complementary plans to modernise supporting and enabling functions. Without a doubt, our most important enabler is our staff; but ensuring we have appropriate estate and fleet is also critical, alongside a timely and relevant business intelligence function (health informatics), an appetite for learning and improvement and clear governance arrangements.

Our People

Our people strategy 'Being our Best', introduced in 2016, continues to be the focus for our workforce, organisational development and education plans and actions. Underpinning our people strategy and action plans sit the principles of prudent healthcare and a prudent workforce.

Our Workforce Plan We continue to strive to ensure robust workforce planning across the Trust.

Having completed our work to understand current and future demand and capacity in 2017/18, we consider action to close the ‘relief capacity’ gap to be a key priority for this coming financial year. We will continue to focus on efficiencies that are within our gift to control, and seek to accelerate plans to deliver where possible.

We will also review all existing vacant posts across the organisation, re-visit our proposals to introduce an operational shift of reflective practice as part of CPD time, and accelerate our review of the clinical team leader role, among other plans. More information on these can be found in our full plan.

Our Emergency Medical Service Workforce Our EMS workforce continues to account for our biggest workforce resource and remains a focus for our workforce planning activities, particularly the balance of resources and need to maximise developments within Step 2 and Step 4.

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STEP 2 (Answer my Call) (Hear and Treat) NHS Direct Wales/111 Pathfinder: We continue to work with the 111 Programme Team to review baseline demand and capacity calculations, and resulting projected workforce numbers; we will work in collaboration with Health Board partners to ensure the successful roll out of 111 across Wales. This will be supported by the introduction of new rotational posts to ensure that nurses gain new skills and experiences, while maintaining existing skills and competencies. To enhance our ability to recruit and to retain our nursing workforce, we are also looking to see how we can use technology to support a flexible approach to working and work life balance, this will include strengthening the Hub and Spoke model by offering opportunities at a local level, to eventually having the ability for homeworking, supported by a centralised clinical leader for advice and support.

Clinical Contact Centre Modernisation: the key actions in support of this are realising the benefits from CAD implementation Phase Two and further improving our hear and treat rates. We note the continued positive impact that substantive investment in hear and treat clinicians in 2017/18 has had on ambulance dispatch in this period.

STEP 4 (Give Me Treatment) (See and Treat) Urgent Care Services, Emergency Medical Technicians and Paramedics: In 2017/18 we also planned to rebalance the skill mix of UCS, paramedics and EMTs by splitting, where appropriate, double paramedic crews on an emergency ambulance and crewing with an EMT. We anticipated that around 20 paramedic posts each year could be converted to EMT as we move from double paramedic to mixed crews. This was reflected in our financial efficiencies. This exercise was complicated by the introduction of the Band 6 paramedic role and creation of a new EMT3 role for those who did not wish to operate at the higher scope of practice. The impact of this development will enable us to revisit this skill mix work in a structured and planned way in 2018/19.

Our Non-Emergency Patient Transport Service Workforce As we continue to implement the recommendations of the NEPTS Business Case, the workforce requirements are expected to change significantly. As non-WAST NEPTS demand is identified as part of the transfer process, the Transfer of Undertakings (Protection of Employment) (TUPE) implications of which will become clear over the coming months, we will need to identify the most appropriate and efficient way of delivering the demand in the future. This is likely to be a mix of community transport schemes, the voluntary sector and directly employed staff.

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At this moment in time, it is not expected that the numbers of operational NEPTS staff will increase. However, this may happen if the capacity of community transport and the voluntary sector does not meet the new identified demand (much of the health board demand is undertaken by private providers) or additional demand is exposed as part of the transfer of work process.

Our Volunteer Workforce It is important that we do not overlook the huge contribution to supporting our frontline teams and services made by our fantastic volunteers, including our community first responders (CFRs) and circa 360 volunteer car drivers. We will seek to conduct a full review of the recruitment and use of volunteers across the service, and develop a volunteer strategy that will look creatively at solving the difficulties experienced in attracting new volunteers, ensuring we maximise and demonstrate that we value their contribution to our work.

