Board meeting 25 June 2015 Time of meeting: 09.00 – 15.30 Venue for meeting: Boardroom, Betsi Cadwaladr University Health Board Headquarters, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW Version: 1
*Please note: There will be a Remuneration Committee at 8.30am
Board meeting Private session
For approval 1. 09.00 Our Space 39.01 Huw George (to follow) 2. 09.20 Liquid based cytology procurement 39.02 Dr Quentin Sandifer (to follow) 3. 09.40 WEDINOS update 39.03 Dr Quentin Sandifer (to follow) For ratification 4. 10.00 Ex-gratia payment 39.04 Ruth Davies (to follow) 10.10 Private meeting close
Public session
Time Reference Preliminary matters 1. 10.20 Welcome and apologies Oral Sir Mansel Aylward 2. 10.25 Declarations of interest Oral Sir Mansel Aylward 3. 10.30 Minutes from the Board meeting on 28 April 2015 Sir Mansel Aylward a) Approval of minutes 39.05 b) Action points c) Matters arising For decision 4. 10.35 NHS Collaboration hosting agreement 39.06 Tracey Cooper 5. 10.55 Governance Accountability Module 39.07 Keith Cox 6. 11.00 Welsh Language Scheme Monitoring report 39.08 Ruth Davies Scrutiny and discussion 7. 11.15 Performance reporting Huw George a) Q4 performance report 39.09 b) May 2015 performance report 39.10 c) Amendments to screening performance 39.11 trajectories d) Finance performance report 39.12 8. 11.50 Risk register 39.13 Rhiannon Beaumont-Wood (to follow) 9. 12.05 Healthcare Inspectorate Wales Annual 39.14 Report Darren Hatton, Healthcare Inspectorate Wales 12.35 Lunch For information and discussion 10. 13.05 Update from the Executive Director of Oral Public Health, Betsi Cadwaladr University Health Board Andrew Jones 11. 13.50 Policy, Research and Development Oral Professor Mark Bellis 12. 14.20 Targeted Intervention review of Betsi 39.15 Cadwaladr University Health Board Sir Mansel Aylward 13. 14.25 Emergency planning 39.16 Dr Quentin Sandifer 14. 14.45 Committee meeting reports Committee Chair
a) Audit Committee Oral Terence Rose b) Audit Committee Annual Report 39.17 Terence Rose c) Information Governance Committee Oral John Spence d) Developing the Organisation Oral Committee John Spence 15. 15.05 Chair’s Report 39.18 Sir Mansel Aylward 16. 15.10 Chief Executive’s Report 39.19 Dr Tracey Cooper 17. 15.15 Non Executive Director reports Oral 18. 15.25 Any other business Oral Sir Mansel Aylward 19. Papers for information a) Revalidation Annual Report 2014-15 39.20 b) Plan of Board business 39.21 c) Minutes from Audit Committee approved on 39.22 7 May d) Minutes from Audit Committee approved on 39.23 4 June e) Minutes from Information Governance 39.24 Committee meeting approved on 4 June f) Executive Team reports presented at the Public Health Wales Executive Team held on 12 June 2015. • Board Secretary report • Workforce and Organisational Development report • Public Health Services report • Public Health Development report • Director of Nursing report 15.30 Meeting close
39.05
Minutes from Public Health Wales Board meeting held on 28 April 2015 Time of meeting: 09.30 – 16.30 Venue for meeting: Canolfan Gorseinon Centre, Millers Drive, Gorseinon, Swansea, SA4 4QN Version: 0e
Present Professor Sir Mansel Aylward Chair Dr Carl Clowes Non Executive Director Tracey Cooper Chief Executive Huw George Deputy Chief Executive and Executive Director of Finance and Operations Terence Rose Non Executive Director Dr Quentin Sandifer (in part) Executive Director of Public Health Services / Medical Director John Spence Non Executive Director Professor Gareth Williams Non Executive Director
In attendance Rhiannon Beaumont-Wood Director of Nursing Keith Cox Board Secretary Cerian Dovey Business Support Manager Dr Judith Greenacre Deputy Director of Public Health Development Dr Sara Hayes Director of Public Health, ABMU Eleanor Higgins Corporate Governance Manager Renata Leonardi-Jones Unison representative, Public Health Wales Faye Walker Underrepresented groups pilot scheme member
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Stephanie Wilkins Unite representative, Public Health Wales
In attendance (in part) Dr Julie Bishop Consultant, Public Health Wales Professor Andrew Davies Chairman of ABMU Nathan Jones Assistant Director of Planning and Performance
Apologies Dr Sally Attwood Director of Performance and Operations Professor Mark Bellis Director of Policy, Research and International Development Executive Team Ruth Davies Director of Workforce and Organisational Development Fadumo Jibril Underrepresented groups pilot scheme member Professor Simon Smail Non Executive Director Alison Ward Interim Non Executive Director
1. Welcome and apologies The Chair welcomed all in attendance.
The Chair welcomed Professor Andrew Davies, Chairman of Abertawe Bro Morgannwg University Health Board and Dr Sara Hayes, Director of Public Health for Abertawe Bro Morgannwg University Health Board.
The Chair also welcomed and introduced Faye Walker, who will be shadowing the Board as part of the pilot training and development programme: ‘Increasing diversity in public appointments in Wales.’
Apologies were received from Simon Smail, Alison Ward, Ruth Davies, Mark Bellis, Fadumo Jibril and Paul Roberts, Chief Executive of Abertawe Bro Morgannwg University Health Board.
Dr Quentin Sandifer will be joining the meeting later in the morning. Therefore item 8 of the agenda, Operational Plan, will be taken at 11.30am.
For the private session, Sally Attwood will be attending for item 1. (Our Space) and Julie Bishop will be attending for item 3 (Transforming Health Improvement).
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2. Declarations of interest No declarations of interest were received in advance of the meeting. Professor Sir Mansel Aylward welcomed all to declare any interests during the meeting where appropriate.
As Chair of the Bevan Commission, Sir Mansel declared interest in Item 14 of the agenda, Bevan Commission Hosting Agreement. John Spence will Chair this item.
3. Minutes from the Board meeting held on 26 March 2015
a) Approval of minutes It was noted that Professor Gareth Williams attended the meeting on 26 March 2015 in part.
Subject to the amendment noted, the minutes (paper 38 01) were approved as an accurate record of the meeting.
b) Action points An update on actions which were marked as ‘in progress’ was provided. Further information on each action is provided in the action table at the end of the minutes.
c) Matters arising The Committee heard that the meeting scheduled to take place on 27 April to present the ‘State of the Nation’ to David Rees, Chair of the Health and Social Care Committee, is being rescheduled.
The Board noted that John Spence also attended the United in Improving Health in Wales conference.
Professor Sir Mansel Aylward confirmed that he had discussed the Graduated Driving Licence with the Chairs of the NHS organisations in Wales.
Stephanie Wilkins asked the Board whether the actual results for cervical screening lab turnaround times within three weeks (on pages 9 and 10 of the Quality and Delivery Framework Q3 performance report) have now been reconciled.
ACTION: Huw George to confirm this has been completed.
4. Chair’s report Professor Sir Mansel Aylward presented the Chair’s report (paper 38 02).
The Board heard that the Minister for Health and Social Services
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formally noted his thanks to Tracey Cooper, Dr Quentin Sandifer and the staff of Public Health Wales for their leading role in tackling the outbreak of Ebola.
There will be a conference in May on the topic of developing a Social Model of Health applicable to Wales. Sir Mansel invited Professor Gareth Williams to the event in his role as Transforming Health Improvement champion.
5. Chief Executive’s report Tracey Cooper presented the Chief Executive’s report (paper 38 03).
The Board queried who had been involved in the recruitment process for the senior positions summarised in the report. It was confirmed that the senior officials in the Welsh Government and the Chair had contributed to the development of the job descriptions.
The Non Executive Directors noted their wish to contribute to future advertisements and requested sight of the Executive Team job descriptions.
ACTION: Advertisements and job descriptions for senior positions to be circulated to the Board for comment.
a) Ebola update Tracey Cooper provided the Board with an update on the Ebola Virus Disease.
Public Health Wales will be supporting the prevention training in the countries affected.
Dr Cooper thanked those among Public Health Wales’ staff that had volunteered to support the response to the outbreak.
6. Finance performance report The Board received the finance performance report (paper 38 04).
The year-end accounts will be submitted to the Welsh Government on 1 May 2015 and approved by the Audit Committee on 7 May 2015. The Board was pleased that Public Health Wales had broken even and noted that there was a £30,000 underspend which had been brokered back to Welsh Government.
The Board also discussed the pattern of overspends and underspends within the organisation and queried whether a rebalancing of budgets was required. Some areas have operated a recurring underspend whilst others have operated a recurring
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overspend. Huw George confirmed that the finance team would be working closely with divisions in order to redress this balance. In particular quarterly meetings will take place between Health Boards and Public Health Wales to ensure the local public health team budgets do not underspend in future.
Concern was raised over missing the public sector payment policy target for a second time. The Board heard that Mr George has recently been addressing the issue of payments being on hold and the number has decreased significantly. It was noted that despite missing the target, performance has improved over the last year.
The Board discussed whether the performance reports should be on the agenda for decision or scrutiny and discussion.
ACTION: Keith Cox to discuss with Professor Sir Mansel Aylward.
7. Risk register The Board received the Corporate risk register (paper 38 05).
Rhiannon Beaumont-Wood introduced the paper and invited the Board to challenge the risks or scoring.
The Board heard that each risk owner is expected to have a risk register within their directorate and are responsible for escalating any risks to the corporate level risk register where appropriate. The Executive Team also scrutinise any directorate level risks that are scored highly and decide whether they should be escalated. Terence Rose noted that this scrutiny should be taking place at Committee and Board level also.
The Board noted that the risk register presented was already out of date. The Board discussed whether a live document could be presented in future.
ACTION: Rhiannon Beaumont-Wood to consider whether a live register can be presented at Board meetings.
Sir Mansel raised a concern over those risks not directly under Public Health Wales’ control (in reference to ID 398). Tracey Cooper advised that we are moving towards agreeing more business focused SLAs for health boards during 2015/16, with a process to ensure escalation arrangements are in place. It was also confirmed that further discussions were underway to agree how to demonstrate to the Board that Public Health Wales is monitoring the performance of partners in helping us achieve our targets.
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8. Board development plan The Board received the Board Development Plan (paper 38 07) for approval.
Professor Simon Smail had earlier shared his concerns about the suggested development content from Academi Wales with Professor Sir Mansel Aylward outside of this meeting. Sir Mansel advised the Board that Professor Smail is concerned that the suggested session from Academi Wales may not suit the Board’s development needs. There were also a number of concerns over the effectiveness of using filming as a development tool.
The Board agreed with Professor Smail’s concerns and decided to discuss further following the Board development day.
ACTION: The Board development plan to be discussed at a future Board meeting after the Board development day has taken place.
9. Annual Governance Statement The Board received the Annual Governance Statement (paper 38 08) for approval, subject to the additions which would be made after the Audit Committee meeting on 7 May 2015.
The Board discussed the inclusion of geographical location in the under-represented groups. Dr Carl Clowes noted his concern that the rural areas of Wales are currently under-represented at Board. The Board agreed that this is a separate concern to that relating to representation by under-represented groups which were drawn from the list of people with protected characteristics described within the Equality Act. It was, however, agreed that geographical representation would be added as an additional matter to be addressed.
ACTION: Eleanor Higgins to include geographical representation in under-represented groups section.
The Board noted that Table 2.1 includes Board Committees only. The Board members were concerned that their work in other areas of Public Health Wales should also be recorded.
ACTION: Eleanor Higgins to include reference to Board membership on other organisational groups and programmes.
The Board discussed whether the all the Champion roles adopted by
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the Non Executive Directors should continue.
ACTION: Non Executive Director champion roles to be discussed at a future informal meeting.
It was noted that despite previous agreement outside of Board, the Governance and Accountability Module will need to be reviewed by the Board in May’s Informal Board, before the Board development day, as the deadline for submission to Welsh Government is at the beginning of June 2015.
The Board approved the Annual Governance Statement subject to the agreed additional material being included in the report and other minor amendments being made.
10. Trade Union Recognition and Facilities Agreement The Board received the Trade Union Recognition and Facilities Agreement (paper 38 09) for approval.
Rhiannon Beaumont Wood noted that there is currently no Public Health Wales representative for the Royal College of Nursing and queried whether the regional representative should also sign the report.
ACTION: The regional representative for the Royal College of Nursing to be included in the signatories on the agreement.
The Board approved the Trade Union Recognition and Facilities Agreement.
11. All Wales Procedure of NHS Staff to Raise Concerns The Board received the All Wales Procedure of NHS Staff to Raise Concerns (paper 38 10) for approval.
Professor Andrew Davies advised the Board about a successful campaign in ABMU to install a culture of being able to raise concerns, called “Let’s Talk” (previously launched as “See it, Say it”.)
ACTION: Professor Davies to share the “Let’s Talk” publication with the Board.
The Board agreed that Non Executive Directors should also be included in this procedure.
Rhiannon Beaumont-Wood queried whether the process flowchart for raising concerns (appendix 5) should include an option to consult
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medical opinion, where appropriate, before speaking with managers. The Board agreed to include the option.
The Board agreed that the “Treat Me Fairly” campaign should be referenced in the ‘Commitment to Support Those Who Raise Concerns’ section.
The Board agreed that concerns with the process can be addressed with Public Health Wales’ own internal processes and procedures. However, the Board also agreed that their suggested amendments should be fed back to the Welsh Partnership Forum.
It was also suggested that ‘respect and dignity’ on p5 of the concerns should be amended to read ‘dignity and respect’.
ACTION: Ruth Davies, Stephanie Wilkins and Renata Leonardi-Jones to discuss the process for feedback to the Welsh Partnership Forum.
The Board approved the All Wales Procedure of NHS Staff to Raise Concerns, subject to the Board’s suggested amendments being feedback to the Welsh Partnership Forum.
12. Operational Plan The Board received the Operational Plan (paper 38 06) for approval.
The Board expressed their thanks to everyone involved in the production of the IMTP and operational plan. In particular, Professor Sir Mansel Aylward and Tracey Cooper noted their thanks to Nathan Jones.
Huw George provided an update on the approval of the IMTP. Letters, previously circulated to the Board, were received from Welsh Government with requests for further information. It was noted that the IMTP does not need to be re-submitted and Public Health Wales would provide an additional paper responding to the requests for further information by 1 May 2015.
ACTION: Nathan Jones to circulate the draft response to the Welsh Government’s request for further information in support of the IMTP, for the Board to comment.
The Board discussed the need for publicising the IMTP and Public Health Wales’ strategic priorities. A communication plan is currently being agreed and the IMTP will be publicised externally once it has received Ministerial approval.
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ACTION: The draft communication plan for IMTP to be shared with the Board.
As part of the future development of the operational plan, it was explained that each objective will be allocated a responsible owner. It was also confirmed that budgets have previously been allocated according to the management structure but work is underway to look at allocating budgets across priorities.
The Board discussed the value of carrying out a lessons learnt exercise on the process of developing the IMTP and Operational Plan and its application over the next three years.
ACTION: Huw George to organise a lessons learnt exercise.
The Board agreed that Public Health Wales should work to a three year plan, with an annual review and not to produce a new three year plan each year.
The Board approved the Operational Plan (paper 38 06).
13. NHS Wales Collaborative Professor Sir Mansel Aylward advised the Board that the NHS Wales Collaborative Hosting Agreement was withdrawn for approval, due to a number of issues which had arisen in the days preceding the meeting.
Concerns had been raised at the NHS Wales Chairs’ meeting and the NHS Wales Chief Executives’ meeting over the governance arrangements and accountability. The Board shared these concerns.
Huw George provided an update from the NHS Wales Chief Executives’ meeting. As well as the concerns over governance, there were also concerns raised over Public Health Wales’ liability, particularly in matters of employment and a query over the five percent charge by Public Health Wales. This was a standard charge put in place for hosting agreements, however it was proposed that a one percent charge would be applied and only on any additional function, including additional staff members, added to the Collaborative after it was established. This requires further discussion with Chief Executives.
The Board heard that Bob Hudson, Director of the NHS Wales Collaborative, will be producing a paper for the NHS Wales Chairs on the governance arrangements and will be discussing the Collaborative further with NHS Chairs. Mr Hudson had also produced
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a decision flow tree and structure.
ACTION: Chair and Chief Executive to circulate further information to the Board, when available, on the governance arrangements of the NHS Wales Collaborative.
ACTION: The Board to receive the amended hosting agreement of the NHS Wales Collaborative, once the paper on governance arrangements has been received.
14. Bevan Commission Hosting Agreement The Board received the Bevan Commission Hosting Agreement (paper 38 12) for approval.
As Chair of the Bevan Commission, Professor Sir Mansel Aylward declared an interest in this item and left the room. John Spence chaired this item.
The Board discussed the funding agreement and budget given to the Bevan Commission. It was noted that it was inconsistent not to have a five percent hosting charge in this agreement, however the current arrangement includes three staff and a small budget of £150,000. No hosting charge will be applied during the agreed period; however, a charge will be applied in future, if the agreement were to continue.
The Board approved the hosting agreement, subject to discussing a five percent charge to cover additional costs if and when the hosting agreement is extended.
15. Update from the Director of Public Health, Abertawe Bro Morgannwg University Health Board Dr Sara Hayes, Director of Public Health for Abertawe Bro Morgannwg University Health Board, gave a presentation on the work being carried out by the local public health team in the health board area.
Dr Hayes informed the Board that they had completed audit of the smoking cessation services being delivered in the health board area. Rhiannon Beaumont-Wood requested that this to be shared with the Board.
ACTION: Dr Sara Hayes to share the smoking cessation services audit with the Board.
The Board discussed engaging with local sports teams to promote more active lifestyles.
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Dr Hayes and Professor Andrew Davies noted their intent to work with Public Health Wales on prevention. Their current focus has been tackling the results of inequalities.
The Board heard that electronic cigarettes are banned on ABMU Health Board sites. Dr Hayes noted that she has no doubt that electronic cigarettes contribute to the number of people wishing to stop smoking but they are also a threat to people choosing to stop smoking tobacco completely. An electronic cigarette smoker who wishes to stop smoking should receive the same support as a cigarette smoker.
