That brings us to item 7.

And that is a statement by the Minister for Health and Social Services: an update on the amber review implementation programme. I call on the Minister to make the statement—Vaughan Gething. 

Diolch, Llywydd. Six months on from the publication of the amber review, I am pleased to update Members on implementation of the review’s recommendations.

The review made nine recommendations and identified a number of areas where further work was required in order to gain an improved understanding of the challenges and opportunities to improve responses to calls in the amber category. In order to ensure there is purpose and pace in delivering the review’s recommendations, the chief ambulance services commissioner has established a year-long amber review implementation programme. This is supported by a programme board, including representation from the national collaborative commissioning unit, the Welsh ambulance service, the NHS Wales Informatics Service and the Welsh Government. The programme board will manage and monitor implementation of the review’s recommendations.

Although it has only been six months since the commencement of the programme, I'm encouraged to note improvement in the typical response time to patients in the amber category. The latest available data shows an improvement in the typical response time during every month between December last year and March of this year when compared with the same period in the previous winter.

There has been a reduction in excessively long waits found by the review team, but there is still much work to be done to eradicate unacceptably long waits for some patients. This is the source of considerable focus through this programme. I expect to see an agreed plan for improvement by the programme board by the end of this month to address the remaining long tail of waits.

Typical response times to amber calls in some health board areas are extremely positive and conducive to a good patient experience and clinical outcome. For instance, the typical response time to amber calls in March 2019—at the height of winter pressures this winter—in Powys was just 18 minutes, and 20 minutes in north Wales. However, there does remain local variation, and whilst amber responsiveness in the Swansea Bay area has improved when compared to last year, there are continued challenges caused by ambulance patient handover delays at the Morriston site.

In recognition of this challenge, I have directed the chief ambulance services commissioner to place immediate and targeted focus on achieving improvements at this site. A series of new actions have now been agreed with local clinical teams. These innovations are being delivered alongside broader whole-system actions in the area to improve community care and enable people to leave hospital when they are ready. We will, of course, monitor the situation closely.

Members will recall that a central tenet of the amber review was the need to focus on certain groups of patients to improve experience. This included people who reside in care homes, who are more vulnerable to falling because they are frail or as a result of the complexity of their conditions. The Welsh Government has provided £1 million for the purchase of modern lifting equipment in almost every care home in Wales, which is proven to support patient experience and, if possible, enable people to stay within their own home. We understand there are now only four care homes in Wales that do not have the up-to-date lifting equipment. 

We've also provided funding for the Welsh Ambulance Services NHS Trust’s falls assistant response service. The primary objective of this project is to enhance patient experience for people who have fallen, but who are uninjured or have minor injuries, ensuring they receive a timely response and to prevent the need for avoidable hospital admission. Falls assistant units have been utilised to attend a variety of calls within the amber and green categories involving people who have fallen or other welfare-related issues. Since 1 December 2018, falls assistant units have responded to almost 1,800 people, with an average response time of just 24 minutes.

Since November 2018, I have made available extra funding to the Welsh ambulance service that has allowed it to recruit 16 additional clinicians to work on its clinical-support desk. Over 80 per cent of these additional healthcare professionals are nurses. They bring their experience and expertise to enhance the skill mix and capacity of the service. More senior clinicians were also recruited to undertake supervisory roles. 

As a result of this enhancement of the clinical support desk function, the Welsh ambulance service was able to resolve over 16,000 calls over the telephone between November 2018 and March 2019. This has meant thousands of people being treated in the community without the need to be taken to a hospital. The Welsh ambulance service is currently considering the optimum staffing levels to enable it to deal with up to 12 per cent of patients over the phone.

While the review found that the clear majority of people felt that getting the best response for their condition was more important, even if it is not the quickest response, there was recognition that waiting for an ambulance can be an anxious time for patients and their families. In order to improve patient choice and reduce patient anxieties, the Welsh ambulance service has introduced a new script for call takers at times of high demand to help provide callers with an indication of how long they can expect to receive a response.

