4. Statement by the Cabinet Secretary for Health and Social Care: Six Goals for Urgent and Emergency Care Two Years On

– in the Senedd at 3:11 pm on 11 June 2024.

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Photo of David Rees David Rees Labour 3:11, 11 June 2024

(Translated)

Item 4 is a statement by the Cabinet Secretary for Health and Social Care, six goals for urgent and emergency care two years on. I call on the Cabinet Secretary, Eluned Morgan.

Photo of Baroness Mair Eluned Morgan Baroness Mair Eluned Morgan Labour

Diolch yn fawr, Dirprwy Lywydd. Thank you for the opportunity to provide an update on the progress we've made over the second year of our six goals for urgent and emergency care programme. Demand for urgent and emergency care has risen consistently as we've emerged from the pandemic, and the last 12 months have seen this trend continue. For too long, the always-open door of the emergency department has meant that it, and the dedicated staff working in units all over Wales, have been at the forefront of responding to this surge in demand generally, as the only ever-open front door.

We set up the six goals programme two years ago to ensure that people get the right care from the right healthcare professional at the first time of asking. For a great many people, that means that the emergency department is not the most appropriate place for them to receive the right level of care, but, until two years ago, they had no alternative but to use the emergency department when they’ve needed urgent care. The six goals programme is changing that.

Last year was another extremely challenging year for urgent and emergency care services, but, despite the combination of higher-than-expected demand coupled with industrial action from 'Agenda for Change' unions and junior doctors, the hard work of NHS staff and the work of the six goals programme has helped to stabilise emergency care performance. More than 0.75 million people completed their treatment in emergency departments within four hours in 2023-24—that’s 57,000 more people compared to the previous year. Response times for amber 999 calls improved, and more than 26,700 people received an ambulance response in eight minutes to a life-threatening 999 call—that's up 13 per cent on the previous year.

Now, we've seen encouraging improvements in some areas, including Cardiff and Vale, in reducing ambulance patient handover delays. However, there is unwarranted variation in performance across Wales, with issues intrinsically linked to challenges in supporting timely discharge of patients from hospital to home. These matters will need to be addressed with urgency over the first part of this year. Whilst there has been progress, there is, of course, still much more to do. Too many people are experiencing long delays in emergency departments, which in turn increases their risk of harm. This is not acceptable and will be a focus for the six goals programme in its third year.

Dirprwy Lywydd, today I'm publishing the second annual six goals progress report. We've continued to support NHS organisations with £25 million in additional programme funding to respond to my priorities to increase urgent care capacity as part of a move towards a 24/7 integrated urgent care model, and to expand same-day emergency care services at the front door of hospitals to help more people to safely avoid admission. We also published the quality statement for care in emergency departments, which sets out the outcomes and standards people should expect to receive when accessing care in high-quality emergency departments.

Since I launched the six goals programme, we have set up 16 urgent primary care centres across Wales, serving a population of 2.2 million people. During the second year of the programme, these services have grown and the latest data shows around 11,000 people are accessing these centres every month. Eighty-five per cent are safely managed without needing to access an emergency department. The expansion of same-day emergency care services over the last year means that more than 7,500 people are using these services every month. Eight out of 10 are discharged home on the same day without needing to be admitted to hospital.

The programme has provided funding to health boards to support care home staff to help more people receive care and treatment in their place of residence and reduce ambulance attendance and conveyance to the emergency department. Our intent is that people who live in residential and nursing homes, if they become unexpectedly unwell, will be remotely reviewed by a senior nurse or doctor in a timely manner and, where appropriate, access safe alternatives to conveyance and hospital admission.

Year two of the programme has also seen the launch of new pathways, including a new NHS 111 pathway to provide advice to parents of young children to help safely avoid unnecessary trips to the emergency department, and fracture liaison services to help frail adults prevent or reduce future urgent care episodes, and I had the opportunity to discuss this in detail last week during the short debate about bone health. Also, access to wearable devices and monitoring technology will also help people to either safely avoid hospital admission or to return home from hospital when they're clinically ready to do so.