The impact of the economy on health and wellbeing was noted. Professor Davies advised that the health board works closely with the university to improve the employability of young people.
The Board asked what Public Health Wales could do to support the health board. Dr Hayes replied that they need more profiling and community engagement.
ABMU’s work on supporting medium term businesses with occupational health and their own improvements in sickness levels were noted by the Board.
The Board thanked Dr Hayes and Professor Davies.
16. Cervical Screening Information Management Systems The Board received the paper on the Cervical Screening Information Management Systems (paper 38 13).
The Board heard that in order to seek funding for the upgraded system, the Welsh Government has agreed to consider a statement of need with both risks and benefits outlined.
Dr Sandifer asked the Board whether a seventh option of both joint in-house and commercial development should be considered. The Board agreed that this further option should not be considered.
The Board noted the paper.
17. Graduated Driving Licence Dr Judith Greenacre provided an update on the Graduated Driving Licence.
Dr Greenacre is working with Dr Sarah Jones and Professor Mark Bellis on a communications plan that will commence following the
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national general election. A stakeholder map will also be produced in order to engage with potential partners.
Sir Mansel reported that letters received in response to his previous letter to Ministers in the Welsh Government and in the UK Government are mostly positive and invite further conversation. In particular, Edwina Hart, Minister for Economy, Science and Transport, has invited representatives from Public Health Wales to discuss Graduated Driving Licence with herself and her officials.
It was noted that Professor Bellis will be the policy lead. Dr Greenacre will be able to provide the Board with a further update following her meeting with Professor Bellis on Friday 1 May 2015.
Dr Greenacre noted the need to review the evidence that supports the Graduated Driving Licence to ensure it is robust, leading to a consistent message from Public Health Wales.
A concern was raised over the potential loss of momentum in the support of the Graduated Driving Licence. The Board were assured that a proposal would be ready for review at the next Informal Board meeting, as per action 37.08 from the previous meeting.
The Board was content for Sir Mansel to respond to invitations for further discussion from Welsh Government.
ACTION: Sir Mansel and Tracey Cooper to arrange a meeting with Edwina Hart to discuss the Graduated Driving Licence.
18. Committee meeting reports
a) Information Governance Committee John Spence provided an update on the Information Governance meeting held on 27 March 2015.
The Committee suggested changes on the presentation of some of the reports received, as well as a better understanding of reporting lines for clinical incidents.
The Committee heard of a new induction pack which would be circulated to the them for information.
The Caldicott Principles in Practice report will be amended in future to show how those areas of partial or non-compliance are being addressed.
The Committee discussed the possible need for encrypted laptops
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for Non Executive Directors, as part of a conversation on the Information Governance risks of home-working. The Committee will receive a report on this topic at the next meeting.
The Committee also received a report on a recent Information Governance audit, which had minor recommendations.
b) Quality and Safety Committee John Spence provided an update on the Quality and Safety Committee meeting held on 14 April 2015.
The Committee received a patient story. The patient made a complaint about his treatment by a member of staff at a follow up AAA screening appointment. The patient was pleased with the way his complaint was addressed.
The Committee received a report on three incidents in cervical screening, bowel screening and a breach of confidentiality. The Committee also received a report on a complaints and concerns review and the self assessment against the Standards for Health Services report. Mr Spence noted that the only area in the self assessment that did not show improvement was Equality, Diversity and Human Rights.
The Committee also received an update on statutory and mandatory training. Progress had been made but the Committee heard that the slow introduction of the Electronic Staff Record (ESR) was having an impact on reporting. It was suggested that an update on ESR is needed for the Board.
Action: provide Board with an update on the Electronic Staff Record (ESR).
The Committee will receive an update on Corporate Manslaughter at a future meeting.
19. Non Executive Director reports
Dr Carl Clowes provided an update on recent meetings and events he attended: • Chaired an appointments panel for two candidates for Consultant positions in Public Health Protection in the South East. Both were competent and both were appointed; • Attended a meeting between the Consuls of Wales on 23 April 2015, in his capacity as Honorary Consul for Lesotho in Wales. The Consuls met with business leaders, politicians, police and local government.
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Professor Gareth Williams provided an update on recent meetings and events he attended: • Attended the appointments panel for the Executive Director of Quality, Nursing and Allied Health Professionals; • Attended the advisory board for the Wolfson Research Institute for Health and Wellbeing at Durham University.
John Spence provided an update on recent meetings and events he attended: • Attended the appointments panel and the selection panel for the Director of Health Protection; • Visited the Welsh Conference of the Chartered Institute of Environmental Health in Cardiff.
20. Any other business No other business was raised.
PRIVATE SESSION
1. Executive Team appointments
a) Executive Director of Quality, Nursing and Allied Health Professionals Rhiannon Beaumont-Wood declared an interest in this item and left the room.
The Board approved the appointment of Rhiannon Beaumont-Wood as the Executive Director of Quality, Nursing and Allied Health Professionals.
a) Appointment of Director of Policy, Research and International Development as a member of the Executive Team The Board noted the appointment of Professor Mark Bellis, Director of Policy, Research and International Development, as a member of the Executive Team.
2. Our Space The Board received the paper on the Our Space Programme (paper 38 17) for approval.
Huw George presented the paper to the Board and noted the Welsh Government’s support for providing the relevant capital funding.
After describing the scoring process and results, the Board were
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asked to approve the Executive Team’s preferred option of building.
The Board did not agree unanimously on whether to approve the Executive Team’s recommendation.
Terence Rose motioned for the Board to approve the Executive Team’s recommended building, subject to space planning advice and that the space planning advice is also sought for the Executive Team’s second preferred building.
The motion was carried, with John Spence seconding the motion and six supporting votes from the Board and one abstention.
ACTION: The Executive Team to obtain space planning advice for the recommended building and also for the second preferred building.
2. Transforming Health Improvement The Board received the paper on Transforming Health Improvement Implementation (paper 38 18).
Dr Julie Bishop presented the paper.
The Board supported the progress made.
3. Public Health System in Wales Tracey Cooper provided an update for the Board.
5. HR issues This item was attended by Non Executive Directors, the Chief Executive and Board Secretary only.
The Board discussed a proposed secondment.
The Board supported the Chief Executive’s proposal.
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ACTIONS IN PROGRESS FROM THE MEETING HELD 28 APRIL 2015
38.09 Professor Andrew Davies to AD 28/04/15 25/06/15 In progress share the “Let’s Talk” publication with the Board.
38.10 Ruth Davies, Stephanie RD/SW/R 28/04/15 25/06/15 In progress Wilkins and Renata Leonardi- LJ Jones to discuss the process for feedback to the Welsh Partnership Forum.
38.14 Chair and Chief Executive to MA/TC 28/04/15 25/06/15 In progress circulate further information to the Board, when available, on the governance arrangements of the NHS Wales Collaborative.
38.16 Dr Sara Hayes to share the SH 28/04/15 25/06/15 In progress audit completed on the smoking cessation services with the Board.
38.17 Professor Sir Mansel Aylward MA/TC 28/04/15 25/06/15 In progress and Tracey Cooper to arrange a meeting with Edwina Hart to discuss the Graduated Driving Licence.
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ACTIONS IN PROGRESS FROM PREVIOUS MEETINGS
No. Action Who Start End Status Action taken to date Revised due date 34.02 Provide the Board with further CL 25/09/14 27/11/14 In progress Update will be provided when 25/06/15 information on the the review of internal engagement which has taken communications is presented place with staff. to the Board at a future Board meeting.
This action relates to 27.09.
36.05 A full discussion on RBW/KC 29/01/15 28/07/15 In progress An implementation plan for accessibility to take place at a the All Wales Standards for future Board meeting. Accessible Communication and Information for People with Sensory Loss will be submitted to the Board for discussion.
This action is linked to 37.01.
ACTIONS COMPLETED FROM THE MEETING HELD 28 APRIL 2015
38.01 Huw George to confirm that HG 28/04/15 25/06/15 Complete It has been confirmed that the actual results for cervical the different target figures for screening lab turnaround quarter 3 and quarter 4 are times within three weeks (on due to the incremental pages 9 and 10 of the Quality performance trajectories set and Delivery Framework Q3 for each quarter. The performance report) have trajectories are set to now been reconciled. increase each quarter and this is reflected in the performance report.
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38.02 Advertisements and job TC 28/04/15 25/06/15 Complete Tracey Cooper shared these descriptions for senior with the Board on 1 May 2015 positions to be circulated to the Board for comment before posting and Executive Team job descriptions to be shared.
38.03 Keith Cox to agree with KC 28/04/15 25/06/15 Complete It was agreed that Professor Sir Mansel Aylward performance reports and the whether the performance risk register should be on the reports should be on the Board agenda for scrutiny and agenda for decision or discussion. scrutiny and discussion.
38.04 Rhiannon Beaumont-Wood to RBW 28/04/15 25/06/15 Complete The most up to date risk consider whether a live register will be circulated register can be presented at before each Board meeting to future Board meetings. allow time for consideration.
A live version will be presented on the day if necessary and where possible.
38.05 The Board development plan KC 28/04/15 24/09/15 Complete Board development session to be discussed at a future now taking place on 23 July Board meeting after the 2015. Therefore, an updated Board development day has paper will be presented to the taken place. Board meeting on 24 September 2015.
38.06 Eleanor Higgins to update the EH 28/04/15 25/06/15 Complete Annual Governance Annual Governance Statement updated and Statement to include approved at Audit Committee geographical representation on 7 May 2015.
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in under-represented groups section and other Committee membership and champion roles held by the Non Executive Directors.
38.07 Non Executive Director KC 28/04/15 25/06/15 Complete This was discussed at the champion roles to be informal Board meeting held discussed at a future informal on 21 May 2015. meeting.
38.08 The regional representative RBW/RD 28/04/15 25/06/15 Complete Representatives have been for the Royal College of included in the signatories. Nursing to be included in the signatures for the Trade Union Recognition and Facilities Agreement.
38.11 Nathan Jones to circulate the NJ 28/04/15 25/06/15 Complete Nathan Jones circulated the draft response to the Welsh draft to the Board on Government’s request for 29/04/15. further information to support the IMTP to the Board.
38.12 The draft communication plan CL 28/04/15 25/06/15 Complete The communication plan was for the IMTP to be shared circulated to the Board on with the Board. 05/05/15.
38.13 Huw George to organise a HW 28/04/15 25/06/15 Complete A lessons learnt exercise is lessons learnt exercise on the underway, and is led by the process of developing the Assistant Director of Planning IMTP and Operational Plan and Performance. A further and its application over the report will be presented to the next three years. Board once the exercise has been completed
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38.15 The Board to receive the TC 28/04/15 25/06/15 Complete The hosting agreement will be amended hosting agreement discussed at the Board for the NHS Wales meeting on 25 June 2015. Collaborative, once the paper on governance arrangements has been received.
38.18 Provide Board with an update RD 28/04/15 25/06/15 Complete Update was provided to the on the Electronic Staff Record Developing the Organisation (ESR). Committee held on 28 May 2015. 38.19 The Executive Team to obtain HG 28/04/15 25/06/15 Complete Advice has been received and space planning advice for the a paper will be presented to recommended building and the Board on 25 June also for the second preferred providing further information. building.
OTHER COMPLETED ACTIONS
No. Action Who Start End Status Action taken to date Revised due date 27.09 Share dates of Chair/Chief CL 19/09/13 30/01/14 Complete An action plan has been 25/06/15 Executive meetings with circulated to the Executive teams and Executive team. CL to share with the Director of Public Health Non Executive Directors and Development/Director of staff side representatives Nursing meetings with also. teams. A discussion on Chair/Chief Executive meetings to take place at a future meeting. This has been added to the plan of Board business, so the action can now be closed.
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33.08 Follow up situation QS 29/07/14 25/09/14 Complete We are awaiting confirmation 25/06/15 regarding decision to on what recommendation will transfer Diabetic be made for the Minister’s Retinopathy Screening consideration. We have Services Wales from Cardiff confirmed to the Welsh and Vale University health Government that Public board to Public Health Health Wales cannot take on Wales. the transfer of the service without an accompanying adequate resource, so the action can now be closed.
34.01 Arrange discussion at future MA 25/09/14 28/04/15 Complete Discussion held at informal 28/04/15 informal Board meeting to Board meeting on 28/10/14. discuss how Non Executive This action links to action Directors can better engage 27.09 regarding Chair and with staff around the Chief Executive visits to staff organisation, for example around Wales so agreed to using a champion / mark as ‘Complete’. constituency area.
35.01 Invite Older Person’s KC 27/11/14 28/04/15 Complete Older persons Commissioner Commissioner for Wales to a has been invited to Board future Board meeting. meeting in July 2015, so the action can now be closed.
35.02 Provide an update in 6 QS 27/11/14 25/06/15 In progress Update has been scheduled 24/09/15 months time on the actions for Board meeting on 24 being taken to address September 2015, so the HCAIs. action can now be closed.
35.07 Invite Welsh Language KC 27/11/14 28/04/15 Complete Welsh language standards Commissioner to Board are expected to be released meeting once Welsh in autumn 2015, so Welsh language standards have Language Commissioner has been introduced. been to Board meeting in
Date: 15 June 2015 Version: 0e Page: 21 of 24 Public Health Wales Minutes from Board meeting held 28 April 2015
November/December 2015, so the action can now be closed.
36.02 Write to Professor Sally MA 29/01/15 01/04/15 Complete Letter sent to Professor Sally Holland once she has taken Holland requesting a further up post as Children’s meeting, so the action can Commissioner for Wales on now be closed. behalf of the Board and wider organisation.
36.03 Invite Ms Ruth Marks to a MA/KC 29/01/15 28/04/15 Complete Ruth Marks has been invited formal Board meeting. to Board meeting in October 2015, so the action can now be closed.
36.04 Invite to Minister for Health MA/KC 29/01/15 28/04/15 Complete Invitation to minister sent. and Social Services to We are awaiting confirmation attend a formal Board of date, so the action can meeting. now be closed.
37.01 The Executive team to meet TC 26/03/15 28/04/15 Complete The Executive Team 25/06/15 and discuss how Public discussed accessibility at Health Wales can improve their meeting held on Friday accessibility for those with 12 June 2015. disabilities and for the younger and older It was agreed that an population. implementation for the All Wales Standards for Accessible Communication and Information for People with Sensory Loss needs to be developed and this action will be taken forward as part of that work.
Date: 15 June 2015 Version: 0e Page: 22 of 24 Public Health Wales Minutes from Board meeting held 28 April 2015
This action is therefore closed.
37.03 A report on Making Every JG 26/03/15 21/05/15 Complete. It was agreed that Judith 28/07/15 Contact Count (MECC) to be Greenacre should produce a presented to the Board at a report to the Board on Brief future meeting. Interventions.
This action was superseded by the Transforming Health Improvement presentation. Action complete.
37.08 The Executive Team to MA/TC/JG 26/03/15 21/05/2015 Complete Oral update provided at explore how best to take Board meeting on 28 April forward next stages of 2015. Further discussions promoting GDL and report took place at informal Board back to Board at next meeting on 21 May 2015, so meeting. the action can now be closed.
37.10 Clarify who is able to amend KC 26/03/15 21/05/15 Complete Confirmation that the 25/06/15 the Public Health Wales Minister for Health and Social statutory instruments and Services has the legislative what implications this could power to amend the have on other NHS Trusts. statutory instruments in order to appoint an additional Non Executive Member. A public consultation is required.
KC confirmed that the appointment of an additional Executive Director can be approved by the Human Resources department of the Welsh Government, so this
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action can now be closed.
37.11 Prepare an updated Board KC 26/03/15 21/05/15 Complete This is part of the Board plan 28/07/15 Composition paper for a of business and a further future Board meeting. paper will be discussed at informal Board meeting on 28 July 2015, so this action can now be closed.
Date: 15 June 2015 Version: 0e Page: 24 of 24 39.06
NHS Wales Health Collaborative: Hosting agreement Author: Mark Dickinson, NHS Wales Health Collaborative and Keith Cox, Board Secretary Date: 12 June 2015 Version: 0j Sponsoring Executive Director: Tracey Cooper Who will present: Tracey Cooper Date of Board / Committee meeting: 25 June 2015 Committee/Groups that have received or considered this paper: • Executive Team
The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper X Discuss and scrutinise the paper and provide feedback and comments Receive the paper for information only
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) X
Date: 12/06/15 Version: 0j Page: 1 of 17 Public Health Wales NHS Wales Collaborative: Hosting Agreement
1 Introduction
Public Health Wales has been asked by the NHS Wales Chief Executives Management Team to host the NHS Wales Health Collaborative. The Board is asked to approve the hosting agreement.
2 Background
The Collaborative was formed on 9 February 2015, with Bob Hudson appointed as Director of the Collaborative.
3 Timing
The Board is asked to make a decision on 25 June 2015.
4 Description
The NHS Wales Health Collaborative brings together the South Wales Collaborative, the Programme Management Unit and the Chief Executives Support Unit. The Collaborative will report into the NHS Wales Chief Executives Management Team. The hosting agreement will be signed by each of the NHS Wales Chief Executives.
5 Financial Implications
The Collaborative’s budget will be agreed between all NHS Wales organisations. The Collaborative will be expected to work within the allocated budget. Full financial arrangements are outlined in section 9 of the hosting agreement.
6 Recommendation(s)
The Board is asked to approve the hosting agreement.
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NHS Wales Health Collaborative & Public Health Wales & NHS Wales Health Boards and Trusts Hosting Agreement
Author: Mark Dickinson and Keith Cox Date: 12 June 2015 Version: 0j Purpose and Summary of Document:
This agreement is to enable and facilitate the hosting of the NHS Wales Health Collaborative by Public Health Wales on behalf of NHS Wales Chief Executives.
The agreement is intended to ensure that hosting arrangements are clear and transparent and that the rights and obligations of all parties are documented and agreed. The agreement sets out appropriate financial arrangements and the obligations of all parties to the agreement.
