Will the Cabinet Secretary ensure that the Welsh Government's responses to Healthcare Inspectorate Wales's recommendations from its national review into patient flow are available publicly in the interest of transparency, and to ensure that the not-for-profit sector can support the Welsh Government to achieve these recommendations where possible?
I welcomed Healthcare Inspectorate Wales’ Patient Flow: A journey through the stroke pathway, published in September 2023.
It highlights the challenges across the health and care system and made 50 recommendations for health boards, Public Health Wales, the Wales Ambulance Service, and the Welsh Government. Seven were for the Welsh Government to respond to.
Our response to these specific recommendations – which reflect the position in October 2023 – was shared with HIW. They are reproduced below.
We are committed to recognising and promoting the third sector and the contribution it makes. It will continue to play a vital role at all levels of the health and care system, particularly through Regional Partnership Boards – £24.6m of the Regional Integration Fund, managed by RPBs directly funds third sector provision.
The important role of the third sector is further emphasised in A Healthier Wales and our National Clinical Framework. I expect its role to be embedded into the way we provide health and social care in Wales with stronger working relationships being forged with third sector partners.
Annex 1: Recommendations for Welsh Government from HIW report on Patient Flow
Recommendation 4: Welsh Government, health boards and WAST must work collaboratively, to consider whether the Immediate Release Directions are effective or need improvements, given the high number of declined Immediate Release Directions occurring across Wales.
The ‘immediate release’ protocol is not a Welsh Government policy. Our expectation of Health Boards is that all patients are transferred from ambulance vehicles to the care of Emergency Department staff in order of clinical priority, always in a timely manner and within an hour.
Recommendation 11: Welsh Government should consider strengthening its promotion of the Help Us to Help You campaign, to ensure people are appropriately educated and understand how to access healthcare in the right place, first time, by guiding them towards the most appropriate care service.
Budget for the Help Us Help You campaign has been secured to enable the “Better Health Starts with You” advertising to run across media in Wales this autumn and winter. The campaign will cover accessing services, mental health/wellbeing, and prevention/self-care. Accessing services will include raising awareness of and promoting alternatives to GPs and Emergency Departments, including pharmacy, optometry and self-care.
Recommendation 14: Welsh Government should consider how it can support WAST to develop and implement improvements with its service delivery model, such as increasing the number of advanced paramedic practitioners across Wales, to help reduce the pressure on EDs and improve flow through healthcare systems.
The Emergency Ambulance Services Committee is responsible for the commissioning of ambulance services, and sets commissioning intentions for WAST to deliver upon as part of an annual commissioning framework based on its ‘five step ambulance patient’ model. The Chief Ambulance Services Commissioner, who acts on behalf of the committee, has established integrated commissioning action plans between each Health Board and WAST with a focus on:
- Better management of 999 patients in the community through the use of the clinical support desk and video consultation technology
- Joint development of pathways to reduce conveyance volumes and enable direct access pathways to help reduce ambulance patient handover delays
- Health Board actions to support timely ambulance patient handover
It is for the committee to consider the value of allocating additional funding for the recruitment of APPs, and to consider the risk of removing paramedics from response duty to undertake significant training requirements in the context of the need to deliver sufficient ambulance response capacity to optimise outcomes.
The Welsh Government has allocated £5m in 2023/2024 to Health Boards to recruit additional AHPs, and has recommended consideration of recruitment of additional APPs as part of this additional funding where appropriate.
Recommendation 18: Welsh Government should work collaboratively with WAST, health boards and social care providers to evaluate and strengthen the current processes in place to improve flow through health and care systems, with a concerted focus on the analysis of flow, the bottlenecks impeding flow and the issues with achieving timely discharge.
