0

Welsh Ambulance Services NHS Trust

Integrated Medium Term Plan Summary 2017-2018

Published: MARCH 2017

www.ambulance.wales.nhs.uk

www.facebook.com/welshambulanceservice

@WelshAmbulance

1

Welcome to the summary document of our Integrated Medium Term Plan (IMTP).

We are conscious that our IMTP is a lengthy, technical document that many may not

have the time to read. This summary is our way of trying to make such an important

document more reader friendly.

The IMTP document 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 stating

our priorities, challenges and main risks. Throughout the main plan we commit

ourselves to 48 actions which can be viewed in more detail in the main IMTP.

We believe our IMTP is vital for us in WAST, regardless of it being a necessity for

Welsh Government, to ensure there is a clear plan in place for the organisation.

In a message from the Chair and Chief Executive they have stated how reshaping an

ambulance service is a long term process and therefore a need to focus on our

services and how we deliver them especially as the type of patients we are seeing

are changing within our ageing population. This can only be achievable with support

from our partners and ensuring our teams have the right skills.

We hope you find this summary a useful insight into the Trust and the work we are

continuing to do to improve the quality of care we deliver to our patients.

1- INTRODUCTION

2

2 - STRATEGIC OVERVIEW

We, the Welsh Ambulance Services NHS Trust (WAST), provide ambulance services for people in Wales, delivering high quality and patient-led clinical care – emergency, urgent and scheduled – wherever and whenever needed. We continue to change the focus of our service to establish ourselves as a clinically-led, quality-driven emergency medical service, non-urgent patient care service and a 24-hour health care and advice service that focuses on delivering the best clinical outcomes for patients.

Developing a Long Term Strategy

In our 2016/17-18/19 IMTP, we outlined a strategic statement of intent outlining where we want to be in 10 years’ time and giving a commitment to develop a long term strategy for ambulance services in Wales. Through the course of 2016/17 we have refined our thinking further by continuing conversations with our staff and our Board around our long-term strategy and our plan to get us there. Clearly, we cannot conclude our thinking on our longer term vision without exploring further with our key stakeholders. Key partners in this process are: Emergency Ambulance Services Committee (EASC) and the Chief

Ambulance Services Commissioner LHBs in their provider role (as opposed to as our Commissioners via EASC),

specifically linking in with their vision for unscheduled care and pre-hospital care in particular

Primary Care Clusters The Unscheduled Care Programme Blue light partners Local authority and third sector partners

We will work with these stakeholders through 2017/18 to explore and further our thinking in this area to inform our longer term strategy and we hope to have ambitions agreed by the end of 2017.

3

Our Refreshed Strategic Aims: A lot has happened in WAST over the last 12 months and so it was appropriate for our Board to review our strategic aims and set our plan against these. The diagram below illustrates our aims. Our Ambition

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

We have subsequently been able to set our priorities for the coming three years against these strategic aims. Our 10 priorities are:

1. We will progress our quality improvement journey, implementing our Quality Strategy.

2. We will further transform our EMS (Emergency Medical Services) service using the 5 step pathway.

3. We will progress Non Emergency Patient Transport (NEPTS) transformation. 4. We will deliver further improvements to Clinical Contact Centres. 5. We will maintain our focus on workforce engagement. 6. We will continue to develop our workforce. 7. We will deliver a programme of improvement and efficiencies. 8. We will deliver patient and system benefits through our health partnerships. 9. We will realise further benefits from our collaborative stakeholder

relationships. 10. We will continue our journey to becoming a highly effective organisation.

• 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 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.

4

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

5

Overview of Our Performance

We have made good progress in improving key elements of performance during 2016/17. This has been achieved by improving our management processes across all directorates, including a strengthened performance management approach. However, we recognise that we still have areas where performance is fragile and where improvements could be made. The following statements summarise our performance: Enhanced Hear and Treat resulted in 1,700 ambulance dispatches being

prevented in December.

RED performance levels across all Local Health Boards was at 65% or higher, with the exception, of Powys in May and October.

AMBER performance remains an area of concern. Our clinical indicators are not

showing the improvement we would wish for. Our complaints and concerns from this patient group confirm the need to refocus our efforts in this area. As at January 2017 our 95th percentile performance was two hours, 11 minutes. The pressures of the winter period have put further pressure on this category of call and reviewing our Amber performance is a priority for 2017/18.

WAST’s performance across its support services, which are key enablers for Operations and NEPTS, have generally improved: staff sickness is below 7%, staff turnover below 1%, all in the context of increasing staff numbers.

Our Performance Ambitions

Last year, we set ourselves 53 performance ambitions to help us measure how we are doing. We ensure that these ambitions are embedded in regular performance reporting and monitoring through our Monthly Integrated Quality and Performance Report and through our Directorate Quarterly Performance Reviews. At the end of Quarter 3 for 2016/17:

16 were either already met or were on track for meeting the ambition in 2016/17. 17 were off track but many with action plans in place to mitigate. 10 are to be measured in Quarter 4 as they are an annual measure or are a 5 year

audit measure. 10 measures are to be reviewed to ensure they are the most appropriate measure for

monitoring the ambition.

Over the last twelve months we have realised some of the ambitions need to be reviewed or alternative metrics need to be set to ensure we capture all data and any issues. We will continue to refine and test our current performance ambitions for 2017/18 and will refresh to take into account our Quarter 3 position for this year 2017/18. Details of both our 2016/17 and our 2017/18 performance ambitions can be found in our full plan.

