Predicting the future of Wales: Welsh Government report published

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Population expansion, economic growth and flooding are just some of the things on the horizon for Wales, according to a ‘Future Trends Report’. The report, published by the Welsh Government on May 5 2017, is a requirement of the Well-being of Future Generations (Wales) Act 2015.

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Physical (in)activity – is it time to get Welsh children moving?

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Many of us are aware of the importance of exercise and encouraging our children to be more active too. But what exactly are the potential benefits of physical activity in childhood? How much are children exercising in Wales today, and how much should they be physically active to stay healthy?

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A financial health check – have local health boards and NHS Trusts in Wales met their financial duties?

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The annual accounts for 2016-17 of National Health Service (NHS) bodies in Wales are the first to report performance against the first statutory financial duty introduced by the National Health Service Finance (Wales) Act 2014.

The annual accounts for 2016-17 for the seven Local Health Boards (LHBs) and three NHS Trusts in Wales were laid by the Auditor General for Wales at the National Assembly for Wales on 9 June 2017.

What are the statutory financial duties?

Under the National Health Service (Wales) Act 2006, each LHB in Wales was required to ensure that the use of its resources in a financial year did not exceed the spending limits set for it in relation to that year by Welsh Ministers.

On 1 April 2014, the National Health Service Finance (Wales) Act 2014 amended the National Health Service (Wales) Act 2006, replacing the duty to balance the books each and every year with a requirement on LHBs to manage their resources within approved limits over a three-year rolling period. This is known as the first statutory financial duty.   It was envisaged that this change in requirement would give LHBs in Wales the flexibility needed to enable more long-term service, financial and workforce planning, as well as helping to ensure the sustainable transformation of healthcare services.

Financial planning in response to the 2014 Act is underpinned by the second statutory duty, which requires that each LHB prepares and has approved by Welsh Ministers a rolling three-year Integrated Medium Term Plan (IMTP).

Welsh Health Circular WHC/2016/054 clarified the statutory financial duties of NHS bodies in Wales and confirmed that, while the change of legislation introduced by the National Health Service Finance (Wales) Act 2014 related to LHBs, the two financial duties also applied to Welsh NHS Trusts.

How will performance against the first financial duty be measured?

Schedule 9 of the National Health Service (Wales) Act 2006 requires LHBs and NHS Trusts to prepare annual accounts. Section 61 of the Public Audit (Wales) Act 2004 requires that these annual accounts are examined and certified by the Auditor General for Wales, who is also responsible for laying a copy of the certified accounts before the National Assembly for Wales.   The annual accounts of LHBs and NHS Trusts report their performance against the two financial duties.

Have LHBs and NHS Trusts met the first financial duty?

The first three-year period under the first financial duty ran from 2014-15 to 2016-17.  Performance against this duty is assessed for the first time in 2016-17 and reported in the annual accounts for 2016-17.

All NHS trusts in Wales met the first statutory duty by balancing their books. However, this was not the case for all LHBs. Only three LHBs reported that they had met the first statutory financial duty by operating within their revenue spending limit over the three-year period 2014-15 to 2016-17. The remaining four LHBs did not meet the first duty, reporting an  overspend over the three years 2014-15 to 2016-17.  The aggregate position for all LHBs for the three-year period to 2016-17 was a net overspend of £253 million. The reported position against the revenue spending limit for each LHB is shown below:

All seven LHBs stayed within their limits for capital spending over the three-year period 2014-15 to 2016-17.

Have LHBs met the second financial duty?

The annual accounts for NHS bodies in Wales from 2014-15 onwards report whether LHBs and NHS Trusts have met the second financial duty.  The performance is summarised below:

A number of these NHS bodies, whilst not having had a three year IMTP approved, have submitted a one-year plan.

What is the impact of the reported deficits?

Paragraph 22, Enclosure 1 of Welsh Health Circular WHC/2016/054 notes that:

Failure to achieve the first financial duty is viewed as a serious matter by the Welsh Government and will be considered in accordance with the NHS Wales Delivery Framework included annually in the IMTP guidance and the escalation and intervention arrangements in the NHS in Wales.