Photo of Baroness Mair Eluned Morgan Baroness Mair Eluned Morgan Labour 3:17, 11 June 2024

(Translated)

Dirprwy Lywydd, the six goals programme is helping to provide better and more appropriate services for people who need urgent and emergency care. It has also helped to stabilise emergency care performance in the face of rising demand. But I am clear that there is much more that we need to do. Some of the issues facing emergency care and hospital discharge, in particular, are deep-rooted and complex. We are committed to continuing to support NHS organisations and regional partnership boards through this programme and other national transformation programmes.

Moving into the third year of the programme, I expect a renewed vigour, determination and a collective resolve to make tangible inroads against these challenges. I want to see a greater focus on proactively supporting people to stay well, preventing deterioration, and enabling them to receive acute care in community settings, and to do so safely. 

This year, there will be more rigorous expectations for improvement against key system markers like ambulance-patient handover performance and unsafe long stays in emergency departments. We will continue to strengthen 24/7 urgent care services, and we will further develop same-day emergency care services and reduce the length of patient stays in hospital, targeting the frail population. On top of this, there will also be a focus on the development and optimal use of enhanced clinical pathways. This will enable more people to access the right services for their needs first time, and it will also reduce demand on emergency departments. 

For urgent care, as part of the clinically safe alternatives to admission, health boards will be expected to demonstrate an increase in the number of people who receive enhanced community care by September 2025. The aim is to provide care closer to home, where that is clinically appropriate.

Health boards will continue to receive additional funding to support the delivery of these priorities. This is part of a wider £180 million investment this year to support NHS organisations and regional partnership boards to deliver integrated solutions across health and social care. All of these actions will form part of our overarching plan to support resilience over the winter period.

We can all do our bit to support the NHS by taking small steps to look after our own health, by taking regular exercise and eating a healthier diet. We can also help by choosing the service that is right for our healthcare needs when we're ill and need help rather than heading automatically for the GP surgery or the emergency department. If you don't know where to go, NHS 111 can provide help and support. Thank you.

Photo of Gareth Davies Gareth Davies Conservative 3:20, 11 June 2024

(Translated)

Thank you for the statement, Cabinet Secretary.

Photo of Gareth Davies Gareth Davies Conservative

It's hard to disagree with the six goals and aims, such as signposting people with urgent care needs to the right place. They're common sense and should be a priority for any Government. However, beyond warm words, it's clear that there are significant and serious issues in the health system, and the recent statistics showing the longest waiting lists on record in the Welsh NHS are clear proof of that, along with the catalogue of failings in the Betsi Cadwaladr University Health Board, which has the lowest percentage of emergency department attendees seen within the 12-hour target. Despite the best efforts of staff on the ground, people across Wales are suffering due to poor management of the health service, which begins here in Cardiff Bay. This has been the case for far too long, and we need these plans to make real systemic change in our health system to make sure that the residents that we serve can get the quality, efficient treatment they deserve.

I'd like to ask about the timescales for the targets that have been set. In the original plan, there are a variety of so-called initial priorities, so how many of the deadlines that have come and gone have been achieved and how many were not? Additionally, there are a number of goals with deadlines by the next Senedd elections in 2026. How likely are those to be met by that time? And to take one example, a particularly important target is that each person assessed as having an urgent primary care need will reliably have access to the right professional or service for that need within eight hours of contacting the NHS. Achieving goals like that will make a difference for people, but the action has to be carried out and not just left as words on a page.

This is also a cross-portfolio plan and, in the original document, it was yourself, the then Deputy Minister for Social Services, and the then Deputy Minister for Mental Health and Well-being. Could you expand on how this cross-portfolio working has developed with the new set of Ministers? And how are you all working together on the continued progress of the six goals plan?

Finally, Cabinet Secretary, the original plan talks about mental health support and outlines the importance of a co-ordinated response from services across the urgent and emergency care pathway. There are many different moving parts to mental health care, as we all know, and responding rapidly to those in need is of vital importance. The commitment to expand provision, such as sanctuaries, houses or crisis cafes, is set for April 2025, so, within the next 12 months, what groups are being worked with to meet that goal? And what will you do, from this point on, to ensure that this target is met, Minister? Thank you.