6

National Policy Context

Our full 2017/18 plan outlines the national policy context within which we are

operating. New policy guidance which has emerged over the course of the last

twelve months and which is relevant to us includes:

Taking Wales Forward (2016-2021)

NHS Planning Framework (2017/18) where we have noted the importance

placed on the following areas within the revised guidance:

Primary Care

The revised approach to National Delivery Plans

Embedding the Wellbeing of Future Generations Act

National Wales Strategic Change Agenda

In our 2016/17 plan, we recognised that the ambulance service operates as part of a complex health and social care system which is progressing a number of complex service changes and developments, both at internal health board level and at a regional level. It is key that we are engaged appropriately in these change programmes and that we are able to model, and influence, the impact of options or decisions. However, we recognise that there is still work to do in this area as, whilst we can provide an overview of those programmes and projects which we believe will impact on our service, we have not in all cases fully engaged with them. From an ambulance service perspective, we are engaged in the following programmes that have major service change implications:

South Central Acute care Alliance (SCACA)

Paediatric, Neonatal and Obstetric (PON) Services

ENT Services South East Wales Vascular Services Transforming Cancer Services (TCS)

Programme All Wales Collaborative Mid Wales Healthcare Collaborative Future Fit A Regional Collaboration for Health

(ARCH) Aneurin Bevan – Specialist and Critical

Care Centre Clinical Strategies for Hywel Dda and

Betsi Cadwalader Health Boards

7

Service Change in Collaboration with Blue Light Partners

Over the last twelve months we have carried out new work with our partners including work within the Community Assistance Team (CAT) in North Wales, the Police Joint Response Unit (JRU) and Clinicians in Police Control rooms. Our ambitions are based on effective working with our partners in the NHS, local authorities, the voluntary and private sectors and our blue light partners. A summary of our specific intentions in regards to our blue light partners is summarised below:

Fire Co-Responders. Will remain a key part of our plans to get skilled help quickly to immediately life threatening calls and will seek to increase the number of fire stations offering this service across Wales.

Public access defibrillators. We will explore what role emergency services staff can play in the checking of public access defibrillators.

Information Sharing. We will develop systems to share information on vulnerability and ensure that we are referring patients who may benefit from a home safety check to the fire and rescue services.

Joint maintenance. We will continue to explore opportunities which will see all our NEPTS vehicles in the Hywel Dda area be bought into a new facility run by Mid Wales Fire and Rescue Services (MWWFRS) to be serviced and maintained.

Estate Opportunities. Continue to explore the benefits of sharing estate on a variety of scales and look at new initiatives such as the locations of our contact centres.

The most common type of emergency we attend is older patients who have fallen, many are uninjured but unable to get up from the floor. Although we acknowledge these patients are vulnerable, as they are not injured they do not become a priority for dispatch, so their wait time increases. These patients go on to represent a high proportion of our complaints. We have already developed new systems to get the right help to uninjured fallers more quickly and we will continue to do so by working with our blue light partners. Some of the models we have developed are the falls improvement, non-injury faller work undertaken by our Clinical Desk and the falls vehicle in the Aneurin Bevan Health Board area. Please click here for more information on the Falls vehicle in Aneurin Bevan.

8

2 - OUR ACHEIVEMENTS IN 2016/17

2016/17 was a milestone year for WAST. It marked the first time the organisation delivered a Board and Welsh Government approved IMTP. We continue to make solid and steady progress in delivering the commitments we made in that plan and of the 154 actions we set then: 125 are left 27 are complete 2 have been closed

We have made progress in many areas, some headlines include: Progress with Quality Strategy implementation Successful implementation of the 111 Pathfinder with ABMU (Abertawe Bro

Morgannwg Health Board) Demonstrated measurable benefits in terms of an increased focus within the

clinical model for example increased hear and treat rates and effective frequent caller programmes

Progress with the NEPTS Business Case implementation Strengthening relationships with our staff as demonstrated through Staff

Survey Recognition at NHS Awards of our Frequent Caller work Alignment of recruitment and training plans with vacancies of less that 4% in

our EMS (Emergency Medical Services) workforce Opening of the Joint Ambulance and Fire Centre in Wrexham Forecasting financial balance in line with 2016/17 – 2019/21 IMTP

We continue to recognise our staff through the development of our Awards

ceremonies and in November 2016 we held one for staff and volunteers in Cardiff.

As well as traditional awards, the Trust introduced category awards, six in total which

were aligned to its new behaviours. We then followed this through with our first ever

celebration and learning event.

We received excellent feedback and it was a great success. We will continue to build upon this and continue to recognise staff for their efforts. For further information on the success of the awards ceremony click here.

Opportunities and Challenges in 2017-2020

Over the life of this plan we have identified a number of general opportunities and challenges we will face along with many other health boards and/or ambulance services. These include: Political Landscape - The life of this plan will be against the backdrop of

Brexit negotiations. The outcome of these negotiations may have a profound impact on Wales.

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

9

closely with 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.

Planning Assumptions - In developing our plan, we have had to make some assumptions. These have been in relation to our finances, performance targets, availability of capital, no significant changes to demand etc. Should these assumptions prove not to be accurate, we will have to revisit sections of the plan.

Leadership Challenge - We believe we have begun to experience a shift in attitude from staff and stakeholders, and this is seen with our 2016 NHS Wales Staff Survey results. We are consciously reinforcing through our activities a set of expected behaviours and approaches to providing care and to how colleagues are treated, continuing to move from “treating everyone the same” to “treating people as individuals” and being flexible around their needs.

