The next item, therefore, is the statement by the Cabinet Secretary for Health and Social Services on the findings of the independent accelerated programme for amber review. Vaughan Gething.

Thank you, Presiding Officer.  In my statement on 15 May 2018, I informed Members that I had commissioned a clinically led, independent review of the Welsh ambulance service’s amber category. I'm pleased to be able to provide Members with an update following the completion of that review. Members will recall that an independent evaluation of the clinical response model, undertaken in 2017, found a universal acknowledgement from within the ambulance service and external partners that moving to the new model was the right thing to do. It found that the new clinical response model had helped the Welsh ambulance service to focus on the quality of care that patients receive as well as improving efficiency in the use of ambulance resources. It also made recommendations for further improvement, including a review of the amber category. 

In light of that recommendation, the amber review that I ordered sought to establish whether patients in the amber category are waiting too long for an ambulance response, and if so whether this is resulting in poorer outcomes and experience for patients. I'm encouraged to note that the amber review has echoed the findings of the previous independent review—that our clinical response model is safe. Our model continues to ensure that those in the greatest need receive the fastest response to improve their chances of a positive outcome, whilst also providing appropriate and timely care for patients who do not have immediately life-threatening conditions.

I've previously outlined the review process in place to keep all prioritisation codes under ongoing review. This review process, undertaken by experts in the field, ensures the allocation of codes to the red, amber and green categories remains clinically appropriate. Members will be aware of my focus on evidence-based measurement. It is interesting to see that the review has advised against introducing new time-based targets for ambulance services. Instead, we will continue to pursue a whole pathway measurement for conditions like stroke, and develop further clinical indicators and measures of patient outcome and experience in line with 'A Healthier Wales'.

Incidents in the amber category will generally receive a blue light and siren response, much like those in the red category. The main difference is that for red incidents all available nearby resources are despatched, whereas in the amber category the nearest and most suitable response is sent. This should help patients to access the right specialist care sooner. The majority of ambulance staff that took part in the review said they believe the prioritisation system works well, and the number of vehicles attending amber calls has decreased. And that should give us confidence that we're getting the right resource to people first time more often. That should improve clinical outcomes for people with conditions like stroke, heart complaints and fractured hips.

The review’s findings also, of course, present opportunities for improvement. The median response time for amber calls has increased by an average of seven minutes during the review period, from April 2016 to March 2018. That's clearly not acceptable and will be addressed through focused and collaborative work. Findings suggest timeliness of response has been affected by a number of capacity-limiting factors. That's despite additional Welsh Government investment of £11 million for patient care services over the last two years, and £38 million in capital investment over the same period.

Ambulance handover delays and staff sickness need immediate attention through a whole-system approach and improved staff well-being. I expect health boards and the Welsh Ambulances Services NHS Trust to work with partners to take responsibility for these issues and to take immediate action to address them. We will of course monitor progress closely.

The review was able to use innovative techniques to track patient-level data through the system. It found no direct relationship between long waits for an ambulance response and poorer outcomes for the majority of patients. However, the experience of patients and their families will be negatively affected and that is supported by public feedback. I expect action to be taken to enable reassurance and welfare checks to be provided when people are waiting longer for an ambulance to arrive.

The review found that incidents relating to people who have fallen accounted for the largest call volume within the amber category. In view of this, I have decided to allocate £140,000 to the chief ambulance services commissioner for a collaborative falls response project involving St John Cymru Wales.  

Anecdotal evidence from operational staff suggested that there were a significant number of calls from nursing homes for patients who had fallen and that it would be beneficial for all nursing homes to have lifting cushions. The national programme for unscheduled care will, therefore, fund several hundred lifting cushions for nursing and care homes across the country. Both of these initiatives should reduce the unnecessary dispatch of emergency ambulance resources to people who have fallen but are not injured and can be safely resettled.

