Health and Social Care Committee

I was on mute. There we go. Hopefully you can hear me. Good morning. It's Colin Dennis, and I'm the non-executive chair of the trust board.

Yes. Thank you, Colin. Jason.

Good morning, everyone. I'm Jason Killens. I'm the chief executive at the Welsh ambulance service.

And Andy.

Good morning. I'm Andy Swinburn, I'm the executive director of paramedicine with the Welsh ambulance service.

Thank you all for being with us. I'm just checking with the team, you normally don't have to unmute your mikes. Is that the case on there? So, you should be able to leave your mikes and they'll be controlled centrally. Colin, you were a little quiet when you were just introducing yourself, so I'll just check if the technical team can put some volume to your voice as well, if that's possible, or if it's something you need to do your side. Okay. We'll make a start, then. Members have a series of questions, but something that is often said by some—I'm not saying it's my view; I'm just putting this to you—is the ambulance service in crisis?

I'll pick that up, if I can, first, Chair. 'No' is the simple answer to that. Whilst there is considerable pressure across the organisation, particularly in the emergency medical service, one of the three service lines we operate, it is fair to say that we are getting to more patients that are immediately life-threatened more quickly than we ever had before; we've got a bigger organisation that's stronger and more resilient than we've ever had before; and whilst we do have more work to do, we've become more efficient with the resources that we have, certainly in the last three years. So, whilst I recognise that there is considerable pressure and, sadly, patients across Wales continue to wait longer than we would like as a result of that pressure across urgent and emergency care, I would not recognise that characterisation.

Thank you, Jason. So, in terms of those pressures that you refer to, what are the biggest challenges?

Well, the single biggest challenge for us, which manifests on us as an organisation, which emerges from the pressure across the rest of the urgent and emergency care system, is one of handover delays at the emergency department. The committee will be familiar with the fact that, when we last came and saw you, at your request, we'd completed a demand and capacity review. That was back in 2018-19, and that identified not only a range of efficiencies that we needed to deliver, but also investment that was necessary to be able to respond to patient activity within appropriate quality and time standards. Since then, we've recruited to that roughly 250 people that that review identified was necessary. The commissioners funded that growth. We've completed a national roster review. So, we've changed all of our rosters across the country, which has given us an efficiency equivalent to a further 72 people. We've grown the amount of work or patients that we provide remote advice to, so 'hear and treat' or 'consult and close' as we now call it, from less than 10 per cent to 10 per cent, and to in excess of 15 per cent daily now. So, we're more efficient there and only sending resources where we need to, increasingly. We've grown our advanced paramedic practitioner cohort and, as I say, we're getting to more patients than we ever have before, more quickly.

Beyond that review, which was in 2018-19, and took us the best part of two years to deliver, given the scale of that, we've grown by a further 100 posts on the front line. We've doubled the size of our clinical support desk. We've grown the advanced paramedic practitioner cohort, which I'm sure Andy will talk about more as we get through this morning, and the benefits of that. We've made further changes to our efficiency—we've reduced the number of multiple vehicles that we send to each case. So, whilst there is still more to do, it's absolutely right to say that we are more efficient, we have grown, and we are more resilient than we were before.

Thank you, Jason. Colin Dennis, I'll bring you in. I'll just ask a further question, and perhaps you can address my question and make any other points you want to as well. But, I suppose, the question perhaps I'd ask you, Mr Dennis, as the chair, is: can the public confidently rely on the ambulance service to provide timely care that meets the needs of patients and their families across Wales?

Okay, thank you. Can you hear me okay now?

I can. I think your volume's been lifted a bit, so thank you for that. I appreciate it.

Okay, perfect. Well, perhaps if I can just address the first question first, and then come to your second one about whether the ambulance service in crisis, I would just like to say that I think, from a board perspective, we can demonstrate financially it's very much under control, providing a balanced budget. So, financially, definitely not in crisis. From a governance point of view, we've delivered an exceptionally strong annual structured assessment on several years running. So, again, the board and governance, I think, are definitely not in crisis. And I think also it's worth mentioning that the ambulance service is far more than just the yellow trucks running around picking up. Clearly, the emergency part is very important, but the ambulance service is also the 111, the 999, the non-urgent transport service and so on. There's an awful lot to it, all of which is being delivered. So, I think the evidence is clear that it's a service that is not in crisis.

To your second question, of can the public rely upon us, I think the answer is, increasingly, 'yes'. As we move to transform the service to provide a higher level of clinical care rather than an old fashioned conveyancing service, which, of course, originally it was generations ago, and certainly compared with the performance in the UK, our performance is equal to and, in some cases, better than other ambulance services across the UK. We all know that there are issues around delays in ambulance in hospitals and, therefore, delays to get ambulances to patients, but if you look at the red response rates, although we fall below the eight-minute target, if you look at the nine and 10-minute delivery for real life-threatening emergencies, we are there to provide that service, and all of the things that Jason and Andy will no doubt talk about later on, in terms of specialisation services, such as falls, dementia, mental health. Again, we're doing an awful lot to provide that clinical support. So, I think the public can rely upon us, but with the caveat that the health sector itself is under enormous pressure, which, of course, everybody is suffering from.

Thank you, Mr Dennis. In your answer there, you referred to the, I suppose, transition from being a transportation service to being an out-of-hospital provider. Can you, perhaps, tell us a little bit more about how that transition is taking place and how that's progressing?

Yes, perhaps if I introduce it, and, perhaps, if we can ask Andy to do a little bit more about paramedicine, because the issue is around upskilling the workforce, which actually touches the community. So, whereas, historically, ambulance services were very much conveyancing organisations, just collecting patients and taking them to hospital, the level of training that is now being given to ambulance crews is remarkably different, if you consider that the paramedics joining it have completed a three-year degree course, or have completed a three-year in-post qualification, having joined as technicians. So, those people who are wearing the paramedic badge have a degree now in the same way that nursing do, and advanced paramedics have a Master's degree that is put on top of that, many of whom have prescribing rights and all sorts of other privileges that were never previously given to ambulance crews in the past. So, the journey that the ambulance service is on, both here and, of course, across the whole of the UK, and, indeed, across the world, is about gradually transforming the operators of the ambulances from simply conveyancers to being people who can provide genuine clinical support.

Also, as Jason commented upon, we're developing much more clinical support and expertise in the call centre, so we can actually triage calls, and those people who do not need conveyance to hospitals can be provided with appropriate advice from paramedics, or from nurses or from other clinicians. So, it's about upskilling.

Thank you, Mr Dennis. Andy, did you want to come in? Andy Swinburn.

Yes, and good morning, everybody. I'm very pleased to come in. I think the fundamental for me is that the nature of the way patients present to us through the 999 system has changed. Traditionally, the ambulance service only dealt with people with life-threatening or limb-threatening emergencies, and that simply isn't the case anymore; that is a small fraction of the presentations that come through the 999 system, with the overwhelming majority of patients presenting with an urgent care problem as opposed to an immediate care problem. Now, that's not to downplay their need for healthcare, but it's to recognise that a blue-light emergency ambulance and conveyance to the emergency department is often not the right way in which these patients can be managed. And if we are to keep continuously using an outdated model of transporting everybody to the emergency department, then the patients won't get the level of care that they need, and it will create excessive strain in parts of the health service that simply can't cope.