National Developments on Paramedic Banding - NHS Employers have agreed a deal with the unions on behalf of the Department of Health in England which will see the role of the paramedic being re-banded from Band 5 to band 6 in April 2017.

Key events and the impact on our service - Our involvement in some important national emergency and resilience planning is a key role for our organisation. In June 2017, the UEFA Champions League final will be held in Cardiff. As well as the game itself, there will be a week-long “celebration of football” in Cardiff, drawing a huge worldwide TV audience. We are fully engaged in the relevant planning processes and working with Welsh Government to minimise the impact on our services and to ensure we are fully geared up for the additional demand such an event is likely to place on us.

Specific Challenges

We have also identified a number of more specific opportunities and challenges which, in many respects, are much more unique to us. One of these is the Demand and Capacity Review. In line with our commitment in last year’s plan, we undertook this review in 2016/17. The process engaged an external company to support the work with the timeframe for the review being 2015/16 – 2020/21. The review identified a number of opportunities and highlighted a number of challenges: Amber Performance - As mentioned earlier, we recognise that there is still

much improvement work to do around the Amber category of calls.

Right workforce, right place, right time - There remains a national shortage in the availability and recruitment of qualified paramedic staff. We recognise

10

that a failure to recruit insufficient numbers in a timely way will result in additional overtime from external providers.

An Ageing Workforce - We are aware of the potential implications of an

ageing population on demand for ambulance services in the future. Our workforce profile tells a similar story, with a large proportion of staff in the 50+ category. This presents challenges as we will need to plan for staff working longer, explore new roles, address pension changes, and set the right conditions for wellbeing across the organisation. These challenges are all recognised and responded to by our People Strategy enabling plans.

Tackling the Diversity Deficit - Our workforce profile also clearly shows a

lack of diversity throughout our staffing. As part of our Treating People Fairly Strategic Plan and local action, we will address the deficit in diversity over the next few years and ensure our workforce better reflects the local community demographic.

Clinical Risk Assurance Review - The Clinical Risk Assurance Review was reported on at the end of March 2017. We acknowledge that this is a critical piece of work that highlights clinical and quality issues and challenges that we need to respond to.

11

3 - QUALITY, SAFETY AND PRUDENT HEALTHCARE

During 2016/17 we have shown our commitment to providing high quality care to our service users as defined in our Quality Strategy (2016- 2019). Year one of this Strategy has focused on strengthening our foundations and developing and improving our indicators and measures. In years two and three we will focus on implementing, monitoring and reviewing, whilst making appropriate improvements and changes in the areas which matter the most, informed by patients, service users and staff feedback. We will continue to develop our structures and processes at Board level and across the organisation to lead on Trust-wide continuous quality improvement including: Ensuring that standards are achieved Triangulating quality data and patient, carer, stakeholder and staff feedback Planning, driving and measuring continuous improvement Identifying, sharing and ensuring best practice across NHS Wales

Structures

During 2016/17 we have made changes to our organisational structures to strengthen the governance arrangements for Quality, Safety and Patient Experience to support front line teams by working with key stakeholders across the following functions: Safeguarding adults and children Concerns - complaints, patient safety incidents, claims and Inquests Patient experience and community involvement Professional Practice Development Quality governance and assurance Quality Improvement Risk Management Health and Safety Mental Health (structure planned)

The following structures and reports have been either redesigned or established during 2016-17: Corporate and Local Risk Registers Quality Steering Group Improving Quality Together (IQT) forum Concerns and Patient Safety

Next steps for 2017/18 Structures: We will continue to strengthen our quality governance by:

Developing a structure for Mental Health across the Trust

Develop our organisational Dementia Strategy

Design and implement the Family Support Model

Develop a Business Partnership Model to support operational teams

Incorporate training for Violence Against Women, Domestic Abuse and Sexual

12

Violence

Work with 1000 Lives Improvement Team to deliver our improvements

Work with the Bevan Commission to embrace advocates for the Trust

Undertake a review of Health and Safety

Processes During 2015/16 the Trust has adopted the Health and Care Standards (2015), NHS Outcomes Framework and the Core Requirements in the Commissioning Framework to monitor the quality of our services and to ensure they meet all of the four Prudent Healthcare Principles.The Board has also approved our Trust Risk Management Strategy and Framework (2016-19) to deliver improvements in patient safety and care, as well as the safety of staff, patients and visitors. We designed the Quarterly Trust Quality Assurance report which informs the QUEST Committee of our Quality Assurance and monitoring of Quality improvements across the Trust.

Next Steps: 2017/18 Processes: We will continue to strengthen our quality assurance and

improvement processes by: Responding to the Commissioning Clinical Risk Assurance Review

Align our internal and clinical audit programmes

Develop Quality reports for each of the seven Health Boards

Develop the Quality dashboard

Develop WAST Quality Improvement Plan

Review the DATIX system for WAST

Develop e-risk assessments and reporting to inform electronic Risk Registers

Take forward the next steps of the sustainable improvement plan for concerns management

Test the implementation of technology for local teams

Develop a quarterly Health and Safety assurance report

Implement the Trust Infection, Prevention and Control Improvement Plan

Promote professional standards

Develop a guidance document for Executive and Non-Executive visits

Outcomes

The Trust Corporate Risk Register identifies the high scoring risks which we monitor and review regularly. We published our 2015/16 Annual Quality Statement in September 2016 which shared our achievements, challenges and our priorities for the year ahead. The Patient Experience and Community Involvement Team (PECI) has embraced the Ageing Well in Wales programme with the Commissioner for Older People. The Trust has engaged with older people to develop our WAST Promises to them, as well as engaging with people with specific needs including dementia, sensory loss, falls, continence care and learning disabilities.