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1 Parties to this agreement
The parties to this agreement are: 1. Public Health Wales NHS Trust (Public Health Wales), which is the hosting body 2. The NHS Wales Health Collaborative (the Collaborative), which is the hosted unit 3. All NHS Wales health boards and trusts, on whose behalf the Collaborative will work
The signatories to this agreement are:
1. Tracey Cooper, Chief Executive, on behalf of Public Health Wales
Signed: ______
Date: ______
2. Bob Hudson, Director, on behalf of the Collaborative
Signed: ______
Date: ______
3. Paul Roberts, Chief Executive, on behalf of Abertawe Bro Morgannwg University Health Board
Signed: ______
Date: ______
4. Judith Paget, Chief Executive, on behalf of Aneurin Bevan University Health Board
Signed: ______
Date: ______
5. Trevor Purt, Chief Executive, on behalf of Betsi Cadwaladr University Health Board
Signed: ______
Date: ______
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6. Adam Cairns, Chief Executive, on behalf of Cardiff and Vale University Health Board
Signed: ______
Date: ______
7. Allison Williams, Chief Executive, on behalf of Cwm Taf University Health Board
Signed: ______
Date: ______
8. Steve Moore, Chief Executive, on behalf of Hywel Dda University Health Board
Signed: ______
Date: ______
9. Carol Shillabeer, Chief Executive, on behalf of Powys Teaching Health Board
Signed: ______
Date: ______
10.Steve Ham, Chief Executive, on behalf of Velindre NHS Trust
Signed: ______
Date: ______
11.Tracy Myhill, Chief Executive, on behalf of the Welsh Ambulance Service NHS Trust
Signed: ______
Date: ______
2 Named points of contact
The following individuals will act as the primary points of contact in relation to any issues that may arise under this agreement: • For Public Health Wales: Huw George, Deputy Chief Executive • For the Collaborative): Mark Dickinson
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3 Purpose and scope of this agreement
This agreement is to enable and facilitate the hosting of the NHS Wales Health Collaborative by Public Health Wales on behalf of NHS Wales Chief Executives.
The agreement is intended to ensure that hosting arrangements are clear and transparent and that the rights and obligations of all parties are documented and agreed.
This agreement does not deal with the work to be undertaken by the NHS Wales Health Collaborative on behalf of NHS Wales Chief Executives. The Collaborative’s annual work plan and performance management arrangements will be the subject of a separate agreement to be developed between the Director of the Collaborative and the NHS Wales Chief Executive’ Peer Group.
4 Status of this agreement
This agreement is not legally binding and no legal obligations or legal rights arise between the parties from it. The parties enter into this agreement intending to honour its content and spirit.
This agreement is one which is subject to S.7 of the NHS(Wales) Act 2006.
The parties agree that they shall act:
• in the spirit of good faith; • in the interests of minimising costs to themselves; • in the interests of maintaining quality at all times; and • in accordance with any applicable statute, directions, orders, guidance or policy.
5 Duration, monitoring and review of this agreement
This agreement commences when signed by all three signatories above and will run, in the first instance, until 31 March 2016. Notwithstanding this, the Collaborative is being established on an ongoing basis.
The Director of the Collaborative will liaise regularly with the Public Health Wales Deputy Chief Executive to monitor the operation of this agreement and to address and resolve any practical issues that may emerge.
The agreement will reviewed in the fourth quarter of 2015/16 by all parties, with a view to either rolling forward the existing agreement or entering into a revised ongoing agreement from 1 April 2016.
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Any agreement by the parties to extend this agreement shall be recorded in writing in form found at Annex A.
6 Termination and notice period
This initial agreement is for a fixed period, as specified above, with no notice period. If the agreement is extended there will be a notice period of six months in writing.
The parties acknowledge that if one of the signatories to this document withdraws or otherwise terminates its responsibilities this agreement will terminate six months after that event and a new agreement will be drafted and agreed by all the parties that wish to continue to engage with each other in respect of the Collaborative.
7 Background
In October 2014, NHS Wales Chief Executives confirmed their intention to establish a new NHS Wales Health Collaborative to support them in delivering on those areas of work that require an all-Wales focus. The core functions initially proposed for the Collaborative are: • Joint planning of services where appropriate and agreed. This may include service, finance and workforce modelling as required • Programme management of discrete pieces of work • Research and evaluation of evidence to develop papers to support policy and strategy development
The functions of the collaborative will be developed and specified during the establishment phase.
On 7 January 2015, Allison Williams, as lead Chief Executive, wrote to Tracey Cooper, Chief Executive of Public Health Wales formally requesting that Public Health Wales should host the Collaborative and its Director. This request was formally accepted by the Public Health Wales Board on 29 January 2015.
Bob Hudson has subsequently been appointed as Director of the Collaborative, which initially consists of the resources and functions of the: • Chief Executives’ Support Office (CESO) • Programme Management Unit (PMU) • South Wales Health Collaborative (SWHC)
The CESO and the PMU were already part of Public Health Wales.
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8 Nature of the hosting arrangement
The hosting of the Collaborative by Public Health Wales will be characterised by a light touch, hands-off approach. Public Health Wales, will provide services and facilities to enable the smooth running of the Collaborative, but will not be responsible or accountable for setting the direction of the Collaborative or for the quality of the work undertaken by the Collaborative. This rests with the Director of the Collaborative reporting directly to the lead Chief Executive (currently Allison Williams).
9 Financial arrangements
9.1 Setting of and responsibility for the Collaborative’s budget
Whilst complying with Public Health Wales Standing Orders and Standing Financial Instructions (see below), the Director of the Collaborative will be accountable to the Lead Chief Executive for the management of the Collaborative’s budget.
The Director of the Collaborative will have an authorisation limit of £60,000 (equivalent to an Executive Director of Public Health Wales) and will specify an appropriate scheme of delegation for the management of the Collaborative’s budget. Expenditure over £60,000 would need authorisation from the Public Health Wales Chief Executive (following discussion with the Director of the Collaborative and the Lead Chief Executive).
The recurring core budget, and contribution shares, for the Collaborative will be agreed between all parties prior to the start of 2015/16. This will include the agreed legacy budgets of the PMU and the CESO, together with any additional recurring funding agreed by NHS Wales Chief Executives and contributed by NHS Wales bodies.
Recurring and non recurring changes to the Collaborative’s core budget will be agreed between the Director of the Collaborative and the NHS Wales Chief Executives. Such changes may include in-year recurring or non recurring uplifts contributed by health boards and trusts to cover additional activities.
9.2 Additional funding
In addition to its core budget, the Collaborative may receive additional recurring or non recurring income from individual NHS Wales bodies or from other sources, for specific work undertaken. The circumstances under which this can happen will be set out in the separate agreement referred to in section 3.
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The Collaborative will inform Public Health Wales of all arrangements for additional funding, and the terms under which the funding is being provided.
9.3 Financial variances
The Director of the Collaborative must aim for a break-even position each financial year. The Director of the Collaborative is responsible for informing the Lead Chief Executive and the Public Health Wales Chief Executive, at the earliest practicable stage, of any significant forecast variances and, in particular, of risks that may result in the underwriting provisions described in section 9.4 below being required.
In the event that there is a predicted under or overspend against the budget for the collaborative in any year, the parties to this agreement shall consider: • in the case of an under spend, whether there are any alternative uses to which the funds can be put consistent with the role of the Collaborative, or whether funds should be returned to contributing bodies • in the case of an over spend, what steps can be taken to prevent the overspend arising • any liability that exists as a result of any overspend will be shared on a joint and several basis between the parties signed to this agreement.
9.4 Financial liabilities
Public Health Wales shall be the responsible legal entity in relation to liabilities to third parties, save where excepted in this agreement.
The activities of the Collaborative will be covered by the Welsh Risk Pool, via Public Health Wales, but will be subject to the normal excess arrangements.
The NHS Wales Chief Executives will collectively underwrite the financial liabilities of the Collaborative, where such liabilities cannot be met from within the Collaborative’s budget or are not covered by the Welsh Risk Pool. This includes any costs associated with redundancy, termination or breaches of employment contract, disputes and health and safety matters.
Full details of the financial information to be reported to the NHS Wales Chief Executive’ Peer Group will be set out in the separate agreement referred to in section 3.
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9.5 Levy to cover the costs of hosting the Collaborative
Public Health Wales will charge a levy to cover the additional costs of hosting the Collaborative (above those costs incurred by Public Health Wales prior to the commencement of the hosting agreement). In 2015/16, a levy of 5% of the Collaborative’s core budget, excluding the budgets inherited from the Programme Management Unit (PMU) and Chief Executives’ Support Office (CESO), which were formerly part of Public Health Wales, will be charged by Public Health Wales. This will equate to a charge of approximately £45,000 (subject to confirmation of the final Collaborative budget). The hosting charge will be reviewed, as part of the overall review of this agreement, prior to 2016/17 (see section 5).
With the exception of the agreed levy to cover the hosting costs and any agreed costs arising from issues detail in clauses 10.1 and 10.2, no deductions will be made from the Collaborative’s budget by Public Health Wales and Public Health Wales’ Cost Improvement Programme savings targets will not be applied. Public Health Wales will not fund the Collaborative’s cost pressures, which must be funded within the agreed Collaborative budget.
10 Obligations of Public Health Wales under this agreement
10.1 General obligations of Public Health Wales
Public Health Wales shall be responsible for providing services and facilities to enable the smooth running of the Collaborative. In general, unless otherwise specified, these services and facilities will be equivalent to those provided to teams and services directly managed by Public Health Wales. Collaborative staff are expected to comply with Public Health Wales’ policies and procedures.
The services and facilities covered by this agreement may be provided directly by Public Health Wales or may be procured from third party providers, including, but not limited to the NHS Wales Shared Services Partnership and the NHS Wales Informatics Service (NWIS).
In hosting the Collaborative, Public Health Wales shall not be required to in any way act outside its statutory powers, duties, Standing Orders, Standing Financial Instructions or governance and legal obligations.
The Collaborative undertakes to indemnify Public Health Wales for any liability, losses, costs, expenses and claims that might arise in relation to the management of financial resources and the risk when discharging its duties and it will hold Public Health Wales harmless in respect of any
Date: 12/06/15 Version: 0j Page: 10 of 17 Public Health Wales NHS Wales Collaborative: Hosting Agreement claims made by any third party arising out of the operations of the Collaborative. The management of any such claim will be undertaken by Public Health Wales, in liaison with the Collaborative. However any such claims that arise as a result of Public Health Wales not meeting its hosting duties (as detailed in this Agreement), then Public Health Wales would be held accountable and manage the claim.
Public Health Wales will not be responsible for the validity, efficacy or approval of the Collaborative’s budget or other plans and the Collaborative will in fulfilling its obligations not place Public Health Wales in a position whereby it breaches any Statute, Regulation, Standing Order, Direction, Measure or any other Corporate Governance requirement.
Specific services and facilities to be provided are set out below:
10.2 Workforce
Public Health Wales will act as the appointing and employing body for all directly employed and existing seconded staff of the Collaborative, including the Director. The following services will be provided to the Collaborative: • Payroll services, including processing of expenses claims etc. • Recruitment and selection support (including provision of selection/assessment tools) • General human resources advice, with first line advice being provided by a named HR point of contact • Access to occupational health services • Access to and support of the Electronic Staff Record system • Access to statutory and mandatory training
Any financial liabilities resulting from the direct employment of staff of the Collaborative (e.g. costs associated with redundancy, termination or breaches of employment, disputes and health and safety matters) will be met from the core budget agreed for the Collaborative. In the event that the core budget has insufficient funds to meet or cover the liability, NHS Wales Chief Executives will collectively underwrite the financial liabilities of the Collaborative.
10.3 Finance and procurement
The Collaborative’s budget will be included within the Public Health Wales ledger and the Director and other Collaborative budget holders will be provided with an income and expenditure account and the following on the same basis as provided to Public Health Wales budget holders: • Specified budget codes for the sole use of the Collaborative • Budget holder reports and information
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• Management accountancy support and advice, with first line advice being provided by a named member of the finance team • Payment of invoices • Internal and external audit • Access to procurement advice and support • Appropriate access to the Oracle finance/procurement system
Public Health Wales will act as the legal entity which enters into contracts and related agreements for goods and services procured on behalf of the Collaborative.
10.4 Accommodation
Public Health Wales will provide suitable accommodation and appropriate accommodation related facilities, including furniture and document storage, for all staff of the Collaborative. In the first instance this accommodation will include: • The offices of the PMU in Churchill House, Cardiff • The offices occupied by the CESO and SWHC at Innovation House, Llanharan
Public Health Wales is currently in the process of rationalising its accommodation in South East Wales and, during the period of this agreement, this may impact on offices currently occupied by the Collaborative. Public Health Wales will be responsible for ensuring that the accommodation needs of the Collaborative are addressed in any accommodation changes planned or implemented. The staff of the Collaborative will be consulted on, and communicated with, on the same basis as Public Health Wales staff in relation to any proposed changes.
10.5 Information Technology
Public Health Wales will provide the Collaborative with access to: • network infrastructure • file servers for document storage • the NHS Wales network and internet • high volume shared printers/copiers • desktop IT support • access to mobile services (which may be charged for separately on an ‘at cost’ basis) • procurement of new and replacement IT equipment • hosting of the Collaborative’s internet and intranet sites and technical support in relation to their ongoing maintenance and development
In cases where there is a change in the arrangements for server storage of files, Public Health Wales will ensure that the Collaborative’s ‘legacy’
Date: 12/06/15 Version: 0j Page: 12 of 17 Public Health Wales NHS Wales Collaborative: Hosting Agreement files are appropriately transferred or archived, at the discretion of the Collaborative.
10.6 Other corporate support services
Public Health Wales will provide the Collaborative with access to: • Legal advice • Welsh language translation services • a lease car scheme for staff meeting eligibility criteria
Such access will be provided on the same basis as for Public Health Wales’ core services. As such, the Collaborative will be charged for such services in circumstances when a Public Health Wales budget holder would be directly charged. This includes any legal costs associated with redundancy, termination or breaches of employment contract, disputes and health and safety matters.
11 Reporting
Hosting reporting shall be undertaken as follows: 11.1.1 Responsible Officer: Will be the Director of the Collaborative and this person will report to the Deputy Chief Executive at Public Health Wales. 11.1.2 Accountable Officer: Will be the Chief Executive of Public Health Wales.
11.2 Variation
11.4.1 No variation to the Agreement will be valid unless made in accordance with the Change Control Procedure found at Annex B.
12 Obligations of the Collaborative under this agreement
The Collaborative will comply with Public Health Wales’: • Standing Orders • Standing Financial Instructions • Policies and procedures (where they are applicable to the activities of the Collaborative as a hosted body)
Staff within the Collaborative will be managed within Public Health Wales workforce related policies. However, there will not be a management accountability from the Director of the Collaborative to the Chief Executive of Public Health Wales.
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The Director of the Collaborative will have overall responsibility for the appointment of Collaborative staff, whilst acting within Public Health Wales recruitment policies. Other than the provision of HR advice and selection tools, or as specifically requested by the Collaborative, Public Health Wales will have no role in the appointment of staff.
The Director of the Collaborative will be responsible for ensuring that all Collaborative staff undertake applicable statutory and mandatory training, which will be made available by Public Health Wales (see section 10.2). With the exception of statutory and mandatory training, the responsibility for the organisation and funding of the training and development of Collaborative staff will rest with the Collaborative.
The Director of the Collaborative is responsible for the management of risk within the Collaborative and its activities.
The Director of the Collaborative will be the Responsible Officer for the Collaborative in accordance with clause 11.
The Director of the Collaborative will be responsible for ensuring any additional pieces of work taken on by the Collaborative, including expansion in workforce and budget are to be discussed and agreed with Public Health Wales.
13 Intellectual property
All intellectual property developed or legitimately acquired by the Collaborative shall be owned collectively by the NHS Wales health boards and trusts.
If the intellectual property is to be exploited in any way then terms will be agreed between all the parties in this respect.
14 Data Protection and Freedom of Information
For the purposes of data protection and freedom of information, all data and information held by the Collaborative will be deemed to be held by Public Health Wales. As a result, any requests for information under relevant Acts will be processed according to Public Health Wales procedures. However, the Director of the Collaborative will be informed as soon as possible of any relevant requests received and discussion will take place with the Director before any of the Collaborative’s information is released to a third party.
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15 Disputes and matters not covered by this agreement
It is inevitable that issues will arise that are not explicitly covered by this agreement. In such cases, and in the event of any disputes, all parties will seek to address these issues and identify appropriate solutions in the common interest of NHS Wales and the public served.
If any party has any issues, concerns or complaints about Hosting, or any matter in this Hosting Agreement, that party shall notify the other parties and the parties shall then seek to resolve the issue by a process of consultation. If the issue cannot be resolved within a reasonable period of time, the matter shall be escalated to the Accountable Officer and the Responsible Officer, who shall decide on the appropriate course of action to take. If the matter cannot be resolved by them within 21 days, the matter may be escalated to the Welsh Government in accordance with the NHS (Wales) Act 2006.
If any party receives any formal inquiry, complaint, claim or threat of action from a third party (including, but not limited to, claims made by a supplier or requests for information made under the Freedom of Information Act 2000) in relation to Hosting, the matter shall be promptly referred to the Accountable Officer and Responsible Officer (or their nominated representatives). No action shall be taken in response to any such inquiry, complaint, claim or action, to the extent that such response would adversely affect Hosting, without the prior approval of them (or their nominated representatives).
16 Governing law and jurisdiction
16.1 This Agreement shall be governed by and construed in accordance with the laws of England and Wales and, without affecting the escalation procedure set out in clause 15, each party agrees to submit to the exclusive jurisdiction of the courts of England and Wales.
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Annex A
The Parties agree that the Agreement will be extended for a period of [insert] months on the same terms.
Date of Extension Length of Extension
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Annex B – Change Control Procedure
1. Changes may be proposed by any party to the Responsible Officer who will then discuss them with the Accounting Officer.
2. The Changes may be agreed or rejected by both of those individuals.
3. All parties will be notified of the decision and any resulting change will be recorded in writing and annexed to this agreement.
4. Any dispute regarding the proposed changes will be dealt with by the escalation procedure except in that different officers of each body will deal with the dispute.
Date of change Clause No.