So, as an ambulance service, we have a real fundamental role in transforming the way we deliver our services to be more of a community-based provider, where we look to manage as many people as possible in the community, through some of the upskilling of our staff that Colin's talked about. But, in doing so, what that does, then, is release capacity within our emergency ambulances, so as that, ultimately, that primary aim, when somebody rings 999 with an immediate life-threatening problem, is that we have an ambulance to send because they aren't then tied up in a handover queue waiting to move patients into the emergency department. So, there's a whole transformation journey we need to do to update our operating model to focus more on managing in the community, so as we have the ability to then keep responding to those patients who absolutely need conveyance to the emergency department.

Thank you. There's quite a bit that's been said that I won't dig into further, because I know other Members want to pick up on some of what's been said. So, I'll move on to the next set of questions now, which are from Sam Rowlands.

Mabon's indicated, Chair.

Sorry, Mabon. I didn't see you.

Thank you. I'll be asking my question in Welsh. I've had a conversation with you, Jason Killens, before, and I'm very grateful for the conversations that we've had. And I accept what you say, there, as to your opinion that there is no crisis in the ambulance service, and your responses so far have been very credible. If there isn't a crisis is the ambulance service, where is the crisis? When a constituent of mine had to wait two days in an ambulance and spend the night in an ambulance outside Wrexham hospital some months ago, and another constituent from Flintshire having had to do the same thing, and who lost her life, whose fault was that, and where is the crisis, therefore?

Thank you for the question. Can I firstly offer condolences to your constituent's family for the loss of your constituent and also apologise to your other constituent, and, indeed, anyone else who has had to either wait for their ambulance to arrive or has then subsequently been waiting in the back of an ambulance before being admitted to the emergency department? And it's that point, I think, that it's worth just unpacking and exploring a bit further. On the use of the word 'crisis', again, 'crisis' suggests that it's uncontrolled, that we're not in control of what's going on, and that's the point that I reject. We know exactly what the challenges are, we know exactly where the pressure points are, and we have a strong grip and control of what's going on and plans to make our bit of the system as efficient and effective as we can, some of which I've already referred to and some of which I suspect we will come on to, which are forward looking.

But, in terms of where's the pressure, the reason that we have response delays in our communities is not because we don't have enough ambulances, it's because our ambulances aren't available to us and in the right place at the right time. That's the reason we've got response delays in our communities. The root cause of that problem is the fact that our ambulances are waiting at emergency departments across Wales to hand over their patients. And let's just be clear, this is not a problem that's unique to Wales; this is a UK-wide problem and it's an international problem. So, it is as bad in the south-west of England and in the west midlands as it is here in Wales. And I know because I'm still in touch with colleagues from when I worked internationally that there are the same problems, certainly in a couple of states in Australia. So, it's not unique to us here in our system in Wales.

But what causes the response delays is our inability to hand over patients at the emergency department, and what causes that problem is the fact that there's a problem with flow through the hospital, through the emergency department into the hospital and back out into the community, particularly in adult social care. So, at any one time, there are something in the order of between 1,200 and 1,500 patients in beds in our hospitals across Wales who could be back in our communities. And we can't get those patients safely back into communities because of problems, particularly in adult social care, with capacity, availability and so on. So, the root cause of the problem for us not being able to respond is not because we don't have enough paramedics, ambulances and availability, it's because those vehicles aren't available to us. And we're losing something in the order of 20 per cent to 25 per cent of our entire fleet capacity every month as a result of the pressure right across the urgent and emergency care system.

We are focused on doing everything we can, as I've already touched on, to be as efficient and effective as we can with the resources we've got available to us. That means, increasingly, that, as Colin and Andy have already touched on, with the growing skill and competence of our workforce—which is very different to that which it was 10 years ago, let alone 30 years ago, when the current model of operation was largely introduced—it means that we can do more in the community. We can close off more episodes of care safely in the community, direct them to other bits of the system, avoiding conveyance to the emergency department. So, we increasingly only take patients who really, really need to go to the ED, and that's the part that we can play in freeing up some of this pressure that exists.

But, the answer to the challenge, the answer to the problem with response delays in our communities, I'm very clear is not hundreds more ambulances, because they will just create bigger queues at our emergency department and continue to create harm for patients in the back of those vehicles who are waiting. So, the answer is us operating differently and the rest of the system continuing to work hard, as it has been, to reduce the pressure and improve flow through hospitals.

Thank you, Jason. I know that Members have got some questions about patient flow. Sam Rowlands.

Thanks, Chair. Good morning. Thanks for joining us this morning. Thank you, Jason, in particular for that analysis just there, as well. My first point really comes on the back of what Mabon ap Gwynfor just highlighted, which, fundamentally, is around patient safety. So, I'm just interested to understand your analysis as to the extent to which those ambulance delays—those long delays—are compromising patient safety and what evidence you may have that there are deaths as a result of those delays.

Thank you. Andy may want to comment on this too, but I'll refer you here to some work that the Association of Ambulance Chief Executives did. So, that's a membership organisation of the 10 ambulance services in England and those in the three devolved nations across the UK. They did some analysis, probably about 18 to 24 months ago, looking at avoidable harm as a result of either response delays or handover delays at emergency departments, and what that found is that clearly there is avoidable harm occurring.

We know that in our system here in Wales, there is avoidable harm occurring as a result of these response delays that we have, or the handover delays at the emergency department. It's something like one in 10 patients is subject to some level of moderate or severe harm or death associated with a response delay or a handover delay. So, it is clear that harm is occurring. We certainly see that in our own reporting here across Wales. And the board—and Colin may want to comment on this—receives a report every time it meets, setting out both the scale of that harm—the level of that harm that we're seeing—and also the actions we're taking, as far as we can within the control that we have, to mitigate and ameliorate that harm.

So, to the nub of the question, 'Is avoidable harm occurring as a result of our inability to respond?'—yes. Do we understand the scale of that? Yes. And are we acting as far as we can within the control that we have across the system to mitigate that? Yes, we are. But, actually, we might want to comment a bit more—

Yes, perhaps before somebody else does come in, perhaps I can understand also the trend in regard to that avoidable harm. So, perhaps, in your analysis over recent years, has that trend got into a worse place or are things getting better—what's that situation looking like?

So, I think I would say that it's pretty static. I mean, clearly, there is variation both geographically and at the time of year. But it's been pretty static for the last couple of years. And the reason I say that is twofold, really: one, because our response times, both in the red, and indeed in the amber and green categories, have largely been static. There is fluctuation, but they've largely been static for the last couple of years. And, secondly, the scale of the pressure or the impact of the pressure across urgent emergency care across the rest of the system has largely been static on us for the last couple of years too.

So, in 2018-19, we were losing about 6,000 hours a month capacity—emergency ambulance capacity too—to this pressure across the system. Now, that's somewhere around 25,000 to 30,000 hours a month and that's been static for the last 18 to 24 months. Yes, there's variation, but, by and large, it's about that kind of level. So, the trend of harm, or avoidable harm, is again largely static, because the pressure is in the system.

Thank you. Did Colin want to come on that point at all, in reference to that?