13

We have designed and launched our online engagement directory to capture all activities offered across the Trust which maximises the Choose Well initiative and helps us engage with the public and our stakeholders.

2017/18 next steps: Outcomes: To ensure we maintain our focus on improving patient experiences

and outcomes to achieve safe and effective care and excellent patient, carer and staff experience we will:

Publish our Annual Quality Statement for 2016/17 by June 2017.

Implement the Trust Patient Experience and Community Involvement annual plan. We will continue to measure patient experience and seek service user feedback to inform our continuous improvement.

Further develop alternative care pathways working with Health Boards and key stakeholders.

14

The Organisation and Prudent Healthcare

There are four principles for Prudent Healthcare set out by the Bevan Commission

these are:

We are committed to these principles of Prudent Healthcare and ensure that they run throughout the full plan and the service developments which we describe. This helps us to make great strides in achieving our ambition to move from a transport-based to a clinically-led, quality-driven service. Working prudently is at the heart of our future workforce training and modernisation agendas. As we continue our ambitious plans for service change, we will continue to consider how roles work together to ensure that patients receive their care from teams that work well together across clinical pathways. We will continue to review the development needs of our staff to enable them to work flexibly and to operate at the top of their competence to be able to meet the needs of patients today, but also anticipating changes to demography and population needs.

Patient Experience and Community Involvement (PECI) Team The Patient Experience and Community Involvement Team (PECI) forms part of the

Quality, Safety and Patient Experience Directorate and has a commitment to

engaging with patients on their experiences of our services, to help us understand

what it feels like to be a patient in our care and to use that learning to help improve

our practice.

The PECI Team also has a distinctive role in educating the public in how to access

and use our services sensibly and appropriately, from children and older people,

carers to those with protected characteristics, through to the mass of the population.

Work will continue throughout 2017/18 to integrate the work of both the PECI Team

and other colleagues across the organisation more closely. We will achieve this by

ensuring the strategic intent outlined in the Engagement Framework is reflected in

the work programme of all relevant teams and is reported regularly to the Board.

15

4 – OUR SIGNIFICANT SERVICE CHANGE

We have identified our key service area commitments and aligned them to the five

step ambulance care pathway and the four step Non-Emergency Patient Transport

Service (NEPTS) pathway. These will be areas in which we will invest our change

capacity and resources.

The EMS 5 Step Pathway:

Step 1: 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.

We focus on the need to get the public to ‘Choose Well’ and be aware of other

services available and not to instinctively call 999. We will do this by:

Working with our Health Board partners and other local agencies to align local choose well initiatives

Engage with schools and communities, stakeholders and the wider public Explore options to work together with Fire and Rescue services (FRS) to

deliver joint safety advice Share information with our partners such as the FRS to ensure vulnerable

members of the public are offered the same advice Continue to focus on demand and capacity through our frequent caller

programme and work with health care professionals to ensure calls are dealt with appropriately, more efficiently and where possible reduce the need for our vehicles – in turn making best use of our resources.

16

Step 2: Answer My Call

Despite the work already carried out last year, we acknowledge we still have much to do. This will include:

The implementation of the new CAD (Computer Aided Dispatch) system

– WAST’s business case for a new CAD was approved in November 2016, a preferred supplier has been awarded and an implementation plan is underway. Delivery of the new system will happen in two phases:

1. The ‘go live’ of the system when call handlers can start to operate it 2. Realigning our processes – this is where the real change and benefits

will be realised

Our CCC Estate – We acknowledge we have insufficient building space and

our estates team are working to change this.

Improve ‘Hear and Treat’ rates –

The graph above shows how increasing our capacity through the winter had a positive impact on our ambulances and the number it prevented being dispatched. We want to expand our capacity so we have a 24/7 presence in all our Clinical Contact Centres (CCCs) and will work with our commissioner to explore resourcing options.

0200400600800

100012001400160018002000

Number of Ambulances Stopped

Number of Ambulances stopped

This step focuses on continuing

to improve our Clinical Contact

Centres (CCC) acknowledging

these are at the centre of the

entire WAST operation and are

a priority area for improvement.

17

Wider CCC Modernisation – We will continue to develop the CCC quality governance and risk processes as these are key to the modernisation, we will develop an action plan to capture, monitor and learn from our near misses and incidents. We will also look at ways to help us deal with peaks in demand such as call handlers being able to log on from home.

111 rollout – The 111 pathfinder was successfully launched in October 2016 as

part of a phased implementation for the Neath Port Talbot and Aneurin Bevan areas. We are still to finalise dates for the further roll out to the remaining areas but will continue to commit to build on our NHS Direct Wales and our 111 services.

Step 3: Come to See Me

This step focuses on how we make decisions about what resources to dispatch to calls.

The Demand and Capacity Review presented opportunities to help ensure

our ambulances and response vehicles are available for calls a higher percentage of the time.