Photo of Baroness Mair Eluned Morgan Baroness Mair Eluned Morgan Labour 3:23, 11 June 2024

Thank you very much. Well, I'm really pleased to hear that you think that systemic change is what's needed, and this is precisely what this is: it's systemic change. It's not doing more of the same and thinking you're going to get different results. So, this is about things like the introduction of the same-day emergency care service, which has increased significantly over the past two years, and urgent primary care centres that are taking literally thousands of people, every month, away from our emergency departments.

And the 111 service, on average, we are seeing at least 70,000 people calling the 111 service on a monthly basis. Don't forget, that service didn't exist two years ago, and that's just the 111 service. There's a '111 press 2' service, which is separate, for mental health. And, as I explained, there's now one specifically for children, and also a 111 service where you press 0 for palliative care. So, all of these things are there to make sure that people have the reassurance that they need, but also that they're directed to the right care and the right experts. And I think that's exactly what you're pointing to is that systemic change.

So, the real issue, in terms of challenge here, is demand. The demand is just unbelievable. It just keeps on coming. If you just look at the red calls for ambulance response times, we've seen the number of red calls double—more than double—since pre-pandemic times. More than double. And then since the end of the pandemic, it's increased again 21 per cent since this time last year. That's a massive, massive increase in demand. Now, okay, we're putting the money in place—we're putting in £25 million additional funding for some of these things—but I think what's quite impressive is despite that massive increase in demand, the average response time, for example, to amber patients, improved, and over 80 per cent of patients in the red category received a response in 15 minutes. Not good enough, but definitely, if you think about the demand, I think it's a performance that obviously needs to be improved upon, but it could have been a lot worse. And what is really interesting, I think, is to note that this approach is something that actually other people are looking at now. So, England are looking at our model, because the fact is, there has been stability in relation to emergency care compared to the English system, and over the past 18 months there has been a better performance in relation to emergency departments in Wales than there has been in England, and those now have been independently verified. So, yes, there is more to do.

On the cross-portfolio working, I worked very closely with Julie Morgan before. I am now working very closely with Dawn Bowden, who is obviously responsible for care now, but also with local government. We have very frequent meetings. I'm meeting with Julie James tomorrow to talk about what we do next and preparing for winter, because obviously, as you know, there is always significant challenge over winter.

On the sanctuary side of things, some have been developed already, but we're doing one thing at a time. So, we'll get to that, but at the moment there is a very clear programme, and obviously we're just doing one thing at a time.

Photo of Mabon ap Gwynfor Mabon ap Gwynfor Plaid Cymru 3:27, 11 June 2024

(Translated)

Well, it appears that 'plan' is the word of this general election. There is a plan for everything. Sunak has a plan. Starmer has a plan. The world and his dog has a plan, apparently. Nobody has more experience of preparing plans than the Welsh Government, with plans coming out of their ears, particularly in looking at the health service, and now we have another plan here this afternoon—this time, a plan on urgent and emergency care.

But any plan is reliant on its substance and implementation, and despite the positive headlines in launching these plans, the Government's record has been very weak on delivery. The six goals before us today are a clear example of this. The progress on the implementation of the six goals has been inconsistent at best, and it's concerning that it appears that we are moving backwards in certain areas. So, I want to paint a very different picture to the one that's been painted by the Cabinet Secretary this afternoon.

Photo of Mabon ap Gwynfor Mabon ap Gwynfor Plaid Cymru 3:28, 11 June 2024

For example, improving ambulance patient handover is at the heart of the goal for rapid response in a physical or mental health crisis, but the latest available statistics show that ambulance handover lost hours were 24.8 per cent higher compared to the previous year. Indeed, in 2022-23, a total of almost 300,000 hours were lost by the ambulance service due to handover delays—the highest figure on record. The goals also include a target for year-on-year improvements in response times to red and amber calls, up to April 2026, as we heard. But the median response time to red calls is currently 8 minutes 17 seconds, which is 43 seconds slower than the same time last year. Fewer than half of red calls lead to a response within eight minutes, with the Government's target of 65 per cent having been merely ornamental for some time. Meanwhile, the median response time for amber calls is 1 hour 15 minutes and 18 seconds—a full 12 minutes slower than the previous year.