Yes, thank you very much. I'd just underline what Jason was saying. We are, as a board, extraordinarily aware of the level of avoidable harm that is being done. It's reported at every board meeting. The statistics are very clear and very stark. We have a special paper that is presented by Jason and colleagues every month, which looks at that. The quality committee looks at this data every time they meet as well, in very close and forensic detail, and we are constantly questioning, as non-execs, whether the board, whether the executives, are taking every reasonable step to avoid the avoidable harm as much as they can. So, in answer to the question, 'Are we aware?'—yes, we are very aware of it. And just to underline that point, when I caught up with Jason yesterday for our routine conversations, he was just on his way back from having given evidence at a coroner's court, so this is something that is very much in our mind all the time. We're very conscious of it.

The other thing I would just make a mention of in terms of where the problem is, if you talked to ambulance crews today, and you asked them what life was like even just five or six years ago, they would say that they would regularly have seen maybe five to eight patients in a shift. Today, they see one or occasionally two, which I think is probably one of the biggest highlights of the difficulty that we're facing, for the reasons that Jason so carefully and adequately outlined in terms of the flow difficulties within the wider system, the whole system.

Thanks, Colin. And perhaps from the board's point of view, I wonder how optimistic you feel that this is going to improve. I mean, I guess you're presented with strategies and have plans coming out of your ears in terms of how these things will change, but are you optimistic about that, or perhaps it's just a fait accompli that it's just the way it is?

I think we're optimistic that if we can continue to transform the quality of service and the skill base of the ambulance teams in the way that we're doing, and if we can continue to enhance technology so that we can triage and provide care remotely in more effective ways, such as the use of wearable technology and other means, I think we can see a significant improvement in the level of care that is delivered to the community. But it will be different type of care than just collecting patients and conveying them almost automatically to a hospital.

We have less optimism that the problems within the hospital flow are going to be solved in the short term, because as the hospitals are doing everything they possibly can to improve their flow, we know there are increasing difficulties in the social care sector that gives them continuing problems with discharge, and we also know there are continuing and growing health problems and health inequalities across Wales that increases the demand. So, I liken a lot of this to trying to walk up the down escalator—the faster and quicker you walk, the quicker the escalator is moving in the wrong direction.

But I am optimistic that the ambulance service can provide an improved level of care to the community that will benefit patients and people in the community, although I'm not sure that we're going to see dramatic changes in the red response rates, or the rates in which ambulances are turned around when they get to hospitals.

Okay, thanks. And perhaps another issue that, clearly, is important to understand is the number of cancellations. I believe, in December of last year, there were nearly 10,000 ambulances cancelled by would-be patients. I'm just interested to understand your analysis of why people are cancelling those ambulances and the potential impact on those patients either in the short or long term.

Maybe I'll start on that and perhaps then ask Jason to come in with a bit more detail. I think the thing to understand is that of all the calls that come into the 999 call centre, approximately a third of those are potentially the life-threatening calls that could become red calls. Over two thirds are non-life-threatening, non-urgent calls in the amber 1, amber 2 or green category. And when the ambulances are being tasked primarily on the life-threatening calls, it is inevitable that the call handlers will be giving advice to the non-life-threatening caller that there is likely to be an extended wait for an ambulance to arrive. A lot of those patients, therefore, whilst they're waiting for an ambulance, will of course be looking at other opportunities to be conveyed to a hospital through a neighbour, a friend, a relative, or even a taxi or some other means. So, of course, as for every ambulance that's being held at the hospital, a larger number of people are self-presenting, because it's inevitable that they are not going to be happy to wait potentially hours in an uncertain environment, not certain and not knowing when the ambulance will arrive.

What we ask always, and the call handlers are always doing this, is that they will always give the advice to a caller to how long they're likely to wait and that if they do decide to make alternative arrangements, will they please contact the 999 centre and cancel an ambulance so that we don't have to wait.

And to give you, again, just one example, I was out with an ambulance not so long ago where we went to a call where the patient had indeed self-presented to the hospital, but we, the ambulance service, had not been told of that, and that ambulance therefore had been on a wasted journey, wasting at least two hours of its time trying to find a location, trying to get access to a house that was all in darkness, because the occupants had left the premises to go to A&E. So, actually, in some ways, the cancellations are at least a good thing, in that if the patient is deciding to self-convey, they do let us know. It's inevitable that that's going to happen with long delays for non-life-threatening cases. Perhaps Jason could fill in a bit more detail.

Thanks, Colin. There's probably not much more to say, but there are a number of things that go on underneath cancellations. So, one is the patient cancels, because either they're making their own way, they've recovered, or, because of the delay, they find alternative means to access care. There are some cancellations that will emerge because they're duplicates, so they're duplicates of another call. There'll be some cancellations or no sends that emerge because we're using some of our management plans to safely manage the activity that we are holding, which at any one point can be something in the order of 200 calls across Wales.

Of course, in that connection, it's just important to remember that you and others across Wales will probably imagine there are hundreds and hundreds of emergency ambulances sitting in our communities waiting to respond. Well, at peak, nationally, there is something in the order of 140 emergency ambulances—at peak. So, it's quite a scarce resource, particularly when we've got this pressure across the rest of the system. So, there are a number of things that are leading to those roughly 10,000 cancellations a month. Some are patient driven, some are driven by us, and some are driven because they're duplicates or we've got other things going on.

Okay, thanks for sharing that. I just want to move on, perhaps, a little bit to a conversation we've been having a fair amount, which is around the patient flow through the system. Are we wasting our time with this meeting with you today if it's all someone else's fault?

No, not at all, because we are part of the system, and we have a role to play. Increasingly, I think, referring back to Colin's point earlier, we are more than just ambulances now. Five years ago, 10 years ago, 20 years ago, we were a clinical or medical conveying organisation, a medical logistics organisation, if you like. Now, we're a provider of care in our communities, and increasingly so. We're providing more and different types of care, with specialist paramedics in palliative care, falls, dementia, mental health, and so on.

So, as the way patients use the emergency ambulance service shifts and the way in which we can manage activity changes, because our workforce is changing, it's more educated, it's higher skilled, it's more experienced than it was before, we are able to offer different types of services. We are part of the system and part of the solution to the problem. We will always need to continue to convey really sick patients to emergency departments very quickly, but, increasingly, what we have to do—this is where we have to change our model of response—is be smarter in managing the activity that we receive, stop sending an emergency ambulance to patients that simply don't need that anymore, because we could offer a different type of care, a different type of service, one that is tailored to their specific need in their home, in their community, avoiding the conveyance to ED.

That's the role we can play, that's the part we can play, particularly given we operate the 111 service, the urgent care line across Wales too. As we increasingly bring the clinical services associated with 999 and 111 together, the entry point that the patient chooses for the system to access healthcare becomes less relevant. We need to be much smarter at how we respond, and by 'respond', I don't necessarily mean send an ambulance. But we need to be much smarter, increasingly, about how we respond to manage that activity differently and only take patients to the emergency department if it's absolutely necessary. But Andy might want to say a bit more about that, perhaps, before we move on to the next question.

Thank you, Jason. I suppose to go to the nub of the question in terms of where's our part within the flow, well, the flow through the system, we have a part to play in that, in that we are at one end of that flow. So, if we can have a bigger part in how flow into the system is created or diverted or managed in a different way, as long as that's safe for the patient, or, indeed, might even be a better level of care than simply transporting to the ED, which I fundamentally believe it is, especially with our older, frailer population who present to us—the more we can manage those people away from secondary care, keeping them safe and well at home, the long-term outcomes for those patients are undoubtedly better—. I attended a workshop only last week on the impact of deconditioning in that group of patients and how quickly that occurs; within a matter of hours of those patients being off their feet, we see an immediate impact upon their ability to manage themselves. So, the more of those patients we can manage in the community—. Yes, we will then have a significant impact on flow, because there'll be fewer people arriving at the hospital, therefore, it'll be easier to manage those people who do need to go into hospital, but also, clinically, this is more sound for those patients, because the outcomes for those patients will inevitably be better if they are managed in their home environment, with all the care delivered that they require without, necessarily, that need for conveyance.