Working with Primary Care – over the life of the plan through working with primary care we intend to work across three linked sections:

A key priority agreed for 2017/18 between WAST and primary care is to focus on developing and evaluating the Multi-Disciplinary Team (MDT) pilot models that have been agreed and initiated with clusters during the last quarter of 2016. These are:

1. GP Out Of Hours Service model 2. Primary Care Practice model 3. Community Based Partnership model

Community First Responders

Our Community First Responders (CFRs) are a valued part of the emergency response team and provide a resource to us to support the provision of our EMS (Emergency Medical Services). CFRs also have an important role in developing community resilience and public awareness and provide pre-hospital emergency care following a set of protocols before the arrival of an ambulance. There are currently more than 200 Community First Responder schemes across Wales comprising of approximately 2,200 volunteer members and these schemes contribute more than 3% to RED performance across Wales. We recognise that there is more to be done. As such our focus moving forward will be on: Embedding Terrafix Mobile data and enable auto allocation

Multi-

Disciplinary

Team Pilots

Training and

Education

Realising

Estate

Opportunities

18

“Go Live” of CFR desks in all CCCs A further fifteen schemes responding to non-injury fallers The implementation of a new scope of practice that will see three tiers of

responders Staff Responder presence in BCU, Aneurin Bevan and Hywel Dda Health

Boards Increase third sector engagement

Emergency Medical Retrieval Service (EMRTS)

We work closely with the EMRTS through the EMRTS Delivery Assurance Group and specifically the North Wales Air Ambulance Implementation Group. It is recognised that the current model does not provide equal access in terms of emergency air support and we recognise the risk this poses the system. Working with our partners in Betsi Cadwalader Health Board, the Air Wales Ambulance service and EMRTs we will work to develop the following areas: Placement of the Caernarvon air base under EMRTS governance Ensure medical equipment is standardised at all bases Recruitment Provision of Consultant medical input to the base.

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. The Trust will then monitor how ambulance clinicians deliver the care bundles to ensure continued improvement in clinical care. In this first year 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 subsequently look to progress in the lifetime of this plan include: The Telemetry Project The Omnicell Project The Out of Hospital Cardiac Arrest Survival The Clinical Indicator Improvement Plan

Step 5: Take me to…

This step refers to patients who are not appropriate for ‘hear and treat’ or ‘see and treat’ services. Our aim is to reduce the number of patients in the pathway that hit this step but if they need a further level of care we will take these patients to the most appropriate place for treatment. To help us achieve this we will deliver a range of clinical care services. In addition we have a strategic focus on the following: The next phase of paramedic pathfinder

19

Full roll out of Mental Health pathway Providing the Chief Ambulance Services Commissioner (CASC) with up to

date pathways and directories Timely handover at emergency departments Working with local health boards to pilot and implement direct admission

pathways We will also work closely with Health Boards to implement a range of alternative care pathways relevant to the local area and the table on page 26 of the full plan outlines the opportunities which we are seeking to exploit with Health Boards.

Our Non-Emergency Patient Transport Service Developments

The range of vehicles we have mean that we can convey a wide-range of patients including those who need stretchers, patients who use wheelchairs and patients who have a limited walking mobility. A large number of the journeys for patients who are able to get in and out of a car are made by our dedicated team of volunteer drivers. In line with the NEPTS Business Case, the commissioning of NEPTS services will continue to change significantly over the three year period of the plan. We will need the full engagement of all health boards to support us in delivering the service that patients need. We have agreed with the Commissioner a four step approach to delivering NEPTS. Our delivery model and service improvement will be based across these steps.

Step 1 – Help me choose

This step focuses on public and health care professionals understanding the service NEPTS provides

Step 2 – Book my transport

This step concentrates on simplifying the booking system for patients through use of new technology and the introduction of an 0300 number for the whole of Wales.

A vital part of what we do involves taking people to and from routine outpatient appointments at clinics, hospitals and day centres. The Non-Emergency Patient Transport Service (NEPTS) makes over 1.5 million journeys every year for patients across Wales and enables them to be on time without the use of an ambulance.

20

Step 3 – Take me to my appointment

This step focuses on constantly looking at new ways to improve the service we provide including taking into account demand and capacity.

Step 4 – Take me home

This step focuses on better coordination and response times.

The next steps for the NEPTS programme will be continuing to embed the progress made to date as business as usual and to ensure the pace of service development continues. There are three strategic actions which have been identified to ensure this happens. They are: Implementation of a new co-ordination model Implementation of new service developments Development of an integrated transport hub

It will also be vital that we work together with the Chief Ambulance Services Commissioner (CASC) to develop the NEPTS commissioning framework.

Specific Patient Group Service Development

We recognise and commit to improve on our Amber calls performance. We aim to do this by developing new operational models and pathways enabling us to respond to patients in a more appropriate way and through clinical practice and leadership shown below:

New Models and Pathways Clinical Practice and Leadership Mental Health Improvement Plan Clinical Desk Falls improvement work to bring

together: Non-Injury Faller work in Clinical

Desk NHSDW pathways Directories of Service iStumble projects in ABMU Cardiff and Vale multi agency

exercise Falls vehicle in Aneurin Bevan Community Assistant Team in

Betsi Cadwalader Community paramedic pilots and

evaluations

Clinical Leadership model Use of clinical data at team level to

support meaningful PADR and feedback

Career pathway focus in particular Development of advanced practice

models Opportunities through the Band 6

development Clinical Audit Plans Clinical Indicator Improvement Plan

We recognise that a large number of our Amber calls are for people who have fallen. Over the last year we have introduced some new pilot projects to ensure we help these patients as best we can.

