Winter Protection Plan 2020-2021

Published: 16 September 2020

PURPOSE The Winter Protection Plan is Welsh Government’s overarching plan which describes the broad context and priorities for health and social care until March 2021. It sets out for stakeholders the range of actions and contingencies that are expected to be put in place across the health and care system, and with wider partners, to manage the public health emergency and provide services over the coming challenging winter period. It provides assurance to the public that we are working together across the country to keep Wales safe. PREPARING FOR WINTER Since the first COVID-19 peak earlier in the year, the NHS in Wales has been developing and implementing plans which focus on preventing four harms: Action has been taken to reduce the impact of the four harms which include:  remaining ready to provide the full range of services needed to prevent, diagnose, isolate and treat COVID-19 patients and  ensuring that we can continue to provide services that are essential at all times. This includes services that are urgent and life threatening or life impacting as well as services that without timely intervention could result in harm over the longer term such as maintaining vaccination programmes  reinstating routine services where it is operationally possible and safe to do so, with strict adherence to infection prevention and hygiene procedures and maximising the use of virtual consultations  clinicians working tirelessly to review referrals of those waiting and ensure people have been prioritised according to clinical need. The Winter Protection Plan adopts a cautious and flexible approach, building on new ways of working and retaining the agility and flexibility which we used to respond to the challenge of COVID-19 itself. Whilst the COVID-19 pandemic has had a profound effect upon the delivery of NHS and social care services, as well as changing the behaviour of the general public in the way they access healthcare, the vision we set out in A Healthier Wales for seamless health and social care remains sound. We remain committed to delivering 5 the transformation needed at pace and scale. This will be crucial to support people and their carers through challenging winter pressures as well as tackling the impact of COVID-19. We will continue to work together to support vulnerable people in their own homes, in hospitals, in care homes, in supported accommodation or other settings. This means:  a whole system approach where seamless support, care or treatment is provided as close to home as possible  services designed around the individual and around groups of people, based on their unique needs and what matters to them, as well as quality and safety outcomes  people only going to a general hospital when it is essential, with hospital services designed to reduce the time spent in hospital  a shift in resources to the community that enable hospital-based care, when needed to be accessed more quickly; using technology to support high quality services. RESEARCH, INNOVATION AND LEARNING Learning and sharing is already taking place across organisations and sectors on a regular basis to inform our ongoing management of COVID-19. The Welsh Government is also working with partners across health and social care to produce a report on the findings from the numerous studies that are being undertaken to identify innovation and new ways of working during the COVID-19 response. This report will be published by the end of the year to inform future planning. Numerous ground-breaking discoveries have resulted in novel and innovative ways of preventing and treating illness that have greatly improved health and wellbeing for the benefit of patients and public. The coronavirus pandemic has demonstrated that effective treatments for disease will only happen through research. Since March, Health and Care Research Wales and NHS Wales have played a vital role in setting up research focused on how we diagnose and test for COVID-19; how we treat patients to enable them to recover; and how we can prevent people contracting COVID-19. In a short space of time, over 7,000 patients in Wales have taken part in research studies. Learning from this research has already informed clinical practice worldwide and this work will continue with Wales taking part in the UK research effort which includes the development of an effective vaccine. PROTECTING THE PEOPLE OF WALES We are listening and learning all the time and the views and questions that have been raised with Welsh Government, including via social media sessions, also help shape our understanding of what matters to people in Wales. To maximise their effectiveness and to ensure they do not make inequalities worse, preparations for 6 winter are informed by evidence drawn from engagement with patients, carers, the public health and social care professionals and professional organisations In Wales we have said we will be guided by the science and our Technical Advisory Cell (TAC). This is still the case and will help us make the right decisions for Wales when it comes to how we will support people over the winter. A key objective for our TAC experts is to interpret national working group outputs into a Welsh context. In addition to this, they provide advice on specific technical areas such as testing, schools and children. They have identified the likely requirements for scientific and technical advice related to COVID-19 in Wales in order to help us prepare for a challenging winter. This includes identifying ‘circuit breakers’ (or triggers) that will help to understand pressure on the NHS and elsewhere so that we can ‘step up’ our response in a planned way, should COVID-19 increase. This will mean we are prepared for any peak. We are also developing early warning signs that can inform on any necessary escalation and de-escalation actions – both locally and nationally. PREVENTION AND RESPONSE Our Test, Trace, Protect Strategy enables us to locate and protect individuals and their contacts as an alternative to national lockdown. It provides a wealth of intelligence on the spread of the disease and the nature of transmission. It also enables us to identify clusters, incidents and outbreaks and take swift and appropriate action. In order to manage clusters, incidents and outbreaks, we have a National COVID-19 Prevention and Control Plan which provides a summary of the overall approach to preventing and containing the spread of coronavirus across Wales. Prevention is always better than cure so preventing the spread of coronavirus should be our overriding priority. We will take a precautionary approach when considering whether to impose new restrictions and where there is uncertainty we should err on the side of caution. However, our actions must also be proportional to what they are seeking to achieve – the Welsh Government’s interventions should not be more restrictive than is needed to contain the virus. We must take care not to take action that harms the people of