General Workforce Efficiency and Productivity Opportunities As we plan and develop our future workforce, we recognise the need to ensure we maintain focus on opportunities to increase workforce efficiency and productivity. Our main areas of opportunity to reduce variable pay spend and spend on private ambulance providers and improve performance include:

Effective resource planning and efficient rostering of resources, with a drive to tackle variability in abstractions and performance;

Improving attendance at work, reducing cumulative sickness absence rates over the next three years;

Improving the working lives of staff by reducing overruns and improving rest break compliance, providing local solutions to ensure staff are given opportunity to take breaks during their shifts;

Maximising the benefits of a technology enabled workforce; Streamlining recruitment and reducing time to hire.

Timely Recruitment Promoting the Trust as an employer of choice is a key objective of this plan, with an emphasis placed on the kind of employment experience the Trust can offer potential candidates and a clear understanding of why people stay within the organisation and are prepared to go the extra mile. Our focus for this programme of work will be:

Continued drive to deliver targets set by the ‘Hire to Retire’ Streamlining Programme for NHS Wales’; a look at our current approach and process of recruitment to ensure we attract and recruit the right person, with the right behaviours and an understanding of the demands of the job to improve retention of new starters

Ensuring timely recruitment and training plans in line with operational needs. Increasing our presence in schools and at careers fairs, ensuring we are visible

and increasing opportunities for work experience (as appropriate), and completion of the Welsh Baccalaureate modules development with the WJEC.

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Building on the success of events such as the Loudoun Square Cardiff Career Event in January 2017, to increase awareness and access to careers in WAST for individuals coming from the BME community, increasing applications from members of ethnic groups currently under-represented in the workforce.

Education, Training and Development of Our People 2017/18 has been another very successful year in terms of the transition to regulated, accredited education and the creation of a vision for the future of education in WAST. Priorities for the coming three years are:

Education Strategy: In 2018/19 we will review and evaluate the existing paramedic education delivery model in collaboration with Swansea University. The Education and Training Team will lead the development of a new strategy to support the ambition of becoming the leading ambulance service. This strategy will include the infrastructure, estate and staffing model required to deliver access to a high quality,

transformational education for all. We will look to collaborate with the wider health, social care, education and emergency service partners to maximise opportunities and turn our vision and aspirations into reality. Our vision is to create a hub and spoke model centred on the development of two or three equitable ambulance academies, supported by local learning cells, with agreement for training facilities to be included in all future operational estates developments. Widening Access: Good progress has been made, and in 2017/18 we developed a Level 3 Award and Certificate in Non-Emergency Patient Transport Services (NEPTS). We will work to introduce this programme in 2018/19 and provide regulated and accredited education for all operational grades of staff.

Improving Employee Experience We will continue to focus on improving the employee experience, increasing access to leadership development opportunities, and taking action to encourage the right conditions for health and happiness across the organisation through the following: Maintaining continued visible, vibrant and compassionate leadership at

executive and senior management Delivering Treating People Fairly through the reinvigoration of our LGBT and

BAME networks; collaborative research with Swansea University on barriers to BAME students and why they often don’t think of/choose Paramedicine as a career.

Delivery of our bespoke team leader programme in 13 cohorts and then on an ongoing basis. This will be supplemented by a leadership development

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programme for middle and senior managers and a proposal for delivery during 2018/19 and beyond, subject to funding support.

Continued development and implementation of the staff awards and recognition programme

Developing a programme of work to move our Go Together Go Far trade union partnership working forward to a next phase

A continued focus on maintaining good mental health and wellbeing, through increased support for self-care, improved resilience and roll out of the Trauma Risk Incident Management (TRiM) support function

A focus on the importance of maintaining good physical health, including action needed to reduce the incidence of violence and aggression faced by our staff, (including a reduction in the number of staff who report being bullied, harassed or abused by members of the public and/or their colleagues) and action needed to reduce the incidence of manual handling injuries, and creating safer work practices and environments.