Thanks for that. I'm conscious that I've been talking a fair amount, Chair, but there are obviously a few points to try and pick up, and I may just deviate slightly from where I was initially going to ask some points, because I'm just trying to get my head around this, the patient flow, the system. As you said, you're a fundamental part, right at the front end but also at the back end in terms of patient transfer back into the community as well. I'm just interested to know about the way in which you're able to feed into the conversations around that system. Are you being listened to? Are your concerns being properly understood in that broader system across both health and social care? We have structures in place, like regional partnership boards, or in public services boards, which are supposed to help bring those local authority responsibilities with health responsibilities. Are you able to feed into those and be properly listened to and understood and influence? Also, we have the all-Wales transfer and discharge service as well, which, obviously, is set up to try and improve that patient flow. Perhaps you could speak to how that is being developed and implemented. But I'm interested to know that point about the collaboration with other health services and local authority charged services, like social care, and whether you're being seriously listened to in those conversations.

Thank you. I'll start, if I can, with RPBs, regional partnership boards. So, we are represented on all bar one now of those RPBs. That's a relatively new feature. So, we hadn't been attending those RPBs probably until six to nine months ago, something like that. But, as I say, we're on all of them bar one. But we don't attend PSBs; we're not a listed member or attending PSBs.

So, in terms of connections and collaborations with services beyond health, our connection point, our point of connection, would be the RPBs, save for one. Of course, for the rest of the health system, we are well connected with the rest of the health system, both at a local level, in dialogue with the health boards directly—so, I've recently undertaken a round of sessions and engagements, meetings, with the health board chief executives and some of their senior teams—we're part of what was EASC, the Emergency Ambulance Services Committee, and, of course, the seven health boards act as the commissioners for the emergency ambulance service in Wales. That's transitioned to new commissioning arrangements from 1 April, and, again, whilst that new committee has only met once so far, we are part of that set of arrangements too.

So, I would say that we're connected well in the health system structurally at national level, but also at a local level, increasingly in dialogue with health boards looking at what kinds of services or what support we can offer them locally. Recognising that we're a national provider and the emergency ambulance service will always need to be a one-size-fits-all solution, there are things that we can do at a local level that are tailored to specific community or health board needs. So, a good example would be palliative care and the specialist paramedics that we operate in Swansea. That's something that is locally commissioned to support palliative care patients in their community, and we've got specialist paramedics trained to do that. So, we're commissioned nationally, but also increasingly we're providing local services to respond to local need. And our connection to the rest of the public sector beyond health really rests in those RPBs.

Thank you. Thanks, Chair.

Mabon ap Gwynfor.

Thank you. Just quickly, a lot of what you've said is, again, making a lot of sense. Earlier, you said that a problem lies at one end of the spectrum of health, which is getting people out of hospitals and into care in the community, and that that is a problem that doesn't lie with the ambulances, but with another element of health provision. Now, you're saying in your responses that what you see the role of the ambulances as is to offer care in the community and to try to avoid getting people into secondary care. That suggests perhaps that there's a problem with the primary care element, if people don't get that primary care in the community and you have to step in and do that. Is the role of an ambulance to provide that primary care, or is there a problem with primary care in the community?

Okay. Andy would probably be best placed to respond to that. I think Colin was waving a minute ago as well. So, I'll give way to Andy perhaps, and then we'll bring Colin in.

Well, undoubtedly, there is pressure within primary care, but I don't necessarily see that this is a failure in primary care as to why we need to intervene, in the way you phrased the question. I probably see it as more that people choose 999 because it's a trusted brand, and we should be proud of that; we should be pleased and proud that people see us as being a responsive organisation, albeit with the challenges we've discussed this morning, but still see us as a responsive organisation, where people will come to us in their time of need and their time of crisis. So, I think there is a role for us to play in that—rather than simply trying to tell the population, 'Sorry, we are too busy, go and find your care elsewhere', actually, for those patients who do choose to come in our direction, that we manage them more appropriately for the nature of the way they are presenting. Like I say, the number of calls that come to us that are of a low-level nature, that really shouldn't be going anywhere near the ambulance service, are a relatively small fraction of our calls and we manage those remotely quite effectively. But, when you break down clinically the nature of the calls that we see that make up the bulk of those patients that we can manage elsewhere, these are pressing care needs that need to be seen relatively soon; what they don't need is an immediate blue light emergency ambulance.

So, I think there's a recognition for us as an ambulance service that those patients are coming to us whether we want it or not. The communities and the people that seek our services are coming to us whether we want them or not, and we have a responsibility to now manage them as effectively as we possibly can—yes, in co-ordination with other services where possible and where necessary, but also, as a service on our own, we can do a great deal more to step into that space, as the nature of patient presentations have changed over the last 20 years or so.

Did you want to come in as well, Colin?

Just briefly, on the question about connectivity within the system, Jason has given a good outline of how that happens at his level, at the operational level, but at the governance level there is close integration as well, in that I as the chair meet regularly with the chairs of all of the health boards and the chairs of all of the trusts in a variety of different forums, also the vice-chairs meet regularly as well, and we are in the process of inviting members of the governance bodies of health boards to come and visit us in our call centre to learn more about what the ambulance service does in the round—rather than just think of it as an emergency service, to learn more about the 111 and the 999 service. So, I think there is a very high level of integration for the ambulance service within the wider system.

And on that broader point of primary care, I would just say that I don't think there's a crisis. I think that there's a huge increase in demand on the primary care services for the reasons that we mentioned earlier: ageing populations, people living longer with comorbidities, health inequalities across the country and so on. So, primary care are facing increasing demands on their services, and, through the ambulance service, particularly the 111 and 999 service, remote triaging, the use of technology and the use of electronic record keeping to provide a better quality of care. And I think the ambulance service does have a role to do that, and plays a part just in what is an evolving service for the community.

Thank you, Colin. I've just got a question myself around engagement with the public and the public's perception of the ambulance service. I'm almost not sure how to ask this question, but I suppose—. All of us in this room will have casework with constituents contacting us where they've outlined unacceptable levels of time that they've had to wait, or a family member's had to wait, for an ambulance. And if you ask a member of the public, I suspect they'll either refer to the ambulance service being in crisis, or under pressure, or some other words to that effect. When I first asked my questions, I think, Jason, you referred to, 'Well, no, we're not in crisis, because we've got good governance; we've got good finance.' But members of the public will measure your performance not by governance or finance, they'll measure it by is an ambulance turning up in a timely manner to support them and, then, where appropriate, transfer them into a hospital setting. That's how they would measure your service. So, how are you engaging with the public? I actually accept that lots of your answers—. We've done work on committee around patient flow, the challenges in the social care sector, so I'm accepting of the answers you've provided in that regard, but how are you engaging directly with the public around some of these issues?