21

An example is the Community Assistance Team (CAT) based in North Wales. The team was set up in August 2016 with the aim to prevent the number of people who need to attend hospital as a result of a fall. This has shown us how effective these pilot schemes can be and we will now look to find a single Welsh Ambulance model for fallers. This will be a key piece of work for us to develop through a falls improvement plan. Moving forward we will use the findings of the Demand and Capacity Review as a platform for discussions with Health Boards around responses to the needs of these patients. Furthermore, we will review our Amber actions in line with the Clinical Risk Assurance Review which was published in March 2017.

National Delivery Plans

We have reviewed and identified which National Delivery Plan implementation boards we should be working with more closely with. We believe the following to be the key ones:

Stroke Cardiac End of Life Diabetes Mental Health

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

5 – OUR ENABLERS

The changes we continue to look for in our service and patient-facing areas can only be achieved through the effective delivery of our plans that allow us to enable and make changes. 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, a strong collaborative ethos and clear governance arrangements. What follows is an overview, through our plan we go into more detail on each of the following areas: Our People Our Finances Our Estate Our Fleet Our Partners, Patients and Stakeholders Service Improvement and Innovation Health Informatics and Technology Research and Development Our Governance Welsh Language

22

Our People

It is through the commitment, professionalism and dedication of our #Team WAST that we are able to provide high quality and safe services. We are also committed to the importance of individual health and well-being and understand the importance of a happy and, in turn, productive team.

Our People Strategy defined as, ‘Being Our Best’ is designed to enable us to build on the positives of the last twelve months and respond to upcoming challenges by using our resources where needed through the four step model, shown below.

At the heart of this strategy sit the principles of Prudent Healthcare and a prudent workforce.

23

Our Workforce Plan Our priority remains effective workforce planning, ensuring we have the right people with the right skills employed in the right place to deliver short and long term objectives. There are three key elements to our approach to delivering our Workforce Plan moving forward:

More information on these can be found in our full plan.

Our Emergency Medical Service Workforce

Our EMS workforce is our biggest resource and therefore continues to remain a focus for our workforce planning activities. The 2016 Demand and Capacity Review has shown that demand for 999 services is expected to grow by approximately 4% year on year to 2020/21 unless action is taken to reduce demand. Through the results of this Review and also a number of pilot projects relating to the clinical desk, we now have a better understanding of things we can do to re-shape our workforce over the next few years to enable us to meet the demand. So far, modernising our workforce has focussed on the development of specialist or extended roles that we believe could help us respond to this demand from our Amber category patients in the future. In future we will explore:

We will continue to progress these opportunities as part of our refreshed plan.

Understanding

demand and

capacity

Reducing

variable pay

expenditure

Identifying

opportunities

to modernise

and redesign

clinical roles

Introduction of rotational posts for nursing staff

between ABMU and the 111 Pathfinder service

Community based paramedics in rural

areas

Rotational opportunities for nurses and

paramedics across the system

Strengthening our clinical leadership

structure

Expanding the expert knowledge of CCC

clinical desk

Maximising the benefits of the Band 6 paramedic

24

Future of Advanced Practice

We currently have 26 funded Advanced Practitioner posts, which is insufficient to respond consistently to 999 Amber and Green calls where they would be an ideal response. We believe our Advanced Practitioners, whether paramedic, nurse or dual qualified have a vital role to play for patients and our own clinical workforce providing supervision and clinical guidance. We are developing a plan to strengthen clinical leadership across the Trust and the Advanced Practitioner role will play a key part in this future vision. Subject to funding we will seek to appoint an Advanced Practitioner to a Clinical Lead post in each health board area and create a working job plan to be agreed before the end of 2016/17. We are also exploring the option to develop a role for the Advanced Practitioner within the CCC (Clinical Contact Centre).

Developments on Paramedic Banding In England, a deal has now been agreed with the trade unions, NHS Employers and the Department of Health that will see the role of a paramedic being re-banded from Band 5 to Band 6 and paramedics moving up the pay scale to Band 6 where appropriate from April 2017. These changes come with the expectation that paramedics will develop and deliver the necessary skills in order to address demand on urgent and emergency care services and put in place measures to look after more people in the community. It is expected these developments will result in a reduction in conveyance rates to hospitals through more ‘hear and treat’ and ‘see and treat’ to ease operational and financial pressure on hospitals. In WAST, we are committed to ensuring our workforce is properly rewarded for its skills and the work they do and welcome the implementation of the Band 6 profile. The detail of how, not if, a Band 6 paramedic role will be introduced in Wales will be discussed in partnership with key trade union officials through early 2016/17, with a view to reaching agreement on an implementation plan and proposals by early summer.

Recruitment Plan

A key objective of our plan is to promote the Trust as an employer of choice, showing the kind of employment experience we can offer potential candidates and giving a clear understanding of why people stay within the organisation and are prepared to go the extra mile. This will be our ‘employee value proposition,’ and we will continue to develop this in 2017/18. As we strive to deliver this objective our focus will be on:

25

Increasing applications from members of ethnic groups currently under-represented in the workforce

Ensuring timely recruitment and training plans in line with Demand and Capacity review outcomes and commissioned workforce.

Increasing our presence in schools and at careers fairs A new electronic starter form to be implemented from April 2017. Developing a structured approach to recruitment and subsequent training

plan Development of a pool of trained assessors Further development of recruitment material for our other roles Refreshing membership of the Recruitment and Selection Group Utilising TRAC for volunteer recruitment

Clinical Education and Training

We continue with our aim to provide high quality, regulated and accredited education for all our operational teams and in 2017 we will be seeking to introduce a level 3 award and certificate for our NEPTS team. We will also be developing new apprenticeship opportunities within NEPTS to commence in September 2017. With the change to paramedic banding and scope of practice coming in 2017 and creation of new roles such as the community paramedic, we will also be developing the content and delivery our paramedic education and training, and aim to create locality learning cells and maximise the use of our new immersive training facility to ensure we are able to reach as many staff as we can. Improving our compliance with Statutory and Mandatory core training and CPD requirements will remain a priority for us all in 2017.