Implementation of sustainable regular immediate colleague feedback to enhance the PADR experience and improve opportunity for clinical reflection and practice development

Implementation of a robust flu immunisation programme for 2018/19 Overall planning for achievement of the Corporate Health Standard Platinum

by 2020/21

Developing Our Long Term People Strategy #FutureofWork We will refresh our People Strategy in 2018/19, aligned to the developing longer term people vision and strategy that will respond to the challenges we think the #FutureofWork in Welsh Ambulance Service will bring, and what that means for the Workforce and Organisation Development Directorate. We are currently exploring how we prepare ourselves to be able to deal with the challenges that may face us, as well as ensuring we are sufficiently agile to respond. All of the above is likely to impact hugely on HR, OD and people practice more generally. There will need to be a shift from traditional modes of HR delivery, away from transactions and employee relations, and much more towards a focus on enhancing manager capability, coaching, and enhancing the employee experience in a variety of ways. We will consider whether we are currently set up to meet these challenges, or whether we need to reconfigure the way we provide services to prepare the organisation for what might be ahead of it.

Our Finances WAST receives the vast majority of its income through a commissioning arrangement, led by the Chief Ambulance Services Commissioner, who acts on behalf of all Welsh health boards on the commissioning of emergency ambulance services. This arrangement is conducted through the Emergency Ambulance Services Committee (EASC) which is responsible for developing collective commissioning intentions and plans. Funding for ambulance services is incorporated as part of the allocations made to NHS organisations by the Welsh Government.

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In 2017/18, we implemented a range of significant service developments that focused on delivering the best outcomes for patients and improving performance. Developments have been introduced on a pilot basis with the full service, activity, performance and subsequent financial impact of these significant developments continuing to be assessed and refined in line with emerging evidence and evaluation and, where appropriate, factored into the financial plan. We are committed to developing services over the immediate and medium term that will increase productivity and efficiency and promote sustainable system wide change.

We achieved a financial break-even position at the end of March 2018 and, once again, the plan for 2018/19 – 2020/21 is forecasting a financially balanced position. This includes an indicated £4.2m (circa 3%) of savings for 2018/19 and cost containment measures. In the short to medium term, we are actively engaged in work to effect service shift across the system, identifying opportunities and recognising the requirement to develop financial plans which release resources for re-investment. Similarly, we will in future years review the benefits realised through recent investments in the Trust, including enhanced hear and treat and band 6 paramedics, as well as capital and technology projects. More transformational activities focus on the implementation of the strategic plans for estates, fleet and ICT, as well as whole system shifts and workforce modernisation.

Our Estate Our ambition to be a leading ambulance service will require an estates infrastructure that is not only fit for purpose but also supports delivery of caring and responsive clinical services.

Our estate is currently located at more than 109 premises in three operational regions throughout Wales and our overarching objectives are to support operational services with the following actions:

Providing modern facilities Improving the working environment for all staff Providing the right type of premises in the right location

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Improving infection prevention and control outcomes Providing value for money for the service Developing a sustainable building stock

Our four key strategic actions focus on the agreed priorities for 2018/19:

Relocating the organisation’s northern administrative centre from its current site at St Asaph to another site in North Wales

Relocating the organisation’s regional central and west administrative and training centre, currently at Cefn Coed Hospital, Swansea.

Progression with the development of an outline business case for an estates solution for Cardiff

Delivery of the Welsh Government endorsed Estates Strategic Outline Programme.