Use of the new script will be monitored and reviewed, with a view to introducing it more widely. The Welsh ambulance service continues to engage with the public to build on its understanding of what matters to patients. The programme team is also working in partnership with community health councils, the Stroke Association and its local patient groups, and NHS Wales partners to develop measures that give greater context to ambulance response times to people who have a stroke. I'm expecting these to be available for winter 2019-20. Any measures developed will be designed for public reporting.

The amber review reinforced that the ambulance service must ensure that planned resources are sufficient to meet expected demand. The trust has commissioned a capacity and demand review to inform future configuration of resources and staffing across Wales, and to improve service resilience during periods of high demand. The review is due to be completed by the end of September this year, and will be considered at the emergency ambulance services committee meeting in October.

The Welsh ambulance service is currently undertaking a mapping exercise to show which services are available across Wales. This should help to identify where there are services that could and should be implemented to support work on admission avoidance. I expect this mapping exercise to be the catalyst for more consistency around pathways of care across Wales.

It is clear that there is still more work to be done to support delivery of the recommendations of the amber review. However, early steps have been made to reduce typical response times to amber calls, to reduce excessively long waits for patients, and to improve the experience for some of the most vulnerable members of our communities.

I will, of course, be happy to provide a further update to Members in the autumn.

Minister, I'd like to thank you for your statement today on the amber review, which I think is showing positive improvements. We have looked at this before, over the last months. I do have some questions and, of course, we're never going to be able to discuss the amber review without touching upon what happens to people who suffer from a stroke.

Now, you've mentioned already that you are working with the various organisations and the ambulance service to consider that, but I think my concern is this: I remember so clearly a meeting that was arranged by Welsh Government with the Welsh ambulance service and with opposition spokespeople, about three years ago, to discuss, when the changes were first made to red, to amber and to the green criteria. And all the talk was about clinical pathways, and how incredibly important that, if somebody was to suffer a stroke, they wouldn't need to go into the red category because they would be able to follow a clinical pathway that would bring them straight to the door or to the bed where they needed to be in order to survive a stroke—and not just to survive it, but to survive it well, which is a very important point, I think, to make.  

Yet, when I talk to ambulance staff and to the ambulance service, they say that these clinical pathways are, in reality, still not in existence. Staff constantly tell me that they take somebody in the end, they still go through the emergency department or the critical admissions unit, and that they've still not developed the pathways to get them to the right place quickly enough. So, I just wanted to ask you to perhaps give a little bit more explanation about this review, about how it's going to be interpreted. And will you be giving credence to the Stroke Association, who are now asking for Wales to build on the approach taken by NHS England, where a new system will track you from the first call to the 999 to receiving the appropriate treatment, and give that a target? Because I think if we're never going to put, or you are never going to put, people who suffer a stroke into that red category, there has to be some fallback position that protects them, because I made the point earlier—and I'm going to say it again, because I think it's vital—it's not just good enough to survive, but we have to survive well. 

And, of course, it's not just stroke that has clinical pathways; there are a number of very clear areas where people who are on an amber response can go through a clinical pathway straight to where they need to be, rather than clogging up our already under pressure EDs. Do you have any view on when these clinical pathways will finally come to fruition—they were talked about three years ago—and how they're going to be identified? And trust me, Minister, I have put some freedom of information requests in to health boards, in to the Welsh ambulance service and some ordinary questions in to you to try to get to the bottom of this, and nobody, but nobody, can bottom it out. So, I think that information just isn't out there, and I would like your reassurance that you are able to do something about this, to make sure there's consistency and a quality of access to service in all areas of Wales for amber review people going through clinical pathways. Your statement touches very, very briefly on the fact that we are going to be doing a mapping exercise to look at resources and to look at other issues to basically futureproof, if you like, the Welsh ambulance service going forward. I was really surprised that you didn't really talk much about the staff in this, because, of course, whether it's red, amber or green, we need the staff to be there to do the job and staff sickness is one of the biggest pressures on the NHS trust. Six months ago you voiced your expectation for the NHS trust to work with partners to take immediate action to address this, and yet the latest figures show another 1 per cent increase in sickness absence, far outstripping NHS board absences. So, how quickly would you expect to see changes to the management of staff absences? How quickly would you expect to see support going in for the ambulance workforce to translate into a lowering of the absence rate? Will you outline the barriers to quickly addressing the reasons behind such high rates of staff absence at the trust? And will you be able to give us an indication of when you might be able to come back to us with positive news on this particular issue?