Staff Survey

We are very proud of our 2016 Staff Survey Results which highlighted some key successes and some areas for improvement. The results showed our engagement scores have risen from 37% in 2009 to 53% in December 2016. We considered the outcome of the survey at a workshop with managers and staff representatives from across the Trust, and agreed a number of priorities for 2017/18, including: Maintaining continued visible, vibrant and compassionate leadership throughout

and particularly at Executive and Senior Management

Continued development and implementation of the Staff Awards and

Recognition programme

A focus on action needed to reduce the number of staff who report being

bullied, harassed or abused by members of the public and / or their colleagues

and,

Implementation of sustainable regular immediate colleague feedback to

enhance the PADR experience and improve opportunity for clinical reflection

and practice development

26

We will look to learn from the results of the staff survey over the life of this plan and take action where required.

Clinical Leadership

Clinical Leadership is at the heart of developing and leading an organisation such as WAST and strong Clinical Leadership across the organisation is seen as key to achieving our vision to be a ‘leading ambulance service providing the best possible care through a skilled, professional and healthy workforce’. We have refreshed our clinical leadership plan to focus on the following: Securing approval for the implementation of a new ‘clinical leadership’

infrastructure with the introduction of clinical leads in each health board Developing clinical leadership skills linked to PADR and the developing career

pathway Creating a strong mechanism for provision of clinical supervision for all clinical

staff and development of competence for our advanced practitioners Strengthening clinical governance and accountability arrangements across

the organisation

Leadership Development

We recognise that vibrant, compassionate leadership is one the most important

enablers to delivering our vision and ambitions, and to ensuring we meet the needs

of every community and individual we serve and those we employ within

#TeamWAST. We continue to enhance our leadership development opportunities

with the launch of our bespoke Team Leader Development Programme in April 2017

and planned creation of a senior manager development programme growing leaders

who passionately care about our patients, our teams and the services we deliver. We

will also continue to support leaders and their teams to develop through team

coaching and team development workshops

It is recognised that certain roles in the organisation also require management development, this will be appropriately reflected in development opportunities available.

Occupation Health and Wellbeing

Maximising the conditions for the health and well-being of our staff continues to be of significant importance for us. In 2016/17, we faced some challenges including increased demand for services, capacity within teams and cultural barriers to engaging in the NHS Wales flu vaccination campaign. In early 2017 we will be reviewing our in-house Occupational Health and Well-being Services, and also our current Employee Assistance Programme to ensure staff receive the best support possible to look after their health and wellbeing, are aware of the tools and support available, and managers feel fully supported to deal with ongoing occupational health issues.

27

Our key Health and Wellbeing priorities include, further developing the Mental Health Pathway for staff, working with our partners in charities like The Ambulance Services Charity (TASC), MIND and Time To Change Wales to ensure that staff can access specialist support services and treatment if needed; developing support to staff financial wellbeing; and the achievement of the Corporate Health Standard Gold. We have also learned from the 2016 Flu Campaign, and this will inform our plan to ensure all clinical, frontline staff receive their flu vaccination in 2017 to achieve NHS Wales target.

Our Finances

We receive the vast majority of our income through a commissioning arrangement lead by the Chief Ambulance Services Commissioner (CASC) who acts on behalf of all Health Boards. Funding for ambulance services is incorporated as part of the allocations made to NHS organisations by the Welsh Government. In 2016/17 we achieved financial balance, and once again for 2017/18 the plan is representing a balanced position. This means we are forecasting that we can deliver the service we describe in this plan within the finances we are allocated. This balanced position is based on a strong savings plan and more details of where we will need to make savings can be found in the full plan. There are a number of risks which exist in terms of us delivering our financial plan and they include: Our funding assumptions Full implementation of the NEPTS business case and the efficiencies it

describes The availability of capital funding from Welsh Government The outcome of the Demand and Capacity Review The delivery of the potential savings we have identified

Corporate Governance

Corporate Governance refers to the rules, practices, processes and relationships by which we in WAST are controlled and directed. It ensures accountability, fairness and transparency in everything that we do and is about making sure we do the right things in the right way at the right time. During 2016/17 our main aim was to ensure our governance and risk management systems met the needs of the service, taking into account the changes happening within the Trust such as the New Clinical Response Model, the 111 non-emergency helpline and the revised management around the Non-Emergency Patient Transport System (NEPTS). Our focus for 2017/18 is to build on the work we have carried out and continue to ensure good governance structures exist and develop them further to make us an even more effective organisation. Key actions will be to:

28

Deliver and improve processes which support the Board Introduce a paperless system for Board, Committee and other meetings Introduce and deliver a governance training module into the leadership

training programme Refine systems for reviewing, amending and updating Trust policies Further develop governance mapping and ensure governance exists within

other groups Ensure the Trust meets its obligations on matters such as Welsh Language,

Freedom of Information requests and direction.