The review found evidence to suggest that there are opportunities to better manage people in the community, either through providing clinical advice over the telephone, referring to alternative services or discharging at scene. Public feedback to the review suggests it is important to people that they avoid going to hospital if it isn't necessary. Eighty four per cent of those surveyed said they would prefer to stay at home, and 88 per cent of people felt it was important to them that medical advice was provided over the phone. Ambulance service staff also felt that expanding the numbers and roles of clinicians in the control room was essential to manage demand effectively. Given these findings, I have agreed to fund the recruitment of more paramedics and nurses to provide clinical advice to the public over the telephone to help manage demand in the community.

Investment of around £450,000 for the remainder of the year will also include a winter pilot of mental health liaison nurses in ambulance clinical contact centres, and that is based on feedback from clinical contact centre staff, who said that they do not have the required training to support people in mental distress. They believe that having a mental health specialist in the control centre would help to relieve pressure and allow more people in distress to be treated in the community.  

We will, of course, continue to work with the Welsh Ambulance Services NHS Trust, health boards and the chief ambulance services commissioner to take forward the review’s recommendations with pace and purpose. I look forward to Members' questions. 

Thank you, Presiding Officer. First of all, Cabinet Secretary, I'd like to thank you for the technical briefing you offered this morning from your officials. It was very helpful. It's a big report, there's an awful lot in it and it makes for interesting reading, much of it welcome, some of it concerning. 

Four areas particularly leapt out at me in terms of sheer statistics that caused me concern. The first is that, over the past two years, over 7,000 people waited over three hours outside a hospital to be transferred in, and over 15,000 people waited over three hours for an ambulance wherever they were when the incident they were involved in happened. There's been a rise in the amount of hours it takes from handover to clear, which is obviously an area we need to look at, and, of course, a very concerning one is the rise in sickness of ambulance staff and trying to discern why: is it down to stress? What are the issues here? Of those four areas themselves, two are indicators of where we're not performing well, and two are indicators of where there might be logjams in the system.

The report as a whole makes some very interesting recommendations, but it does repeatedly reference placing clinicians in settings such as control rooms, nursing homes, police services as a means of improving management of the service and assessing the situation. In terms of implementation, how sure are you that you have the capacity to already put those clinicians in place? Are we aware of how many roles will be needed and where they are? Because it's all very well for this report to say, 'We could do so much better if we have people over there, over there and over there', there's a great devolution from the Welsh ambulance service, and it may well be right—I'm not certainly not arguing that—but what I am concerned about is that it's all very well saying, 'Let's put these clinicians in the control room'; 'Let's put more people here, there and everywhere', but we know the staff shortages we have. So, I'd be interested to know what you've done to assess that particular issue. And, again, with reducing the long waits of patients such as non-injury fallers—it tends to be our older population—this, again, is looking for social care workers and district nurses. So, how are they going to be better incorporated into the care pathways for these individuals? How are you planning to build that capacity? 

I do welcome the bespoke plans with the local health boards, but the implementation of these plans is highly dependent on those health boards. We know that ambulance services have received additional capital investment in this year's budget, but in order to drive forward change, how will you, how will health boards, be supported to put in place these improvements? Will they be asked by you to demonstrate how they will do that in their integrated medium-term plans, because if you don't monitor this, it could very easily get lost in the mix?

With regard to improving the service, we did initially expect this review to be made public in September, and it is now the first week of November. One quote from the review says,

'In order to avoid the combination of factors that were seen last winter, the ambulance service and the wider NHS must ensure it takes every opportunity to maximise the availability and efficiency of resources in order that the patients of Wales receive the highest quality and timely ambulance response.'

So, how, then, are LHBs going to be able to implement this ready for this winter and Christmas period? Were they privy to this review before us here in the Assembly? Have they been able to put in place resilience plans prior to the winter?

Presiding Officer, I just have one last question. At the back of this review is a list of the protocol cards that are used by call centre staff, and I was really surprised to see that there is not a sepsis protocol card. As you know, sepsis kills more people each year than bowel, prostate and breast cancer combined. And there are key indicators. I know it is a chameleon, but the key indicators of chills and shivering, confusion and slurred speech, severe muscle pain, fast breathing and very high or low temperatures are real indicators that someone might be having a sepsis episode. We know if we can rescue people early, they've got more chance of a proper, full recovery. No protocol card. Would you please undertake to just have a look at that and see if it would be appropriate to put a protocol card and add it to the 19 other protocol cards that the ambulance service currently work to?