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39.07
Governance and
accountability module Author: Eleanor Higgins, Corporate Governance Manager Date: 22 May 2015 Version: 0c Sponsoring Executive Director: Keith Cox, Board Secretary Who will present: Keith Cox, Board Secretary Date of Board Team meeting: 25 June 2015 Committee/Groups that have received or considered this paper: Executive Team
The Board is asked to: (please select one only) Approve the recommendation(s) proposed in the paper X Discuss and scrutinise the paper and provide feedback and comments Receive the paper for information only
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) X
Priorities for action include relevant priority for action(s)
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Public Health Wales Governance Accountability Module
1 Introduction
The Governance and Accountability Module is a framework that Boards are required to self assess against to establish how well the organisation is governed. It is also a requirement of the Welsh Government and forms part of the supporting information for the Annual Governance Statement. The self assessment covers the period April 2014 – March 2015.
2 Background
The narrative has been updated to provide a self assessment for April 2014 – March 2015. The Board discussed and agreed the scores and supporting narrative at the informal Board meeting on 21 May 2015. 3 Timing
The final scoring of the three themes has been reported in the Annual Governance Statement, which forms part of the Annual Accounts and Annual Report and was submitted to Welsh Government on 5 June 2015 4 Financial Implications
None. 5 Recommendation(s)
The Board is asked to approve the Governance and Accountability Module and the final scoring.
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Public Health Wales Governance Accountability Module
Governance and Accountability Module Self Assessment Author: Eleanor Higgins, Corporate Governance Manager Date: 22 May 2015 Version: 0c Purpose and Summary of Document:
The Governance and Accountability Module is a framework that Boards are required to self assess against to establish how well the organisation is governed. It is also a requirement of the Welsh Government and forms part of the supporting information for the Annual Governance Statement. The self assessment covers the period April 2014 – March 2015.
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Public Health Wales Governance Accountability Module
Governance and Accountability module – summary of self assessment scores for 2012/13, 2013/14 and 2014/15
The following table provides a summary of the scores which Public Health Wales has awarded itself in previous years. The scores for individual statements have reduced since 2012/13 because the organisation has grown and evolved over the years and we recognise that there are always new areas which require improvement. This has also resulting in our holding ourselves to a higher standard than we have done in previous years. The scores for each overall theme have remained the same.
Disagree
disagree disagree Theme 1 – Setting the direction Strongly or agree Strongly
Neither Neither
Agree Key * 2012/13 agree ^ 2013/14
° 2014/15
a) We make an effective contribution to the achievement of the strategic vision for health services in * Wales ^ ° b) We have a clear purpose, vision and overall strategic direction that effectively aligns our local * needs with the national strategy for health services in Wales ^ ° c) Our citizens, staff and other stakeholders inform and influence our organisation/ business’s * purpose, strategic vision and direction ^ ° d) We carry out our work instilled with a strong sense of values, supported by clear standards of * ethical behaviour ^ ° e) We promote equality and recognise diversity across all our services and activities * ^ ° f) We apply and embed professional standards and quality requirements in a way that meets the * needs and expectations of patients, service users, citizens and other stakeholders ^ °
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Public Health Wales Governance Accountability Module
Disagree
disagree disagree
Strongly Strongly or agree Strongly
Theme 2 – Enabling delivery self assessment statements Neither
Agree Key * 2012/13 agree ^ 2013/14
° 2014/15
a) We have the right people, with the right skills, doing the right things, in the right place, and at the * right time to meet our responsibilities for the provision of safe, high quality care ^ ° b) The different services and parts of our organisation/business work well together, and everyone * understands who does what and why ^ ° c) We properly safeguard all those who work in or access our health services (including those who * may accompany patients or service users), paying particular attention to the needs of children and ^ vulnerable adults ° d) We have the right facilities (equipment and environment) to enable us to consistently deliver safe, * high quality services across all the communities we serve ^ ° e) We support the development and delivery of high quality, safe and accessible services through * strong, effective financial planning and management ^ ° f) Our workforce at all levels in the organisation/business are equipped with the information they need * to help them carry out their work effectively, and this information is shared appropriately and securely ^ held ° g) We are an innovative organisation/ business that takes proper account of the risks (both * opportunities and threats) to the achievement of our aims and objectives ^ ° h) We have strong, effective relationships with our workforce, partners, citizens and other * stakeholders ^ ° i) Decisions taken throughout our organisation are made by those best placed to do so, are well * informed, timely and are effectively communicate ^ °
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Neither agree agree Neither
Theme 3 – Delivering results, achieving excellence self or disagree
Disagree
disagree
Strongly Strongly Strongly
Agree assessment statements agree Key * 2012/13
^ 2013/14
° 2014/15
a) We have a clear understanding of how well we are performing overall, what services are doing well, * and what services need improving (including those services that are carried out by others on our ^ behalf) °
We respond quickly and effectively to address areas of concern, including those relating to individuals’ performance b) We operate in accordance with all legal and other requirements placed on us * ^ ° c) We know what our citizens and others (including our workforce) think of us, and this influences * what we do and how we do it ^ ° d) We measure our performance against ‘best practice’ and other standards set for the services we * provide and we use the results to drive improvement in the provision of high quality, safe and ^ accessible services ° e) We learn from our own and others experiences, and in turn share our learning with others * ^ °
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Overall assessment maturity matrix
We do not yet have We are aware of We are We have well We can a clear, agreed the improvements developing plans developed plans demonstrate understanding of that need to be and processes and processes sustained good where we are (or made and have and can and can practice and how we are doing) prioritised them, demonstrate demonstrate innovation that is and what / where but are not yet progress with sustainable shared throughout we need to improve able to some of our key improvement the organisations demonstrate areas for throughout the / business, and meaningful improvement organisation / which others can action. business learn from Theme 1 Setting the * Direction ^ ° Theme 2 Enabling * Delivery ^ ° Theme 3 Delivering * results achieving ^ excellence °
Overall Maturity * Level ^ °
Key * 2012/13 ^ 2013/14 ° 2014/15
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Note: In establishing your level of agreement in relation to each of the statements made, you must be able to demonstrate through your supporting narrative not only what your organisation or business is doing, but how well it is working and the resulting impact on organisational performance.
Theme 1 - Setting the Direction
Desired Outcomes:
We place the people who use our services at the heart of our work
We make sure our purpose is clear and know to develop and deliver our services to improve overall health and well being
We are a value based organisation/business and carry out our work openly, honestly, ethically and with integrity
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a) We make an effective contribution to the achievement of the strategic vision for health services in Wales
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree
agree
Supporting narrative √ Public Health Wales makes an effective contribution to the achievement of the strategic vision for health services in Wales. The organisation plays a pivotal role in improving public health in Wales and is committed to setting the direction in Wales for reducing inequality resulting from the socio-economic determinants of health.
We responded to the consultations on both the Public Health Bill and the Wellbeing of Future Generations Bill and also contributed to the ‘national conversation’. The responses focused on the links between the two Bills and provided the Welsh Government with examples of areas which could be included in the Bills where tangible outcomes could be realised.
We continue to establish clear system leadership on critical public health issues. We have achieved this in areas such as: work undertaken by the Public Health Wales Observatory; WCISU; emergency preparedness for the NATO summit; emergency preparedness for the Ebola outbreak in west Africa; public health research and development; infection reduction activities and programmes; and the Transforming Health Improvement in Wales programme.
We a one year operational plan which the organisation has been working towards. During the year we began developing a three year integrated plan for 2015 – 2018. During this development we have engaged with health boards, local authorities and the Welsh Government, through a series of workshops and engagement events, to agree shared priorities.
We continue to lead the work on Prudent Healthcare and have produced a prudent healthcare e-book which is an online resource to support the development of Prudent Healthcare.
Supporting evidence Integrated Medium Term Plan Together for Health Programme for Government NHS Wales Delivery Framework NHS Outcomes Framework Our Healthy Future Fairer Health Outcomes for All Nursing and midwifery strategy
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b) We have a clear purpose, vision and overall strategic direction that effectively aligns our local needs with the national strategy for health services in Wales
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree
agree
Supporting narrative √ Public Health Wales has a dual role, both locally and nationally in contributing to the national strategy for health services in Wales.
Our current strategy was launched during 2013. During the year our one year operational plan reflected the strategy and provided a clear purpose, vision and overall strategic direction. During 2014 the Board revisited the strategy and confirmed that the aim ‘a healthier, happier and fairer Wales’ still applied. A series of workshops and engagement events took place with staff and stakeholders to identify shared priorities for the public health system in Wales. The strategic plan for 2015-2018 includes seven strategic priorities, three of which are shared with the public health system in Wales. We will continue to engage with stakeholders to ensure our strategy is fully aligned with health boards and local authorities.
Supporting evidence Integrated Medium Term Plan Together for Health Programme for Government NHS Wales Delivery Framework NHS Outcomes Framework Our Healthy Future Fairer Health Outcomes for All Nursing and midwifery strategy
c) Our citizens, staff and other stakeholders inform and influence our organisation/ business’s purpose, strategic vision and direction
disagree Strongly
nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
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Citizens Public Health Wales has long established links with various groups for engagement. The Screening Engagement Team works in partnership with a variety of agencies at a local level including local authorities, health boards, minority groups, community and development teams and third sector agencies. We have recently developed resources around screening for transgendered people which were developed in partnership with transgendered service users.
A Service User Experience and Learning Panel is now well established and embedded ad chaired by the Director of Nursing. A Non Executive Director champion has been identified together with a Community Health Council representative. A patient story is heard at each meeting and the panel discuss any lessons which can be learned from the story. These are reported to the Quality and Safety Committee and in turn to the Board. The panel also considers learning from complaints, concerns and incidents so that analysis from these is used to inform our business purpose, strategic vision and direction.
Staff A ten point plan for ‘developing the organisation’ has been produced following engagement and consultation with staff. The plan has been fully incorporated into the three year strategic plan for the organisation. Each of the ten points represents a strategic objective that supports the development of the organisation.
We engage with staff representatives through the partnership forum. Representatives from the partnership forum attend Board meetings as full non-voting members to contribute fully to discussions and decisions at Board level. We are in discussions with the BMA about securing a representative at Board meetings.
Stakeholders We regularly engage with partners and stakeholders. The Transforming Health Improvement in Wales programme has been taken forward by stakeholder groups. We engaged with a number of stakeholders to seek joint appointments or to agree memoranda of understanding for working together. These include: the Police and Crime Commissioner; Natural Resources Wales; Sport Wales; and Community Housing Cymru.
We also hold the annual Welsh Public Health Conference which has become well regarded amongst professionals in Wales and the UK.
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The score for this statement has remained the same as the previous year. However, significant improvements have been made during the year, which we will continue to build on during 2015/16. We would, therefore, expect to see considerable improvements in this area, which mean we could afford ourselves a higher score next year.
Supporting evidence Patient stories Social media strategy Staff engagement sessions Service user experience and Service user experience Staff and stakeholder engagement learning panel feedback surveys strategy Partnership forum Terms of Staff conference Conferences arranged in partnership Reference with others
d) We carry out our work instilled with a strong sense of values, supported by clear standards of ethical behaviour disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √ In all our actions, whether with colleagues, stakeholders or partners, Public Health Wales seeks to be professional, persuasive, open, reflective and responsive.
We have a strongly professionalised workforce who work with a strong sense of values which are supported by clear standards of ethical behaviour, with a strong commitment to health inequalities. The Medical Director oversees medical revalidation for the medical workforce and the Director of Nursing provides a professional lead for nursing and midwifery staff.
Public Health Wales adopted a full set of policies and procedures when it was established on 1 October 2009. These policies and procedures are systematically reviewed in order of priority. Regular policy and partnership forum meetings have been established to progress and agree policies between management and trade union representatives. It has recently been noted by the Executive Team that some of these policies are out of date and action is required to update them.
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Board members adhere to the standards of good governance set for the NHS in Wales, which are based on the Welsh Government’s Citizen Centred Governance Principles.
Supporting evidence Corporate Policies Declaration of Interest Board and Committee Arrangements Standing Financial Instructions Standing Orders Appraisals / Performance Reviews Scheme of Delegations WAO reviews Nursing and midwifery strategy WAO Structured Assessment Internal Audit reviews Other external reviews
e) We promote equality and recognise diversity across all our services and activities
disagree Strongly
nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √ We have put in place a revised Strategic Equalities Plan (SEP) and a working group to action the plan which has representation from across Public Health Wales. The SEP considers equality issues affecting all aspects of our work as well as our workforce. The group aims to facilitate learning across directorates and divisions to actively engage staff in strategic decisions. A priority for 2015/16 has been identified to recruit an Equality Officer to embed equality and diversity across the organisation.
All Public Health Wales accommodation has been audited to be compliant with the Disability Discrimination Act.
Dignity at work and equality and diversity training is mandatory for all Public Health Wales staff. Compliance of uptake of training needs to improve. We continue to focus efforts on improving compliance rates. There is a dignity at work policy in place which is one of the main drivers for managing incidents of harassment as well as being a management tool.
The recruitment of staff is supported by the two tick system whereby anyone applying for a post who self declares themselves as disabled can receive automatic shortlisting when applying for jobs within the NHS, providing they meet the essential criteria for the post, as set out in the person specification. This is further supported by HR policies and procedures.
A range of equality and diversity data is collected from service users eg Screening. However, this is not available for analysis of the workforce. The roll out of Electronic Staff Record will allow staff to update
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Public Health Wales Governance Accountability Module their equality and diversity information directly. This will, in turn, provide more accurate information for analysis.
We have an approved Welsh language scheme and action plan which demonstrates the organisations commitment to offering bilingual services to the public of Wales.
We are working to develop a consistent approach for carrying out equality impact assessments (EqIA). The central message is that EqIA activity should be started at the beginning of planning a new policy or when substantially revising an existing policy. We are also looking to improve access to our services and to be more inclusive in the way in which we engage with the wider public.
The Board has agreed to participate in a pilot programme with the Welsh Government to increase diversity on public appointments in Wales. Two individuals from underrepresented groups have been appointed to shadow the Board for a period of 12 months with the aim of providing them with the necessary skills and knowledge when applying for public appointments in Wales.
Supporting evidence DDA audits Single Equality Scheme Welsh Language Scheme Dignity at Work Policy Strategic Equality Plan Equality Impact Assessments (EQIA)
f) We apply and embed professional standards and quality requirements in a way that meets the needs and expectations of patients, service users, citizens and other stakeholders
disagree Strongly
nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √ We receive regular scrutiny from internal and external auditors and other regulatory bodies to ensure that, as a minimum, our services and activities comply with the national standards. We have also adopted and embedded the Standards for Health Services which set national benchmarks for all our services and activities. The Executive Team receive quarterly updates on how we are progressing our improvement programme. This is then reported into the Quality and Safety Committee who have an oversight role.
CPA accreditation applies to microbiology and screening for compliance with national standards and ongoing audit arrangements. The standards for health services have also been mapped to the CPA Date: 22/05/15 Version: 0c Page: 14 of 39
Public Health Wales Governance Accountability Module standards. In 2015 CPA accreditation will be replaced with ISO 15189, and the microbiology labs are making preparations for the new accreditation process.
2013/14 was the second year that Public Health Wales produced an Annual Quality Statement. The Statement provides an open and honest assessment of what Public Health Wales is doing to ensure all its services are meeting the needs of the population of Wales and reaching high standards. It also provides a summary highlighting how the organisation is striving to continuously improve the quality of the services it provides and commissions in order to drive both improvements in population health and the quality and safety of healthcare services.
The Nursing and Midwifery strategy was launched in May 2014 and identifies, underpins and supports regulatory and fitness to practice requirements.
2014/15 was the second full year of revalidation for the medical workforce. All doctors for whom Public Health Wales is the designated body have had revalidation appraisal in the past 15 months. Compliance with reappraisal within 12 months stands at 92 per cent.
There is currently no systematic way for talking to the public about health, although it does work well in some areas. In roads have been made through the social media strategy where feedback has been sought via social media channels. The Service User Engagement and Learning Panel receives feedback from service users.
Supporting evidence Annual Quality Statement Doctor / Nurse registration CPA and UKAS accreditation HSE Regulations / Regulatory Public Health Workforce Screening Services Quality Bodies Development programmes Standards Medical revalidation Annual performance reviews
Theme 1- Setting the direction: Your overall assessment
In relation to this particular theme, what is your overall assessment of where and how you: . are governing well . need to strengthen your arrangements . have noteworthy practice which you may wish to share
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Public Health Wales has an established Board and governance arrangements in place. We have revisited our strategy and confirmed that it continues to provide a clear purpose. The development of the three year strategic plan for 2015-18 has included close engagement with our stakeholders to ensure it is aligned with their priorities. We continue to develop and deliver our services to improve overall health and wellbeing. This can be evidenced through the Transforming Health Improvement in Wales programme; modernisation of screening programmes; and reconfiguration and automation of microbiology services.
Strengthen arrangements We need to continue our work in strengthening learning from service users and stakeholders to inform service improvement and focus on continue embedding equality and diversity within the organisation.
Noteworthy practice for sharing We have started to engage fully with stakeholders and partners and are developing joint appointments and memoranda of understanding. We arranged a joint conference with the WLGA entitled ‘united in improving health in Wales’. The aim was to strengthen the links between public services, third sector and others to improve health and tackle inequalities and initial feedback from the day has been extremely positive.
What maturity level have you demonstrated you have reached for this theme overall: 3
‘We are developing plans and processes and can demonstrate progress with some of our key areas for improvement.’
In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success?