Finally, I know it's not entirely within just the remit of the amber review, but we can't talk about how we deliver good-quality red care, amber care and green care from the Welsh ambulance service without actually touching upon the waiting times that we see in our emergency departments. Ambulance crews are still reporting significant delays in hospital handovers. I would like to know, Minister, what strategy are you employing to ensure that health boards and the trust are carrying out the immediate action that you expected six months ago. We're already told that we're losing thousands and thousands and thousands of staff hours to ambulance handover. Tonight, ITV Wales will be broadcasting a report that the Welsh ambulance service is losing the equivalent of 15 full ambulance shifts a day outside emergency departments, and that crews have clocked up 65,000 hours in 2018 just waiting to offload patients in hospitals, and we hear stories of patients who are on amber call finally getting to the hospital, being taken in for treatment and then being popped back into the ambulance because there's nowhere else for them to go. So, I'll be really interested to know what you're going to be able to do to actually try to compress that time. You talk in your statement about that fact that you feel that it's getting better, but I'm afraid the statistics simply do not bear out that assertion that well.

Thank you for the comments and the questions. I'll deal with your final point, actually, because it follows on from some of the conversations we had earlier more generally about our whole system, because the lost hours are an impact upon the staff and the patient, they're an impact on the community, because the risk that is being managed if an ambulance is held up at a hospital site means that a potential risk in the community where that paramedic crew could be going is not being managed, but it's also about there are people in the wrong place waiting in emergency departments who aren't able to go into beds if they need to go into beds or to be able to be discharged. And so we have a number of medically fit people at any one time in each of our major hospitals, and that's why I focus on health and social care, going back to the part of the point of having a parliamentary review that covers health and social care. In the recent round of meetings that I'm undertaking with health and local government partners there's been a real focus on delayed transfers. But, on that point, the front door of a hospital is only part of the system, and, actually, without the link with social care, we won't see the flow that we need, and so the very understandable frustrations that staff have, whether they're in an emergency department or an ambulance, and that patients themselves have—it's not going to be realised.

Now, we have seen progress. So, our delayed transfers of care have moved on positively and they're still at historical lows, which is a good contrast with the position in England, but the progress we've made since the introduction of the new model in ambulance services has stalled, and I want to see further progress made on lost hours, but that won't happen unless there's a focus on the whole system, because otherwise we'll simply shift the problem from one part to another, and, if we build extra capacity into one part of that system without actually understanding the flow through it, we'll simply clog people up in a different part of the system. So, it is part of the reason why I've taken the time not just, a year on from 'A Healthier Wales', to go and review more general progress, but I want to look again at the health of the whole system, because otherwise we won't answer the problem properly in a way that is properly sustainable.

On your point about staff, actually, there has been progress made on sickness absence within the health board; there's been a reduction over the last six months in sickness absence rates—within the ambulance trust, rather. The challenge, though, is to make sure that that is sustained, because the ambulance service has the highest sickness absence rates of any part of the NHS family, as you know and as you've regularly pointed out from time to time. It's partly about mental health and stress-related absences. It's also about musculoskeletal absence, as one of the two largest parts of that. We've made some progress within the ambulance service in reducing mental health-related absences, but we haven't seen the sort of reduction we want to on musculoskeletal-related absences. So, that does help us to know that the employer knows the area that it needs to go at to see further improvement, because there's been an improvement of more than a percentage in terms of the absence rate, but it is still at a significantly higher rate than the NHS Wales average. 

On your point about stroke care—and, again, it's part of the system, not the whole story, and I think it's fair the way that you put the question about the clinical pathways. They're not just about what happens when someone is delivered by a paramedic crew to a part of the hospital system; it is about what happens through the whole part of our system. So, the staff audits that I take a regular interest in tell us about whether people are admitted to the right part of our system, how quickly they're seen when they're there, but also then the focus we'll need to have on revising some of those measures about how quickly people receive rehabilitation. That's a key part of living through and living well after a stroke as well.

