Joseph Cattle

Eluned Morgan AS/MS 
Ysgrifennydd y Cabinet dros lechyd a Gofal Cymdeithasol 
Cabinet Secretary for Health and  Social Care 

Gavin Knox, 
Assistant Coroner 
South Wales Central 
Coroner's Office 
The Old Courthouse 
Courthouse Street 
Pontypridd 
CF371JW 

Dear Mr Knox, 

Llywodraeth Cymru
Welsh Government 

17 April 2024 

Re:  Regulation 28 Prevention of Future Deaths report - Joseph Leonard Scott Cattle 
(deceased) 

Thank you for your letter of 22 February 2024, in which you enclose a copy of a Regulation 
28 Prevention of Future Deaths report ('the report') following the conclusion of the inquest 
into the death of Mr Cattle.  I would like to offer my sincere condolences to Mr Cattle's family 
on their sad loss. 

In the report you ask for details of action taken or proposed by the Welsh Government 
around funding, guidance and targets provided to the Welsh Ambulance Services Trust 
(WAST), Local  Health Boards (LHBs) and  Local Authorities to support improvement to 
ambulance patient handover performance. 

You  also ask about how WAST is funded, and whether this can or should be increased or 
managed differently. I will respond to your two questions in turn. 

What funding, guidance and targets are provided to public bodies with a view to reducing 
ambulance patient handover delays? 

Overall management strategy to support improvement. 

Improving ambulance patient handover performance cannot be isolated to a single 
intervention, process or 'silver bullet' and requires a true whole system effort. This is 
because long ambulance patient handover delays are intrinsically linked to both difficulties 
experienced by community-based services to manage people safely in their home or local 

Rydym yn croesawu derbyn gohebiaeth yn Gymraeg.  Byddwn yn ateb gohebiaeth a dderbynnir yn Gymraeg yn Gymraeg ac ni fydd 
gohebu yn Gymraeg yn arwain at oedi. 

We welcome receiving correspondence in Welsh.  Any correspondence received in Welsh will be answered i n Welsh and corresponding 
in Welsh will not lead to a delay in responding. 

 
 
 
 
 
 
 
   
 
 
 
 community, and challenges with supporting timely discharge of patients from hospitals to 
home. 

The former has an impact on available ambulance capacity as demand for a response and 
conveyance to hospital can increase at certain times of day and during weekends in 
particular; and the latter has an impact on available bed  capacity. A lack of available beds 
can occasionally result in patients waiting longer periods for admission which reduces 
available space in the emergency department, consequentially causing occasionally long 
delays for the transfer of patients from ambulances to the care of emergency department 
clinicians. 

The overarching Welsh Government strategy towards enabling better outcomes and 
experience for people who need to access urgent or emergency care services is set out in 
the Six Goals for Urgent and Emergency Care Policy Handbook. This strategy describes our 
expectations for LHBs and partners to place greater emphasis on assessing the needs of 
their local populations who are at greater risk of needing an ambulance response and 
admission to hospital, and coordinating their care through clear plans and wrap around 
support. 

The document also sets out the intention to safely manage people who do not need to 
access the services of an acute hospital in their local communities, thus freeing up 
ambulance response and emergency department capacity for those who have an absolute 
clinical need for them. 

The handbook also describes expectations of LHBs to improve ambulance patient handover 
processes and to focus on timely flow of patients through the hospital system and out into 
the community. 

We established a national improvement programme ('the Six Goals for Urgent and 
Emergency Care programme') to enable LHBs to deliver on the objectives set out in our 
strategy, and have allocated an additional £50m in support over the past two years. The 
annual Six Goals allocation will increase to £27m in 2024/2025. 

This programme is complemented by other national programmes including the Strategic 
Programme for Primary Care and the Regional  Integration Fund (RIF) programme which, 
among other priorities, both focus on supporting safe avoidance of admission to hospital 
and enabling people to return home from hospital when ready. 