Priorities for improvement Action to be taken Timescale Measure of success Continue to foster learning from Service User Experience and To be completed by March Service user feedback service user experience and Learning Panel 2016 performance reports will be complaints Service user engagement embedded into the reporting strategy system Patient stories at Board Board will have opportunities to meetings hear from service users directly. Strengthen equality and diversity Identify and deliver appropriate To be completed by March Equality Officer will be appointed within organisation training and development in 2016 Equality and diversity will be relation to equality and embedded within the diversity organisation Implement strategic equality plan Appoint Equality Officer Strengthen engagement with Review stakeholder To be completed by March Stakeholders, service users and Date: 22/05/15 Version: 0c Page: 16 of 39
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service users and stakeholders communications and 2016 the public will be engaged in our engagement strategy and planning and all that we do. actions
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Theme 2 – Enabling delivery Desired outcomes:
We make sure that everyone involved in delivering health services understands each others contribution, and how together we can deliver a better service
We work constructively in partnership with others to improve the quality and safety of services for our patients, service users and the wider community
We foster innovation and make the best use of all the resources available to us, including our people, facilities and finances
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Public Health Wales Governance Accountability Module a) We have the right people, with the right skills, doing the right things, in the right place, and at the right time to meet our responsibilities for the provision of safe, high quality care
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √ We have developed an integrated medium term plan, which includes workforce development and has been approved by the Board. The plan for 2015-18 includes a ten point for ‘developing the organisation’. It was produced following engagement and consultation with staff. The plan has been fully incorporated into the three year strategic plan for the organisation. Each of the ten points represents a strategic objective that supports the development of the organisation.
A leadership and management development programme has been developed following feedback from staff and was launched in February 2015. The programme aims to strengthen the skills set for those in leadership and management roles.
The Microbiology service and Cervical Screening Wales are undergoing service redesign and modernisation. There is a risk that the results of the changes in these service areas may leave people in the wrong place with the wrong skills.
A review of the Executive Team structure has been completed and a revised structure implemented which is aligned to the strategic priorities.
All staff are required to undertake statutory and mandatory training. The Board had expressed concern in previous years with the low level of compliance in some areas. The situation has improved considerably during 2014/15. A new policy has been issued which sets the target at 90 per cent compliance. We are still short of this target, but compliance is considerably improved on previous years.
Supporting evidence Professional registration Performance Policies Developing the organisation plan Medical revalidation Annual performance reviews Nursing and midwifery strategy Defined and Practitioner Strategic plan Concerns and incident reporting registration policy and process
b) The different services and parts of our organisation/business work well together, and everyone Date: 22/05/15 Version: 0c Page: 19 of 39
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understands who does what and why
disagree Strongly
nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √ A ten point plan for ‘developing the organisation’ has been produced following engagement and consultation with staff. The plan has been fully incorporated into the three year strategic plan for the organisation. Each of the ten points represents a strategic objective that supports the development of the organisation.
Staff engagement events took place during autumn 2014 where strategic priorities and other objectives were discussed.
Difficulties are experienced from working across multiple sites. The ‘our space’ programme was launched in 2013 and aims to align flexible working practices, new technology and the organisation’s accommodation strategy to enable Public Health Wales to move toward developing a workplace for the future. An early part of the programme invited staff to attend a series of workshops where they could feed in their views about how the organisation works together.
Teams have started working together and good examples include alcohol awareness scratch cards being distributed in the mobile breast screening units; and brief intervention smoking cessation being delivered in dental practices.
Supporting evidence Developing the organisation ten Feedback received from Public Health Wales Staff e-bulletins point plan staff Internal consultation documents Intranet site Corporate communications strategy
Organisational structures
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c) We properly safeguard all those who work in or access our health services (including those who may accompany patients or service users), paying particular attention to the needs of children and vulnerable adults disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
Those who work in our services
All Public Health Wales staff are provided with a job description, which contains specific responsibilities and common responsibilities, relating to risk management, competence, supervision and health & safety
Staff can raise concerns via the Whistleblowing Policy, (section 5 page 6 of the policy which details the three steps that staff can follow to escalate their concern). Staff are encouraged to raise issues via any mechanism they feel comfortable with. This can include raising issues with staff representatives, line managers and in local team meetings. If the issue cannot be dealt with at a local level, they should be escalated up to a Director, or, to one of the relevant Governance Committees or Corporate Leads.
A Named Nurse for safeguarding provides leadership, expert advice and ensures procedures are in place to support staff in relation to responsibilities in Safeguarding. A safeguarding strategy ‘Safeguarding in Public Health Wales’ has been developed which includes safeguarding children and vulnerable adults. This strategy also specifies that training is mandatory for all staff and Board members.
Those who access our services
The Safeguarding Children Service, is an independent service of designated professional experts, providing assistance to NHS in keeping children safe.
Complaints and concerns raised by children, young people and vulnerable adults are dealt with under the Putting Things Right – handling concerns, complaints and claims policy.
Supporting evidence Safeguarding strategy Safeguarding Group Safeguarding Children Service Date: 22/05/15 Version: 0c Page: 21 of 39
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Named Nurse for Safeguarding Quality and Safety Committee
d) We have the right facilities (equipment and environment) to enable us to consistently deliver safe, high quality services across all the communities we serve
disagree Strongly
nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
An estates database has been created to provide a central reference point for all information available on the buildings occupied by Public Health Wales. This also includes a list of fire wardens for each location and in completing this work the facilities manager has secured sufficient fire wardens for each location. An asbestos management plan has also been implemented for the organisation which has assisted in minimising the risk of asbestos to the workforce and users of our facilities. An internal audit report into asbestos was completed in 2014. It confirmed that work was underway to address asbestos management arrangements in the organisation, but also identified a number of areas for improvement. A follow-up report was completed in early 2015 which confirmed that all actions had been completed and substantial assurance was awarded.
The organisation does experience some difficulties from working across multiple sites, which was identified last year. A review of accommodation is underway as part of a wider project entitled ‘our space’. The project aims to create a modern fit for purpose working environment that will make better use of space; incorporate new technology and flexible working practices to support the delivery of organisational priorities and the revised healthier, happier and fairer Wales strategy. It is hoped the review of accommodation can assist in improving cohesion and understanding across the organisation of different team’s contributions and priorities.
Microbiology and Screening laboratories are subject to formal standards for health and safety and work to standing operating procedures and this is assessed via CPA accreditation.
The service redesign of microbiology, including automation, and the introduction of HPV test of cure for Cervical Screening Wales are large steps towards ensuring we have the right facilities to deliver safe, high quality services.
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Supporting evidence Business planning Capital programme Estates strategy Accommodation Strategy Standard 22 – Risk, Health H&S and Infection Control Policy and Safety Management
e) We support the development and delivery of high quality, safe and accessible services through strong, effective financial planning and management disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
Regular finance reports are forwarded to the Board and monthly financial performance reports are submitted to the Welsh Government along with monthly Director of Finance commentary. Monthly financial position / performance reports are also presented to the Public Health Wales Executive Team and to individual divisional directors.
The Wales Audit Office audit the accounts on an annual basis and provide assurance in the form of an a structured assessment and annual audit report. For 2014/15 the WAO made some minor recommendations for improvement but overall concluded that governance arrangements for the organisation were sound. In addition, the NHS Wales Shared Services Partnership – Audit & Assurance Services undertake regular audits of financial and associated systems, along with providing assurance on internal control.
Regular training sessions on budgetary control are provided and all new budget holders are required to complete this training. The Trust has a budgetary control procedure and a finance guide is available on the intranet, which includes information on both budgetary and financial control.
An integrated medium term plan has been developed which includes a financial plan.
Supporting evidence Board reports WAO Structured Assessment Budget strategy for 2013/14 Annual Governance Statement Annual accounts letter WAO and Internal Audit Reports
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f) Our workforce at all levels in the organisation/business are equipped with the information they need to help them carry out their work effectively, and this information is shared appropriately and securely held
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
Staff can access information from a wide variety of sources, including:
Specific information systems used by specific services (eg laboratory information management systems (LIMS), screening programme call/recall systems) Internal websites and document databases Library and knowledge management service and Observatory External sources facilitated by internet and intranet access
There is a strong informatics function specialising in areas specific to the organisations activity (including screening, surveillance, microbiology). All staff have access to IT equipment necessary for them to carry out their work.
The Information Governance Committee; Information Governance Working Group; and local Information Governance contacts all contribute to the effecting sharing of information and secure storage of information. The Committee is reassured by the low number of complaints and errors which are reported in relation to Information Governance.
The ‘our space’ project is also considering ways of working across the organisation and part of this work will look at accessing and sharing of information for staff. Staff feedback has identified that some staff experience issues with the IT infrastructure in the organisation. This has prompted the informatics team to set up a process for staff to use their own devices for work purposes, whilst retaining full security of data and information, which goes some way to addressing the concerns raised.
Supporting evidence Intranet Internet E-bulletin
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Information Governance Information Governance Policies and Procedures Committee Working Group
g) We are an innovative organisation/ business that takes proper account of the risks (both opportunities and threats) to the achievement of our aims and objectives
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √ Public Health Wales has a risk management strategy in place which includes a risk management framework. The strategy involves 5 key areas: developing risk management in Public Health Wales; embedding key risk management systems and processes; ensuring statutory compliance; ensuring Public Health Wales is risk aware and staff are appropriately trained and skilled in risk management; ensuring compliance with regulation and monitoring. We have revised the risk management policy during the year and will implement the revised policy during 2015/16. The format of the risk register has also been refreshed and linked to the strategic objectives.
The Audit Committee receives the corporate risk register at each meeting. The Committee has started receiving an in depth review of specific risks at each meeting, where the responsible owner of the risk attends the Committee meeting to take questions and give detailed explanation on the mitigating actions for the risks.
All incidents are reported to the Quality and Safety Committee. Any risks that are identified as a result of reported incidents, are discussed in detail and appropriate risk assessments and action plans developed.
The Board has received training on their responsibilities for risk management and risk appetite.
Supporting evidence Corporate Risk Register
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h) We have strong, effective relationships with our workforce, partners, citizens and other stakeholders
disagree Strongly
agree nor nor agree
Disagree
disagree Strongly
Neither Neither
Agree Agree
Supporting narrative √
Workforce
We work closely in partnership with staff and staff representatives through the Partnership Forum and local negotiating arrangements. Representatives from the partnership forum regularly attend Board meetings as a full, non-voting, Board member.
Staff engagement events have taken place to discuss the ten point plan for developing the organisation which is now incorporated into the strategic objectives for 2015-18.
Partners / stakeholders
Staff within the organisation work closely with health boards and local authorities. The main contact with local authorities is through the local public health teams. We have a long-standing vacancy on the Board for a local authority Board member. This poses a considerable risk to our relationship with local authorities in Wales. We have appointed an interim local authority Non Executive Board member while we await the changes to our regulations. This is improved our working relationship with local authorities.
We have engaged with a number of stakeholders to seek joint appointments or to agree memoranda of understanding for working together. These include: the Police and Crime Commissioner; Natural Resources Wales; Sport Wales; and Community Housing Cymru.
There are well established health protection partnership arrangements with Consultants in Communicable Disease Control appointed as ‘responsible officers’
Staff representatives are members of all Wales peer groups eg NHS Wales Chairs, Vice Chairs, Chief
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Executives, Directors of Finance, Medical Directors, etc. Chairs of Committees also attend meetings with their respective all Wales Committee Chairs.
Citizens
The Service User Experience and Learning Panel engage with those who use our services and receives feedback via patient stories and lessons learned from complaints.
We regularly use social media to communicate with citizens and stakeholders. We established successful routes of communication during measles outbreak and this included an effective use of social media. We have reviewed our used of social media to ensure we are maximising every opportunity for engagement through this medium.
Supporting evidence Staff engagement workshops Public and Stakeholder Screening Engagement Annual Engagement Strategy Report Partnership Forum Service user stories Service User Experience and Learning panel
i) Decisions taken throughout our organisation are made by those best placed to do so, are well informed, timely and are effectively communicated
disagree Strongly
nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
All decisions taken by the Board and Committees are made openly and transparently.
The Wales Audit Office produce a structured assessment each year for Public Health Wales. Last year (2013) they concluded that the governance arrangements and functioning of the Board were sound, but that there some recommendations which could further strengthen the organisation’s decision making processes. All recommendations made have now been completed.
The structured assessment for 2014 concluded that:
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Sound financial management continue to ensure the Trust breaks even and to meeting savings targets The Trust has improved its focus on its strategic and operational priorities, and related risks, and its governance arrangements, though some aspects are improving too slowly Arrangements for seeking and responding to service user feedback are improving
Some recommendations were made relating to identifying and recording divisional risks; service user experience; and information governance.
Board, Committee and Executive Team papers are published routinely on the Public Health Wales website.
Supporting evidence Board intranet page Executive Team meetings Scheme of Delegation Standing Financial Instructions Standing Orders
Theme 2 – Enabling delivery: Your overall assessment
In relation to this particular theme, what is your overall assessment of where and how you: . are governing well . need to strengthen your arrangements . have noteworthy practice which you may wish to share
Governing well We continue to achieve high quality, safe and accessible services through sound financial planning and management. The organisation is forecast to a balanced position for 2014/15.
Our governance arrangements are generally sound.
Strengthen arrangements A number of issues have been identified with staff working across different locations and a project is underway to address these issues and propose options to improve accommodation and ways of working.
The Executive Team has identified the need to review the risk management process in the organisation to ensure the flows of assurance are working well.
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Noteworthy practice for sharing We have developed our three year integrated plan by engaging with stakeholders to ensure priorities are aligned.
What maturity level have you demonstrated you have reached for this theme overall: 3
We are developing plans and processes and can demonstrate progress with some of our key areas for improvement.
In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success?
Priorities for improvement Action to be taken Timescale Measure of success Consider ways to improve issues Our space project March 2016 Reduce number of buildings arising from staff working across occupied by Public Health Wales different locations and co-locate staff Review risk management process Implement revised risk June 2015 Risk management arrangements and information flows management policy to be embedded across Monitor risks at regular organisation with divisional risk Executive Team meetings registers feeding into corporate risk register and linked to integrated medium term plan.
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Theme 3 – Delivering results, achieving excellence
Desired outcomes:
We provide high quality and accessible health services in a manner that ensures equity of access and minimises waste, harm and variation
We build on our strengths and take early, decisive action to improve services where we need to. We learn from our own and others experiences to continuously improve the provision of health services
We contribute to the overall improvement of health services in Wales by sharing our learning with others
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a) We have a clear understanding of how well we are performing overall, what services are doing well, and what services need improving (including those services that are carried out by others on our behalf)
We respond quickly and effectively to address areas of concern, including those relating to individuals’ performance
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
The Board receives reports summarising the organisations performance against the Quality and Delivery Framework which includes a mixture of qualitative and quantitative measures to asses performance against the strategic objectives. The Board has scrutinised performance data and commended areas which are doing well. They have requested further assurance for areas which need improving and regularly monitor progress against improvements. For example they requested further assurance on the performance of Stop Smoking Wales and within the screening division.
The Quality and Safety Committee places emphasis on identifying, reviewing and assessing quality performance measures.
The Service User Experience and Learning Panel receives stories from service users and discusses the learning from their stories and also from complaints and concerns. These inform improvements to our services.
All medical staff are required to comply with medical revalidation. Non medical staff are required to undergo regular performance review and personal development.
We aim to respond to all concerns / complaints received within 30 days, however by February 2015 we had only responded to 75 percent of concerns within that time period.
Supporting evidence Standards for Health Services Quality management systems Performance reports Service user experience and
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learning panel
b) We operate in accordance with all legal and other requirements placed on us
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
The standing orders, standing financial instructions and scheme of delegation are reviewed periodically by the Board and are available on the Public Health Wales internet.
The Annual Governance Statement is prepared in line with Welsh Government requirements and takes account of best practice issued by HM Treasury. The Statement provides an assurance of the governance arrangements in the organisation. The Audit Committee play a key role in the completion of the statement and by providing assurance to the Board that the organisation is operating in accordance with all requirements placed on us.
A Local Counter Fraud specialist is in place and reports regularly to the Audit Committee. They provide specialist criminal investigation, surveillance capability and financial investigation services.
A review of the Terms of Reference for the Audit, Information Governance and Quality & Safety Committee was undertaken and has confirmed that there is no overlap in responsibilities between the Committees. This has also clarified which information needs to be received by which committee. Workplans for each Committee have been developed to ensure clarity of roles.
The Wales Audit Office audits our accounts on an annual basis and provides assurance in the form of an annual audit report and structured assessment. Internal audit arrangements are provided by NHS Wales Shared Services Partnership – Audit and Assurance Services.
Statutory and mandatory training is required of all staff.
Public Health Wales policies and procedures highlight any legislation relevant to the policy.
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We have a Strategic Equalities Plan (SEP) in place. The SEP considers equality issues affecting all aspects of our work as well as our workforce.
We also ensure all our facilities comply with the Disability Discrimination Act.
The Welsh Language Board has approved our Welsh Language Scheme which demonstrates the commitment to communicating with the public in the Welsh and English languages on the basis of equality and championing the Welsh Language.
Supporting evidence Standing Financial Instructions Standing Orders Risk Management structure Statutory requirements Policies and procedures Scheme of Delegations Welsh Audit Office Structured Health & Safety Professional Register of interests Assessment Lead Standards for Health Services Professional registration Welsh Language Scheme Medical revalidation
c) We know what our citizens and others (including our workforce) think of us, and this influences what we do and how we do it
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
Currently feed back is received via the following routes: The screening programmes conduct satisfaction surveys for some of the populations they invite for screening. The screening programmes also have a public information group which include user representatives and which develop public information materials As part of its quality management system, Public Health Wales microbiology services conduct stakeholder satisfaction surveys. The Public Health Wales Networks evaluate each of their conferences and have themselves been externally evaluated
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Other conferences are also evaluated Stop Smoking Wales get user feedback from survey sheets All Public Health Wales websites have a feedback facility Service user experience and learning panel and service user stories
In each of the above cases, views are fed into the relevant management groups for consideration and action. These only represent part of the organisation and work is continuing to make this routine across the entire organisation.
Representatives from the partnership forum attend Board meetings as full, non-voting Board members. We are still establishing representation from professional groups.
We have engaged with our staff and stakeholders throughout the year. These engagement events have helped to shape the strategic priorities for the organisation and have also informed a ten point plan for developing the organisation. We plan to continue engagement in this way to ensure our strategy and services are fully aligned with those of our stakeholders.
A proposal has been drafted to increase the visibility of the Board members and Executive Team. Further work will be undertaken in 2015/16 to take this forward.
Supporting evidence Screening Engagement annual Putting things right Reports on the Screening Services report satisfaction surveys
Equality Group Staff survey Service user experience Staff engagement events
d) We measure our performance against ‘best practice’ and other standards set for the services we provide and we use the results to drive improvement in the provision of high quality, safe and accessible services
disagree Strongly
nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
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Supporting narrative √ Performance is regularly measured against ‘best practice’ from the UK and internationally. Screening services, for example, regularly compare screening programmes with those taking place in England, Scotland and Northern Ireland. Each programme is developed and improved using international evidence and research. The all Wales pathology modernisation work programme has drawn upon international best practice.