Wales in other ways. Returning to all Wales restrictions is not what we want to see. It is therefore important that everyone plays their part in helping to prevent and contain the spread of the virus. We want to take a more local approach, so that decisions are taken at the most appropriate level, using local knowledge and expertise to inform decision making by local elected Leaders and local action. In Wales, we already have a well-established way of bringing together all the relevant local agencies through Incident Management Teams and Outbreak Control 7 Teams. Our plan also envisages the need to create local or (if required) regional Enhanced Health Protection Areas. Although this involves restrictions once again being imposed, the intervention should be more targeted and shorter in duration. It will also be tailored to the situation in each locality or region As we have seen recently in areas like Wrexham and Caerphilly, we have moved swiftly to take action when rates of the virus have increased. The seven local health boards are working closely with relevant local authorities and other partners to put in place local COVID-19 prevention and response plans for their areas. These local plans describe how health boards, local authorities and other partners, such as the Test Trace Protect regional teams, businesses and other organisations in the area will work together. The plans set out the measures taken locally to prevent the spread of the virus, drawing on evidence of areas of high transmission risk. They describe how any rise in local cases and clusters will be identified and what the local response will be. Our approach to escalating our responses is illustrated below: Test Trace Protect The Minister for Health and Social Services published our Test, Trace, Protect (TTP) strategy in May. It was developed in consultation with key partners including Public Health Wales, health boards and local authorities. The Test Trace Protect strategy is published here: Our Test, Trace, Protect strategy, built on scientific evidence and drawing on international experience, is to enhance health surveillance in the community through mass population testing of individuals with symptoms, undertake effective and extensive contact tracing, and support people to self-isolate where required to do so. Test, Trace, Protect is about reducing the harm caused by coronavirus and helping the public and professionals get back to their normal daily lives. It sets out what we need to do to prevent transmission of the infection and to track the virus as restrictions begin to be eased and we move into the next phase of the response to the COVID-19 pandemic. The people of Wales are our most important partners. It is only through their willingness to do the right thing – follow hand hygiene advice, social distancing, report their symptoms, identify their contacts and heed advice when told to selfisolate - that we can break the chain of transmission. Prevention New cases and clusters Incidents and Outbreaks Enhanced Health Protection Area All-Wales measures / restrictions 8 Test, Trace and Protect will potentially be with us for some time, until a vaccine is developed and possibly beyond that. Our testing strategy initially focussed on people in hospitals, care homes, and symptomatic key workers. Now, Test, Trace, Protect also means asking people to report symptoms, testing anyone in the community who is showing symptoms of COVID-19, and tracing those they have come into close contact with. Contacts will be advised to self-isolate in order to stop further spread among family, friends and the community. This is the key. Contact tracing is a long established public health approach to containing the spread of many infections and has proven effective in controlling coronavirus in other countries. Our approach will bring together and build on the existing contact tracing expertise of our local health boards and particularly our local authorities to deliver this strategy on the ground. The key to ensuring the operation can successfully reduce transmission of the virus is twofold. Firstly speed in all parts of the process (from getting a test and test result turnaround times to rapid identification of close contacts) and secondly continuing support from the people of Wales, to heed the essential broader behavioural and public health messages and measures. An extensive network of testing facilities is available across Wales, from community testing units to mobile testing units and mass drive-through testing centres. The number of tests we will need in Wales will depend on the spread of the disease, the prevalence of symptoms and the emerging evidence on how testing can best be used to prevent infection. Our testing policy is being kept under review. Next steps:  launching the NHS COVID-19 ‘App’. The secure and anonymised Smart phone application will alert the user if they have been in close proximity to someone who has tested positive. In addition it will integrate symptom checking and test booking, providing an easy means to facilitate our test, trace, protect approach.  increasing testing capacity at Welsh laboratories  helping people to understand how and when to get a test. VACCINATION PROGRAMMES We will need to be prepared more than ever before to provide vaccination programmes for seasonal flu, and potentially for a COVID-19 vaccine, if and when one becomes available. Health boards and GPs are working closely to ensure that the most vulnerable people have access to the vaccinations and then to expand access to the vaccinations if possible. GP surgeries will be the first point of call supported by pharmacists and other providers. The influenza vaccination programme is delivered annually usually through GPs in primary care and by health boards. 9 The key focus is to maximise uptake rates amongst people at risk, such as those with clinical conditions and health and social workers. We want 75% of these people to be vaccinated. Ideally and if stocks allow, we want to extend the offer of vaccination to other groups such as household contacts of people who were shielding and those aged 50 and over. There will also be a focus on the uptake of children’s flu vaccinations. In addition to the flu vaccination programme, rollout of a COVID-19 vaccination programme could potentially begin from November 2020 if a vaccine becomes available. There are a number of challenges to doing this because of the need to protect the staff and patients involved and because of the huge logistic challenge this presents. We are working through all the issues to ensure that Wales is ready if a vaccine is available. Next steps:  confirming the level of vaccine available  agreeing the arrangements for the distribution of supplies and delivery of the vaccination programme  keeping the public informed about when, where and how they can get vaccinated, as well as encouraging them to take part, will be a fundamental part of the plan  co-ordinating broader vaccination programmes with the forthcoming delivery of