Our Fleet

We operate more than 700 vehicles, the majority being emergency medical service ambulances (EMS), rapid response vehicles (RRV), non-emergency patient transport (NEPTS) and hazardous area response ream (HART). We also manage and maintain 87 vehicles on behalf of the Health Courier Service. Positive progress has been made over the last year to implement a range of national projects and service initiatives, but there is still more to do. In 2018/19 we will:

Implement the recommendations outlined in the fleet strategic outline programme (SOP)

Review the fleet profile in conjunction with the recommendations of the demand and capacity review

Pilot a virtual fleet logistics help desk in CCC Progress a new ambulance workshop in the South East Finalise the vehicle maintenance project Utilise the vehicle telematics system data Develop EMS fleet commissioning measures.

Health Informatics

The overall purpose for our health informatics team has been defined as:

“Enable promote and support the effective use of data,

information, knowledge and technology to support and

improve health and health care delivery.”

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Health informatics is about getting the right information to the right person at the right time and is a critical function to us delivering the most appropriate and effective care to our patients; good quality data will be a critical enabler to our plan. The key actions in support of delivering the IMTP for 2018/19 are: Introduction of Qlik reporting solution that provides enhanced intelligence to our

decision makers and informs our decision making process and practices. Continuing to roll out a suite of mobile applications to support the Trust’s

requirements as part of local delivery plans; Further support the information requirements of the national 111 rollout including

a review of the current national directory of services database currently hosted by WAST.

Continue to provide and develop the requirements arising from the CASC and develop the non-emergency patient transport commissioning suite of information.

Compliance to the General Data Protection Regulation (GDPR), as we transition from the UK Data Protection Act (DPA) which gives us compliance to the latest legislation for the Trust.

Develop a records management programme that ensures clinical and corporate records are retained, archived and disposed of in accordance with guidance given by the Department of Health

Supporting the development of the Trust’s long term digital innovation and transformation programme

Supporting the development and introduction of Phase 2 of the CAD (Computer Aided Dispatch) programme.

Longer term priorities are focussed on: Supporting the deliverables of the Trust’s ePCR programme. Meeting the requirements set out as part of the Trust’s long term digital innovation

and transformation programme. Supporting the requirements of the Welsh Government’s strategic objective for

improvement and innovation with better use of data and information to improve decision making, plan service changes and drive improvement in quality and performance.

Harnessing the local requirements of the ‘Informed Health and Care: a digital health and social care strategy for Wales’.

Ensuring local digital advances and innovation by supporting the information requirements of the ‘Once for Wales’ technical platform.

Information Communication and Technology (ICT) The Trust’s programme for modernisation of its services and clinical practice will require a sustained and focused investment across several areas of information and

“Providing Trust staff and patients with secure, timely and

appropriate access to electronic, patient-centred information

at the point of care in order to support high quality care

aligned with the Trust’s service development priorities.”

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communication technology. The key priorities for the team are framed around the four key themes of the wider Welsh Government and NHS Wales Strategy.

Corporate Governance In simple terms, governance refers to the way in which organisations ensure that they are doing the right thing, in the right way, for the right people, in a manner that upholds the values set for the Welsh public sector. The focus for our 2018/19 plan is to capitalise on the foundation work which was carried out in 2016/17 and 2017/18. This is principally to ensure good governance exists in our systems and processes and that we have the right environment where governance is understood and encouraged. Key actions for 2018/19 and beyond are:

Develop and deliver an annual programme of Board and Committee business. Induction of a new Board Chair To meet the Information Commissioner’s Office target of responding to 90% of

all FOI requests within 20 working days. To ensure Trust policies are up to date and are subject to regular review Continue the governance mapping of groups, programmes and projects Embed Board Assurance Framework into Committee and Board business.

Partnerships and Engagement Engaging and developing strong relationships with our patients, staff, NHS Wales organisations and public sector partners is important for our organisation. We do not work in isolation but rather as part of a wider system where relationships are important in improving the services we provide.