The Transforming Health Improvement in Wales programme reviewed public health interventions from across the UK and other parts of the world that have a proven track record of effectiveness. A ranking exercise to rate the intervention for each outcome based on potential population impact and deliverability was completed.
All screening programmes operate a total quality management framework and standards for delivery are outlined in each programme specific quality manual. There is also an ongoing programme of evaluation and all reports and statistics are published annually on the Screening website. Programme performance and individual performance are monitored on an ongoing basis as this enables the service to target re- training or interventions as required. Screening programmes are being developed further so that they continue to meet performance standards.
Public Health Wales has strong links with international colleagues and members of staff regularly attend international meetings and conferences where best practice and innovation is shared. An example is participation in the British Isles Health Inequalities proposal to work across nations to develop an evidence base, produce strategies, monitor progress and enable research on reducing health inequalities. During the year we launched a Charter for International Health Partnerships in Wales. The Charter sets out agreed principles which will help formalise overseas volunteering, further strengthen international health partnerships and promote Wales’ profile on the world stage.
The 1000 Lives Plus programme regularly draws on international work and comparisons when introducing new service improvement initiatives. The target for smoking cessation is based on an international benchmark.
Members of the Board, Executive Team and staff within the organisation attend all Wales and international meetings where best practice and experience is openly shared.
Supporting evidence Standards for Health Services Internal and External audit Reviews and inspections by reviews regulatory bodies International conferences and Staff involvement with Staff Membership of professional Date: 22/05/15 Version: 0c Page: 35 of 39
Public Health Wales Governance Accountability Module
activities professional groups bodies Sharing of best practice within and between professional groups via regular monthly / quarterly meetings
e) We learn from our own and others experiences, and in turn share our learning with others
disagree Strongly
agree nor nor agree
Disagree
disagree
Strongly Strongly
Neither Neither
Agree Agree
Supporting narrative √
We foster a sense of learning through engagement with others.
Board meetings are planned to foster learning from others and sharing experiences. Alternate Board meetings take place in localities across Wales and individuals are invited to present to the Board to share learning experiences. We hold an annual general meeting which provides an opportunity for staff and stakeholders to reflect on the work undertaken during the year. A leadership and delivery group has been established to facilitate learning across divisions and directorates.
We play a full part in the all Wales networks and are engaged in all areas where experiences are shared and discussed.
We have strong links with the Chief Medical Officer and Chief Nursing Officer in Welsh Government, Public Health England and public health colleagues in England, Scotland and Northern Ireland. The Director for Public Health Development attends meetings of the ‘5 nations’ (Wales, England, Scotland, Northern Ireland, Republic of Ireland) and the Director for Public Health Services attends meetings of the Public Health England Advisory Board and Director of Nursing has developed stronger links with counterparts within the four nations.
The Welsh Public Health conference is organised by Public Health Wales and provides a forum for sharing of experiences and learning and is highly regarded amongst professionals in Wales and the UK.
The health protection team take part in formal reviews in relation to health protection and regular debriefs during and after outbreaks. We successfully ensured business continuity during the NATO Summit and Date: 22/05/15 Version: 0c Page: 36 of 39
Public Health Wales Governance Accountability Module coordinated the emergency preparedness for the event. We have also been actively involved in leading the Welsh response to Ebola.
Supporting evidence Annual General Meeting Stakeholder meetings Board meetings
Committee meetings
Theme 3 – Delivering results, achieving excellence: Your overall assessment In relation to this particular theme, what is your overall assessment of where and how you: . are governing well . need to strengthen your arrangements . have noteworthy practice which you may wish to share
Governing well We have embedded planning and performance across the organisation.
We operate within all legal and other requirements placed upon us.
Strengthen arrangements We need to continue to learn from service user engagement.
Noteworthy practice for sharing We launched the Charter for International Health Partnerships in Wales. The Charter sets out agreed principles which will help formalise overseas volunteering, further strengthen international health partnerships and promote Wales’ profile on the world stage.
What maturity level have you demonstrated you have reached for this theme overall: 3
We are developing plans and processes and can demonstrate progress with some of our key areas for improvement. In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success?
Priorities for improvement Action to be taken Timescale Measure of success Continue to foster learning from Service User Experience and To be completed by March Service user feedback service user experience and Learning Panel 2016 performance reports will be complaints Service user engagement embedded into the reporting Date: 22/05/15 Version: 0c Page: 37 of 39
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strategy system Patient stories at Board Board will have opportunities to meetings hear from service users directly.
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Standards for Health Services
Governance and Accountability Maturity Matrix
1 2 3 4 5 We do not yet have a We are aware of the We are developing We have well We can demonstrate clear, agreed improvements that plans and processes developed plans and sustained good understanding of where need to be made and and can demonstrate processes and can practice and we are (or how we are have prioritised them, progress with some of demonstrate innovation that is doing) and what / where but are not yet able to our key areas for sustainable shared throughout the we need to improve demonstrate improvement improvement organisations / meaningful action. throughout the business, and which organisation / others can learn from business
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39.08
Welsh Language Scheme Monitoring Report 2014-15
Author: Caren Prys Jones, Welsh Language Officer Date: 12 June 2015 Version: 0e Publication/ Distribution: • Welsh Language Commissioner • Welsh Language Committee • Public Health Wales Board • Public (Internet) • NHS Wales (Intranet) Review Date: 31 March 2016 Purpose and Summary of Document: This report has been produced in accordance with the annual reporting framework detailed in Public Health Wales’s Welsh Language Scheme. The report is being sent to the Welsh Language Commissioner, in line with her directives. The report has been agreed by the Public Health Wales Welsh Language Committee is also being shared with its Board.
Work Plan reference: Welsh Language Scheme Public Health Wales Welsh Language Scheme Monitoring Report 2014-15 1 Introduction
1.1 Public Health Wales is committed to placing users at the centre of our services. We want to ensure that they receive services that are appropriate to their needs, and are effective.
We consider communication and language to be core components of a public health service and, it follows, therefore, that an appropriate and efficient service is one that meets the language and communication needs of the service user. We acknowledge that some people can only communicate and participate in their services as equal partners effectively through the medium of Welsh. We are committed to meeting the Welsh language needs of our service users.
In 2010 we published our Welsh Language Scheme in which we expressed our commitment to see sensitivity to Welsh language needs reflected throughout the organisation, and to increase the availability and quality of our Welsh language services. Our Scheme contains a commitment to monitor the implementation of the Scheme, and to report to the Public Health Wales Board and the Welsh Language Commissioner on our progress.
In previous years we have produced comprehensive monitoring reports in line with the Welsh Language Commissioner’s requirements. This year, the Commissioner is requesting a concise report in view of the fact that we submitted a comprehensive response to the Welsh Language Standards Investigation in February this year. The report that follows has been produced in accordance with the Commissioner’s revised requirements.
2 New policies and initiatives
2.1 Number and percentage of new policies and initiatives that were subject to a language impact assessment
Number Percentage
13 69%
Date: 12 June 2015 Version: 0e Page: 2 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15
Policy / Initiative Equality Impact Assessment?
Home working Yes
Confidentiality Yes
Outbreaks management Yes
Domestic abuse Yes
Safeguarding adults at risk Yes
Statutory and mandatory training No
Infection prevention & control precautions to Yes minimise transmission of RTIs
Infection control for building development, No change & adaptations policy
Fire Safety Yes
Maternity, adoption, paternity leave & IVF policy Yes & Procedure
Research misconduct and fraud procedure No
Transporting personally identifiable information No data
Nursing and Midwifery Strategy Yes
2.2 An example of a policy or initiative which was amended following consideration of the language impact assessment
An Equality Impact Assessment was undertaken on the draft version of the Public Health Wales Nursing and Midwifery Strategy. A number of amendments were made to the strategy concerning the Welsh language in the light of the assessment. The Welsh language now features in seven of the strategy’s ten themes, namely:
• Dignity and Respect:
‘Reviewing attitudes and behaviours, the use of Welsh
Date: 12 June 2015 Version: 0e Page: 3 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15
language and other forms of communication in the context of dignity and respect in working with colleagues and the public.
‘Driving improvement plans which respond to ‘Doing well, Doing better’, Standard 10 Dignity and Respect, and the Standards relating to Welsh Language.’
• Communication:
’Participating in Welsh language awareness sessions.’
• Professional Development:
‘Scoping educational and development needs of nurses and midwives in Public Health Wales to develop learning programmes, including the use of Welsh Language skills and other communication methods.’
• Co-production:
‘Routinely listening to and engaging with people in the language of their choice.’
• Revalidation, Appraisal and Supervision:
‘Providing a structure that supports a process for gaining feedback from the public and colleagues in the language/medium of their choice, which may also be required for revalidation purposes.’
• Quality Improvement:
‘Undertaking audits and actively seeking the views and experiences of service user, in the language of their choice, to drive up quality, in order to deliver services that are centred on service users’ and carers’ needs.’
• Research and Development:
’Undertaking regular audits, as part of a structured work plan, to identify and demonstrate good practice and help improve the quality of services, including the use of Welsh Language.’
The supporting action plan also contains actions relating to the Welsh language.
Date: 12 June 2015 Version: 0e Page: 4 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15 3 Services provided by others
3.1 Number and percentage of third party agreements that were monitored in conformity with the relevant requirements of the Welsh language scheme We do not have the necessary monitoring arrangements in place to enable us to provide the required data.
3.2 An example of third party compliance with the relevant requirements of the Welsh language scheme
Public Health Wales has a Smoking Prevention Social Marketing contract with a third party. The contractor is required to manage bilingual Facebook and the printing and distribution of bilingual support resources. Public Health Wales holds weekly meetings with the contractor at which bilingual requirements are discussed. The contractor complies fully with the Welsh language specifications.
4 Face to face contact with the public
4.1 Number and percentage of posts in the organization’s main receptions that have been identified as posts where Welsh language skills are essential
Location Number Percentage
14 Cathedral Road, Cardiff 1 100%
Temple of Peace, Cathays Park, Cardiff 1 100%
4.2 Number and percentage of posts in outpatient clinic receptions that have been identified as posts where Welsh language skills are essential
Service Number Percentage
Breast Test Wales 0 0%
Date: 12 June 2015 Version: 0e Page: 5 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15
4.3 Number and percentage of the above posts filled by individuals who met the Welsh language skill requirements specified
Reception Type Number Percentage
Main reception 0 0%
Temple of Peace 0 0%
5 Information technology
Percentage of the organization’s website that is available in Welsh
and
Evidence relating to the process used to ensure that existing content, updates and new content complies with the requirements of the Welsh language scheme
Public Health Wales currently has 37 websites, of which 22 are fully bilingual, 12 are partially bilingual and 3 are monolingual. Some of the monolingual or partially bilingual websites are aimed at health professionals, not the public. We will consider the need to review the language content of websites aimed at health professionals as we begin to prepare for the introduction of the Welsh Language Standards.
The websites and their bilingual status are set out below. Where websites are 100% bilingual, the content management process ensures that the Welsh and English language content is uploaded simultaneously.
Website and URL % Content Management Welsh Process / Comments Public Health Wales 85% Changes to the English and www.publichealthwales.org Welsh sites are usually www.iechydcyhoedduscymru.wales made simultaneously but .nhs.uk occasionally the Welsh site is updated a short time after changes have been made to the English site
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Public Health Wales Health 0% The website is aimed at Protection health professionals. A new http://www.wales.nhs.uk/healthpr fully bilingual website is otection under development and will be launched in late 2015. Welsh Healthcare Associated 20% This website is being taken Infections Programme (WHAIP) offline late in 2015 and all http://www.wales.nhs.uk/whaip content moved to the new fully bilingual health protection website above.
Public Health Wales Observatory 96% Web pages relating to the http://www.publichealthwalesobser rapid query answer service vatory.org/ and for primary care (RASP) http://www.arsyllfaiechydcyhoeddu were migrated from the scymru.org/ monolingual ATTRACT website. This service is aimed at GPs. Page content is currently being reviewed and will be translated as part of this process. RASP Q&As were produced in English only in accordance with current Public Health Wales translation guidance.
New web page content is routinely translated as part of the process for adding analytical content onto the site. Any review of webpage content would usually also take into account the need also make corresponding changes to the welsh site.
Changes to the English and Welsh sites are usually made simultaneously, but occasionally the Welsh site is updated a short time after changes have been
Date: 12 June 2015 Version: 0e Page: 7 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15
made to the English site Congenital Anomaly Register and 99% Changes to the English and Information Service (CARIS) Welsh sites are made www.caris.wales.nhs.uk simultaneously but on rare occasions, the Welsh site is updated a short time after changes have been made to the English site Welsh Cancer Information and 100% Surveillance Unit (WCISU) www.wcisu.wales.nhs.uk Antenatal Screening Wales 100% www.antenatalscreening.wales.nhs .uk www.screeningservices.org/asw/ Bowel Screening Wales 100% www.bowelscreeningwales.org.uk www.screeningservices.org Breast Test Wales 100% www.breasttestwales.wales.nhs.uk www.screeningservices.org Cervical Screening Wales 100% www.cervicalscreeningwales.wales. nhs.uk www.screeningservices.org/csw Newborn Hearing Screening Wales 100% www.newbornhearingscreening.wal es.nhs.uk www.screeningservices.org 100% AAA Screening Wales www.aaascreening.wales.nhs.uk www.screeningservices.org 100% Newborn Bloodspot Screening
www.newbornbloodspotscreening. wales.nhs.uk
Date: 12 June 2015 Version: 0e Page: 8 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15
www.screeningservices.org Stop Smoking Wales 50% All pages intended for the www.stopsmokingwales.com public are bilingual. www.dimsmygucymru.com However, an online quit tool was added to the website in January 2015 which is currently available in English only. The Welsh language version of the tool will be available to the public by June 2015.
The core site contains approximately 10 pages without Welsh equivalents. These pages are almost exclusively those with information for health professionals aimed at incentivising dentists and opticians to refer smokers into the service.
With the exception of the online quit tool, Welsh and English pages go live simultaneously. All Wales Sexual Health Network 100% www.shnwales.org.uk All Wales Mental Health Promotion 100% Network www.publicmentalhealth.org Physical Activity and Nutrition 100% Network www.physicalactivityandnutritionw ales.org.uk/ All Wales HIV Network 100% www.hivnetworkwales.org.uk Planet Health Cymru 100% www.planethealthcymru.org Welsh Health Impact Assessment 80% The Welsh site is updated Support Unit a week or so after changes
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http://www.wales.nhs.uk/sites3/ho have been made to the me.cfm?OrgID=522 English site Health in Wales 100% www.wales.nhs.uk 100% Health Challenge Wales www.healthchallengewales.org www.heriechydcymru.org
1000 Lives Improvement corporate 40% A new fully bilingual site website will be launched www.1000livesplus.wales.nhs.uk later this year. In the www.1000amwyofywydau.wales.nh interim we are reviewing s.uk our Welsh language content and making urgent changes or updates. 100% Improving Quality Together www.iqt.wales.nhs.uk 95% NHS Wales Awards http://www.nhswalesawards.wales. nhs.uk/home
http://www.nhswalesawards.wales. nhs.uk/hafan 85% EppCymru http://www.wales.nhs.uk/sites3/ho me.cfm?orgid=537
http://www.wales.nhs.uk/sites3/w- home.cfm?orgid=537 100% Ask About Clots
www.askaboutclots.co.uk 0% The future of this site is Complex Care under review www.complexcarewales.org 95% Champions for Health http://www.championsforhealth.wa les.nhs.uk/home http://www.pencampwyriechyd.wal es.nhs.uk/hafan
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100% NHS Wales Centre for Equality and Human Rights www.equalityhumanrightswales.wa les.nhs.uk 100% Frisky Wales www.friskywales.org www.cymruchwareus.org
Healthy Working Wales 100% www.healthyworkingwales.com (public www.cymruiacharwaith.com area)
International Health Coordination 95% One section of the site Centre requires translation (5 www.iechydrhyngwladol.wales.nhs. pages) uk www.internationalhealth.wales.nhs. uk
GP 1 80% English uploaded first www.gpun.cymru.nhs.uk followed by Welsh one to www.gpone.wales.nhs.uk two weeks later when translation received 100% Screening for Life www.screeningforlife.wales.nhs.uk 100% Add to Your Life / Ychwanegu at Fywyd www.addtoyourlife.co.uk www.ychwaneguatfywyd.co.uk
Cancer National Specialist Advisory 0% The future of this site is Group under review (outcome expected June-September http://www.wales.nhs.uk/sites3/ho 2015) me.cfm?orgid=322
Date: 12 June 2015 Version: 0e Page: 11 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15 6 Recruitment
Number Percentage
Posts advertised where Welsh 4 of 258 1.6% language skills were specified as being essential
Posts filled by individuals who met 3 of 4 75% the Welsh language skill requirements specified
Of the 258 posts advertised, 254 were advertised as ‘Welsh desirable’.
7 Language skills
Number and percentage of the organization’s workforce who have recorded their Welsh language skills on the electronic staff record (ESR)
Number Percentage
579 (of 1475) 39%
8 Training to improve Welsh language skills
Number and percentage of the organization’s workforce who received training to improve their Welsh skill to a specific qualification
Number Percentage
1 0.07% (Receptionist, 14 Cathedral Road, Cardiff)
Date: 12 June 2015 Version: 0e Page: 12 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15 9 Language awareness training
9.1 Number and percentage of the organization’s new staff (i.e. since 1 April 2014) who received Welsh language awareness training
Number Percentage
19 of 172 11%
NHS Shared services took over e-learning in October 2014 and the e-Learning Administration System was decommissioned and all e-learning was transferred to the Learning@NHSWales site. The Welsh Language Awareness e-learning that was available on the old site was not transferred to the new site. This means that Public Health Wales has had no access to Welsh Language Awareness e-learning since October 2014.
Shared Services intends to develop an all-Wales Welsh Language Awareness e-learning package. Public Health Wales’ Welsh Language Officer will be a member of the development group.