The Welsh Government has established a national improvement programme (‘the six goals for urgent and emergency care programme’) supported by £25m in additional funding. The programme plan for 2023/2024 includes a specific focus on supporting Health Boards, RPBs and local authorities to improve patient flow through the comprehensive goals 5 (‘optimising patient flow through discharge planning from the point of admission’) and 6 (‘a home first approach’) work programmes of work which include specific workstreams on:
- Reducing patient deconditioning;
- Implementing the Trusted Assessor model;
- The SAFER and Red 2 Green enabling tools; and
- Discharge to recover then assess models
This work is underpinned by a clear focus on data, ongoing analysis of barriers / blockages, sharing and learning. Relatively new data is now captured in respect of length of stay and pathways of care delays, with action plans owned by Health Boards and RPBs to enable improvement. This area will be a central focus over quarter three and four of 2023/2024 to enable resilience over the winter period.
This work is underpinned by a clear focus on data, ongoing analysis of barriers / blockages, sharing and learning. Since the HIW review began in 2021, a new formal system, Pathways of Care Delays (PoCD) Reporting framework, has been implemented (April 2023) to provide validated monthly data at a regional health board level as well as at local authority level on patients who remain in a hospital bed more than 48 hours after being declared clinically optimised, together with the reasons for the delay. The data is being used to work with regions to identify areas for improvement as well as actions being taken to address delays and will be a useful tool to support a collaborative approach to improve patient flow and hospital discharges. The Welsh Government is working directly with health boards and local authorities to review and understand their data so that suitable actions can be developed to drive improvements. The PoCD data will be useful for addressing some of the HIW report recommendations regarding discharge either directly in response to the recommendation itself or indirectly to provide supporting data on discharge delays.
In addition, there is a focus on the activity needed within regions and between partners that will support improvements. To achieve this, health boards and local authorities are required to produce robust, joint Action Plans that identify key themes and trends that contribute towards tackling delays. The Plans help translate PoCD data into meaningful action that will improve services and patient flow and identify and help resolve issues. This forms a critical part of the reporting process and in moving to regional outcome focused solutions and a central focus over quarter three and four of 2023/2024 to enable resilience over the winter period.
Recommendation 30: Welsh Government must work with the Thrombectomy Wales Oversight Group, the National Clinical Lead for Stroke, and health boards, to consider how timely and equitable access to thrombectomy treatment for stroke can be made, for all relevant people across Wales.
Welsh Government set out the strategic intent for improvements in stroke services and outcomes for people affected by stroke in the Stroke Quality Statement published in September 2021. This set out the quality attributes for stroke care in Wales, replacing the previous Stroke Delivery Plan. Our aim, as set out in the Stroke Quality Statement, remains for people of all ages to have the lowest possible risk of having a stroke, and, when it does occur, to have an excellent chance of surviving, and returning to independence as quickly as possible.
The Stroke Implementation Group (SIG) was funded by Welsh Government and established to oversee implementation of the Stroke Delivery Plan, and subsequently developed the Stroke Quality Statement. The Welsh Government funding of £1m per year also supported into post the national Clinical Lead for Stroke, The National Allied Health Professional Lead for Stroke and the SIG Programme Manager (The National Stroke Programme Team).
The SIG is now being replaced by a Stroke Improvement Network as a part of the overarching Cardiovascular Strategic Network under the governance of the NHS Wales Executive. Welsh Government continues to fund these networks via the NHS Wales Executive allocated funding to support the development of networks as set out in the National Clinical Framework.
The Thrombectomy Wales Oversight Group was established under the governance of SIG and will continue to operate under the new network and NHS Executive arrangements. Welsh Government will continue to set the strategic direction and support the clinically led activities to improve stroke care and stroke outcomes in Wales through the established arrangements in place, including The Thrombectomy Wales Oversight Groupwork. Robust mechanisms are in place through which Welsh Government works closely with the National Stroke Programme Team, the Performance & Assurance Directorate within the NHS Wales Executive, and the Stroke Association all of whom are pivotal members of The Thrombectomy Wales Oversight Group which meets every 2-3 months, seeking opportunities for improvement and new innovations to improve the existing thrombectomy pathway. This has resulted in some exciting innovations:
- The deployment of artificial intelligence within radiology departments to accelerate diagnosis of stroke, enhance clinical decision making and reduce onward pathway delays.