The RIF allocation of £145m per year is intended to create sustainable system change 
through the integration of health and social care services.  Through the RIF's Home from 
Hospital model of care activity,  Regional Partnership Boards are focussing their efforts on 
preventing hospital admission alongside expediting a swift discharge from hospital. This is 
helping people to return  home from  hospital in a timelier manner with the necessary support 
in  place at discharge. 

I have directed each LHB to develop a local 'six goals' programme plan that incorporated 
actions to improve ambulance patient handover performance and patient flow,  among other 
local priorities. This programme plan forms a key part of LHBs' broader Integrated Medium-
Term Plans (IMTPs). 

Welsh Government officials are currently working with the NHS Executive and ambulance 
commissioners to consider additional focused plans to enable consistent delivery of 
condition specific pathways that will support better management of frail / older people 
without the need for conveyance to emergency departments. These plans will also enable 
action to support people with time critical complaints e.g. stroke and/ or STEMI  (a type of 

 heart attack) to avoid the emergency department entirely, through direct access to the right 
clinician, first time. I expect this work to commence in  quarter 1 2024/2025. 

Social Care in the Community 

Welsh  Government acknowledges the  challenges  facing  our social care  workforce and the 
need  to  attract  more  care  workers  into  the  sector to  support  the  work around  community 
discharge and patient flow. Social care is competing with sectors such as retail and hospitality 
in  terms of pay which  are offering  more pay for less intensive roles, therefore the option for 
progression and the ability to build a career in social care is our priority. We are committed to 
raising the profile and status of the workforce through registration of the workforce, promoting 
and  improving  pay,  terms  and  conditions,  through  the  work  of the  Social  Care  Fair  Work 
Forum. 

We are moving in to the third financial year of our Programme for Government commitment 
to pay the real living wage to social care workers in Wales, providing funding circa £113 
million across 2022-23 and 2023-24 to support this commitment.  In 2024-25, the then 
Minister for Finance and Local Government confirmed funding within the Local 
Government's Revenue Support Grant (RSG) to meet the costs of the Real Living Wage of 
£12 an hour for social care workers alongside recurrent funding to the sector in the form of a 
£45 million Workforce and Sustainable Social Services grant, to support a range of 
workforce interventions, including further salary uplifts and to support additional staffing in 
some areas. We also continue to invest in Social Care Wales recruitment campaign, 
'WeCare.Wales', which promotes the variety of roles available in Social Care. 

All of these measures are aimed at improving experience and outcomes and reducing 
pressure on  emergency care services. The demand for social care will continue to grow and 
so it's essential we all have effective workforce planning systems in place to meet this 
demand. We will continue to work in partnership through the Social Care Fair Work Forum 
with unions and employers on what steps can be taken to further improve terms and 
conditions for this sector and make social care a more attractive place to work. 

Quality statement for care in ED 

I recently 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 across Wales. 

In  2024-25, LHBs will focus their plans on the delivery of a small number of clinically 
endorsed priorities, including two actions focussed on patient flow and  experience in 
emergency departments: 

•  Reduce risk of harm caused by crowding in emergency departments; and 
• 

Improve patient experience by providing better quality facilities and alignment of the 
right workforce capacity to respond to patient demand. 

Hospital discharge guidance 

Hospital discharge is an  important part of efficient patient flow,  and we are taking forward a 
number of initiatives to help ensure a person is discharged as appropriately, safely and 
timely as possible once their treatment has been completed and they no longer need to be 
in  hospital. 

The Welsh Government has published updated  Hospital Discharge Guidance aimed at 
frontline staff to support their discharge processes. The guidance has also been expanded 
to include more detailed supporting information for patients, their families and carers, on 

 discharge practices from admittance to a hospital ward to the point they are ready to be 
discharged. 
The guidance includes specific information on support for patient transport as well as the 
considerations that should be taken to ensure that people are discharged efficiently but 
safely, either back home or to their usual place of residence, and with the right level of care 
and support if this is required. 