9.2 Number and percentage of the organization’s entire workforce who have received Welsh language awareness training since it was introduced
Number Percentage
725 49%
10 Complaints
Number of complaints received about the 4 implementation of the Welsh language scheme
Date: 12 June 2015 Version: 0e Page: 13 of 14 Public Health Wales Welsh Language Scheme Monitoring Report 2014-15 11 Publicity
Evidence of the methods used to promote the organization’s Welsh language services, e.g. telephone services, website, etc.
11.1 Welsh Language Commissioner’s ‘Cymraeg’ posters, lanyards, and badges have been issued to Screening Services, Stop Smoking Wales, and Hywel Dda Public Health Team. The posters are displayed in screening clinics when Welsh speakers are on duty. Welsh speaking screening and Stop Smoking Wales staff wear the badges and lanyards.
11.2 When service users call the following telephone helplines, the first thing they hear following the bilingual greeting is an invitation to select the language in which they wish to receive the service.
Stop Smoking Wales: 0800 085 2219
Bowel Screening Wales: 0800 294 3370
12 Workforce planning
12.1 Evidence of the current status of the organization’s Welsh language/bilingual skills strategy
Following organizational restructure which came into effect on 1 April 2015, the Welsh language is now part of the portfolio of services for which the Director of Workforce and Organisational Development is responsible. Responsibility for the development of the Welsh Language Skills Strategy has been assigned to the Welsh Language Officer. Target date March 2016.
Date: 12 June 2015 Version: 0e Page: 14 of 14 39.09
Performance Report Quarter 4 2014/15
Author: Public Health Wales
Date: 15 June 2015 Version: 0a
Sponsoring Executive Director: Huw George, Deputy Chief Executive/Executive Director of Operations and Finance
Who will present: Huw George, Deputy Chief Executive/Executive Director of Operations and Finance
Date of Board / Committee meeting: 25 June 2015
Committee/Groups that have received or considered this paper:
Executive Team
The Board / Committee are asked to: (please select one only)
Approve the recommendation(s) proposed in the paper X
Discuss and scrutinise the paper and provide feedback and comments
Receive the paper for information only
Link to Public Health Wales commitment and priorities for action:
(please tick which commitment(s) is/are relevant) X X X X
Date: 15/06/15 Version: 0c Page: 1 of 13 Public Health Wales Quarter 4 2014/15 Performance Report
Quarter 4 2014/15 Performance Report
Author: Nathan Jones, Assistant Director of Planning and Performance and Chris Orr, Business Support Manager Sponsoring Executive Director: Huw George, Deputy Chief Executive and Executive Director of Operations and Finance Date: 15 June 2015 Version: 0c Distribution: • Public Health Wales Board Purpose and Summary of Document: The purpose of this performance report is to provide the Board with detail on Public Health Wales’ Quarter 4 (2014/15) performance. It contains information presented to Welsh Government as part of Public Health Wales’ JET meeting on 29 April 2015.
Date: 15/06/15 Version: 0c Page: 2 of 13 Public Health Wales Quarter 4 2014/15 Performance Report
1 Executive Summary
1.1 Overview of performance
Number of performance indicators (some of which 58 are broken down further by health board) Green (performance meets target) 28 Amber (performance is within 10% of target value) 8 Red (performance is more that 10% below target) 14 Not available (due to the availability of data and will be 1 included in the June report) No target 7
1.2 Performance summary
Service Delivery Indicator Standard/Target Performance Page Reference Stop Smoking Wales Number of smokers treated 7692 (Quarter 4) 2208 52 week success rate (of four week Page 5 >=15% 28.1% quitters) Health Improvement Programmes Healthy Working Wales - organisations completing a full 7 (Quarter 4) 6 Page 5 assessment Healthy Working Wales - organisations achieving a Small 31 (Quarter 4) 24 Workplace Health Award National Exercise Referral Scheme Page 6 4329 (Quarter 4) 4120 (NERS) - take up NERS - number consultations 5796 (Quarter 4) 6873 NERS – 52 week retention 1079 (Quarter 4) 1142 Screening Breast screening uptake >=71% (Quarter 4) 70.7% Adominal aortic aneurysm >=72% (Quarter 4) 74.1% screening uptake Newborn hearing screening per cent entering screening >=99% (Quarter 4) 99.6% programme Breast screening: normal results 95% (Quarter 4) 93.8% Page 8 sent within two weeks of screen Breast screening: assessment appointments within three weeks of 50% (Quarter 4) 27.1% screen Breast screening: per cent women invited within 36 months previous 65% (Quarter 4) 30.6% screen
Date: 15/06/15 Version: 0c Page: 3 of 13 Public Health Wales Quarter 4 2014/15 Performance Report
Bowel screening coverage >=53% (Quarter 4) 50.9% Bowel screening waiting times for 95% (Quarter 4) 99.6% screening test results Bowel screening waiting time for 60% (Quarter 4) 65.6% colonoscopy Cervical screening coverage >=80% (Quarter 4) 77.9% Cervical screening laboratory turnaround times: within three 80% (Quarter 4) 91.9% weeks Cervical screening waits for results: 83% (Quarter 4) 93.6% within four weeks Microbiology Microbiology - CPA accreditation Full Full Page 7 status and move to ISO 15189 Public Health Indicators Indicator Standard/Target Performance Page Reference Healthcare Associated Infections Clostridium difficile rate (per <= 31 by 09/15 35.79 (Quarter 4) 100,000 population) Page 9 MRSA rate (per 100,000 5.66 (Quarter 4) <=2.6 by 09/15 population) Vaccination and Immunisation Uptake of all scheduled childhood >=95% 84.6% (Quarter 4) vaccinations at age 4 Influenza vaccination uptake >=75% 68.1% (as at 24/03/15) among the over 65s Influenza vaccination uptake among under 65s in high risk >=75% 49.5% (as at 24/03/15) Page 10/11 groups Influenza vaccination uptake >=75% 45.3% (as at 24/03/15) among pregnant women Influenza vaccination uptake >=50% 42.9% (as at 24/03/15) among healthcare workers Quality Indicator Standard/Target Performance Number of written N/A 14 concerns/complaints received Written concerns/complaints responded to within target 100% 93% (Quarter 4) timescales Page 12 Number of serious untoward N/A 2 incidents (SUIs) reported SUI investigations completed 100% 100% (Quarter 4) within target timescales
Date: 15/06/15 Version: 0c Page: 4 of 13 Public Health Wales Quarter 4 2014/15 Performance Report
Workforce and Resources Indicator Standard/Target Performance Workforce Sickness absence rate 3.75% (01/04/14 – <=3.25% 31/03/15) Percentage of non medical staff 77% (Survey undertaking PADR in past 12 >=70% undertaken December Page 12 months 2014) Percentage of medical staff undertaking performance appraisal 100% 100% within the last 15 months
Date: 15/06/15 Version: 0c Page: 5 of 13 Public Health Wales Quarter 4 Performance Report
1.3 Stop Smoking Wales
Target Actual Q3 14/15 Q4 14/15 7692 Number of smokers treated 1345 2208 (Q4)
Self reported quit rate at four weeks >=50% 51.6% 53.6%
CO validated quit rate at four weeks >=40% 43.6% 46.1%
52 week success rate (of four week quitters) >=15% 27.5% 28.1%*
Client satisfaction rate (% of responses) >=80% 97.5% 97.5%
*Of those successfully contacted
1.4 Health improvement programmes
ASSIST performance Q4 Target Actual Q3 14/15 Q4 14/15 Number of secondary schools targeted by ASSIST 20-25 22 20
Healthy Working Wales performance Q4 Target Actual Q3 14/15 Q4 14/15 Organisations completing a Corporate Health Standard mock assessment 8 5 4
Private sector organisations completing a mock assessment 1 12 1
Organisations completing a full assessment 7 6 6
Private sector organisations completing a full assessment 1 9 3
Date: 15/06/15 Version: 0c Page: 6 of 13 Public Health Wales Quarter 4 Performance Report
Organisations achieving a Small Workplace Health Award 31 21 24
Number of Workboost interventions delivered 150 116 64
Mental Health First Aid Q4 Target Actual Q3 14/15 Q4 14/15 Number of trainees N/A* 188 196 *No Q4 target was set for Mental Health First Aid as the contract with MIND terminated 30 November 2014. Decision to continue the programme with in-house support not taken until this time. Alcohol Brief Intervention training performance Q4 Target Actual Q3 14/15 Q4 14/15 People trained to deliver alcohol brief interventions 25 576 361
Training sessions delivered 4 33 26
National Children’s Obesity Referral Programme Q4 Target Actual Q3 14/15 Q4 14/15 Training programmes delivered 10 12 12
National Exercise Referral Scheme performance Q4 Target Actual Q3 14/15 Q4 14/15 Number of referrals 5796 6481 7672
Number of consultations 5796 6083 6873
Take up 4329 3474 4120
Completion of 16 week intervention 2165 2113 2281
52 week retention 1079 1079 1142
Date: 15/06/15 Version: 0c Page: 7 of 13 Public Health Wales Quarter 4 Performance Report
1.5 Microbiology Division
Target Actual Q3 14/15 Q4 14/15 Microbiology - CPA accreditation status Full Full Full
EQA performance – bacteriology >=95% 98.6% 96.2%
EQA performance – virology >=95% 99.7% 100%
Turnaround time compliance – bacteriology >=95% 94.5% 95.1%
Turnaround time compliance – virology >=95% 91.2% 97.0%
Turnaround time compliance – urgent samples >=95% 98.4% Not available
Non processed samples – bacteriology/virology TBC 1.4%/1.0% 1.6%/1.0%
Number of samples processed – bacteriology N/A 256,866 261489
Number of samples processed – virology N/A 98,289 104700
Date: 15/06/15 Version: 0c Page: 8 of 13 Public Health Wales Quarter 4 Performance Report
1.6 Screening programmes
Q4 Actual Programme Standard Target Q3 14/15 Q4 14/15 Uptake >=70% >=71% 71.1% 70.7%
Normal results sent within two weeks of screen >=90% >=95% 95.9% 93.8%
Assessment appointments within three weeks of Breast Test Wales >=90% >=50% 39.1% 27.1% screen
% women invited within 36 months previous >=90% >=65% 16.4% 30.6% screen
CPA Accreditation Laboratory CPA accreditation Full Full Full Full
AAA Screening Programme Uptake >=80% >=72% 75.1% 74.1%
% offered screening >=99% 100% 100% 99.9% Newborn Hearing Screening Wales % entering screening programme >=95% >=99% 99.3% 99.6%
Coverage >=60% >=53% 50.3% 50.9%
Bowel Screening Wales Waiting times for screening test results >=95% >=95% 99.7% 99.6%
Waiting time for colonoscopy >=95% >=60% 81.1% 65.6%
Coverage >=80% >=80% 78.0% 77.9%
Cervical Screening Wales Lab turnaround times: within three weeks 100% >=80% 81.0% 91.9%
Waits for results: within four weeks 100% >=83% 83.6% 93.6%
Date: 15/06/15 Version: 0c Page: 9 of 13 Public Health Wales Quarter 4 Performance Report
1.7 Healthcare associated infections
Q4 Target Actual
Q3 14/15 Q4 14/15
Clostridium difficile (rate per 100000 population) <=31 45.95 36.18
MRSA rate (rate per 100000 population) <=2.6 5.28 5.66
Performance trends
8.0 100.0 89.2 6.9 90.0 7.0 80.0 6.0 5.4 70.0 5.0 60.0 42.8 50.0 4.0 40.0 3.0 30.0 2.0 20.0 1.0 10.0 0.0 0.0 1 2 2 2 3 3 3 4 4 4 5 5 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 5 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ------1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ------l l l l ------t r t r t r t r r r r r c c c c v v v v y y y y g g g g n n n n n n n n l l l l p b p b p b p b t t t t r r r r r r r r c c c c v v v v y y y y u c u c u c u c g g g g a a a a n p n b n p n b n p n b n p n b p p p p e e e e a a a a o o o o u a u a u a u a e e e e e e e e u u u u u c u c u c u c J J J J a a a a p p p p e e e e a a a a o o o o u u u u a a a a J J J J e e e e e e e e u u u u J J J J J J J J O O O O A A A A S F S F S F S F D D D D A A A A J J J J N N N N J J J J M M M M O O O O A A A A S F S F S F S F M M M M D D D D A A A A N N N N M M M M M M M M 12 month rolling rate of C. difficile/100,000 population 12 month rolling rate of MRSA bacteraemia/100,000 population
Date: 15/06/15 Version: 0c Page: 10 of 13 Public Health Wales Quarter 4 Performance Report
1.8 Influenza vaccination rates (as at 24/03/2015)
Influenza vaccination Influenza vaccination Influenza vaccination Influenza vaccination uptake among uptake among the over uptake among under uptake among pregnant healthcare workers 65s 65s in high risk groups women (until end of Feb 2015)
Target Actual Target Actual Target Actual Target Actual
Wales 68.1% 49.5% 45.3% 42.9% Abertawe Bro 65.3% 44.1% 41.2% 41.0% Morgannwg Aneurin Bevan 70.0% 53.0% 44.3% 40.0% 70.2% 51.5% 48.8% 49.6% Betsi Cadwaladr >=75% >=75% >=75% Cardiff and Vale 70.0% 50.5% 45.6% 44.9%
Cwm Taf 67.5% 50.0% 45.9% >=50% 44.9% Hywel Dda 65.0% 46.3% 42.9% 34.8% Powys 66.6% 47.9% 46.6% 48.6% Velindre NHS Trust 69.1% Welsh Ambulance 31.0% Service NHS Trust N/A Public Health Wales 41.2% NHS Trust
Date: 15/06/15 Version: 0c Page: 11 of 13 Public Health Wales Quarter 4 Performance Report
1.9 Childhood vaccination
Uptake of all scheduled childhood vaccinations at age 4
Area Target Actual Q3 14/15 Q4 14/15 Wales 84.8% 86.1% Abertawe Bro Morgannwg 84.4% 83.6% Aneurin Bevan 83.4% 80.7% Betsi Cadwaladr 88.2% 91.9% >=95% Cardiff and Vale 81.3% 84.0% Cwm Taf 86.6% 90.3% Hywel Dda 84.8% 86.1% Powys 85.0% 88.9% Performance Trend
Date: 15/06/15 Version: 0c Page: 12 of 13 Public Health Wales Quarter 4 Performance Report 2 Enablers
Enablers Actual Q4 Target Q3 14/15 Q4 14/15
Percentage of non medical staff undertaking PADR in past 12 months >=70% 77%*
Percentage of medical staff undertaking appraisal in past 12 months 100% 100% 100%
Number of written concerns/complaints received N/A 21 14
Written concerns/complaints responded to within target 100% 90% 93%
Number of serious untoward incidents (SUIs) reported N/A 1 2
SUI investigations completed within target timescales 100% 100% 100% * Survey undertaken in December 2014 indicated 77% of respondents had undertaken PADR. Sickness absence
Performance trend Performance Indicator Target
Sickness absence rate <=3.25%
Actual
01 Feb 2015 - 31 01 March 2014 – 01 April 2014- 31 Jan 2015 28 Feb 2015 March 2015
3.67% 3.70% 3.75%
Date: 15/06/15 Version: 0c Page: 13 of 13 39.10
Performance Report May 2015
Author: Public Health Wales
Date: 15 June 2015 Version: 0a
Sponsoring Executive Director: Huw George, Deputy Chief Executive/Executive Director of Operations and Finance
Who will present: Huw George, Deputy Chief Executive/Executive Director of Operations and Finance
Date of Board / Committee meeting: 25 June 2015
Committee/Groups that have received or considered this paper:
Executive Team
The Board / Committee are asked to: (please select one only)
Approve the recommendation(s) proposed in the paper X
Discuss and scrutinise the paper and provide feedback and comments
Receive the paper for information only
Link to Public Health Wales commitment and priorities for action:
(please tick which commitment(s) is/are relevant) X X X X
Date: 15/06/15 Version: 0l Page: 1 of 13 Public Health Wales Performance Report- May 2015
Performance Report- May 2015
Author: Nathan Jones, Assistant Director of Planning and Performance and Chris Orr, Business Support Manager Sponsoring Executive Director: Huw George, Deputy Chief Executive and Executive Director of Operations and Finance Date: 15 June 2015 Version: 0l Distribution: • Executive Team Purpose and Summary of Document:
The purpose of this report is to provide the Public Health Wales Board with a performance update against our key services for May 2015.
Date: 15/06/15 Version: 0l Page: 2 of 13 Public Health Wales Performance Report- May 2015
1 Executive Summary
1.1 Overview of performance
Number of performance indicators (some of which 23 are broken down further by health board): Green (performance meets target) 5 Amber (performance is within 10% of target value) 2 Red (performance is more that 10% below target) 8 Not available (due to the availability of data and will be 6 included in the June report) No target: 2
1.2 Key performance issues
The areas highlighted provide an overview of key performance issues as at May 2015 (as detailed in 1.1). Updates on these issues will be provided by the relevant Executive Director (as required).
1.2.1 Stop Smoking Wales
The targets for number of treated smokers and SSW capacity were not achieved in April or May. However, the percentage of clients that were CO validated was above target at an all Wales level and within a number of health boards (see page 4). (Executive Director of Health and Wellbeing)
1.2.2 Breast Test Wales
Percentage of assessment invitations given within three weeks of screen continues to be below 50% target and has reduced from 23.6% in April to 18.3% in May (see page 6). (Executive Director of Public Health Services)
1.2.3 Cervical Screening Wales
Laboratory turnaround times fell from 92% in March to 70.4% in April (May data not available until June). This is below the standard (100%) and quarter 1 target (92%) (see page 6).