Thank you for the comments and the range of questions. I'll try and deal with them as well as I can in the time available. You, of course, referred to a range of figures at the start, particularly on the focus on handovers and others, and, of course, you have 475,000 calls to the service. But there's a recognition that there's more improvement needed on a more consistent basis across the country, because there is some variation in the country about not just handover rates, but that's one part of the whole system. What the review tries to do is to place all of that within the whole-system context. So, lots of improvement in getting the right response to the right people. They need that to discharge at the scene where possible, and, if they need to go to hospital, properly discharged, and also for them to be able to leave a hospital setting promptly as well. So, it is part of a wider system.

I recognise your points about sickness. There are certainly measures to take, and I'm pleased to say they will be taken forward by employers, together with trade unions as well. And I don't know if you've seen the constructive response to the recognised trade unions within the service, but it's positive; there's a recognition of the need to improve sickness rates in particular in the service, and, of course, that's also partly recognised in the pay and conditions conversations and negotiations that are taking place in the recent months.

On your point about recruiting appropriate clinical staff to contact centres, it might help to reflect that there are three clinical contact centres in the country, so, three centres to recruit staff to. There'll be a challenge there about making sure we have the right staff to recruit. We're confident we'll be able to do that, as well as staff within the wider system. And, actually, in the wider system and the points you make there, actually we're looking at being able to get on with the winter plans, drawn up by health and social care together, including the ambulance service. So, that money is based on funding those plans in addition to the £10 million that I announced previously, together with Huw Irranca-Davies, the Minister, to actually put into the social care system. We're looking at the whole system as part of that, and those plans are consistent with findings in the amber review.

You also talked about clinical leadership and accountability to be able to take this forward. And in this, we're in a positive place because you have leadership within the paramedic workforce that is positive about our direction of travel, including the need to invest in the numbers of people we have. So, that's about training, about retaining the bursary as well as recruitment of experienced staff. It's also about investing in the skills of the workforce in social care and in the health service. I hope you've had time to look at some of the investment in the future of advanced paramedics as well, what they can do, both within a contact centre, but also in their job on the ground, of being able to see and treat, and hear and treat, as well. I'm really pleased that Jo Mower, the national unscheduled care lead, is having an impact with her colleagues in the wider unscheduled care system. She comes with real credibility because she is still a serving clinician. She's a consultant in emergency medicine, and she's working part-time in that role and part-time as the unscheduled care lead. So, she has real credibility with colleagues across the system.

I'll deal with your point about sepsis as well, because, if you look at the national early warning scores that are used, that's part of the early warning system for sepsis. Now, I'll happily have a look at the specifics you mentioned, but I do just want to get over that this is a challenge for the whole system. And actually, in my time in the job and previously as the Deputy Minister, I have definitely seen over that time a much higher profile of sepsis within ambulance centres, where staff are based, with much more visible material, and, actually, we know that we are getting better.

Now, the challenge is what else we could and should do to continue that improvement. So, it's not about complacency; it's a marker of improvement that's been made and what more we could do. Actually, I think the NEW scores and the fact that they're in here as a measure that we use is really helpful, because that should help us to identify people at risk of sepsis and to make sure that that is a risk that is properly and appropriately resolved. On this, I know that we share the same objective about wanting to do more, to see more lives saved and to see more avoidable disability not taking place within our health and care system.

Thank you, Cabinet Secretary, for your statement. There are obviously things to welcome in the report, as Angela Burns has already said, and in your statement. I'll be particularly interested to see how the falls response project with St John Ambulance progresses, and I hope you'll come back to us to tell us. I'm very optimistic that that will have some positive outcomes.