vaccine research studies. SHIELDING We recognise that it has been a particularly difficult time for people who have been shielding since March. The advice to ‘shield’ was put in place by the Chief Medical Officer to protect those who were clinically extremely vulnerable to the effects of COVID-19 and likely to experience a poor outcome if they contracted the virus. In addition to the advice to remain protected at home, a package of support was put in place, which included access to priority supermarket slots, which enabled people to remain entirely at home. We are grateful to the thousands of volunteers have been making life better for their communities and supporting the vulnerable, for example through food and medication deliveries, particularly for those shielding. As it can create its own harms to physical and emotional well-being, shielding was only ever intended to be a short-term measure to protect people at the peak of prevalence. Those who have been shielding are now advised that they can do whatever others in Wales are able to do but still need to be very careful about minimising contacts, maintaining a 2 metre distance from those who are not part of their household and being strict about hand and surface hygiene. As we plan for the winter and accept the likelihood of further outbreaks, we will ensure that those who are clinically extremely vulnerable continue to be considered 10 in our response. People will be kept well informed, for example through discussions between patients and their doctors and by using local or national announcements to highlight if any action or change to shielding advice is necessary. Next steps:  Decisions to reintroduce shielding Given the associated harms with long periods of isolation at home, it is important that shielding is never advised without careful consideration and therefore the decision to reintroduce shielding, even on a local basis, will be agreed by Ministers, following a recommendation by the Chief Medical Officer.  Maintenance of the Shielding Patient List To ensure we remain prepared to implement advice to shield at any point on a local or national basis, the Shielding Patient List will be maintained whilst the advice to shield is paused. GPs and secondary care clinicians will continue to update the list as appropriate.  Support to people who need to shield Local authorities will continue to receive a monthly update of the shielding patient list for their local area to enable them to identify and support this group as required. Supermarkets will continue to offer priority slots to this group whilst shielding is paused.  Development of a risk tool The four UK nations are working together to develop a risk assessment tool which will enable a more individual discussion of personal risk between clinicians and patients. HEALTH INEQUALITIES As a Government we are committed to reducing health inequalities and to achieve a fairer Wales in every aspect of our society. We have underpinned this by landmark legislation such as the Wellbeing of Future Generations (Wales) Act. COVID-19 has brought many issues for us to address and we must ensure communities, patients, staff and organisations remain focussed on equity and equity of access to the services they need. Following the World Health Organisation guidance on essential services is part of that drive to ensure people continue to get the urgent care and treatment they require. Ethical considerations are part of our decision making to ensure fairness and equity. It is known that people from Black, Asian and Minority Ethnic (BAME) backgrounds, vulnerable groups and poorer communities are disproportionately affected by coronavirus. We must pay attention to higher risk occupations, including those working in public transport; social care and healthcare workers; people working in some retail, catering, security, and manufacturing settings. Having more than one illness or condition is also associated with poorer outcomes for COVID-19 and additional support may be required for groups (e.g. people who are shielding) who have unequal access to a range of resources, including health and social support. 11 We must ensure that our plans do not pose further disadvantage to the most vulnerable in society or the highest risk patients or communities. Next steps:  promoting use of the All Wales COVID-19 Workforce Risk Assessment Tool. This Tool is suitable for use for all health and social care staff thought to be vulnerable or at risk, regardless of ethnicity  the tool addresses individual risk factors and has the potential to be used in a wider range of workplace settings for staff to assess their personal risks and support discussion with employers about appropriate protection. PERSONAL PROTECTIVE EQUIPMENT (PPE) At the onset of the COVID-19 pandemic, we ensured that the NHS Wales Shared Services Partnership (NWSSP) rapidly expanded its existing NHS-only supply and distribution process for health boards, to one delivering across numerous settings. NWSSP also began supplying local authorities with PPE for distribution to the social care sector, as well as delivering to primary care staff, including independent GPs, pharmacists, and dentists and optometrists. While there were initial concerns about shortages, the level of supply was maintained throughout the most challenging times. Since March, over 293 million items of PPE has been secured and issued to the health and social care sectors in Wales. Next steps:  It is important that we continue to proactively plan for the winter and ensure we continue to maintain sufficient supplies of PPE, including risks arising from a possible no-deal Brexit, and new surges of the virus worldwide. We are taking account the potential for further waves of COVID-19 combined with existing winter pressures.  Working in partnership with Welsh Government, NWSSP is developing a plan for PPE procurement to March 2021. Engagement with key stakeholders is underway with the expectation that this plan will be published in September 2020.  Arrangements are being put in place to continue regular deliveries of PPE to local authority equipment stores for onward distribution to all social care settings throughout Wales, including care home providers.  PPE will also continue to be supplied to primary care contractors, including GPs, optometrists, dentists and pharmacies.  A stockpile of critical products will be held to ensure resilience and our own self-sufficiency of supply for the health and social care sectors in Wales throughout the winter and to March 2021. As we approach the winter, we have 160 million items in stock, with orders placed for more than 300 million further items. 