In addition, Discharge to Recover then Assess (D2RA) Pathways Guidance is in place to aid 
patient flow and appropriate discharge. Under D2RA pathways, patients admitted to hospital 
should be assessed and  provisionally allocated to one of four pathways as early as possible 
following admission. This is to identify what level of support and recovery they will need at 
the point of discharge. 

To ensure we have accurate data on delayed discharges, the Pathways of Care Delays 
{PoCD) Reporting Framework has been implemented. This is a formal  reporting mechanism 
that provides health and social care partners with a  comprehensive and vital overview of 
their regional discharge delays so that relevant interventions and actions can be targeted 
more appropriately. 

The monthly PoCD data ensures health and social care teams have a clear position on the 
areas that have the highest numbers of delays and the most consistent delays. Regions are 
asked to use this data to draw up coordinated action plans between health and social care 
partners to establish new or improved working practices aimed at tackling largest delay 
groups. 

Further guidance,  targets and monitoring. 

In practice, the Welsh Government monitors the performance of NHS Wales bodies in 
several different ways. In  relation to the monitoring of ambulance patient handovers to 
emergency departments, a number of specific measures have been put in  place in order to 
ensure the Welsh Government can assess how LHBs and WAST are performing. 

A Welsh Health Circular ("WHC") was issued in 2016, setting out expectations of LHBs and 
partners to deliver timely ambulance patient handover through consistent delivery of a range 
of actions for both pre and post arrival such as:  communication, alternative pathways, 
staffing levels, and booking in processes.  It is the expectation of the Welsh Government that 
these actions are done consistently to meet handover targets. 

LHBs are expected to take this guidance into account when exercising their functions. 
Although the WHC includes an objective that patients arriving at an emergency department 
by ambulance should be handed over to the care of emergency department clinicians within 
15 minutes, it accepts that in exceptional cases, patients may have to wait up to 60 minutes. 
The WHC sets out what the LHB and WAST must do when a handover exceeds 60 minutes. 

Audits of LHB delivery against the guidance have previously been undertaken on the behalf 
of Welsh Government by the NHS Wales Delivery Unit. Monitoring and  scrutiny of delivery 
of the policy expectations within the guidance is undertaken through a number of 
mechanisms. 

Securing improvements in ambulance patient handover performance was established as 
one of a small number of Ministerial priorities in the NHS planning framework in 2023/2024 
and this has been rolled over in 2024/2025. 

This requires LHBs to develop plans to achieve the national ambulance handover 
performance target that no patient will wait longer than one hour for transfer from 

 ambulance vehicles to the care of emergency department clinicians. This target was also 
included as an objective for all LHB chairs for 2023/24. I consistently seek assurances from 
Chairs of LHB on their LHB's commitment to making improvements through regular national 
meetings. I hold regular meetings with the Chairs,  and performance against targets is a 
recurring topic. 

Assurance on progress made by LHBs against ambulance patient handover targets is also 
sought by Welsh Government officials and NHS Executive officers through bi-monthly 
integrated quality planning and delivery meetings. 

Performance against this specific target is a standing agenda item at each LHB meeting 
(with the exception of Powys LHB, as it does not possess a major emergency department 
within its borders).  LHB executives with responsibility for quality, planning and performance 
- for example Medical Directors, executive Directors of Nursing,  Directors of Planning and 
Chief Operating Officers - are asked to provide an update on plans to achieve the national 
target at each meeting, and Welsh Government and NHS Executive officers provide 
challenge and scrutiny, reinforcing policy expectations. 

In addition to ambulance patient handover targets and expectations to reduce pathways of 
care delays, LHBs are also expected to describe in local six goals programme plans how 
they will reduce the numbers of patients spending longer than seven,  14 and/ or 21  days in 
hospital beds. These measures are intended to optimise patient experience, reduce risk of 
deconditioning and reduce bed occupancy; thus enabling timely flow of patients through the 
hospital system and out into the community. 