In a written statement on 9 June 2017, the Cabinet Secretary for Health, Wellbeing and Sport, Vaughan Gething AM, set out how the Welsh Government had responded to the financial performance concerns in the four LHBs that reported an overspend in the three-year period 2014-15 to 2016-17. This included monitoring of their financial performance and undertaking financial governance reviews.   The Cabinet Secretary noted that “these reviews have recently concluded, and we will be considering the lessons to be learned and follow-up action required early in this financial year”.

The Cabinet Secretary also reported that:

Additional cash support has continued to be provided when required to all Boards in deficit to enable them to meet their normal cash commitments including payroll expenditure. This cash assistance is repayable in future financial years when appropriate and improved plans are developed and approved under the Act to enable the repayment of deficits.

The requirement to repay the cash assistance and overspends will add to existing financial pressures on LHBs in the short and long term.   The first financial duty is to be assessed on a rolling three-year period.  Therefore, any overspends reported for 2015-16 and 2016-17 will be assessed next year with LHB’s financial performance in 2017-18.    The value of the total overspend reported by four LHBs for 2015-16 and 2016-17 is £198 million.

NHS Wales is facing long term funding and sustainability pressures including an increasingly ageing population with increased morbidity, a growing rate of obesity and related conditions and developments in technology leading to more complex treatments coming on line.

A number of recent reports have highlighted the pressures facing healthcare in Wales. The Health Foundation report The path to sustainability: Funding projections for the NHS in Wales to 2019/20 and 2030/31 (October 2016) stated that the NHS in Wales is “facing the most financially challenging period in its history” and the savings needed are “extremely challenging”. The report set out that NHS Wales needed additional funding, but also improved efficiency and services adapted to meet changing patient needs.

Similarly, the Public Policy Institute for Wales report Efficiency and the NHS Wales Funding Gap (October 2016) identified the need for improved efficiency and service change, but also for a more strategic and sustained national approach to improving efficiency and supporting change. The Welsh NHS Confederation have also highlighted the financial pressures facing NHS Wales and argued that there will need to be some difficult choices made on future services and priorities in an environment where finances will continue to be extremely tight.

The Cabinet Secretary’s written statement of 9 June 2017 reports that he is confident that the health and social services budget has broken even overall in 2016-17. At the same time, the evidence suggests that ongoing and future financial challenges remain.

Article by Dr Paul Worthington and Joanne McCarthy, National Assembly for Wales Research Service.


This post is also available as a print-friendly PDF: A financial health check – have local health boards and NHS Trusts in Wales met their financial duties? (PDF, 407KB)

The Silent Killer. Assembly Members to debate Ovarian Cancer report.

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Ovarian Cancer

Ovarian cancer is often described as ‘the silent killer’ because symptoms are not well-known or often mistaken, meaning the condition is usually discovered in the late stages when successful treatment is much more difficult.

Ovarian cancer is the fourth most common cause of cancer death for women in Wales, with 238 deaths in 2014.

The National Assembly’s Petitions Committee considered a petition submitted by retired palliative care nurse, Margaret Hutcheson who called on the Welsh Government to support yearly screening for ovarian cancer. The petition gathered 104 signatures online. On 9 February 2017, the Petitions Committee published its report. Assembly Members will debate the report in plenary on 27 March 2017.

The Committee’s report

Whilst the Committee did not support the petitioners’ ambition for a national screening programme using the CA125 blood test, they did agree on the importance of early detection, recognising the significance of diagnosing ovarian cancer at the earliest stage. The Committee heard that unfortunately many ovarian cancers are diagnosed at the late stage, meaning that many women will not be treated until it is too late, when their treatment options may be more limited. The Committee said they wanted to see improved screening to permit early diagnosis of ovarian cancer but concluded, that at the moment, there is no screening test reliable enough to use for ovarian cancer:

The Committee took evidence on the effectiveness of the CA125 blood test, and on other potential detection methods, but concluded that there simply is not currently the weight of evidence to conclusively prove that lives would be saved by introducing an annual screening programme. However, they recommended that the potential for such a programme should be kept under review.