12 CARE HOMES Care home providers and their staff have faced unprecedented challenges during COVID-19, and have responded with commitment and determination in supporting and maintaining the well-being of their residents. Since the beginning of the pandemic, we have sought to make decisions that uphold the rights of people living in care homes and comply with our legal obligations to protect and uphold the rights of everyone in Wales. Care homes provide care and support to some of our most vulnerable people. We know people living in care homes are particularly vulnerable to COVID-19 and can have a poorer prognosis if they become unwell due to the virus. This has been, and continues to be, an intensely difficult period for people living and working in care homes and their families. Given the impacts on both mental health and general well-being, the decision to restrict routine visiting in March was not taken lightly and was considered necessary to protect care homes and those living and working in them from the risk of COVID19 infection. However, as we made clear during the lockdown period and beyond, our expectation was that visits in exceptional circumstances such as end of life should continue and be accommodated sensitively. We have kept the guidance on visitors to care homes under review and relaxed restrictions on visiting as lockdown has eased. We know how hard this physical separation has been and thank everyone for the way in which they have responded. Sadly, as we have seen recently, local lockdown restrictions will affect visits to care homes and cause further separation between people and their loved ones. We must do what we can to encourage and be creative in how we use other forms of communication so that families can keep in touch. We recognise the invaluable role the independent sector plays caring for some of the most vulnerable people in our society and the further significant pressures brought by COVID-19. We will continue to work with partners in local authorities and health boards, to find ways to support the overall stability and sustainability of the regulated care sector, including care homes. Next steps: The National Care Homes Action Plan, to be published at the end of September, will set out updates and actions under six key areas:  infection prevention and control  personal protective equipment  general and clinical support for care homes  residents’ well-being  social care workers’ well-being  financial sustainability 13 SOCIAL CARE Through the winter, there will be a continued focus on maintaining the resilience of the social care sector to support people’s wellbeing in keeping with the principles of integration, prevention, collaboration and co-production. In addition to care homes, some key areas of focus include:  protecting the rights of people who need care and support and carers who need support, including through developing a National Plan for Carers  supporting the workforce  stabilisation and reconstruction of the sector  continued focus on integration of health and social care, with regional partnership boards supporting the integrated delivery of winter plans. NHS READY FOR WINTER The system has undergone an extraordinary transformation across all settings in these demanding times and exceptional timescales. It is important to recognise the progress and resilience achieved to avoid overwhelming the NHS and social care, manage the peak and also to cope with the sustained pressure we are still facing. Plans were very quickly put in place that allowed for up to 10,000 extra acute hospital beds and 450 critical care beds, both on existing hospital sites and through the rapid construction of field hospitals. Whilst we did not see the 100,000 hospital admissions that were expected and the up to 28,000 potential deaths in Wales, it was crucial that we were prepared to address the very visible pressures and ensure systems were not overwhelmed. At the peak of the pandemic in mid-April, we saw over 2400 confirmed or related COVID-19 patients in NHS hospital beds. At the same time there were over 300 confirmed or related COVID-19 patients in critical care beds. This has reduced considerably but we must be mindful that this winter will be particularly challenging and we want to keep these numbers as low as possible. At the time of publishing, Wales has sadly seen just under 1600 COVID-19 deaths. Whilst no deaths were reported for eight consecutive days in early September, the rate of the virus is rising again and we need to maintain our collective efforts to minimise the number of deaths. Over 12000 people were discharged and were able to recover at home. However we cannot afford to be complacent. Since March the NHS in Wales has been planning on a quarterly basis to respond to the COVID-19 public health emergency and more recently to safely reintroduce a wider range of services. As more services are available, hospitals have ensured that all appropriate environmental measures have been taken to keep patients safe. This includes 14 treating people with or suspected COVID-19 in separate areas to those who do not have the disease to prevent the risk of it spreading. These are usually referred to as green and red zones. Essential and routine services The World Health Organisation identified a list of essential services that should be available during the pandemic and we have followed that advice in Wales. The full list of essential services is extensive, but to provide examples:  the Royal College of Surgeons has issued guidance on the recovery of surgical services  the Chief Executive of the NHS in Wales has written to all Health Board and Trust Chief Executives stating that urgent cancer diagnosis, treatment and care must continue as well as possible during this period to avoid preventable death and disease, and  services need to be maintained for patients needing essential cardiology or cardiac surgery intervention. Guidance has been issued across a wide range of specialties to help decision making about individual care. This will be made by clinicians in discussion with patients and their families and in the best interest of each individual. The NHS is working hard to reintroduce other routine services and increase the numbers of patients that it can see. When they submit their plans to manage the next six months in October, NHS organisations will provide an update on how they expect to provide services in their areas during the winter period. This will include what actions they will take with their partners in social care, care homes and the voluntary sectors to join up and deliver the services that people need. It is a challenging task to manage normal winter pressures in the NHS such as respiratory illnesses, flu and heart attacks alongside a potential increase in COVID19 patients needing to come to hospitals. Ensuring that the NHS is able to strike the right balance between delivering essential, including urgent and emergency services, in maintaining strict infection prevention and control arrangements as well as accommodating the usual increases in demand for winter and ensuring there are the right levels of COVID-19 bed capacity will be difficult. Careful planning for possible scenarios over the winter will be essential. Urgent and emergency care Throughout this pandemic the NHS has been there for patients who need urgent and emergency care and will be there for patients this winter, however the way we access care when we have an urgent need for advice, assessment or treatment has changed considerably over recent months. The ‘lockdown’ of the population to control the spread of COVID-19 saw a sharp reduction in 999 ambulance incidents and patient attendance at Emergency Departments and a large increase in the amount of calls to the NHS 111 Wales 15 service and use of NHS 111 Wales online. 