Our Estate

At WAST we aim to be a leading ambulance service and therefore 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 over 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 Improving Infection Prevention Control outcomes Providing value for money for the service Developing a sustainable building stock

Our priorities for 2017/18 and beyond: Upgrade and improve Tredegar Ambulance Station and implement plans

to co-habit with South Wales Fire and Rescue at the sites within the Vale of Glamorgan area

To relocate the administrative function currently located at the HM Stanley building in St Asaph, North Wales to a modern facility

Upgrade the infrastructure of the CCC (Clinical Contact Centre) at Vantage Point House, Cwmbran to also assist with the full and successful implementation of the new CAD (Computer Aided Dispatch) system

To undertake feasibility work to relocate to the fire station at Llandrindod Wells

To undertake feasibility work to relocate the operational response from Newquay fire station to a shared facility with Hywel Dda Health Board in Aberaeron.

29

Our Fleet

We operate 736 vehicles, the majority being Emergency Medical Service Ambulances (EMS), Rapid Response Vehicles (RRV), Non-Emergency Patient Transport (NEPTS) and Hazardous Area Response Team (HART). We employ 35 staff spread across Wales and four in-house workshops in Wrexham, Cardiff, Blackwood and Bangor.

Our fleet will be impacted by the results of the Demand and Capacity Review and when these impacts are clearer, they will inform the long term direction of our vehicles and help us determine our optimum fleet profile to meet our demand. We currently dispatch the ‘IDEAL’ response to 999 calls around 80% of the time. We will need to adjust our fleet to ensure the ideal response ratio increases. With fleet being such a critical enabler, however, we must not stand still in the meantime and will:

Develop a new ambulance workshop in Cardiff Begin a pilot involving Mid and West Fire and Rescue Services (MWFRS)

servicing our vehicles Update our Strategic Outline Plan (SOP)

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.”

30

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 and good quality data will be a critical enabler to our plan. The Health Informatics Teams will be required to support a number of strategic developments including: the CCC and Clinical modernisation, the 111 pathfinder, the workforce and OD and NEPTS service programmes and the community engagement plan. The table below shows our highest priority actions for the next three years;

2017/18 2018/19 2019/20

Introduction of a common Business Intelligence (BI) platform

Build upon the work around the BI platform and start the migration process over to this enhanced platform

Review of the Data Warehouse infrastructure

Introduction of an analytics training programme

Consider the technologies used to deliver mobile data requirements within the Trust

Expand the Records Management Strategy

Introduction of the General Data Protection Regulation (GDPR),

Continuation of the GDPR project

Introduction of a National Archives function

Develop a Records Management strategy

Information Communication and Technology (ICT)

ICT is also a key enabler for WAST. We have made huge progress over the last twelve months. In line with the National Strategy our focus for the next three years will be categorised into four sections; Information for you - We will work with areas such as NEPTS (Non-emergency Patient Transport Services) and NHSDW (National Health Service Direct Wales) to put in place electronic services for patients to enable them to access services.

“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 Trusts service development priorities.”

31

Supporting Professionals – Implementation of the new CAD (Computer Aided Dispatch) system, continued preparation for the replacement of network services through the national Emergency Services Mobile Communications Programme (ESMCP) and continued support for the national 111 pathfinder. Improvement and Innovation – work with partners to improve information sharing, look to further improve our capability to capture data and create new technology solutions to support the Trust. Planned Future – Focus on the vital need for resources and finances and ensure maximum return on investment, review and revise current systems and ensure ICT staff are given the appropriate skills to ensure they can play their role in supporting these future developments and systems.

Partnerships and Engagement Our 2016-2019 plan reflected our commitment to engagement and the need for strong relationships with our patients, staff, NHS Wales organisations and public sector partners.

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

This year has seen our organisation’s reputation shift in a much more positive light. As we move into 2017/18 we will sharpen our thinking as to where our public service collaboration and partnership work might and should take us as we move forward, which will then have a bearing on the direction we take in our Directorate and on our work for the next few years. Some key actions that will make a significant difference to the organisation through 2017/18 are:

Developing an embedded stakeholder intelligence system to bring together feedback from staff/patients and external stakeholders

Deliver a system of improved internal communication for staff and volunteers Develop an organisational story that ensures all staff are able to view our

ambitions and see their role in delivering them

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.

32

Deliver on the content of the Engagement Framework Delivery Plan being developed in Quarter 4 of 2016/17

Ensure continued engagement in the Wellbeing of Future Generations Act agenda

We will need to consider an investment in technologies by 2018/19, including a new Trust website, intranet and online magazine and will need to dedicate time to research and implement this. We will also look to secure the commissioning of a BBC documentary series exploring the broad and challenging work of the Trust.

6 - DELIVERING OUR PLAN

We are aware that writing a plan stating what we are going to do is in some respects the easy bit. Our Board, Welsh Government, our Commissioners, our staff and indeed all our other stakeholders are going to want assurances that we are actually delivering what we promised. To respond to these expectations we have put a number of things in place: For each of our 48 strategic actions we will have what we call a plan on a

page for each of them. These will describe the activities that will be carried out and give 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 (i DAG). This group is chaired by the Director of Planning and Performance and will track each of the actions to ensure people are making the progress they 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 actually be delivered you may request copies of the plans on a page which have been developed by contacting us, details below.

7- 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.

33

GLOSSARY

CAD

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

CASC

Chief Ambulance Services Commissioner - commission’s 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.

Cluster

A cluster is a group of GP’s working with other health care professionals to plan and provide services locally.

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.

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.

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, 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 on a yearly basis.

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.

TRAC

An online recruitment system implemented in WAST in April 2016.