The financial investment that you mention in your statement is also welcome. Can you confirm to us today that that is new money for the ambulance service? And can you also, perhaps not today—. If it is new money, it will clearly have come from another part of the health budget and I'd be very grateful if you could write to Members to confirm out of which part of the healthcare budget the new money for the ambulance service—if it is new money—has come.

The report makes a number of recommendations, and I'm struggling a little bit to see quite how your statement reflects the recommendations, but I would accept that it does, broadly, in spirit. I'd like to draw your attention to one particular recommendation where the report recommends a programme of engagement to ensure clarity on the role of emergency ambulance services and how calls are prioritised and categorised. Do you accept that specific recommendation and, if so, can you tell us whether this programme of engagement will provide opportunities for concerns to be raised again about the breadth of calls that are included within the amber category? Your statement says that prioritisation, as it stands,

'should improve clinical outcomes for people with conditions like stroke, heart complaints and fractured hips.'

But would you accept, Cabinet Secretary, that these are actually quite different conditions and that, for some of them, they are much more time sensitive than others? I would suggest, for example, that stroke is much more time sensitive, in terms of the ultimate outcome for the patient, than fractures. In fact, of course, the report shows that internally the service does effectively use an amber 1 and an amber 2 code, as well as protocols to prioritise based on the information of what's happening for the patient. And it also states that the relationship between time and care has been established for a number of conditions, such as acute heart myocardial infarctions and stroke. So, therefore, wouldn't you accept that this shows that time actually does matter for patients and that this internal categorisation reflects that? Would you be prepared to consider, as you work with the ambulance trust to move this forward, whether it is time to look again at formalising a target, particularly for those amber 1 calls? I understand the reluctance to overburden the system with targets—none of us would wish to do that—but where those calls are time sensitive for patients like patients with stroke, I'm a bit bemused by your reluctance to be prepared at least to consider setting a target.

In terms of categorisation, the report also identifies that, sometimes, calls are initially regarded as amber and then get upgraded to red calls because of additional information becoming available. The report also states that there are times when the staff felt that there was an inability for call handlers to deviate from the system because the system was restrictive, and I wonder if you would take another look at that to see whether it needs to become a little bit easier for staff to use clinical judgment to move calls up a category to red or perhaps from amber 2 to amber 1, if necessary.

And finally, can I just ask you again a little bit more—? You did respond to Angela Burns's question about the sickness rates and the stress that I think we can accept is probably at the root of those sickness rates. You mentioned in your response to Angela Burns that you will be expecting the local health boards and the ambulance trust to work on that and to work with the trade unions on that issue. But can you give us a little bit more detail about what exactly that work will consist of and the time frame for it? Because you know very well, of course, Cabinet Secretary, that our health and care services—and none more than our ambulance service—depend entirely on our staff, and, if there's a question about the well-being of the staff, I think that we would all like to be further reassured about how those questions with regard to their well-being are being addressed.

Thank you. I'll deal with that last point first. The challenge about dealing with staff well-being is obviously important, and it's an issue now. So, I've made it clear that that work should begin immediately in the conversation between employers and the trade unions. There is a regular ongoing conversation about staff well-being in every part of our national health service, especially as we look—following the agreement on a three-year pay agreement—to try and reduce levels of sickness. That means we need to understand some of the reasons why staff are going sick. It's not just about managing people efficiently; it is about understanding the stresses that exist. I've announced over the last year a range of measures to try and support staff, because this is a particularly stressful job. So, it has to come from what our staff, through their trade unions as their elected representatives, are telling employers, and to make sure that's taking place. I expect to receive a report within a period of months about what that looks like from the employer's side. It'll be part of the regular conversations I have with not just the chair of the ambulance trust, but also with the chief ambulance services commissioner and the chair of the Emergency Ambulance Services Committee.