999 calls and levels of attendance at Emergency Departments have now returned to pre-COVID-19 levels, presenting a significant challenge to NHS Wales, heightened by the need for physical distancing in hospital which reduces space for patients. We have seen rapid developments to how urgent and emergency care services are delivered to patients over a short space of time in order to ensure patients who are COVID-19 positive or suspected of having COVID-19 receive the treatment they need, and at the same time protect those who are most at risk. These changes, and the new ways the public accessed services over the spring and early summer, are something we want to maintain beyond the current pandemic to reduce the risk of harm for staff and patients and improve outcomes and experience. We will invest £30 million in the transformation of the urgent and emergency health and care system over the rest of the year to support this aim. Specifically, we want to see achievement of six goals:  better co-ordination of planning and support to help high risk or vulnerable people and their carers to remain independent at home, preventing the need for urgent care  signposting, information and assistance for all who want or need urgent care, ensuring they get the right support, in the right place, first time  community alternatives to attendance at an Emergency Department and/or admission to acute hospital for people who need urgent care but would benefit from staying at, or as close as possible, to home  the fastest and best response at times of crisis for people who are in imminent danger of loss of life; are seriously ill or injured; or in mental health crisis  optimal hospital based care for people who need short term, or ongoing, assessment/treatment for as long as it adds benefit; and  a home from hospital when ready approach, with proactive support to reduce chances of readmission. We expect to see health boards, the Welsh Ambulance Services NHS Trust and their partners across the public sector develop robust plans that help achieve these six goals for the public over the remainder of the year and beyond. One of the key changes locally will be how patients who need, or want, urgent advice or care access services. Health boards are working with their partners to develop new approaches to ensure people who think they need to access the Emergency Department can access the advice, care or information they need in the right place, first time through a ‘contact first’ approach. This will help people to access clear, professional advice on which service is best suited to meet their needs by dialling a number for remote assessment by a qualified doctor or a nurse, or accessing an online symptom checker. Depending on the severity of the condition, they may be:  encouraged to self-care 16  signposted to a more appropriate service in their local community or  directly booked in to an appointment in an Emergency Department. This approach is being tested in the Cardiff and Vale area with plans for other health board areas to trial a ‘contact first’ approach before the winter period begins. Field Hospitals A number of field hospitals were set up around Wales in a matter of weeks in the spring to provide thousands of additional beds for a predicted increase in hospital admissions caused by COVID-19. Thankfully these additional beds were not needed at that time, primarily because of the support from the public in complying with lockdown restrictions and maintaining good hygiene and social distancing, as well as changes in the way we accessed urgent and emergency care. Based on learning from the first wave, 5000 beds are available to ensure health boards are able to manage future waves of COVID-19 and any potential spike in emergency admissions. This has been achieved by retaining a range of field hospitals, new hospital facilities and additional bed capacity created in existing hospital sites. Crucially, this additional capacity is designed to enable health boards to continue to undertake planned surgical procedures and manage urgent and emergency care demand during the historically challenging winter period; in addition to the management of any potential increases in numbers of patients admitted to a hospital bed caused by COVID-19. Field hospitals, and additional bed capacity in general, will be available for as long as they are needed to provide extra capacity for the NHS. Next steps: To support the NHS to be ready for winter organisations will  develop and submit in October their operational plans for the next six months  work together with local authorities and key partners to develop an integrated response PRIMARY AND COMMUNITY CARE Primary care services include those services provided by local GP practices, pharmacists, dentists and optometrists. They also include the wider community team such as district nurses, health visitors and physiotherapists that support patients locally. For primary care services and particularly for community nursing, their front line is your front door, and they along with other NHS clinicians have been there to support patients during lockdown and will be there through the coming winter. GP services, pharmacies, other health professionals and community nurses have continued to provide important care to patients, including care home residents, through the most 17 difficult periods of the pandemic. Emergency primary care services, 111 telephone and out of hours services, including for pharmacy, also continued to advise, care and treat patients who needed them. It is very important that patients continue to use these services when they feel unwell. We saw a reduction in the numbers of people that were contacting some primary care services so the message is please seek help if you feel unwell. This advice particularly applies to children. Parents should be confident that they can safely contact their surgeries for advice and care from their GPs, including the uptake of childhood vaccinations. The way that patients are contacted might change, and you may speak to a doctor or other clinician by phone or possibly a video consultation, but they remain open and available to patients. The COVID-19 pandemic accelerated a number of changes in local health care. GPs and their teams are continuing to work hard to ensure that patients have access to timely care whether through telephone consultations, video consultation or face to face where needed. Some patients were asked to go to a different surgery or medical centre so that GPs could see routine patients safely and separately from patients with suspected