A similar story emerges with discharging patients from hospital beds. In April 2024, there were 1,738 people occupying an NHS hospital bed that experienced a delay in their transfer of more than 48 hours—the highest monthly total in 12 months. Based on Royal College of Nursing calculations, this means that more than 576,000 people in Wales experienced delays in their care across an entire year, which equates to over 1 million days of delay in total. 

Welsh patients also continue to face long hospital stays, despite the plan's aim to facilitate a greater shift away from hospital-based care. Research commissioned by the Government on this issue last year corroborated studies showing that hospital stays in Wales remained significantly higher than those in England. Furthermore, in the absence of reliable and resilient arrangements to facilitate this shift, we have instead witnessed an alarming rise in unsafe corridor care in recent years, as outlined in an RCN report published at the start of this month. 

Then, we have to contextualise the preventative aspects of the plan to reduce the risks of readmissions with the reality that funding on preventative programmes has been contracted in recent years, as this Government has had to throw ever-increasing resources at fighting fires at the front line. 

There's nothing wrong with having ambitious plans, and I'm certainly not accusing the Cabinet Secretary of lacking ambition in this plan. But there's nothing worse than ambition that does not have a credible path to delivery. And I'm sure the Cabinet Secretary will agree with me that a failure to be upfront and honest about what is achievable can have damaging implications for public confidence in our health service, as well as the morale of its staff. 

Can I ask the Cabinet Secretary, therefore, in light of all the statistics I've listed in my contribution, whether she truly believes that urgent and emergency care in Wales is more efficient, streamlined, and, most importantly, safer than it was when the plan was developed? Does she also agree that achieving the goals in this plan would have been much easier and much quicker if Wales had a fair funding model from Westminster?

And finally, when referring to problems within the waiting times, for instance, the Cabinet Secretary, like Sunak, refers to the impact of industrial action by NHS staff. But they are taking industrial action to highlight the dangers within the health service, and the need to improve working conditions and recruit more. Does she accept, therefore, that this criticism is unfair?

Photo of Baroness Mair Eluned Morgan Baroness Mair Eluned Morgan Labour 3:32, 11 June 2024

Diolch yn fawr. I will agree with you that if we had more money we could do more, and that would very much be welcome. And, obviously, we're hoping that a new Labour Government will help to stabilise the economy and that more money will then flow into public services. 

I think it's really unfair to say that there is no plan. It's not just a plan; we've actually delivered here. I won't say that about everything that I do in my portfolio, but on this one, I really think this is an area where we have seen a transformation. The fact is there are 80,000 people every month who now are able to phone an alternative to an emergency department or a GP practice. That's not a plan; that's something that's being delivered. It's the same thing for same-day emergency care centres—7,500 people are now not going to the emergency departments, they're coming in to the same-day emergency care centres and they're leaving to go home the same day. Urgent primary care centres—16 of them, 16 new centres, 11,000 people a month. This is not a plan. This is what's being delivered. I do think it's really important to note that.

Is it pressurised? Absolutely, it's pressurised. And why is it pressurised? It's because the demand has just increased and increased and increased. As I say, it's doubled since before the pandemic, and since the pandemic we've seen a 21 per cent increase in demand. You're not going to manage to fix that at the flick of a switch, which is why this is a much more strategic and systemic approach that is trying to look at what it is we need to do across the whole system.

The fact is that, in April, we had the third highest demand for ambulances on record. [Interruption.] It's not good enough, but that was the third highest on record. And yet—[Interruption.]

Photo of David Rees David Rees Labour 3:35, 11 June 2024

Cabinet Secretary, hold on a second. There are Members who are making comments from sedentary positions. Let the Cabinet Secretary respond to the questions that were put to her, please.