And, in the statement, I have committed to both develop measures and to report on them publicly to understand that the ambulance part of that equation is doing its job properly, and that will then feed into the wider staff audit that we publish in association with the Royal College of Physicians to tell us about the care being delivered within our hospital setting and, crucially, the further investment that I'm sure we need to make in rehabilitation services as well.   

I'd like to thank the Minister very much for his statement. It is good to see some positive progress being made, and I'm sure we'd all like to congratulate the staff who've worked really hard to deliver this. It's quite demanding what the Minister is expecting of them, and I think we can all be really pleased that there is definitely some positive progress. 

A few specific questions. The statement shows an improvement in waiting times for amber calls as compared from last winter to this winter, but we're not quite comparing like with like, because, in terms of the pressure and in terms of the nature of the weather, we had a very, very cold winter the winter before last, not quite such a cold winter and perhaps not such pressures the winter before. So, I'd like to ask for the Minister's assurance that he will keep this under review, and to make sure that when comparing those performances in terms of responses that he's not comparing oranges with apples, that we are comparing the same thing over a longer period of time. And I'm sure, Presiding Officer, that that would be his intention, and we're only talking about a short space of time here, obviously.

The Minister speaks about the purchase of modern lifting equipment for care homes. I'm really pleased to see so much progress is being made. The Minister says that he understands that there are only four care homes left that don't have that equipment; I'd like some reassurance of the rigour of the nature of that understanding, and whether there are plans—. Are there specific reasons why those four homes haven't been able to take up this opportunity that's been offered? Is it something—? Because, in some buildings, it may be do to do with the nature of the buildings—it may not be physically possible—or are there plans to cover that gap? Because, if there are, I think that would be something that the service and the Welsh Government could be really proud of, to have made that investment—not a huge investment in the scheme of things, but, as the Minister has rightly said, one that can make a huge difference to the outcomes for those particular individual patients. 

I'm very pleased to see what the Minister has said about the number of calls—I think 16,000 calls—that have been able to be resolved from the desk, so that people haven't had to go into hospital services and haven't had to have an ambulance at all. But I'd also like to put that together with the points the Minister's raised about the ambulance service continuing to engage with the public, and the point that he says that the majority of people felt that getting the best response for their condition was more important, even if it wasn't the quickest response. I'd like now to ask the Minister what specific work is being done to monitor how some of those 16,000 patients who didn't get to see an ambulance when perhaps they'd made a call and they'd first made that call thinking an ambulance was what they needed—. Because if that—from what he's telling us today about what has been a positive response overall—is reflected in that group, I think that would be really useful in terms of reassuring the public that when they do get a call back and the outcome of that call is that an ambulance isn't needed—. I think if that's good feedback from that group of patients—and of course it's a lot of patients so they will be talking to neighbours and so on—if they're happy with that bit of their experience, I think that will help with introducing further innovation that will stop people going into hospital, which basically is the last place that anybody wants to be if they can possibly avoid it. 

My final point—I'd like to come back to the issues that Angela Burns raised about stroke. Now, it is of course true that the whole pathway is important, right through to the rehabilitation that people receive, but the Minister will be very well aware that the Stroke Association, who speak, very importantly, for patients and their families, continue to call for a whole episode measure, by which they mean from the point at which the call is made. And I think we should be—. They're being very reasonable, they're not asking for stroke to be put into the red category, they're understanding that it's different. That whole episode—. And they're specifically referring, as the Minister knows, to from the point the call is made to the point that the patient is in the appropriate hospital bed being treated.

The Minister in his statement refers to the programme team continuing to work in partnership, speaks about measures that will be developed, designed, for public reporting—very pleased to hear that. Can he confirm today that in that process he will consider whether one of those measures ought to be the kind of whole-episode approach that the Stroke Association is advocating? I'm not expecting, Presiding Officer, that he can make that commitment today, because that would be to second guess the work that he's put in place, but can I ask if it's possible for him to confirm today the possibility that that whole episode measure is on the table for discussion through the process that he's outlined?