It's a great question. Of course, I recognise that, from the public's perspective, from a caller's or a patient's perspective, or a relative's perspective, success or failure is how quick we turn up; it's less about what we do when we get there for them, and more about how quickly we get there, bring order to the chaos, provide assurance, begin care, manage pain—all of those kinds of things. So, I recognise, from your constituents' perspectives, from service users across Wales, they will measure us and measure our success on how quickly we turn up.

In roughly half the cases—Colin touched on this earlier—of 999 calls categorised as immediately life-threatening—actually, it's just over half—we arrive in around eight, nine or 10 minutes. I accept we're missing the target of 65 per cent within eight minutes, but we arrive, in over half of those cases, in somewhere between eight and 10 minutes, which, when you think about our geography and our road network and the fact that there are 140 emergency ambulances at peak across Wales, and then you put on the pressure and everything else, it feels okay. It's not great, and it should be better, but it feels okay.

In terms of the nub of your question, how we engage with our communities, well, of course, there's a range of ways we do that: clearly, through print and broadcast media, through social media, through local engagement events managed by our PECI teams—that's our patient experience and community involvement teams—

So, 'Is that working?' I suppose, is the question.

Well, I think, whilst, of course, we continue to receive concerns from our communities on a daily basis about our timeliness of response, it's also true to say that we receive on a daily basis compliments about the service that we provide, where our people have given great care, or that we've turned up very quickly. So, there's balance, I think, that's important to put into the narrative here. I do think communities largely understand that the reason we can't respond as quickly as we would like is because the emergency ambulance fleet is delayed elsewhere in the system, and I see that in the letters and the correspondence that I get on a daily basis from your constituents, either via political offices, or directly from service users—they recognise, largely, that we're unable to respond. Clearly, they're unhappy with the fact that it's taking a long time to respond, but they do recognise and understand that it’s because of reasons beyond our control. So, there’s more, of course, we can do to engage with communities, and it’s a continual effort, but I do think that, largely, service users recognise that we’ll offer great care when we get there, our people deliver a good service day in, day out, but there are constraints around it.

You say there is more you can do to engage, and I think this is really important, because the public have a perception. I know you say they understand the challenges, but I suspect there are many that don't. So, you say there's more that you can do to engage. What more could you do to engage better with communities?

I think it’s doing more of what we’re already doing. So, it’s continuing the work of the patient experience and community involvement team, who engage with communities, it’s continuing the use of social media to engage, it’s continuing to use print and broadcast media, but also it’s about using political offices, too. I can think of a number of occasions where we’ve offered briefings, which MSs, MPs, local councillors and so on have used to keep local interest groups across the issues. We clearly work closely with Llais as well to ensure that they’ve got appropriate, up-to-date messaging that they can share with community groups. So, there are lots of ways, but it’s just about doing more of the same.

And I suppose I ask the question about engagement not just to let the public know about what the challenges are for you, but in terms of making sure that they're appropriately contacting you, or contacting an emergency service correctly. That's obviously the key message that you want to be presenting to the public.

I think there's a subtle difference there. I think the evidence would say to us that attempting to educate the public about when to dial 999 is a hard ask. It’s a very hard ask.

Why is that?

Andy might want to comment more on this. What is your emergency and what is my emergency is something very different. And trying to explain to a member of the public what is a genuine life-threatening emergency, to someone who is not trained, is very, very difficult. So, increasingly our position here is let the public contact us whichever way they want to—111, 999, or increasingly through digital platforms, either the website or the NHS app in due course—and we need to be smarter at how we manage and respond to that work. We're not going to stop people calling us.

So, rather than telling people not to contact you, or to contact you in a certain way, your messaging is contact us, and then triage them to—

The message is contact us and let us sort it out. Because what we've had in the past—and we've tried this—when we've said, 'Don't call us unless it's this, this or this' is that it just doesn't work.

Thank you. Mark Drakeford.

Chair, thank you very much. I'm going to mostly ask you some questions about staffing, but there were two questions arising out of the discussion so far that I just wanted to test with you first.

We have 1,700 people sitting in a hospital bed today in Wales while clinically fit for discharge. As we heard from Andy, every day they sit there their ability to manage on discharge gets worse, because they lose those abilities. Wouldn't we be better spending less money on the ambulance service and using that money instead to fund those services that could help to get those people out of hospital so the abysmal productivity figures you've offered us this morning could be improved? Then your ambulance drivers could be looking after five people in a shift instead of one in a shift. We're spending an awful lot of money on ambulance staff doing very little, when we could have used that money to fund services that got those people out of hospital and allowed you to do more with the people you had.

So, Jason, would you like less money?

Thank you for the question. Of course, I recognise it's perhaps delivered in a deliberately provocative way, but perhaps I'll just say a couple of things. I'm not pitching for more money and I'm very clear with commissioners I don't want more emergency ambulances; that is not the answer. The number of emergency ambulances we currently have is sufficient to respond to the activity we have if they are available to us, and that's the challenge we've got.

In direct response to the question, the reason that our crews are doing one job a shift, one patient a shift, instead of five, six, seven or eight, is because they're delayed at the emergency department. The average handover is taking in excess of two hours, where it should be taking 15 minutes. That's the reason that they're not responding to more patients during the shift. And of course, when they don't respond to those patients, that's when we see the level of cancellations rise that was referred to a few questions ago, where patients elect not to wait for their ambulance, take themselves to the emergency department, which in itself is a problem for the emergency department and creates avoidable harm, or where we've got avoidable harm happening in communities and, sadly, some patients dying because we're not able to respond as quickly as we could because the average handover is in excess of two hours rather than 15 minutes.

So, the productivity point that you raise in the questions is entirely valid—one patient a shift instead of five, six, seven or eight—but that's not because the activity isn't there for those crews to go to. It is there and it is necessary for those crews to respond. They can't, and that's why we've got avoidable harm happening. I can see Andy has put his hand up; he might want to come in.

Excuse me, Mr Drakeford, but it clearly was a provocative question in terms of shall we defund the ambulance service to put other parts in. My argument would be that our principal objective should be to keep as many people out of hospital as we possibly can, because the more we manage in the community, the less deconditioning we will see. So, my objective for our organisation is that if we can create, as I've described earlier, that more community-based provision and prevent that admission to hospital, we will have a direct impact on those patients being prevented from deconditioning. Deconditioning will commence whilst you are waiting to be handed over at the front doors of the emergency department. It doesn't take two weeks; it happens in hours. So, simple prevention of any transport to the emergency department and keeping that person well at home is a principal way we can really, as an ambulance service, have a direct impact on the deconditioning and extended lengths of stays for patients in secondary care.

Thank you very much for those answers. A slightly less provocative question next, and then I will get to the staffing issues, Chair, I promise. Am I remembering correctly that in March 2020 the ambulance service in Wales had met its targets for 48 months consecutively? So, for four years, month in and month out, the ambulance service met its targets. And then, in March 2020, we had the extraordinary impact of the pandemic, and you haven't had a question yet that has invited you just to give us a very condensed account of how you think that pandemic experience continues to impact upon the performance of the ambulance service today. I think we would not have a rounded picture of the current challenges if we didn't give you a chance just to reflect on that for a moment.

Thank you. Again, it's a great question. Without the data in front of me, I can't for certain say that we met our target for 48 consecutive months prior to March 2020—

You did.

I knew the former First Minister would know the answer to that. He's giving you the answer.