There are various trials looking at ways to prevent and detect ovarian cancer earlier.

Cancer Screening

Cancer screening involves testing apparently healthy people for signs that could show that a cancer is developing. Current cancer population screening in the UK includes breast, cervix and bowel cancer screens. In order for a screening test to be made available on the NHS, the test has to be proven to be accurate and safe. There are ongoing studies to find a general population screening test for ovarian cancer but until their work is completed, ovarian cancer screening will not be available in Wales, or any part of the UK. The Welsh Government has made clear that it would not introduce an ovarian cancer screening programme unless it is recommended by the UK National Screening Committee, who provide independent, expert advice to all UK Ministers about screening.

The CA125 blood test

CA125 is known as a tumour marker for ovarian cancer. A tumour marker is a chemical given off by cancer cells that circulates in the bloodstream. Women with ovarian cancer tend to have higher levels of CA125 in their blood than women who do not have ovarian cancer. But CA125 can also be raised for other non-cancerous reasons. So the test is not completely reliable. The CA125 blood test can detect ovarian cancer, but research has shown that it is not accurate enough to be used as part of a screening programme because positive results could also be due to other conditions.

UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS)

The UKCTOCS trial, which commenced in 2001, involved 200,000 women aged 50-74 years. It is a randomised trial in which women taking part are allocated randomly for screening with either CA125 or ultrasound, or to a control group who are followed up without screening. The results of the UKCTOCS trial were published in December 2015. They indicated that screening based on an annual blood test may help reduce the number of women dying from ovarian cancer by around 20 per cent. The result was similar for women who received an ultrasound. However, the results included a large ‘confidence interval’ – effectively the size of the uncertainty in the result. This was due to the low numbers of women who have so far developed and died from ovarian cancer in the trial – about 650 out of 200,000 – and means that the range of possible benefit could be anywhere between 0 and 40 per cent. Therefore, the study concluded that longer follow-up is needed to establish more certain estimates of how many deaths from ovarian cancer could be prevented by screening. As a result it will continue to run for another 3 years.

Committee Recommendations

While the Committee concluded that it could not recommend that annual ovarian cancer screening be introduced, it did make 3 recommendations:

  • That the potential for a national screening programme be kept under review by the Welsh Government;
  • That more work should be done with GPs to ensure that women who present with symptoms of ovarian cancer are referred for appropriate tests; and
  • More should be done to improve awareness of ovarian cancer including identifying common symptoms and advising when people should seek medical help.

Better ways to screen for ovarian cancer are being researched. Hopefully, improvements in screening tests will eventually lead to a lower ovarian cancer death rate.

You can see what some of the main cancer charities; Ovarian Cancer Action, Cancer Research UK and Target Ovarian Cancer had to say on this by visiting the Petitions Committee webpage.

Article by Sarah Hatherley, National Assembly for Wales Research Service.

This post is also available as a print-friendly PDF: The Silent Killer. Assembly Members to debate Ovarian Cancer report. (PDF, 151KB)


Getting there on time? Evaluating the Welsh Ambulance Services’ Clinical Response Model

24 February 2017

Article by Paul Worthington, National Assembly for Wales Research Service

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Ambulance driving along a road

Background to the new clinical response model

Ambulance services in Wales have seen significant and recent change. In April 2013 the Strategic Review of Welsh Ambulance Services (the McClelland review) set out a number of recommendations for improving services, including proposals for new ways of monitoring performance on ambulance response times.