On the final point, it is of course my expectation that the Stroke Association, in work in partnership with the NHS family, will be putting forward the sort of measures they want to see. That's whole point about having them engaged in the conversation, to make sure they can put forward their perspective and we end up with something that is useful as opposed to simply yet another process measure that doesn't tell people much of value at all. We've managed to have lots of process measures in and around the healthcare system and I'm keen that we don't introduce another process measure that counts volume or activity but doesn't tell us something useful. 

On your other point about comparing like for like, I can confirm we are comparing like with like. We're looking at the volume of calls, and in particular on the amber category it's worth noting that in April of this year we had 10 per cent more calls in the month of April than April the last year. So, actually there's a significant amount of activity that is taking place and that definitely affects calls within the amber category. 

In terms of the point about response from the four care homes, I asked about this particular question before making the statement, about why four care homes had not, and it's simply a matter of contact—so, the Welsh ambulance service trust have contacted and made it clear that the offer is available for those care homes that don't have modern, up-to-date lifting equipment, and it's simply about the response from those homes. But the Welsh ambulance service trust have not given up and they continue to try to make contact with those homes. If we could then say we have complete coverage that would be a very positive thing to say. But, within the care homes within Wales, to only have four is in itself a significant marker of achievement. 

And on, I think, your final point of the four points that I thought you asked about, in terms of patient experience, it's something the chief ambulance service commissioner is really interested in, in understanding, in all the measures that he's taken on board since we introduced the new clinical response model, the richness of the data that's available to understand not just the impact of the work that our staff do on outcomes and experience but then to make sure you're properly capturing the patient experience itself. So, yes, you can expect to see that, and I expect when the programme board's time of life comes to an end we'll understand more about what people who have received the service and taken part in the service actually think whether they've been transported to another place to have healthcare delivered, or indeed whether they've been able to do that in their own homes. 

Minister, can I just ask why we're still in this rather ridiculous position of fire service co-responders not being called out to amber incidents, when of course they can prevent those calls escalating into red status calls through delay, or in some cases negate the need for having an ambulance or hospital admission at all? I have to say, this fight about who pays for the calls isn't a good enough reason to deny these constituents a speedy response to get them to safety and out of pain. So, can you tell me what opportunities the implementation programme has found for the effective use of co-responders to—quote—'improve experience and clinical outcomes' for those who are identified as amber call-outs, and why only now is the ambulance service conducting a mapping exercise about where services are and a capacity and demand review, particularly as co-responders, in the whole time I've been an Assembly Member, have been available to plug gaps?

I don't think the capacity and demand review, or indeed the mapping exercise, is entirely related to co-responders at all, actually. It's about understanding properly across the whole service, having introduced a new clinical response model, having had a variety of methods to look at piloting different ways of running the service—to understand what exists in different parts of the country, and what has the best evidence to actually succeed. Now, some of that may well be about making better use of community co-responders and other organisations. We're looking at the falls unit that I mentioned in the statement as well. We've had falls pilots looking at different models to deliver a falls service. So, it is about understanding where is the evidence and how do we get more consistency. And the fire and rescue service could be part of that, but it's not about a lack of willingness or a lack of desire to want to have a relationship with the fire and rescue service. It is about how do we make the best use of people's skills and ability, in terms of value for the public purse and understanding what the role map and the contractual ability is to deploy fire and rescue staff in a different way. Because there is a difference of opinion with representatives of the workforce in the fire and rescue service as to whether or not their role and their contractual responsibilities mean they could and should be required to act in this way. Now, we're open, from a health point of view, to having a proper partnership with the fire and rescue service, to understand the cost of that and the value of that, even more importantly, but it does require some progress on the fire and rescue side as well. I personally think that it would help to bolster numbers and maintain head count within the fire and rescue service, but of course we have to respect the fact that there are negotiations taking place with representatives within the workforce, as well as our understanding of how public value is properly deployed.

Thank you, Minister.