In terms of the impact of the pandemic, of course, that was profound at the time and, arguably, we are still managing our way through some of the impacts of that now, particularly in attendance, for example, where we're continuing to work to bring down non-attendance through absence rates that peaked through the pandemic. So, we haven't returned to the pre-pandemic state yet.

The single biggest thing that has shifted since the beginning of the pandemic, or pre pandemic to where we find ourselves now, is the impact of this pressure across urgent and emergency care. So, pre pandemic, we were seeing something in the order of 6,000 or 8,000 hours' worth of emergency ambulance production lost per month. That's now at 25,000 to 30,000, and has been sustained for many, many months and indeed across a couple of years. And so, if I was to try and point to one particular thing that has shifted considerably, it's the pressure across the system, and it's the impact of that pressure on us in the post-pandemic state, which we continue to see today.

There, of course, are individual impacts on our staff, on our clinicians, from the pandemic, which we're still managing. Some staff haven't been able to return to work. Small numbers, but they're there. Of course, as with communities, we lost some of our people through the pandemic, and that's had an impact on our people too. But there is a consequence. We are still managing the consequence of the global pandemic three years on.

Thank you very much. On to staffing, then. I think you've offered us a very rich account during the morning of the way in which the ambulance service has developed over the last 20 years. It is a very different organisation than it would have been back then. But across the whole of the 20 years that I've had an interest in the ambulance service, poor industrial relations has been a constant feature of the Welsh ambulance service. What would be your frank assessment of the state of industrial relations in WAST today? How is that impacting upon your sickness levels, which continue to be the highest of any Welsh health organisation? What is the impact upon attrition rates? Because, yes, it is true, you are recruiting more people, you've got more capacity, but you're losing people as well. So, I'd just be interested to get, as I say, a frank assessment of the current state of play.

Thank you. I'll perhaps start and Colin might want to come in on some of the trade union relationships too. I think I would characterise them as good and strong, but challenged. We operate with four trade unions in WAST, three in the general emergency medical service sphere, and then the Royal College of Nursing for our nurses, largely in 111. We do have productive relationships with our trade unions at local, regional and national level. We've invested heavily, actually, in time and building those relationships in the post-pandemic state. I certainly see the senior trade union reps on a monthly basis. Indeed, I've been engaging on a three-weekly cycle with full-time officers from the three major trade unions on a range of topics in the last probably three or four months that we're working through together.

So, I think partnership is strong, and I can point to a number of examples in the last three to five years where that's borne fruit. But it does remain challenged. I'm not going to say to you that everything is great, because it's not. But certainly at a senior level, I think there is respect and recognition for each other’s roles and the constituents we have to manage. And I'm personally of the view that there is place for a strong trade union movement. It's good for our people, it's good for trade union members, it's good for our staff, and it's good for the quality of service we provide to patients. And we continue to work together, I think, pretty effectively—not without some challenge, but pretty effectively.

I think the final point I'd make, perhaps, that would exemplify that is how we worked through the recent industrial action together. It was a very difficult set of experiences for our workforce, many of whom had not been through industrial action in their career before. Indeed, most of our reps hadn't either. But we took a particular position as a leadership team, seeking to support our people through that, and I do think, coming out the back of that, it could have been very different. The outcome of that period, that 6 months or so, could have been very different and much more fractious.

In terms of sickness, it is right to say that we have the highest absence rates in the NHS in Wales. As far as the ambulance sector across the UK is concerned, we're about middle of the pack, so we're certainly not an outlier. We do have more improvement to make, as I touched on a few moments ago, but we have nearly halved the absence rate since its peak through the pandemic. We've got about 1.5 per cent to 2 per cent to go to get back to the pre-pandemic position. And on attrition, again, it is fair to say that attrition has stepped up. In the pre-pandemic state, when you talked to staff about the reasons for leaving, some of it is about the workplace experience, their frustration and their inability to do the job they joined for. Some of it is about the fact that there are other opportunities for degree-educated paramedics now in the health system that just did not exist 10 years ago. So, our people are more portable; they could work in different settings in the healthcare system where they just couldn't before. And, then, thirdly, there's a societal issue here, whereas people who joined the ambulance service in the 1990s and 2000s would largely be staying for a long period, potentially for life, for a non-fulfilling career, increasingly, we're seeing colleagues join us who want to experience different things and are with an organisation for two, three, five years on average. So, there's a range of things in there, but, hopefully, that helps. And I think Colin might add a few more bits to it.

Yes, if I may. Thank you, Jason. I would just say that, from a governance and a board point of view, I think the relationship with the trade unions is very positive. Trade unions join us for our board meetings, our board development sessions. I meet with the trade union representatives on a personal basis on a very regular, six-weekly cycle. We have very open and very friendly dialogue. We are well connected. So, I think there is a very close, supportive relationship. As Jason said, there is inevitably going to be tensions because of the role of the trade union representatives representing their members. And, actually, I have a lot of respect for our trade union representatives, who have all come from the ambulance service. Some of them are still practising as paramedics in the service whilst they're still fulfilling union roles as well. So, they come with very, very good intentions. And, I think, if you compare it to an industrial setting, then our relationships are particularly strong in that comparator.

In terms of sickness, I would just make a point that a lot of ambulance work is very physical, and I think it's worth just separating out short-term and long-term sickness, in that we do have a significant number of our ambulance service people who suffer from a range of long-term conditions, some of which are psychological, in terms of post-traumatic stress disorder and stress and anxiety. Quite a number are suffering from quite long-term musculoskeletal issues as a result of the work they're doing, and those take much longer to remedy and, perhaps, get them back into the workforce. So, I think making a comparison of the ambulance service with other areas of the health sector is useful and valuable, but I think it's also, perhaps, worth while just making comparisons between the ambulance service and other very physical roles in terms of sickness levels.

The other point that I just wanted to mention was about just the general morale and relationship within the health service. We see the way in which people conduct their careers is changing. People joining a career for life was very much the norm 20, 30 years ago or more; it's not the norm today, as Jason has just pointed out. People don't necessarily have whole-of-life careers, and a higher level of turnover is probably to be expected. Also, bear in mind that the 111 and the 999 services are essentially call-centre operations, and they do suffer from a much higher attrition rate because of the nature of the work. The good news, though, is that a lot of the people who are moving from the call centres are actually moving to other jobs in the ambulance service or the health sector. So, they're not lost to us, but they do appear in the leaving statistics. I hope that's helpful.

Can I put one last one, Chair?

Yes, absolutely, Mark.

Thank you. So, we've learnt, sadly, in recent times, that uniformed services can be particularly vulnerable to cultures that go wrong. And we've learnt not just in Wales, but more broadly, that those services can be vulnerable to cultures of misogyny, homophobia and all the other things that we would not want to see. How confident are you that, in WAST, there are systems in place that would alert you to such difficulties were they to be occurring? And what services do you have in place to respond to staff welfare in those circumstances, to respond to people's own mental health and well-being and all the challenges we know that occur when people work in places where the culture has gone wrong?

Thank you. That's a really important question, actually, for our people, for our workforce. So, I'd start here by saying that we recognise that we do have pockets of poor behaviour in some of our workplaces across Wales. We commissioned and undertook an external culture review about two years ago, because we recognised that there were some challenges in some of our workplaces. That review, when it reported, confirmed that for us, and it was the commencement of a journey that we continue to be on now, focusing on improving our culture in many aspects.