COVID-19. Local hubs for urgent and emergency care and the rapid rollout of remote video consultations has helped to maintain access to GP services and patients will continue to have access to their GP, Pharmacist and District Nurse throughout the winter. Community pharmacies have remained open throughout the pandemic to ensure patients continue to receive their medicines and advice on a range of common ailments. Since the initial COVID-19 period, we have seen a steady recovery in the availability of critical pharmacy services such as the common ailment service. In June, common ailment service consultation numbers reached their highest ever level at over 8000 consultations across more than 600 pharmacies (85% of all pharmacies). Additional arrangements were put in place for pharmacies to support their prescription deliveries through the National Volunteer Prescription Delivery Service and the Royal Mail which has been meeting any additional demands during the pandemic. This support for shielding patients continues until 30th September and will be able to be reactivated if required. New systems, such as Consultant Connect, put GPs and other community based health care staff in touch with hospital consultants and specialists for advice on management of patients within the community. This helps to keep people safely at home without the need for a trip to hospital. Video consultation tools to support remote working are being provided to up to 3000 community pharmacists and pharmacy technicians helping them to work differently during the pandemic and in the future. We recognise the limitations COVID-19 has placed on dental services and the alternative arrangements put in place for people to be able to access advice and 18 treatment. Aerosol generating procedures in particular pose very high risks to both patients and dental staff and this will be kept under review. Optometrists across Wales have worked during the pandemic to ensure people continue to access eye health care. There remains full coverage of ‘open’ optometry practices across Wales to ensure patients have access to timely care whether that be via a telephone consultation, video consultation or face to face. The development of optometry ‘cluster’ working arrangements during the lockdown will continue to evolve, supported by the ability of qualified optometry practitioners to provide patient prescriptions if needed. This enables optometrists to manage more cases locally and also reduces the need for people to go to a hospital for eye care. Next steps: We will build on this experience to ensure the ongoing resilience and support of all the primary care areas in providing a response during the winter months, including:  maintaining services throughout the winter period  continuing to provide First Point of Contact and Out of Hours Services  managing patients with routine care needs in a safe environment  providing support to patients with COVID-19 to manage their symptoms safely at home. MENTAL HEALTH The pandemic has had a big impact on people’s mental health and emotional wellbeing, both for those with pre-existing conditions but also for others who found the time during lockdown and the changes to their daily living and working conditions particularly challenging. Mental health services and substance misuse services are recognised as essential services which must be maintained during the pandemic. While services have been affected and service models have had to adapt, for example, by using technology instead of face to face consultations, a safe and sustainable response for people who need to access mental health support during this period remains our expectation. Whilst some services, notably primary care referrals, experienced a reduction in demand during the early part of the pandemic, referrals are now increasing. We recognise that over the autumn and winter period there will be particular challenges to respond to mental health needs, especially in the context of an expected increasing in demand. However, given the emerging evidence about the impact of the pandemic on the mental health and wellbeing of our communities, including those in our BAME communities, those that are financially vulnerable and those with an existing mental health condition, it is vital that we encourage people to access mental health services when they need them, now and in the future. Loneliness and isolation is a big issue for many people which has been exacerbated by the pandemic. We will continue to monitor the impact of the pandemic and to work 19 with partners, including communities, to consider how best to combat loneliness and isolation and provide the support people need when and where they need it. Next steps:  We will shortly publish a refreshed 2019-22 Mental Health Delivery Plan which will reflect strengthened cross Government action and investments in response to the pandemic impact on mental health. This will focus particularly on protective and preventative actions in areas such as employment support, debt support, homelessness prevention and education.  The Welsh Government is working with partners, including the NHS and Third Sector, to provide support in response to the immediate impact of the pandemic on mental health. This work has focused on improving access to lower level, preventative support services with an investment of an additional £1.3m in this financial year. Current improvements include strengthening the CALL Mental Health Helpline, availability of an all Wales Cognitive Behavioural Therapy resource (Silvercloud) and launching the Young Persons Mental Health toolkit. Additional funding is being provided to the third sector to help fill gaps in this type of provision.  The Welsh Government will continue to work closely with the NHS to support current recovery planning for mental health services provided by the NHS. This includes assessing future demand for services and an increased digital offer, as well as ensuring inpatient and other mental health services remain available and can meet identified need. CHILDREN AND YOUNG PEOPLE Whilst it is recognised that children and young people currently appear to be less susceptible to the virus than adults, there is little doubt that the wider effects of COVID-19 have had a significant impact on their lives. We know that the rules and advice on keeping safe have been challenging for children and young people affecting their social lives, their education and disruption to their plans for the future. We cannot ignore the impact these restrictions will have on their physical, emotional and mental well-being. For those children and young people living in difficult family circumstances or for children and young people in care, the consequences are likely to be intensified. Young people have needed to quickly adapt to our new environments. They have missed education and those in examination year groups have had to come to terms with substantial changes to the examination results system and its outcomes. Working alongside children and young people and putting their interests and rights in the forefront of our policies and planning will help everyone to keep safe. We need to continue to invest time in effectively explaining and communicating government rules and guidance to children and young people. By positively encouraging our young people to keep to the rules, we will have powerful and influential partners to help combat the spread of COVID-19. 