Following on from the McClelland review, from 1 October 2015 Wales Ambulance Services NHS Trust (WAST) implemented a new clinical response model for a 12 month pilot period, which was later extended for an additional 6 months. It was intended that during this trial, only the most serious calls, categorised as Red (immediately life-threatening), have had a response time target. All other calls would receive an appropriate response, either face-to-face or telephone assessment, based on clinical need. The new model has three categories of calls:

  • Red: Immediately life-threatening (someone is in imminent danger of death, such as a cardiac arrest). The target is for 65% of emergency responses to arrive within 8 minutes;
  • Amber: Serious but not immediately life-threatening (patients who need treatment delivered on the scene and may then need to be taken to hospital);
  • Green: Non urgent (can often be managed by other health services) and clinical telephone assessment.

The new clinical response model has also been supported by the development of a series of Ambulance Quality Indicators (AQI), which are published on a quarterly basis and contain a more detailed set of performance measures, including patient experience and clinical outcomes.

Performance against the new targets

The most recent statistics on ambulance response times published by the Welsh Government are for January 2017; Table 1 below shows the trends and Table 2 sets out the figures for January 2017 by Local Health Board area:

Table 1: Average red calls per day, and the percentage arriving at the scene within 8 minutes, Wales


Table 2: Emergency ambulance responses in Wales to red calls, January 2017


The performance data for January 2017 also shows that:

  • There were 39,864 emergency calls, an average of 1,286 per day, 4.3% down on the daily average for December 2016.
  • Of the total, 1,980 (5.0%) were red, 26,456 (66.4%) were amber and 11,428 (28.7%) were green.
  • 75.4% of emergency responses to red calls arrived within 8 minutes, above the target of 65%, but down from 75.8% in December 2016.
  • Performance ranged from 66.2% in Powys to 79.5% in Cardiff & Vale.

Ambulance services inquiries during the Fourth Assembly

In 2015 the Fourth Assembly’s Health and Social Care Committee undertook a short inquiry into the performance of Welsh ambulance services; later in the same year the Committee held additional sessions to examine what progress had been made in response to its original recommendations. This was shortly after the pilot of the new clinical response model had commenced.

As a result of the follow-up inquiries, the Committee wrote to Welsh Government welcoming the fact that the all-Wales target for emergency response times had been met for the first month of new trial model. However, the Committee was concerned that significant regional variations persisted and stated that it would like to see these addressed as a matter of priority and that it expected to see sustained progress in relation to response times at the local and national level.

In his response, the Deputy Minister for Health welcomed the Committee’s recognition of the progress achieved since the initial 2015 inquiry and stated that:

I am proud that we took a step forward for patients by implementing a clinical response model pilot intended to prioritise patients who need an immediate clinical intervention. The pilot is designed to enable ambulance clinicians and resources to be despatched appropriately based on clinical need.

The response also noted the progress made month-on-month against the targets and the publication in January 2016 of the first set of the new AQIs. The Deputy Minister also noted in further correspondence to the Committee that:

During the year-long clinical response model pilot, the AQIs will be published quarterly to allow a clearer understanding of trends and the impact of seasonal variation, sitting alongside the monthly publication of ‘Red’ response times. I can only re-iterate that the way we are sharing key information on ambulance services in Wales makes us the most transparent country in the UK and among the most transparent worldwide.

Review of the clinical response model

The Cabinet Secretary for Health, Wellbeing and Sport set out in a Ministerial Statement in September 2016 that the final evaluation report of the clinical response model was due in December 2016 and that he would make a final decision on the future of the pilot by the end of March 2017.

An interim report on the model received by the Emergency Ambulance Services Committee (EASC) in September 2016 had identified no significant areas of concern. The EASC has also received an update on the draft final evaluation report which indicates that:

…the removal of time based targets for the majority of calls has allowed for more efficient dispatching of ambulance resources, increased opportunities for hear and treat; and supported timely responses to patients with the greatest clinical need.

The EASC was due to have sight of the final evaluation report in January 2017, prior to its submission to the Cabinet Secretary for Health Wellbeing and Sport, who is due to make a statement regarding the evaluation to Plenary on 28 February 2017.

Image Source: Image from Flickr by Diluvienne. Licensed under Creative Commons.