We have a range of support networks in place for groups of staff across the organisation. Formal access to counselling is available, should colleagues need that. We've undertaken a whole load of development with specific teams—so, organisational development work with specific teams where we've identified poor practice and poor culture. Particularly in the sexual safety and misogyny piece, we've undertaken a lot of work—we've very openly undertaken a lot of work here—surveying our people, sharing the feedback from that in a round of roadshows with our staff about 18 months ago. We've undertaken reverse mentoring for senior leaders, there are women's networks and other support networks in place for colleagues. We've increased recently our capacity to deal with concerns and complaints that are raised by our staff, because we're seeing more of those coming through, which is a good thing to see. We're seeing more concerns being raised about behaviour in the workplace, which is a good thing in the short term. So, we've increased capacity to be able to support staff and conclude those investigations quickly.

We've led the way across the UK ambulance sector, actually, here in Wales on the work that we've been doing. So, when we started this journey, we were sharing the approach we were taking with other ambulance services across the UK and the emergency services across Wales. NHS England picked up the approach we were taking and have now adopted that across the 10 services in the UK. And colleagues on the committee may have seen some broadcast media coverage with the BBC about us being very overt and upfront that we've got some problems—it's not a universal problem with culture, but we have some problems with pockets of poor behaviour, which we recognise, and we've got a lot of work under way to modify that behaviour in the workplace.

Thank you, Jason.

So, I think, in summary, sadly we see some poor behaviour amongst our people. We know it's there, and we are very keen and committed to making our workplaces as safe as we can for all of our people.

Thank you, Jason. Just for time, I know we've got two other sections, and I know Mabon's got some questions and so has Joyce, so we've probably got less than 10 minutes for each section. If you could just bear that in mind in terms of the length of answers, just to help us get through the questions as well. Mabon ap Gwynfor.

Thank you, Chair. If I could ask some questions—please forgive my lack of understanding in some regards—just in order to square some circles, and if you could give a brief answer. You've said from the outset that you don't want more money, that that's not the issue, and that you don't need more ambulances. That's one statement that you've made. But, later in your presentation, you said that only 140 emergency ambulances are available at the peak and that it is a scarce resource. So, which is true, therefore?

Well, both are true, because if the 140 ambulances we had available to us across Wales were handing over in 15 minutes instead of two and a half hours, they would be sufficiently available to be responding to the activity we currently see within reasonable response times. So, both statements are true, but it's because the current fleet is not available in the right place at the right time, as a result of pressure across the rest of the system, that we've got the challenges that we have.

Thank you for that, but you also say that you want to do more work in the community, and to follow on from the question asked by Mark Drakeford—the probing question that he asked earlier—would you not want to have more financial resources in order to provide community resource and, therefore, avoid this situation where people have to wait outside in ambulances, and so that you can treat, given that you yourself said that you're not just a conveyancing service now; you also employ and upskill the paramedics? So, wouldn't it be better to have the resource to do that work in the community rather than have them waiting outside hospitals?

So, my starting point here, and Andy may want to comment more, is that we recognise that we operate in a system, not just a health system, but in the public sector, where resource is scarce. And what I don't want to do is pitch for and secure investment that would be a bad spend, and a bad spend for me would be a lot more ambulances joining lots more queues, taking lots more patients to emergency departments that don't need to be there. If we are going to invest, then we need to be investing in our ability to be able to provide care for patients in the community, and that's what we've done this year. Seventy-five per cent of the growth that we've secured this year through the very generous settlement from the Welsh Government to the health system has been invested in additional clinicians, both in our contact centres and also in advanced practice. So, where we are able to invest and grow our workforce, we're going to do it in a targeted way where we're going to see better results and more efficient results, rather than more generalist ambulances on the streets to join bigger queues.

Thank you. In terms of the funding that you do receive, you have had to look at savings worth £6.4 million, I think, and you've already achieved about £3.4 million in savings. Could you provide more detail on how you've saved that £3.4 million and where you expect to save the remainder?

So, you're right to say that this year's savings target to offer a balanced budget is just over £6 million. That's consistent with what we saw last year. We're confident we're going to be able to deliver that. There's a number of schemes that underpin it. Some are about vacancy management in the non-clinical workforce, and some are about recurrent savings in the way we procure services such as fleet, fuel, equipment, uniform and so on. So, there's a range of schemes that underpin that £6 million-worth of savings. Some of them are recurrent and some of them are non-recurrent, managed through the year.

Okay. Following on from that, then, from the savings that you have made, how has that affected your delivery of vital services? How has that affected your capital programme? Where, for example, have you had to cut back in terms of upgrading elements of equipment or where have you had to stop any developments you had hoped to make?

Okay. So, the delivery of the recurrent savings programme—roughly £6 million this year and roughly £6 million last year—has no impact on the capital plan. So, the capital plan sits unconnected to the savings requirement. But, in terms of what impact it's had on the front line or our ability to deliver patient-facing services, very little, because we've managed so far to deliver those savings and protect front-line jobs, so there's no—. Well, we've grown the organisation in terms of clinical patient-facing posts each year in the five, nearly six, years that I've been here now. So, we haven't reduced the front-line workforce. What we've been able to do is identify those savings, those efficiencies, in other non-patient-facing areas. I would just say, of course, that as each year goes by, it gets harder and harder, because most of our spend, certainly in the revenue budgets, is on people. Nearly 80 per cent of our spend is on people and most of those are patient-facing clinicians, given the nature of our organisation, so it does get harder every year, but the impacts on patient-facing roles has been very limited.

Thank you very much. Thank you, Chair.

Thank you, Mabon. Joyce Watson.

Okay. I'm just going to ask about non-emergency patient transport services, but before I do that, I want to ask you to send us exactly what it is you're doing in relation to the staff welfare, sexual harassment and so on, and how you're proactive in that space, rather than what I listened to, more or less, which seemed to be reactive. So, I'm going to leave that there, because we haven't got time, and await your response.

So, I want to move on, as I said, to the non-emergency patient transport service. The projection of an ageing population is going to go up to 30 per cent—and by 'ageing' I mean 75 years or older— within the next 10 years, and of course, as a consequence of that, the demand for out-patients and appointments and discharge and transfers will go up. So, how are you going to manage that in the non-emergency, and how do you use other partners or work with other partners to manage it?

Okay, thank you. So, I'll happily write to the committee with more detail on the approach we've taken to our culture work, and we'll get that over to you in the next week or so.

But in terms of non-emergency patient transport, you're absolutely right to identify the growing ageing population. Of course, this is an issue for us not just in the non-emergency space, but also in the emergency space. But specifically with non-emergency, our commissioners, the seven health boards, co-ordinated through the new joint commissioning committee for Wales, are currently undertaking a strategy review for non-emergency patient transport. We're part of that; that's clearly forward looking. It's taking into account a whole range of issues, not only the ageing population point that you absolutely rightly make, but also service changes that are happening at a local health board level, and we will respond, as the provider, to the commissioning intentions that emerge from that activity. But there is work under way as we speak, forward-looking work as we speak, looking at how we will provide, and what type and level of non-emergency patient transport is necessary across Wales going forward.

So, on the second point of your question, about how do we work with partners, we operate what's known as a plurality model here in Wales, so we control and subcontract to other providers some non-emergency patient transport activity. We provide most of it directly, but where we subcontract that out, that's operating on the plurality model, either through contracts with providers such as St John Ambulance Cymru, or on a more ad hoc basis, where competitive pricing is used to identify providers to undertake specific journeys.