20 The emerging evidence in relation to COVID-19 continues to suggest that children are significantly less affected by infection with the condition than adults, whilst a significant proportion of children with COVID-19 do not appear to develop any symptoms. Low case numbers in children suggest they have a very limited role in transmitting the condition. Recovery from COVID-19 appears to be good with both most infants and children largely appearing to make a full recovery. The Welsh Government’s advice to parents continues to be that in the event that they are concerned about the health of their children, they should contact a health professional as soon as possible. Next steps: We will continue to:  work with social services colleagues so that children and young people in care are properly supported and that children’s rights and best interests are at the core of the work we do  work in partnership with local authority children’s social services so that the well-being of staff and the children and young people in their care is paramount  communicate government messages effectively to children and young people and work with partners so they are explained and understood  support health boards in reopening children’s services that were suspended as part of the COVID-19 response as soon as possible, so as to minimise any longer term impacts of lack of access to these services. REHABILITATION Rehabilitation is a core and integral component of care and has become a particular area of focus during the pandemic as we have begun to understand the recovery challenges that patients face, and some of the longer term issues including for patients that have been in critical care. We also recognise an increase in the need for rehabilitation support due to the impact of lockdown. The Welsh Government published a national rehabilitation framework and guidance in May to help local planners and clinicians to consider the demand for rehabilitation, reablement and recovery throughout health and social care services. We introduced the specific COVID -19 guidance for the discharge of patients in April 2020. This reinforces the “Home First” ethos, with a strengthened focus on rehabilitation and reablement to return people to living independently and lessen the need for longer term placements and care packages. Good progress has been made in implementing pathways that allow patients to go home earlier with support. Further work is needed to ensure this is the default process to get people home or to the right community setting as soon as possible. 21 Next steps: Health boards, local authorities and the third sector will continue to collaborate at a national and local level to:  identify and support those people who need rehabilitation, whether this is when recovering from COVID-19 or because of the impact of the lockdown  improve access to rehabilitation services at or close to people’s homes at the time it is needed, preventing urgent care and inappropriate admission to hospital  Routinely offer people care in line with the pathways, adopting a home from hospital when ready approach, with proactive rehabilitation KEEPING EVERYONE INFORMED Keeping everyone well informed, through a variety of means (including press conferences, use of television, radio, newspapers and social media) has been an important aspect of managing the pandemic and has helped everyone play their part in tackling it. Continuing to communicate information clearly and consistently about risks, the impact of individual and collective behaviour, and what people can do going into the winter season to look after themselves, their families and communities, will be very important. Through the multi-media Keep Wales Safe campaign, we will continue to remind people of the ongoing need to protect themselves and others throughout the winter period. Advertising will focus on promoting the behaviours which prevent the spread of COVID-19, and on the need to participate in the Test, Trace, Protect programme. Also under the Keep Wales Safe campaign, we will be asking people to “Protect the NHS” this winter. This will include encouraging people to use NHS Wales services appropriately, signposting to NHS 111 for support. We recognise the need to be flexible to enable rapid changes in messaging to respond to issues as they develop through the winter, so our communications will adapt to address areas of concern. For example, during September we are focusing on the return of students to schools and universities, and the risk of infection these steps bring. In addition to messages aimed at the wider general public, we will undertake highly targeted communications where there is a clear need, including with BAME communities and young people. This will build on extensive work already undertaken to engage with young people with a targeted campaign aimed at 16-24 year olds over the summer months. Our relationships with partners, including health boards and local authorities, allow us to share our messaging quickly, and we have a well-established communications network within the public sector which enables us to work together to reach as many people in Wales as possible to Keep Wales Safe. 22 WORKFORCE COVID-19 has highlighted the need for rapid action to support transformation across the health and social care workforce to provide greater resilience over the winter period. Front line staff and key workers have been magnificent in their response throughout the pandemic and they remain crucial to our success over the coming winter. Ensuring their wellbeing, including their mental health, must be a priority. Our key areas of focus are:  continuing to protect and support the staff who have been caring for patients in NHS and social care settings, as well as the rest of our workforce  putting in place actions to fill gaps in the workforce and embracing the opportunity that has arisen from the pandemic to encourage more people to work in health and social care  developing a health and social care workforce to provide services closer to home. The effect of lockdown on services has led to a dramatic change in the way we work  ensuring that we have a workforce that is trained and comfortable with digital technology  continuing to invest in the education and training of professions across the health and social care system  influencing cultural change across organisations and sectors through building compassionate and collective leadership capacity at all levels  ensuring that our services have the workforce needed to sustain care during the winter. Implementation of the plan developed by Health Education and Improvement