That leads me back to your point about money. The money announced is new for the ambulance service trust. There's a challenge over where money comes from, in that some will come from a central pot. But you should remember that this is a service that is commissioned by health boards. That's a model that's been set up following the review that Professor Siobhan McClelland undertook, and so it is for health boards to fund the service that they are commissioning. They can't expect that service to deliver new and additional measures without looking sometimes at not just the efficiency of the use of the resource, but the amount of it as well. There are times when we've intervened in the past to make sure that money is provided from health boards. I'd much rather not to have to do that in the future. We can always top slice. Sometimes that is appropriate to make sure it happens quickly, but, moving forward with the range of the recommendations, I'd expect those decisions to be made by the system as a whole.

On falls response, which you mentioned at the start of your statement, I'll be happy to return to Members to give an update on the impact of both the £140,000 that I announced to go together with the project with St John, together with the projects about delivering lifting cushions and the impact of that. On your broader point about reviewing categories of clinical conditions, and whether they are in the right target of red, amber or green, in some ways, this goes back to the reason why we have a new clinical response model. It's still relatively new. Because we understood that we had a 40-year-old target, which covered a huge a range of conditions, that actually didn't do much good for the patient. It sent resources in different directions to try and meet a target that made no difference to outcomes. It was the only measure we had in the ambulance service. We are in a much better place now in having a proper category of red calls, where time does make a difference, and in having other quality measures that are published every quarter on the quality of care that is provided. There is much more scrutiny now of what the ambulance service does—and the good that it does—than there was in the past.

You can see that isn't just a good decision because of the independent review that we had done in 2017, or indeed this one, but the fact the work that we have done is being followed up and copied in the USA, Canada, Australia, Chile and beyond internationally. And, here within the UK, a similar approach is being taken in both England and Scotland. One of the differences is that England has introduced, without evidence that has persuaded the independent review here, a time target in some parts of what we have in the amber category. Scotland, though, have taken the exact same approach that we have done, in saying that it is not appropriate to introduce a time target within the amber category. We are, though—as I'm sure we've seen from the review and the briefing that you'll have had the opportunity to attend today—looking at the whole pathway approach for a range of conditions, including stroke, for example, where the whole pathway matters. We're working alongside people like the Stroke Association to understand what it is appropriate to measure to give us a real understanding of what the whole system is doing, as well as the ambulance service's part of it. But I do not intend, on the basis of a review that has said very clearly that we should not introduce a time target, to nevertheless, as a political imperative, try and introduce one nevertheless. I don't think that's the right way to run the service. I believe that undertaking, seriously, with real pace, the recommendations in this review will be the right thing for both our staff and, crucially, for the public that they serve.

I, too, welcome the statement and, indeed, the report, which is a mine of information, which I’m sure we will, after full consideration, find is useful in many respects.

I fully accept what the health Secretary says about targets, but I think we ought to acknowledge that, without the Government’s failure so spectacularly to meet the targets that it set itself, we’re unlikely to have had this report in the first place. We must continue to have targets, but, of course, those targets must be meaningful targets. That is a point that is incontestable, and we certainly don't need targets that are misleading. Nevertheless, I was somewhat troubled by the page in the report—page 23—which really sets out to pooh-pooh targets, I think, if you look at it with some care. It says, for example:

'The value of a response time as a measure of the impact and quality of ambulance service care is… questionable',

'if health services are preoccupied with hitting targets then the actual journey an individual patient experiences becomes secondary', and various other expressions of that kind. I think that the public at large, of course, do want to have ambulance services delivered as quickly as possible, and the failure to do so causes inevitable stress, and that stress impacts, of course, upon ambulance staff themselves, who are trying to give the best possible service to the public.

Much of this is perhaps beyond even the health Secretary’s control. We all know about the needs and means problems of the health service and the excess of demand over supply, which will probably always be there, but I would like the health Secretary to give us an assurance that, because the Government has consistently failed to meet many targets, and has failed to meet them by sometimes very large measures, which are exemplified and illustrated in the report itself—and, indeed, the health Secretary in his own statement says that the median response time for amber calls has increased by an average of seven minutes during the review period itself—. This is all very unwelcome news, but the existence of targets is essential if they're properly used, not just as a stick to beat management with, but as a tool to improve the service, and are essential to achieving the result that everybody in this place wants, which is better healthcare for as many people as possible. And, if we are able to square that particular circle, obviously, that’s going to impact upon sickness rates of staff as well. I think the 7 per cent staff sickness rate is an indictment, in a sense, not necessarily of the Government, but of the inability of the country actually to have a proper debate about the amount of money that ought to be put into the health service and the way in which that can be done to produce the most effective results. But, ultimately, we're all trying to achieve the same objective, but we've got to have the right information upon which to make the necessary political decisions about allocating resources and how to manage them, which are vital to a successful health service in Wales.