There has been, of course, an underperformance in services for oncology patients, and that is of particular concern. So, have you got an update on rectifying that?

So, I don't have specific detail in front of me about performance for oncology and renal—of course, that's the other group of patients in the non-emergency space that are time dependent and time critical. What I can say is that there was an operating deficit within the non-emergency patient transport service until very recently, when we re-let contracts and were able to deliver efficiencies as a result of that, so it now balances. There has been improvement, I know, specifically in renal performance, but we are seeing a growing cohort of patients that are accessing and do need those services. So, in that letter to the committee, I will happily share both the performance trend for oncology and renal patients, and if there is improvement activity that’s necessary, share with you the action plan that we have.

The issue here for those particular services, and the focus on them, are those people who can't wait for treatment, so we have to have a particular focus on that. You said you managed most of it, and what you can't manage yourself you'll outsource. But along with that there's a demand and capacity review that's going on, and this will form part of that. So, we'll be more than interested to know how you're focusing attention in those particular areas, and of course they can be more acute where you have rurality and access to services being further removed from the patient. I'm assuming—but I could be wrong—that those are the more difficult to outsource because of the need of the patients.

You're right to reference the demand and capacity review under way in the non-emergency patient transport service. That’s a proactive, forward-looking piece of work, again done jointly in partnership with commissioners, to look at what activity we expect to see in the coming years and how best to service that. Some of that will be around changes to the fleet mix that we have in the non-emergency service. You’re right to say that work is under way, and that’s a good thing, because it gives us a benchmark from which we can operate, identify efficiencies and improve access to all cohorts of patients. And it will also take into account those changes that are happening at a local health board level that we’re aware of currently, which will see shifts in activity, either where those patients come from or go to, or in the volume.

On the rurality point, it’s fair to say that we would, I think, use local providers much more in those rural and remote areas to service activity, particularly in an ad hoc way, than we would in our urban centres. So, in the urban centres, the provision is largely by us, but the ad hoc provision in rural and remote areas of the country is likely to be greater.

I have two final questions, and one is—and I think everybody would agree with this—that the ambulance service does bear a disproportionate level of risk in the health and care system. So, do you feel that the Welsh Government is focused on that, and giving you adequate support?

Andy, you may want to comment here on risk and patient safety, but largely I would say 'yes'. We have a number of touch points with Welsh Government officials, both in relation to performance, but also in relation to quality and safety. It's a feature of our integrated quality and performance meeting with Welsh Government officials on a monthly basis. It's a feature of our performance management arrangements with our commissioners. It's a feature of our joint executive team meetings, so our director team with the Government's health and social services group director team, on a six-monthly basis. Of course, we're subject to the tripartite review arrangements with Health Education and Improvement Wales, Audit Wales and Government colleagues too. And our director of nursing and quality, through his peer group arrangements, and with the chief nursing officer in Government, also receives support. So, I think there are a number of routes through which quality and safety are assessed, and I do think, by and large, that we see good support from Government for the challenges that we face. But, Andy, you might want to add something to that.

Yes, just in terms of the risk, I think it is fair to say that our two principal risks in terms of patient care will be those patients in the back of ambulances waiting to be handed over, where we see the clinical risk of the delay in treatment for those patients, and then the other one being those patients who are waiting in the community for a response, and their treatment being delayed as well, and, obviously, resulting in many of the things we've talked about earlier in the conversation. So, I think there is a significant risk that we have to manage within that very front end. But I think it is also worth considering other parts of the front end of the system, such as the emergency department. Many emergency departments are now managing patients in corridors and areas that aren't principally patient-treatment areas, so I think they see a significant amount of risk as well. So, I wouldn't necessarily want to get into some bidding war between us and other parts of the system, and see who's got the biggest risk, as there is risk right across. But, yes, you're right to say that we have a significant amount in terms of that handover and the patients in the community.

My final question is: what confidence do you have in your ability to provide a civil contingency response in the event of a major incident, like they had in the Manchester Arena, for example, and, at the same time, maintain your business continuity? And how does WAST utilise insights from past incidents to improve those operations?

Thank you. So, there's quite a lot in that. In terms of confidence to be able to respond, of course we have plans in place, major incident response plans in place, which are tested not only internally, but also with partners. There's a range of exercises that take place every year to stress test those plans. All of our commanders who operate those arrangements are trained to national training and education standards, and are tested on their competence to do so.

The Manchester Arena inquiry obviously had a significant number of recommendations, and our assessment of those recommendations and their impact on us and the service is just concluding. We've been in discussion with Government officials and with our commissioners about the need to be able to respond to those recommendations already. We'll be bringing forward a business case in due course, which will see a need for some investment to be able to fully satisfy the recommendations from the Manchester Arena inquiry. That's consistent with the ambulance services across the rest of the UK too, as you would imagine. We are close to and understand what's going on in those services as well, and our approach is consistent with those.

And then, in regards business continuity during an incident, it depends on the duration, the nature and scale of any major incident, as to what extent there would be an impact on our ability to deliver routine or core services. But it is fair to say that, certainly in the immediate response to a major incident, we would expect there to be an impact on routine service. We have plans in place to do that, to be able to manage that safely and effectively, and they have been deployed before. And, again, they're consistent with services across the rest of the UK.

Thank you.

Thank you, Joyce. We're just over time, but a couple of quick questions to finish, if I can. Do you have confidence, or what level of confidence do you have in your ability to provide a civil contingency response in the event of a major incident—I'm thinking, for example, such as the Manchester Arena incident—and then maintain your current level of service in that period as well?

I think that goes, if I can, Chair, to the point I've just made. So, if we had an incident similar to the nature of the Manchester Arena, there would be an impact on core service. Let's just be clear about this. There was an impact on core service in the north-west during the Manchester Arena attack, and there was an impact on core service in London during the 7/7 bombings—I can talk personally about this because I was involved, I was one of the people that responded to it. So, whenever there's a major incident, because of the nature of the surge that's required to respond to the incident scene, there is an impact on core service delivery. But we have plans in place to do that in a safe and effective way.

And, Jason, just finally, how will the outcome of the Emergency Medical Retrieval and Transfer Service review and the reconfiguration of air bases in mid and north Wales impact your service, if at all, in your view?

There won't be an impact for us. I recognise this is a deeply controversial issue, particularly for residents in those areas that are affected by the changes. What I would say is that the evidence and the modelling that I've seen suggests that these changes are a good thing to do. More patients will have access to the critical care services provided by EMRTS, as a result of the changes that they do today, and a redistribution of those assets—bearing in mind, of course, that EMRTS is in addition to the road response provided by us; it is not instead of, it's in addition to, and it brings to the patient's side critical care services that we can't offer but are offered in the hospital. It does make sense to me, and seems sensible, to make these changes to be able to offer improved access to more patients across Wales more of the time. But in terms of our ability to respond, there's no impact.

Okay. Thank you for your answer, Jason, and colleagues as well. We appreciate you coming in to committee this morning, and, of course, thank you as well for your evidence papers that you provided ahead of the session as well; we very much appreciate that. We'll certainly send you a transcript of the proceedings to review. And if there's anything else you feel that you want to add, following this session, of course we'd welcome that, but we do very much welcome your time in committee this morning, so diolch yn fawr iawn.

Diolch yn fawr. Thank you very much.

Thank you, all.