The next item is a statement by the same Cabinet Secretary—the Cabinet Secretary for health—and an update on the pathfinder 111 NHS service in Wales, and I call on Vaughan Gething to make his statement—Vaughan Gething.

Thank you, Presiding Officer. I am pleased to have this opportunity to update Members on the NHS 111 pathfinder service in Wales. This is testing the practicalities of implementing a new and integrated service to help meet people’s urgent care needs.

The Welsh 111 service brings together NHS Direct Wales and GP out-of-hours call handling and triaging into a single service. It provides many opportunities to simplify access to services for patients, whilst supporting the delivery of primary care plans for Wales. The service supports patients in making the right choices about care, in the right place, at the right time.

The new 111 service provides health advice and urgent care support through a free-to-call telephone service. This directs patients to the most clinically appropriate service for their needs. This should allow patients to be treated closer to home, whereas, too often in the past, this would have been in an emergency department, which is not always the right place for their care.

The Welsh 111 model was launched in Abertawe Bro Morgannwg University Local Health Board in October last year, and extended to Carmarthenshire in May 2017, this year. We’ve already received positive feedback from local clinicians, operational staff and, more importantly, the public who have made use of the service.

The 111 service in Wales differs from other UK models. We have a far greater proportion of clinical staff within our service than significant areas of England, for example. The 111 pathfinders in ABM and Carmarthenshire demonstrate that the service can support the assessment, direction and management of patients more effectively, using a range of healthcare professionals in a clinical support hub. That hub utilises the skills of experienced GPs, nurses and pharmacists, working within a clinical contact centre, and the hub is operational during the peak periods of out-of-hours demand. The GP within the hub has both a direct clinical role in dealing with complex calls, and crucially they also act as a supervisor, overseeing and managing queues. They also act as a resource for the wider unscheduled care system, for example, paramedics and nursing homes have a direct line in to 111 and there have been tangible benefits.

Between 4 October last year, when we launched the service, and 30 April this year the service within ABM has dealt with more than 73,000 calls. Access to the service since launch has been good and the feedback from patients, particularly via social media, has been positive. I am also pleased to say that locally within ABM and Carmarthenshire the in-hours GP services and emergency department staff have been positive about the service, and importantly there are no significant patient safety issues.

We’ve commissioned a formal evaluation from the Public and Corporate Economic Consultants unit in association with the University of Sheffield, and that report is expected in late July. That report, together with the valuable information gleaned by those delivering the 111 pathfinder, will help us to identify issues that need to be resolved prior to any final decision being made about the pace and timing of an all-Wales roll-out. When we launched the pathfinder in Wales we wanted to build on the good practices and initiatives that were already taking place, whilst learning lessons from similar services in England and Scotland. We want to ensure that we have a clinically safe and robust service in Wales. Adopting the pathfinder approach with some caution will ensure that lessons from the evaluation can be incorporated, and take on board advice from clinicians and patients. These can then be built into the design of our permanent model.

I recognise that there is more still to do if we are to implement a national service to support the people of Wales using prudent healthcare principles. I have therefore asked the 111 programme board to provide me with a robust plan by autumn this year for taking the service forward. I expect that plan to set out options for how the 111 service could operate post pathfinder as a national service to support patients and the NHS to treat patients with urgent care needs more effectively.

I want this plan to outline the future strategic role of the 111 service and its role at the heart of our unscheduled care system here in Wales. I’ll therefore consider a number of issues, including: the potential role of the 111 service as a single point of access for non-emergency health services, and the potential to integrate other healthcare inquiries into 111 in the longer term; agreeing how expanding the range of specialists employed within the clinical support hub could better support patients with complex and specific conditions, for example, paediatric diabetes and mental health; to quantify the resources required to deliver the service on both an interim and a longer term basis; the opportunities and economies of scale and other benefits that may be presented by the co-location of 111 clinical support hubs with the Welsh Ambulance Services NHS Trust’s clinical contact centres; the potential to expand the opening times for the hub to provide greater resilience and support to other areas of the NHS; and the development of a nationally agreed and managed directory of services, along with an IT digital platform allowing Skype calls for transforming the way that patients and professionals interact.