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Our partnership and engagement agenda is supported by some basic principles, which are outlined below and are reflected in our Engagement Framework:

The Wellbeing of Future Generations (Wales) Act 2015 Whilst we are not one of the 44 named organisations in the Wellbeing of Future Generations (Wales) Act 2015 (WBFGA), we are committed to working within the spirit of the Act. We are adopting an approach which reflects the principles of the Act, based on sustainability principles, the seven wellbeing goals and five ways of working, including in 18/19 piloting our approach to engaging with a limited number of Public Service Boards to deliver positive benefits for communities across Wales.

To ensure we listen and, where appropriate, act on the views of our stakeholders to

improve our services.

Ensure we are visible in the collaborative arena, and are a credible voice within NHS and

the wider public service in Wales.

Ensure we identify opportunities for collaboration with partners, and that our relationships

are well developed to allow us to deliver on them.

Ensure our relationship with our employees, patients, stakeholders (including politicians

and the media) and the people of Wales is based on trust and understanding, helping to

build our reputation as a “brand” in which there is confidence and for which there is

support.

To create a sense of collective ownership in the Welsh Ambulance Service, as an

organisation which employees and stakeholders have a mutual interest in supporting.

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7 - DELIVERING OUR PLAN

We are aware that writing a plan stating what we are going to do is, in some respects, straightforward. Our Board, Welsh Government, our Commissioners, our staff and, indeed, all our other stakeholders will need assurances that we are delivering what we promised. To respond to these expectations, we have put a number of things in place:

For each of our 44 strategic actions there is a plan on a page which describes the activities that will be carried out and gives timescales to help make the strategic action a reality

We have created a forum within the organisation which is known as the IMTP

Delivery and Assurance Group (iDAG). This group is chaired by the Director of Planning and Performance and tracks each of the actions to ensure we are making the progress we originally set out to.

All of this will then be summarised to Trust Board on a quarterly basis. If you have particular interest in any of our strategic actions and want to know more about how they will be delivered, you may request copies of the plans on a page which have been developed by contacting us using the details below.

8- CONTACT US

We hope you have found this document informative and interesting. For further

information on anything mentioned in this summary please click here to view our full plan. Alternatively please contact Olivia Barnes (Olivia.Barnes@wales.nhs.uk) in the

Planning and Performance Directorate.

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GLOSSARY

APP

Advanced Paramedic Practitioner

BAME

Black, Asian and minority ethnic

CAD

Computer Aided Dispatch system – new system for the Clinical Contact Centre.

CASC

Chief Ambulance Services Commissioner - commissions ambulances on behalf of 7 Health Boards which WAST is held accountable to.

Clinical Indicator Improvement Plan

Working with our Clinical Team Leaders to provide them with access to 3 out of the 7 of our clinical indicators.

EASC

Emergency Ambulance Services Committee - have developed a set of Ambulance Quality Indicators (AQI’s) to monitor and improve performance.

EMRTS

Emergency Medical Retrieval and Transfer Services – aka Welsh Flying Medics.

ePCR

Electronic Patient Clinical Record

FOI

Freedom of Information

HCP

Healthcare Professional

IMTP

Integrated Medium Term Plan – this document has to be produced and sets out our direction for the next three years. In 2016 our plan was approved by Welsh Government and Trust Board and now we need to write a yearly refresh to provide updates.

LGBT Lesbian, Gay, Bisexual, Transgender

NEPTS

Non-Emergency Patient Transport Service – Trust vehicles that convey patients to and from routine hospital appointments.

NHSDW

NHS Direct Wales - health advice and information service available 24 hours a day, every day.

Omnicell

A project to input automated medicine supply cabinets in hospitals and ambulance stations.

Out of Hospital Cardiac Arrest Survival

A project providing patients suffering from a heart condition with timely access to high quality pathways of care. Working with Welsh Government and NHS partners.

PADR

Personal Appraisal Development Reviews carried out by line managers throughout the Trust for all staff on a yearly basis.

SAI Serious Adverse Incident

Telemetry

This is a 3 year funded project to increase the accuracy of diagnosis of patients suffering a heart attack using an Electro Cardio Gram machine.