I agree with some of the broad narrative, even if I disagree with the conclusion that the Member reaches on some of the points. I'm sure that, with this report—. There will be an opportunity for the Government to appear before the committee to discuss it, at some point, I'm sure. I see that your neighbour isn't in the Chamber at the moment, but I'm sure that comrade Lloyd will want to have a look at the report in more detail.

I don't share your view or your statement that there’s been a spectacular failure to meet targets and that why I have this report in the first place. We actually moved to a different system on targets before your arrival in this place, and the decision that I took as the Deputy Minister. That was a challenge to recognise that we had an inappropriate target. Even if we had met the target, it would not have delivered the right care for patients. And it was a view that was widely shared within the paramedic workforce in particular; they were deeply frustrated about being required to try and hit a target regardless of the good it did for the public. So, we undertook a review; Professor McClelland undertook a review. We then made a decision to actually pilot a new clinical response model, after a proper review that actually looked at the effectiveness of the old target and came up with a possible way forward of a better way to run our system. And that’s why we have a different target. We were the first UK nation to do that, and now other UK nations are following us, but not just because we have a different target—it is a more appropriate target, and that's the point. 

When you refer to the report, about whether the targets are being pooh-poohed, if you actually look at the reference to it then actually it's looking at response times as the sole indicator of the service, and actually that's not an appropriate way to look at the way that the whole service delivers care. Again, the challenge even there is, if you only have one time-based target, even if that is an appropriate measure for that part of the service, we all know that is then used as a way to try and judge the success or otherwise of the whole service.

Just on your point about the public view, the public view about ambulance services is of course they want a timely response, but, in undertaking this independent review with assistance from the Picker Institute, the public view has come back that timeliness matters, but the right response matters more, and people are prepared to wait a slightly longer period of time for the right response. But that does not mean that people are contracting out to wait for a very, very long response in all or any circumstances; we recognise some waits are too long, and action will be taken to address them. I'm sure I'll have the joyous opportunity to be scrutinised by Members in this place or in the committee to see whether we actually manage to achieve that in the near-ish future.

Thank you, Cabinet Secretary. It's reassuring that the new clinical model is shown to be achieving the objectives that we've set for it, and that it is clinically safe. But, as you acknowledge in your statement, the patient experience still is seen to be wanting in some areas. Inevitably, if you shift priority from one area to another, there are going to be longer waits for some. You say in your statement that there is no direct relationship between long waits and poorer outcomes for the majority of patients, but the patient experience does get negatively affected, and I don't think we should dismiss that. The patient experience is important, and I'd like to know a little bit more what we plan to do aside from making sure the patients who are waiting are still clinically safe. That aside, what are we going to do to make sure that the patient experience itself does not become overly negative? You said during the review period the median response time for amber calls increased by an average of seven minutes, which is disturbing. You say this is going to be addressed through focused and collaborative work, and is affected by a number of capacity factors. Perhaps you can tell us a little bit about that. I think it is important we keep scrutiny on this. I think it's good that it's safe, but there's still much more to be done. You say the review is independent, and, of course, it is independent of the ambulance service, but it's still a review by the NHS, and I wonder if you would consider involving the Wales Audit Office to provide a degree of external assurance as well.

Thank you for the comments and questions. The Wales Audit Office, with their own programme, regularly decide what to look at in terms of public service delivery, and I have no difficulty at all with the Wales Audit Office taking a greater interest in where we are. I'm sure that, at some point, they will want to, when they decide in their judgment that it's the right time to do so.