In conclusion, though, I am very pleased with the progress that has been made to date, which I have seen for myself on a visit earlier this year, and I want to acknowledge the hard work of the 111 team centrally, but in particular the clinicians and operational staff who are making this work and making it a successful pilot to date. The 111 pathfinder service has been a success so far. Lessons are already being learnt and considered as plans are developed for the future roll-out. A number of big decisions do, though, still need to be made, but I have made it clear that this is about doing it right, not necessarily doing it quickly. I believe that 111 will provide us with significant opportunities to enable patients to receive the most appropriate service for their care needs, at the right time and in the right place.

Cabinet Secretary, thank you very much for your statement today. This is still a service in its infancy, and I have questions in three specific areas. The first is about resources, both human and financial. I wondered if you can give us a bit more of an overview as to how the intended pulling together of NHS Direct Wales and GP out-of-hours will go, based on the experiences that you have in ABM and of course the very few months that it’s been rolled out in Carmarthenshire. I’ve had a number of meetings with staff in these areas and also with staff throughout Wales, and one of the areas that comes up quite a lot is how difficult it is to get human resource, to get people, involved currently in NHS Direct Wales. There is a feeling that it is understaffed. It’s hard to recruit and so I wonder what is going to happen when this service pulls all those people together. How do you intend to be able to recruit them? On the financial resources element, can you perhaps give us an overview of the kind of cost that you anticipate, because I’m not clear whether or not you think that putting these two services together will just give you a fund of money and that’ll be what you spend? I would suspect that you might need some pump-priming exercises to carry this forward.

The second area I’d like to just have some clarity on is about the clinical directory. I picked here that there’s a potential development of a nationally agreed and managed directory of services, along with an IT digital platform. One of the things that I’ve really picked out from the pathfinder projects is that the directory of services is quite different for the different areas, and I anticipate that that will continue as it’s rolled out across Wales. I have a concern that if this becomes a national directory of services, then what flexibility will you look to build into the system to ensure that it reflects the local area, so that if you’re phoning in Angle or from the middle of Cardiff, you’re going to have access to quite different directories of services? You’re going to have access to, or no access to, not just what I would call medical clinical services, but other help that you might be pointing people into, because this is about general well-being as well. So, I’m very keen to explore with you how you see that directory of clinical services going. I’m extremely concerned that one directory that is supposed to fit all of Wales will actually not do what we could do very successfully with this, which is enable people to understand it. I think I’d just like to illustrate that by saying that I’ve met a number of clinicians who’ve said, ‘Wow, it’s not until those pathfinder services came together that we realised some of us didn’t realise that we did this or could offer that.’ So, if the clinicians don’t know it, how is the person in the street going to know about it?

Finally, you mention that you’re asking some organisation, the Public and Corporate Economic Consultants unit, to have a look and to evaluate it. I just wondered if you’ve got any interim commentary that you could share on how you think it’s gone and what feedback you’re currently having from either ABM or indeed from Carmarthenshire. Some of the feedback I’ve had has been very, very positive but there are some glaring holes, and I’d just be interested to know what your feedback is. Thank you.

Thank you for those comments and questions. I’ll come back to, if you like, the last bit and the first bit and try and take those together. On the point about financial resource, there has been a need for pump-priming to get the service to work, because this is an additional service in some ways, but also we’re trying to bring together things that already exists. So, it’s how current budgets are used, but also how we get people into the right place.

The point about the directory of services is well made, and I tried to convey in my statement about the challenges and questions that are set about options for me as well as the service about how we take this forward. You can understand the attraction of having a national directory of services to allow you to deliver consistency, balanced against the point you make about what is flexibility and the understanding of that. One of the things that we regularly find is that the clinicians, of course, don’t know everything. How could they know every single part of the service that is provided within a health board area, let alone across the country? I think sometimes it isn’t about whether clinicians know all of that; it’s about how you get information to the person who’s advising the member of the public. Equally, we don’t expect the member of the public to know every single thing about how the health and care service system works. It’s about how we help that person to navigate that system and to make the right choices, because that member of the public is still making a choice about what to do.