Where there are concerns about progress, the Welsh Government's Quality and Delivery 
Board is briefed with  recommendations for additional action including escalation to Joint 
Executive Team meetings held between executives of both Welsh Government and the 
relevant LHB. These meetings are held every six months. Where concern remains about 
performance, discussions are held at tri-partite meetings with Audit Wales and Health 
Inspectorate Wales, which inform recommendations made to Cabinet Secretaries on a 
LHB's escalation status. 

If potentially serious concerns arise, further steps may be taken. A serious concern arises 
when the severity, frequency or persistence of problems appears to exceed that which can 
be dealt with through routine arrangements. The Welsh Government and external review 
bodies, as appropriate, will work closely with the NHS body to ensure potential serious 
concerns are explored and their causes understood. 

If there is no longer any cause for concern, the NHS body will be informed, and  routine 
arrangements will continue.  If it is established that there is an issue that requires action, 
then the Welsh Government and external review bodies will consider the seriousness of the 
issue,  their apparent causes and the capability and capacity of the NHS body to resolve 
them before making decisions on the form and extent of the action required. However, the 
Intervention Guidance states that these formal powers are seen as a last resort and will 
normally only be used if other intervention is unlikely to succeed. 

How WAST is funded, and whether this can or should be increased or managed differently. 

LHBs in Wales are provided with an  initial revenue allocation on an annual basis. For 
Hospital and Community Health Services and Prescribing, LHBs are responsible for 
commissioning services for their resident population from within their core allocation, which 
would include funding to  be  provided to WAST under commissioning arrangements for the 
provision of their service. 

 Up until the end of 2023/24, WAST received a core funding allocation via the Emergency 
Ambulance Services Committee. The Committee, made up of the chief executives of LHBs, 
a chair and the Chief Ambulance Services Commissioner, held statutory responsibility for 
the planning and securing of sufficient emergency ambulances services for the population of 
Wales.  Discharging this responsibility requires close collaboration between commissioners 
and WAST, as the provider organisation, to ensure that all available resources are used 
effectively. 

These commissioning arrangements were reviewed  in 2022-23 as part of a wider 
independent review of national commissioning  of NHS services in Wales. That review 
recommended establishing a new joint committee of LHBs to hold responsibility for 
commissioning of specialised services and emergency ambulance services among others. 
The new NHS Joint Commissioning Committee (JCC) was established on 1 April 2024 and 
now has responsibility for planning and securing emergency ambulance services for the 
people of Wales.  It is for the committee to consider all relevant factors in determining the 
quantum of funding allocated to WAST for delivery of emergency ambulance services. I will 
hold the chair of the NHS JCC to account for effective commissioning of emergency 
ambulance services and,  as described previously in this letter, achievement of the 
Ministerial priorities I have set of all organisations from 2024/2025 onwards. 

Additional funding. 

In terms of procuring ambulance vehicles, WAST submitted a Strategic Outline Programme 
(SOP) in 2016 that was endorsed by Welsh Cabinet Secretaries for its Vehicle Replacement 
Programme. The endorsement of the SOP allows WAST to submit Business Justification 
Cases (BJCs) setting out its vehicle replacement requirements on an annual basis.  I will 
then make a decision on the BJC. Capital funding over the last three years is as follows:-

•  2021-22 - £10.854m 
•  2022-23 - £12.230m 
•  2023-24-£11.121m 

The SOP will be refreshed on a regular basis. It is important to recognise that the SOP 
covers the WAST fleet of vehicles and not only emergency ambulance vehicles. 

In addition to this core funding, we provided £3m to the WAST in 2022/2023 to enable 
recruitment of 100 new staff. WAST also has access to national programme funding 
budgets including the Six Goals for Urgent and Emergency Care programme's innovation 
and delivery fund. 

Yours sincerely, 

Eluned Morgan AS/MS 
Ysgrifennydd y Cabinet dros lechyd a Gofal Cymdeithasol 
Cabinet Secretary for Health and Social Care