- Pre-hospital virtual triage is being piloted in Cardiff & Vale University Health Board which will enable patients to be taken straight from the ambulance to a CT scan.
- Since March 2022 inter hospital transfers for thrombectomy is classified as a ‘category red transfer’ – the most urgent response. Wales is the first nation to have a ‘red’ inter-hospital transfer arrangement.
Welsh Government is committed to ensuring people in Wales have timely and equitable access to thrombectomy.
Whilst the Stroke Programme Team develops the CRSC model, arrangements are in place with the Welsh Health Specialised Services Committee to commission specialist services like the thrombectomy service.
Recommendation 44: Welsh Government must consider the process in place for social work teams and their role in assessment and allocation to patients in hospital, and whether the services across Wales are appropriately funded and managed to support the discharge process from hospital to improve patient flow.
Through our Pathways of Care Delay reporting framework we now have access to clearer discharge delay information to support patient flow. The monthly submitted information is collated through health board systems and then validated with local authority partners. This ensures that all partners have a clear picture around discharge delays as well as where the delays are occurring (geographically) and the reason codes behind each delay. This will allow teams to focus efforts and resources to best support discharges and improve overall flow.
In addition to this, we require health boards and local authorities to develop joint action plans on pathways of care delays. These action plans should set out how each of the Regions are using their data on discharge delays to develop meaningful actions. The action plans are expected to take account of local and regional issues that might be impacting on discharge processes, so that health board and local authority partners can respond accordingly and ensure that teams are focused in the most effective areas to deliver effective patient flow and discharge.
Earlier in the year this new data set identified delays in assessment as a key area for improvement. As a result, in February 2023 the Minister wrote to all Local Authorities, Health Boards and Regional Partnership Boards setting out her expectations in relation to work to enhance Trusted Assessor Capacity to help reduce delays due to assessment. Each region provided a plan for increasing Trusted Assessor Capacity and Officials met with Regions on a monthly basis to maintain focus, drive progress and monitor impact. Regions have made use of both core resources and funding provided through the Regional Integration Fund to increase Trusted Assessor capacity and over the 7 month period between February and September 2023 Trusted Assessor roles/functions have been increased by 69 (exceeding the target of 48).
We have published Once for Wales guidance for Trusted Assessor Roles to supplement and inform safe and effective discharge. This guidance is supported by an online toolkit designed to enable the regions further develop Trusted Assessor roles and functions and very shortly, by a dedicated Competency Matrix linking to the accredited training that continue to enable regions to further build their capacity of Trusted Assessors and improve patient flow.
Recommendation 47: Welsh Government, health boards and local authorities must work collaboratively to consider the options of improving the accessibility to care in the community, such as domiciliary care.
We established the Strategic Domiciliary Care Group in May 2023. The purpose of this is to bring together leaders in local authorities, health boards, providers and other key stakeholders to agree the priority actions and levers of change as a national approach to domiciliary care.
Increased capacity of reablement services should decrease the demand for longer term domiciliary packages of care, which is also a priority for health and social care.
More broadly we recognise the importance of redirecting resources to support the community care system, in order to relieve pressure on emergency care and improve patient flow. Our Further, Faster work aims to strengthen community health and care services and is focused on those living with frailty given they are one of the population groups where demand for services is increasing at the fastest rate. We launched our ‘statement of intent’ document for Further, Faster back in June. Since then, we have further refined these proposals through our discussions with local authority and NHS partners at our Integration Action Group. This group first met at the end of September and will continue to meet through the winter to monitor progress.
We are committed to improving pay, terms and conditions and addressing recruitment and retention issues in domiciliary care and the social care sector more widely. The draft Pay and Progression framework was subject to consultation over the summer. The outcome of this and next steps will be published in due course. Our continued commitment to the Real Living Wage saw £70m invested this year to ensure all social care workers continue to get paid a wage rate based on living costs.