But I think the most encouraging thing—this comes back to your first and last points—the most encouraging things is that we had a service that was designed in a cautious way, that understood that in parts of England where it had had its most negative publicity, there was something about understanding the model, having enough clinicians to be receiving the call and giving advice in the first point, to make sure that there was high-quality advice being provided—it wasn’t simply about redirecting people into an emergency department. You will have seen, I’m sure, recent reports in the last few weeks that there’s still concern that, in some parts of England, that is what is happening. But we learned directly from colleagues in England, but also from Scotland, too, where they’re taking a slightly more cautious approach.

But, within Wales, we brought together people running out-of-hours services. Steve Bassett, in particular, has been really important, and because clinicians are seeing other clinical leaders bringing things together and having those conversations, it’s made a real difference as to the level of buy-in we had at the start. Because there was scepticism not that long ago whether this would really work, not just amongst the public, but within the clinical community as well. So, we had a sense check done not just by Steve Bassett, but also Linda Dykes, who’s an emergency consultant in north Wales, but she’s also working as a GP as well—she can see both sides of, if you like, the primary and secondary care divide. She’s still doing work on how to bring some of that care together in north Wales too. So, that was important, again, with the buy-in and the credibility that she has.

But the most encouraging part of this is that, yes, you do need to bring those people together to make sure that the clinical support hub and the quality of care that is being provided remotely are actually delivered, but also, we have had really positive statements made from emergency departments about the fact this has been a good thing. Andy MacNab, the lead consultant for emergency medicine in Swansea, has commented that he thinks it’s a good thing and they haven’t seen an inappropriate bounce in numbers in terms of people being inappropriately sent to them, or not sent to them as well.

So, as we go through the evaluation, that’s what I expect to understand—to see what’s come from it—because my anecdotal feedback has been positive so far from individual staff, from the project team and the numbers that they see. It’s a real positive. The PACEC group are the same people who did the evaluation of the new ambulance model, as well. I hope that will give Members some confidence. This is something where you see a different evaluation that has looked critically at what’s been done, talked about those things that have done well, but, equally, pointed out areas for improvement. That’s exactly what we want from the evaluation, and that helped to guide me and the wider service in making choices and providing advice, which, of course, I will update Members on in due course.

You have described how the 111 service works, and, for the record, I think it’s a good idea, and I look forward to measuring its success in future. You say the pathfinder service has been a success so far, but its success, of course, will be measured in its outcomes. You tell us that 73,000 calls were made to the ABM service between October 2016 and April 2017, but, again, it’s outcomes that are important. What effect has that had, for example, on the number of patients attending emergency departments? We speculated, as this was being launched, whilst wishing it well, that if it had been a miserable failure, it would probably lead to an increase in the number of patients attending EDs. I assume from what we’re hearing in this update that that certainly hasn’t happened, but we need to know what the evidence is. We need to be able to measure the impact of 111, not just measure the positive feedback, as important as that is, of patients in that part of Wales.

You tell us that lessons have already been learnt. Perhaps you could give a taste of what lessons have been learnt, and, as much as it’s a pleasure to have you making another statement to us this afternoon—the second one in a row—you tell us that a formal evaluation has been commissioned from the Public and Corporate Economic Consultants unit in association with the University of Sheffield and this is expected in late July. Why make a statement now?

In terms of making a statement now, I gave commitments to make a statement before the end of summer recess, so I’m delivering on the commitments that I had previously made. I’d have thought that’s a good thing for a Minister to do.

Now, look, in terms of the evaluation—the broader point—we already have really positive feedback. In terms of the initial surveys that have been done, over 90 per cent of patients say they’re happy with the service they’ve received. So, that’s a good place to start, but the formal evaluation is really important to go into more depth, and I would expect that Members will be interested in seeing the evaluation when it’s published. There’ll be more questions for us to go through, whether in this forum or in committee, because I need to understand, before I make choices in the autumn about the future of the service, the different impacts in terms of the roll-out and how a programme might work, but also the choices we make, going back to Angela Burns’s comments about a directory of service, but also to have a more in-depth understanding of the impact across the whole system. As I said, it’s really good to have the direct feedback from somebody like Andy MacNab, working in a really busy emergency department, and to understand that this hasn’t led to a significant bump up in the numbers coming in—certainly the numbers coming in inappropriately. There will be more of that detail with the evaluation.