On your broader point about what we're doing about capacity, that partly goes back to the comments made with Angela Burns about having the right capacity in different parts of the system, so whether it's the local contact centre or the number of staff we have on crew, on shift, at the right time, and the different peaks and troughs in demand that are relatively predictable throughout the year as well. And I expect not just to report that, but you'll see in the quarterly ambulance quality indicators a range of information about how we're able to meet demand throughout the whole year. For example, in the amber area we publish information every quarter on the average response on the sixty-fifth percentile and the ninety-fifth percentile, so you can tell how many long waits there are within the system; you can tell where they are in different parts of the system by health board as well.

What we'll also be doing immediately this winter is we will be looking to have what are referred to as welfare checks. The challenge there is whether people are calling back to check, if someone is still waiting, how they are, because often people are reporting back when deterioration has already taken place and some time ago. People often wait before they call back and say, 'This person is a lot worse', and so actually there's something about being able to more regularly call back that person and say, 'This is the position. Is there any change in the condition?' That goes back into that being the call of someone in the contact centre, or the clinician ringing them back, as to whether to change the categorisation of their call. It's not done to try and fix the system. It's done if there's extra information that the condition of that person has changed and that's the right thing to do. So, this winter we'll make sure those welfare calls are being done through the winter, when they'll be needed.

On your point about whether long waits cause harm, the report also recognises that it is a challenge about patient experience; you're right to point that out. But the relationship between harm is complex and uncertain. That's why further work is needed, because the logic says that, for some conditions, if you wait a long period of time, it may well cause harm, or the condition may deteriorate. We need to understand that better to then understand whether we do need to change anything about the system to properly meet and understand people with those conditions,

So, evidence has lead us to this point. The evidence we now have has led to recommendations that we'll undertake, and I'm sure that we'll have further evidence in the future on the back of the unanswered questions that the review has prompted. So, we're completely open about where we are and, as I say, I have no problem at all with the Wales Audit Office wanting to add their view as to how successful we have or haven't been on generating an improved ambulance service here in Wales.

Thank you for your statement, Cabinet Secretary. The move to the clinical model for ambulance response was one of the most important changes made to unscheduled care. Ensuring patients got the right response based upon their need also sped up response times for the most vulnerable patients.

Unfortunately, other factors have hampered the Welsh ambulance service’s ability to deal with the large volumes of calls they receive that are not immediately life threatening. The Welsh ambulance service received almost half a million calls last year—around 1,300 calls per day—the vast majority of which were amber calls. Nearly 50 per cent of those amber calls took longer than 30 minutes to respond to. Some responses have taken many hours. We are losing thousands of hours each month from delays in handover at hospital. According to the latest ambulance quality indicators, this averages around 4,000 hours each month.

Cabinet Secretary, what assessment have you made of the impact LHB bed cuts are having upon the Welsh ambulance service? The majority of our hospitals are now operating at bed capacities of around 90 per cent. Do you consider this to be a safe level or will you be opposing further bed cuts?

Another drain on resources is the large number of repeated calls by frequent callers, which make up between 6 per cent to 7 per cent of all calls each month. Cabinet Secretary, what steps are the Welsh Government taking to reduce the number of frequent callers?

I welcome the fact that you are recruiting more nurses and paramedics to provide clinical advice over the phone, in order to help manage demand. Is this in addition to the roll-out of the 111 service, and will you outline how the roll-out is progressing? How will it complement the Welsh ambulance service?

Finally, Cabinet Secretary, a large number of calls to the ambulance service each month relate to dental problems, and dental issues are the top reason for calls to NHS Direct. Cabinet Secretary, with some patients facing a trip of 90 miles to see an NHS dentist and hundreds of people prepared to queue for five hours to register for an NHS dentist, it is clear that shortages are having an impact on the NHS as a whole. So, what is your Government doing to ensure shortages of staff in one area of the NHS are not leading to increased demand on unscheduled care services, particularly the Welsh ambulance service?