Wales, together with those of other key national and local organisations, will support greater workforce resilience through the delivery of a coherent and coordinated approach to support the health and care workforce. TECHNOLOGY AND DIGITAL INNOVATION Digital innovation has been a key part of the COVID-19 response through implementation of planned projects and services. In the last few months, the use of technology has been accelerated across Wales, supporting delivery of the Test Trace Protect Programme and allowing people to continue to access healthcare advice and services from their homes. This has included a national roll-out of video consultations for primary, secondary and community care. The new systems have supported key services including GPs, Community Nurses, Community Mental Health Teams, Health Visitors, Community Midwives, Outpatients and Diabetes clinics to maintain a visual link with their patients. Digital innovations were introduced at great pace to assist in reducing the need for face to face consultations and to help people keep in touch. In a short period virtual appointments have really taken off. Around 40% of outpatient appointments over the last 5 months have now been carried out virtually, with 84% of patients and clinicians providing positive feedback. 23 Remote working has been supported across the NHS with the roll out of digital devices. The Welsh Government has also supported Digital Communities Wales to expand their digital device loan scheme by over a thousand devices. These have been supplied to care homes and hospices so residents can continue to access health and wellbeing services as well as keep in touch with relatives. The accelerated rollout of the digital eye care programme has enabled remote diagnostics and electronic referral, thereby reducing hospital attendance, in particular for shielded and vulnerable individuals. Next steps:  maintain new ways of working and remote consultation services to support operations and service delivery  continue to develop the digital contact tracing platform and integrate with other aspects of Test Trace Protect programme  develop digital platforms to support large scale vaccination programmes and shielded patient lists potential further development of digital COVID-19 testing platforms (if Wales only services required). FINANCE The Welsh Government has provided more than £1.3bn to support the NHS COVID19 response. This funding has supported the measures taken through the early part of the pandemic and will continue to support NHS organisations across Wales to prepare for the anticipated challenges that winter will bring. This will include responding to a potential second wave of the virus, alongside normal winter pressures and increasing access to essential services. The NHS stabilisation package of £800 million announced in August will help the NHS plan these complex arrangements and have the resources to cope over the coming months. It also funds the procurement of Personal Protective Equipment for both the health and social care sectors, so that an appropriate ‘buffer’ of supplies can be established to respond to any second wave of infections. It will also ensure that a reliable supply is available for primary care providers – including GPs, dentists and optometrists. Local authorities have been an integral part of the response to the pandemic providing vital services and support in their communities in difficult circumstances. The Welsh Government has provided £62.7 million from April to September to support adult social care providers. We acknowledge that many social care providers will continue to face financial pressures for some time to come, which may well be exacerbated during the coming winter. As a result the Minister for Housing and Local Government recently announced an additional £264 million for local authorities for the remainder of 2020- 2021 for COVID-19 related costs. 24 WORKING TOGETHER ACROSS WALES This Winter Protection Plan demonstrates our commitment to the people of Wales that we have made throughout this exceptional public health emergency – we will always make decisions that are in the interest of Wales, to do the right thing for Wales and make decisions that keep Wales safe. We have been using the scientific evidence to inform those decisions and we recognise it has been very difficult and challenging for us as individuals and communities. Working together as a nation has made a huge difference, with people and organisations across Wales playing their part in helping to limit the impact of the virus. However, the virus has not gone away and the decisions we have made recently and will need to make over the coming months will be crucial. Limiting people’s movements and placing restrictions on their daily lives is never something that the Welsh Government has taken lightly. However we will make those difficult decisions to help to save lives and reduce the risks to the most vulnerable people. Our collective actions, to adhere to social distancing, maintain hand hygiene, avoid touching our face and to wear a mask when required, for example on public transport, are the most effective actions that can be taken to avoid transmitting the virus and preventing the spread across Wales. Everything else we have to do and decide will be driven by the success of us sticking to these rules. We must maintain that discipline to avoid further restrictive measures being taken. Our NHS staff and key workers went above and beyond to care and treat people during the first wave and they will be there for us again this winter. We must still do everything we can to avoid overwhelming NHS and care services. We have seen how fragile the balance is between easing lockdown and the rapid increase in cases over recent weeks. Winter is challenging every year with seasonal illnesses taking a toll on the NHS and social care and this year is even more precarious as we manage them alongside COVID-19. Now is the time to take that extra care and vigilance and consider our personal responsibilities and the contribution we make as individuals, so that we do not place avoidable pressure on key workers this winter and we prevent a major second wave if at all possible. One other important and familiar part of winter is the seasonal flu campaign. It is more important than ever that those offered the vaccination take up the opportunity. This will protect them and others and reduce the number of people that have to be admitted to hospital and possibly die as a result of flu. Again this is where we can make a personal contribution to the safety and wellbeing of our families, friends and communities. Everything that has been set out in this plan is happening and collectively making a difference to the lives of people across Wales. We continue to learn and adapt as we understand this new and complicated virus. Using innovation, new ways to prevent infection, protect and treat patients and maintain health and care services are at the heart of this plan and keeping Wales safe.