Photo of Baroness Mair Eluned Morgan Baroness Mair Eluned Morgan Labour

And yet, 70 per cent of patients spent less than four hours in emergency care facilities, and the average time to triage was 20 minutes. So, you're right, it's not good enough—of course it's not good enough—but we are going to take a bit of time to cope with trying to deal with that enormous increase in demand. And these kinds of systems, responding with the six goals programme, I think has alleviated this. Just imagine what it would have been like had we not introduced this programme.

In relation to strikes, obviously we want to avoid industrial action. We can't do any of this without the workforce. That's why I was particularly pleased that we were able to make an offer to three sections of the BMA last week and that that will be recommended to their members. I hope that that means that we'll be able to continue to deliver the service that the people of Wales deserve and require.

Photo of Joyce Watson Joyce Watson Labour 3:36, 11 June 2024

Thank you for your statement today, Cabinet Secretary. I think the most important thing about the six-point plan is that people get the right care, at the right time, and in the right place. Opening up 16 urgent primary care centres across Wales is a really, really good investment, because most of those urgent primary care centres are closer to home than the A&E—as most people refer to it—would have been. And it also means that they can then carry on with the ongoing care afterwards, because they're in their localities, and they'll be seen and treated by people who know and understand their needs. You can't overstate that. The £25 million additional programme funding to increase urgent care capacity to 24/7 will again help in alleviating what is an emergency care pressure that you've just identified. And if you ask anybody—

Photo of David Rees David Rees Labour 3:37, 11 June 2024

You need to ask your question now, please, Joyce.

Photo of Joyce Watson Joyce Watson Labour

I am going to. If you ask anybody that's been there, they will tell you they have good service. So, going forward, and, again, looking at progress along the plan, when can we expect to see the next statement from you that shows, I suspect, even further progress on this path?

Photo of Baroness Mair Eluned Morgan Baroness Mair Eluned Morgan Labour 3:38, 11 June 2024

I'll try and make another statement next year. I think it's really important, because I like to keep the momentum going. I think there's been real progress—this is real delivery. But there's quite a lot we've done that I haven't mentioned. For example, we've put £5 million into the allied health professional community workforce, trying to make sure that people get that support in the community—the physiotherapists, those reablement workers—trying to make sure people are fit and healthy and they don't need to then go into a hospital. One of the things we're doing is we've increased—and Jenny Rathbone will be pleased to hear this—the amount of money going in to community nursing and specialist palliative care nursing in the community, particularly at the weekend. We're identifying the 0.5 per cent of people at the greatest risk of going in to emergency care. We know who's likely to finish up in emergency care, so we put the support in before they get there—try and keep them at home and give them the support. I think there are a lot of really exciting things that we're doing.

On top of that, of course, we've got the pathways of care delays reporting framework—that's now been in place for a year—so we know what's the hold-up, why are people still in hospital. All of that now is an all-Wales system, so we can hold everyone to account. And then, there's the thing I talked about last week—the fracture liaison service. One in two women over 50 are going to break a bone after 50. And if you've broken it once, the chance of you breaking it again is much greater. With this development of a fracture liaison service, we've done a huge amount of analysis to look at what are the costs involved in this, not just to the person but to the NHS, and it's enormous. So, why don't we put that support in? Once we know if somebody has fallen, put the support in to make sure they don't fall again and finish up back in hospital, particularly those people who then find it difficult to get home. So, all of that, I think, are really positive developments.

Something I'm particularly keen on is trying to get care homes and nursing homes to take a bit more responsibility, to be a bit less risk-averse, not to just send people in to hospital. Because if they go into hospital, they'll be there for a long time. So, let's bring the hospital to them, let's get the consultants on a remote monitoring machine to say, 'Right, let's have a look at them. What are they like?' Because if they go into hospital, it's going to be really difficult to get them out, and they don't want to be in hospital; they want to be in their home environment. So, that's what we're trying to do—again, to identify who are the people who are likely to finish up in hospital. If they go to hospital, they're likely to stay there for a long time, and nobody wants that. 

Photo of David Rees David Rees Labour 3:41, 11 June 2024

(Translated)

Thank you, Cabinet Secretary.