Whilst I’m sure you’re delighted to have me make another statement, I hope that in the future, when I make further choices in the autumn, I’ll talk about the reasons why we’re making choices at that point in time for what I think will be a continuing impact across our unscheduled care system. Because we do know that just leaving things as they are—just leaving it with NHS Direct Wales and just leaving it with the primary care out-of-hours service and emergency departments—that doesn’t properly meet the needs of people who have real care needs. It’s about how we manage those needs, how we deal with them properly and appropriately, in the best way, to make use of the resources that we already have. I think one of the key lessons has been that our broad approach in having more clinicians within that team within the hub has made a real difference, and actually it’s made a really big difference to people in primary care as well, who feel much better supported, and our ability to staff that particular group has been improved. So, there are real advantages. You don’t need to take my word for it; clinicians will say that as well, and we’ll see what the evaluation says in due course.

Thank you for your statement, Cabinet Secretary. The 111 service has been well received by a lot of my constituents who had the benefit of the pathfinder service. However, quite a lot of constituents are still unaware of the service, and whilst I appreciate the infancy of the scheme, we must ensure that those hard-to-reach constituents are made aware of the service. I am pleased to see that you are considering the wider roll-out of the service, and I look forward to receiving the results of the formal evaluation.

As the recent National Survey for Wales shows us, one in four of the Welsh public find it difficult to make a GP appointment, which puts pressure on out-of-hours services. The 111 service addresses this problem, and the sooner we can make it available in the rest of Wales, the better. Cabinet Secretary, what are the major barriers preventing the wider roll-out of the service at the present time?

You mention the development of a digital platform to allow Skype-type chats. So, Cabinet Secretary, do you see video-conferencing playing a greater role in primary care, particularly in rural areas? And how can we improve our infrastructure to make greater use of voice over IP services in future?

Finally, Cabinet Secretary, you have asked the programme board for a robust plan for wider roll-out by the autumn. What do you envisage will be the timescale for the complete roll-out of the service to all local health board areas? I look forward to working with you to ensure this service, which hugely complements our primary and urgent care services, is available to every person in Wales. Diolch yn fawr.

Thank you for the comments and questions. I’m pleased that there’s recognition of a service innovation that the Member recognises her constituents have commented on positively. It is, of course, a service innovation based around the ABM area, with Carmarthenshire starting afterwards, so a real innovation starting in south-west and mid-west Wales. The challenge always is understanding what you need to do before you actually start with the roll-out, and we did have to make changes. If we’d simply tried to implement the system with the old primary care out-of-hours system, NHS Direct Wales, it would not have worked. We need to get buy-in from clinicians, so actually something has to go into that. It should be easy, if we’re going to roll out the service, to get that sort of buy-in on the back of a successful pathfinder, but there are some pretty significant challenges ahead of that. We need to understand, both from a financing and from a recruitment point of view, about putting more people into clinical contact centres, to make sure that we learn lessons from the scripts that people are given to use and guide people when using the service, and to make sure that we understand we have genuine buy-in from people across the whole health and care system, if this is going to roll out on a national basis.

The roll-out would not be done in a big bang by pushing a switch, I think, to then go across the country at one point in time. I think that would be foolish, and we’d risk trying to deliver what looks like a service innovation and improvement and undermining it by going in that sort of way. So, there must be a proper and organised roll-out. That’s why I indicated in my statement that I’ve asked the programme board to come back to me with a robust plan on the back of an evaluation to understand the choices that are available to us. I will need to come back to Members in the autumn once I’ve had that advice and I can indicate the path that will be taken on rolling out this service.

The other point that I haven’t answered is your point about telemedicine. I think that not just in video-conferencing but in all parts of telemedicine there is huge potential across Wales, and not just for rural Wales, actually, to improve the quality of care, and particularly the quality of experience for individual patients. We see it in some parts of our system already—in eye care, for example, transferring images in a way that is really positive for patients and good for the service, but also delivering a greater efficiency for citizens making use of the service, as well as the staff within it. So, not just in this area but across our whole health and care system there’s a real potential and a need to do that on a more consistent and demanding basis.

I thank the Cabinet Secretary.