The Welsh ambulance service is a vital part of our NHS, and I hope that implementing the amber review team’s recommendations will lead to greater improvements for patients and staff. The Welsh public support the approach that delivers the best response, even if it’s not the quickest. However, that doesn't mean we leave patients waiting for hours in pain. Hopefully, the amber review will deliver similar improvements to those we saw in red call responses. Thank you.

Thank you for the comments and questions, and I welcome the praise and acknowledgment for the model and the move to implement that. That was not a straightforward or necessarily popular decision at the time.

I'll try and deal in turn with, I think, the four areas that you covered on bed cuts and the ambulance service. I don't believe that the numbers of beds are actually the challenge for ambulances as to why they're spending too long outside hospitals when they need to discharge patients. Actually, it's about flow through our whole system. It's a system-wide problem. And, actually, we do know that unlocking flow in a better relationship with other parts of the health service and a better relationship with social care will actually deliver results throughout the system. That's, actually, why myself and the Minister are putting money into partnership between health and social care, to try and make sure that health recognise it's in their interest as well to work with local government to do that and not simply to pass responsibility between the two, as well, of course, as the health service taking control and ownership of what it could and should do to see flow throughout the system.

On your point about frequent callers, there are two points there. One is about individuals. There's quite a lot of work that's been done on a range of NHS Wales awards over the last two years on frequent callers. Often, they don't need an emergency ambulance response, they have a different healthcare need. So, the Welsh ambulance service, together with both other parts of the health service and, sometimes, local government and partners and the third sector too, have gone to those individuals and discussed what their need is, even if it's clear that it isn't an emergency ambulance service.

We've actually seen a reduction in frequent callers over the last two years. That hasn't come from a ministerial directive, that's come because we've had greater scrutiny on our figures, greater information, and our staff have chosen to address that because they recognise it's good for them and the job they do, but also good for those individuals and the healthcare need they have. 

The second part of frequent callers are some care homes. There is a challenge here, for some care homes are much more likely to call out than others. Often. it's a fall response, people who aren't injured but staff won't undertake lifting. So, that's partly why we're investing in a lifting pilot. There's an unfinished piece of work to be done between myself and the local government Secretary about the role of the fire and rescue service as well, as a potential answer for a lifting service. That's also why, in my statement, I made reference to lifting cushions, because we do have to reduce the level of unnecessary call outs to care homes. They are part of the frequent callers challenge we face. 

On 111, the roll-out is being successful. I'm pleased with how those proceedings have gone through in Powys as well as the next port of call. We're seeing, around the country, a roll-out of a successful service, and that's actually run and administered through the Welsh ambulance service trust. They're actually running the call centre for it, but it's in partnership generally with each of the health boards. So, I'm content that it's a good news story for Wales. We're rolling out a successful service at the right pace in different parts of the country. 

Finally, on dental services, I won't deal with the question properly today because I will have the opportunity in the coming weeks to deliver a different statement on dental services and reform in Wales. 

Finally, Suzy Davies.

Diolch yn fawr, Llywydd. You mentioned fire and rescue services there. I wonder if you could just give us some indication of your thinking on the role of co-responders in response to amber calls. You'll be aware, obviously, of the service they provide. You've raised the effects of pain and so forth on an amber call, but they're also extremely well placed to spot when an amber call could be turning into a red category call. I've brought examples to the Chamber before where actually the presence and absence of co-responders have arguably been the difference between life and death on amber calls. Can you reassure me now that there will be no move to limit the role of co-responders to red calls only, and that your term 'the most suitable response' can still include co-responders to some amber calls to prevent them turning red and, obviously, prevent all the pain and suffering and, in some cases, danger that can arise when an amber call does turn red? Thank you.

The Deputy Presiding Officer (Ann Jones) took the Chair.

I can offer you reassurance that where a co-responder is the appropriate response, then that is what should take place. That should be a matter for clinical judgment as to the right response, rather than any kind of directive from myself or the head of the service not to use co-responders where they are the right resource for the right person at that time.

Thank you very much, Cabinet Secretary.