Waiting times from samples being taken to test results being sent are below the standard (100%). 79.4% was achieved in May, which is a small rise on April (74.6%) (see page 6). (Executive Director of Public Health Services)
Date: 15/06/15 Version: 0l Page: 3 of 13 Public Health Wales Performance Report- May 2015
1.2.4 Bowel Screening Wales
Waiting times for colonoscopy remain below the quarter 1 target (85%) at 60% for April (May data not available until June). This is an increase of slightly over 5% from 54.7% in March (see page 6). (Executive Director of Public Health Services)
1.2.5 Healthcare Associated Infections
Rates for both clostridium difficile and MRSA continue to decline, although they have not yet reached all Wales target levels. Some health boards reached target levels in April and/or May, with some achieving this for both months (see page 10). (Executive Director of Public Health Services)
1.2.6 Sickness absence
Public Health Wales’ sickness absence rate is above the target of 3.25%. For the twelve month rolling period until March 2015 the sickness absence rate is 3.75. This is up from 3.70 reported in February 2015 (see page 11). (Director of Workforce and Organisational Development)
Date: 15/06/15 Version: 0l Page: 4 of 13 Public Health Wales Performance Report- May 2015
2 Monthly performance (May 2015)
2.1 Stop Smoking Wales
Performance of Stop Smoking Wales Health Board /Trust Clients that became a treated % of clients that were CO SSW capacity of appointments smokers in this month validated as quit in this available in this month month
Month Year to date Month Year to date
Target Apr May Target Actual Target Apr May Target Apr May Target Actual
Wales 1448 576 490 2896 1066 45.3% 41.3% 3081 2498 2890 6162 5388 Abertawe Bro 50.6% 259 113 82 517 195 38.6% 550 488 493 1100 941 Morgannwg Aneurin Bevan 278 111 125 556 236 44.4% 35.4% 592 596 678 1184 1274 313 157 104 625 261 41.0% 45.5% 665 406 534 1330 940 Betsi Cadwaladr >=40% Cardiff and Vale 230 95 57 461 152 44.0% 41.6% 490 306 469 980 775 Cwm Taf 155 33 41 309 74 43.1% 50.0% 329 204 324 658 528 Hywel Dda 164 53 71 328 124 48.5% 44.2% 349 298 250 698 548 Powys 50 14 10 99 24 42.9% 26.7% 106 86 94 212 180 *Note 2.8% equivalent total number of smokers annual target profiled through the year with a rising trajectory.
Date: 15/06/15 Version: 0l Page: 5 of 13 Public Health Wales Performance Report- May 2015
Performance Trend
Monthly Treated Smokers- Wales 1800 1600 1400 1200 1000 Actual 800 Target 600 400 200 0 April May June July August Sept Oct Nov Dec Jan Feb March
Cumulative Treated Smokers- Wales 18000 16000 14000 12000 10000 Cumulative Target 8000 Actual Cumulative 6000 4000 2000 0 April May June July August Sept Oct Nov Dec Jan Feb March
Date: 15/06/15 Version: 0l Page: 6 of 13 Public Health Wales Performance Report- May 2015
2.2 Screening programmes
Screening Programme Performance Actual Standard Target Q1 Screening Programme Report Description Mar 2015 Apr 2015 May 2015
Normal results sent within 2 weeks of screen >=90% >=95% 97.4% 94.8% 94.0% Breast Test Wales Assessment invitations given within 3 weeks >=90% >=50% 41.7% 23.6% 18.3% of screen Laboratory Turnaround Time for Gynae Not 100% >=92% 92.0% 70.4% Cytology Test Results (3 weeks) available
Waiting time from sample being taken to Cervical Screening 100% >=95% 94.5% 74.6% 79.4% Wales screening test result being sent (4 weeks) Waiting Time for Colposcopy Appointment - Not All CSW Direct Referrals with abnormal >= 90% N/A 98.7% 97.4% available cytology (8 weeks) Waiting Time for Screening Test Results (result letters issued within 7 days of receipt >= 95% N/A 99.6% 99.6% 99.5% of test kit in lab) Bowel Screening Wales Not Waiting Time for Colonoscopy >= 95% >=85% 54.7% 60.0% available
AAA Screening Not Surveillance Uptake >= 90% N/A 100% 97.0% Programme available Well babies - the percentage of babies who Not complete the screening programme within 4 >= 90% N/A 99.1% 98.7% available Newborn Hearing weeks Screening Wales Those babies who complete assessment >= 80% N/A 97.7% 90.6% 86.7% procedure by three months of age
Date: 15/06/15 Version: 0l Page: 7 of 13 Public Health Wales Performance Report- May 2015
Breast Screening: Normal Results Sent Within 2 Weeks Breast Screening: Assessment Appointments Within 3 of Screen Weeks of Screen 100.0% 100.0% 95.0% 90.0% 90.0% 80.0% 85.0% 70.0% 80.0% 60.0% 75.0% 50.0% Actual Actual 70.0% 40.0% 65.0% Target 30.0% Target 60.0% 20.0% 55.0% 10.0% 50.0% 0.0%
Cervical Screening: Laboratory Turnaround of Results Cervical Screening: Test Results Issued Within 4 Weeks Within 3 Weeks 100.0% 100.0% 90.0% 90.0% 80.0% 80.0% 70.0% 70.0% 60.0% 60.0% 50.0% 50.0% Actual Actual 40.0% 40.0% Target 30.0% Target 30.0% 20.0% 20.0% 10.0% 10.0% 0.0% 0.0%
Date: 15/06/15 Version: 0l Page: 8 of 13 Public Health Wales Performance Report- May 2015
Cervical Screening: Colposcopy Within 8 Weeks of Direct AAA Screening: Surveillance Uptake Referral 100.0% 100.0% 95.0% 95.0% 90.0% 90.0% 85.0% 85.0% 80.0% 80.0% 75.0% 75.0% Actual Actual 70.0% 70.0% Target 65.0% Standard 65.0% 60.0% 60.0% 55.0% 55.0% 50.0% 50.0%
Bowel Screening: Results Issued Within 7 Days of Lab Bowel Screening: Colonoscopy/Flexi-Sig Within 4 Receipt Weeks of SSP Appointment 100.0% 100.0% 95.0% 90.0% 90.0% 80.0% 85.0% 70.0% 80.0% 60.0% 75.0% 50.0% Actual Actual 70.0% 40.0% 65.0% Target 30.0% Target 60.0% 20.0% 55.0% 10.0% 50.0% 0.0%
Date: 15/06/15 Version: 0l Page: 9 of 13 Public Health Wales Performance Report- May 2015
Newborn Hearing Screening: Well Babies Completing Newborn Hearing Screening: Assessment Completed Screening Within 4 Weeks by 3 Months of Age 100.0% 100.0% 90.0% 90.0% 80.0% 80.0% 70.0% 70.0% 60.0% 60.0% 50.0% 50.0% Actual Actual 40.0% 40.0% 30.0% Standard 30.0% Standard 20.0% 20.0% 10.0% 10.0% 0.0% 0.0%
Date: 15/06/15 Version: 0l Page: 10 of 13 Public Health Wales Performance Report- May 2015
2.3 Healthcare associated infections
Healthcare associated infections
Performance Indicator Clostridium difficile rate (per 100,000 MRSA rate (per 100,000 population) population) Target Apr-15 May-15 Target Apr-15 May-15 Wales 44.2 37.8 4.0 3.4 Abertawe Bro Morgannwg 70.1 36.1 2.3 6.8 Aneurin Bevan 37.8 40.7 2.1 4.1 Betsi Cadwaladr <= 31 by 49.2 44.2 <=2.6 by 7.0 5.1 Cardiff and Vale 09/15 30.5 32.0 09/15 5.1 0.0 Cwm Taf 24.7 27.9 0.0 0.0 Hywel Dda 53.9 49.1 6.3 3.1 Powys 9.2 8.9 0.0 0.0 Performance trends
100.0 89.2 8.0 6.9 90.0 7.0 80.0 6.0 5.1 70.0 60.0 5.0 50.0 42.6 4.0 40.0 3.0 30.0 2.0 20.0 10.0 1.0 0.0 0.0 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 1 2 3 4 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 5 5 5 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ------l l l l l l l l t t t t r r r r r r r r r t t t t r r r r r r r r r c c c c v v v v y y y y y c c c c g g g g v v v v y y y y y g g g g n p n b n p n b n p n b n p n b n n n n n n n n p b p b p b p b u c u c u c u c c c c c u u u u a a a a a a a a p p p p p p p p p p e e e e a a a a a e e e e o o o o a a a a a u u u u a a a a o o o o e e e e e e e e u a u a u a u a u u u u e e e e e e e e J J J J u u u u J J J J J J J J J J J J J J J J J J J J O O O O O O O O A A A A A S F S F S F S F A A A A A S F S F S F S F D D D D D D D D A A A A A A A A N N N N N N N N M M M M M M M M M M M M M M M M M M 12 month rolling rate of C. difficile/100,000 population 12 month rolling rate of MRSA bacteraemia/100,000 population
Date: 15/06/15 Version: 0l Page: 11 of 13 Public Health Wales Performance Report
2.4 Healthy workforce
Sickness absence
Performance Target Actual Indicator 01 Mar 01 Apr 2014 01 May 2014 - 28 - 31 Mar 2014 -30 Feb 2015 2015 April 2015
Sickness absence rate <=3.25% 3.70% 3.75% 3.80%
Performance Trend
2.5 Concerns and complaints
Written concerns and complaints
Actual Performance Indicator Target May 2015 Year to date Number of written N/A 4 10 concerns/complaints received
Written concerns/complaints responded to within target 100% 100%* 80% timescales *Two complaints breached the 30 day timescale and holding letters have been sent in both cases.
Date: 15/06/15 Version: 0l Page: 12 of 13 Public Health Wales Performance Report
2.6 Incidents
Serious untoward incidents (SUIs)
Actual Performance Indicator Target May 2015 Year to date Number of serious untoward N/A 0 2 incidents (SUIs) reported
SUI investigations completed 100% N/A 50%* within target timescales *One SUI has not been completed within the target timescale set by Welsh Government. This is due to the number of records reviews required as part of the lookback exercise. An extension to the timescales has been sought from WG and agreed.
2.7 Performance Appraisal
Performance Appraisal
May 2015 Performance Indicator Target
Percentage of medical staff undertaking performance 100% 100% appraisal within the last 15 months
Date: 15/06/15 Version: 0l Page: 13 of 13 39.11
Amendments to Screening Performance Trajectories Author: Quentin Sandifer, Executive Director of Public Health Services Date: 15 June 2015 Version: 1.0 Sponsoring Executive Director: Executive Director of Public Health Services Who will present: Executive Director of Public Health Services Date of Board / Committee meeting: Board, 25 June 2015 Committee/Groups that have received or considered this paper: None
The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper x Discuss and scrutinise the paper and provide feedback and comments Receive the paper for information only
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) x
Priorities for action include relevant priority for action(s)
Date: 15 June 2015 Version: v1 Page: 1 of 3 Public Health Wales Proposed revisions to Screening Trajectories June 2015
1 Introduction
This paper asks the Board to receive and approve amendments to the performance trajectories for some of the screening programmes delivered by Public Health Wales as published in the 2015-16 Operational Plan. The paper is accompanied by a schedule identifying the specific amendments for which a change is requested and a technical report setting out in detail the reasons for the proposed changes to the trajectories for the breast screening programme.
2 Background
Public Health Wales published its Operational Plan for 2015-16 in April. This included quarterly projections of achievement against targets and key performance standards. Following publication the Executive Director of Public Health Services has found it necessary to advise the Chief Executive and Chairman, and also Welsh Government, that some of the screening services’ trajectories were over-optimistic.
The Executive Director met Irfon Rees from Welsh Government last month and it was agreed that Public Health Wales should submit a revised schedule setting out the requested amendments. It was also requested that the Executive Director submit a detailed technical report to explain the current state of, and proposed plans for, recovery against key performance standards for the breast screening programme. The Executive Director recognises that there have been longstanding concerns expressed by Board members and Welsh Government officials with specific reference to the ‘round length standard’.
3 Timing
As requested by Welsh Government the revised trajectories and the accompanying paper were submitted to Irfon Rees on 15 June 2015 with the caveat that they were subject to approval by the Board, which was meeting on 25 June 2015. The Chief Executive and Chairman received the documents before they were submitted and agreed to their release.
4 Description
Amendments to trajectories
The principal changes are marked in the schedule and summarised below:
• Planned year end Breast Test Wales coverage reduced from 70% to 68.5%; only increased 1% last year and though expected to Date: 15 June 2015 Version: v1 Page: 2 of 3 Public Health Wales Proposed revisions to Screening Trajectories June 2015
increase this year, as round length recovery continues, it is now considered unrealistic to believe that it will increase by 3% as previously stated.
• Planned year end Bowel Screening Wales coverage reduced from 55% to 53% as it is now considered unrealistic to believe that it will increase by 4% as previously stated.
• Planned year end uptake for the Abdominal Aortic Aneurysm Screening programme remains unchanged but the trajectory is smoothed quarter by quarter.
• Planned Breast Test Wales round length trajectory is reduced from 50/65/80/90 to 35/45/55/65 reflecting the reality of current and projected performance as detailed in the accompanying technical report.
• Planned year end achievement against standard for Bowel Screening Wales colonoscopy waiting time reduced from 95% to 90% to reflect the reality of waiting times in health boards on which Public Health Wales is wholly dependent for the achievement of the standard.
• Planned trajectory of the Cervical Screening Wales achievement against standards for laboratory turnaround and waits for results moderated to reflect expected in-year challenges; the planned year end position is not changed.
Technical report on the impact of digital implementation, Breast Test Wales
The paper provides a detailed account of the impact of the introduction of digital equipment on Breast Test Wales performance indicators.
Whilst some of the changes to trajectories reflect a more practical realisation of achievements within our control, a recurring theme in both papers is our critical dependency on actions and decisions taken by health boards. Some changes to trajectories are in response to a more realistic appraisal of this dependency.
5 Financial Implications
There are no additional financial impacts.
6 Recommendation(s)
The Board is asked to approve the revised trajectories as presented and to note the supplementary technical report on the impact of the introduction of digital equipment on Breast Test Wales performance indicators. Date: 15 June 2015 Version: v1 Page: 3 of 3 Public Health Wales Proposed revisions to Screening Trajectories June 2015
PUBLIC HEALTH WALES PROPOSED CHANGES TO PUBLISHED TRAJECTORIES
Target Actual position Planned 15/16 Standard March 2015 Q1 Q2 Q3 Q4
Breast screening uptake >=70% 72% 69% 70% 71% 72%
Q4 Breast screening coverage >=70% 67% reportable 68.5* only
Q4 Bowel screening coverage >=60% 51% reportable 53** only
Cervical screening coverage >=80% 78% 80%
Laboratory CPA accreditation Full Full Full Full Full Full
Abdominal aortic aneurysm screening uptake >=80% 74.7% 75.0% 75.3% 75.6% 76%***
Abdominal aortic aneurysm screening coverage (Awaiting UK >=80% N/A N/A N/A N/A N/A definition)
Newborn hearing screening percentage offered screening >=99% 100% 99% 99% 99% 99%
Newborn hearing screening percentage entering screening >=95% 99% 99% 99% 99% 99% programme
Newborn bloodspot screening uptake (newborn babies) >=99% 99% 99% 99% 99% 99%
Newborn bloodspot screening coverage (all babies) >=95% 95% 96% 96% 96% 96%
Antenatal screening informed choice (NB Health Boards deliver >=90% 92% 92% 92% 92% 92% information, outside of ASW control)
Breast screening: normal results sent within two weeks of 90% 94% 95% 95% 95% 95% screen
1 Public Health Wales Proposed revisions to Screening Trajectories June 2015
Breast screening: assessment appointments within three 90% 42% 50% 60% 70% 80% weeks of screen
Breast screening: % women invited within 36 months previous 90% 22% 35%^ 45%^ 55%^ 65%^ screen
Bowel screening waiting times for screening test results 95% 99.6% 95% 95% 95% 95%
Bowel screening waiting time for colonoscopy 95% 66% 80% 85% 88% 90%^^
Cervical screening lab turnaround times: within three weeks 100% 92% 92% 80%^^^ 85% 90%
Cervical screening waits for results: within four weeks 100% 95% 95% 80%^^^ 85% 90%
Notes on proposed amendments:
* Planned year end BTW coverage reduced from 70% to 68.5%; only increased 1% last year and though expected to increase this year, as round length recovery continues, it is now considered unrealistic to believe that it will increase by 3% as previously stated.
** Planned year end BSW coverage reduced from 55% to 53% as it is now considered unrealistic to believe that it will increase by 4% as previously stated.
*** Planned year end uptake for the AAA programme remains unchanged but the trajectory is smoothed quarter by quarter.
^ Planned BTW round length trajectory reduced from 50/65/80/90 to 35/45/55/65 reflecting reality of current and projected performance as detailed in the accompanying technical report; the principal reason for the reappraisal of the trajectory is the fact that North Wales (accounting for 25% of the screening population) will not complete one post digital screening round until January 2016 so cannot make any substantial recovery by definition before this time.
^^ Planned year end achievement against standard for BSW colonoscopy waiting time reduced from 95% to 90% as all units apart from Hywel Dda currently struggling to maintain waiting times and the problem of colonoscopy wait, noting Public Health Wales is wholly dependent on health boards, shows little sign of improving.
^^^ Planned performance of the CSW service will be affected by the installation of new liquid based cytology and HPV testing kit in the cervical screening laboratory as well as successful implementation of cervical cytology LIMS. This is becoming very complicated – when the trajectory was originally set LIMS implementation was expected to be completed by the end of June 2015 – this is not going to
2 Public Health Wales Proposed revisions to Screening Trajectories June 2015 happen and the reasons are outside the control of Public Health Wales although considerable executive director and screening service staff time is being expended to secure implementation at the earliest possible date (for the record NWIS are fully involved and apprised of the reasons for the delay and Public Health Wales works closely with NWIS and the third party supplier). The delay in LIMS will very likely impact on the implementation plans for the installation of new laboratory equipment – an unavoidable consequence. Again considerable executive director and screening service staff time is being expended to address this. Therefore the proposal is to retain the planned year end position but adjust the Q2 position. It is sincerely hoped that we can avoid an impact in Q3.
Please also note that in stating that we will achieve the standard for newborn hearing screening and bowel screening waiting times for screening test results, the comparison with current achievement should not be misunderstood as a reduction in effort. Whenever we can sensibly state an ambition to over-achieve we will do so as demonstrated elsewhere in the schedule.
3 Appendix
Background, Overview and Impact of the Digital Equipment Implementation Programme on Breast Test Wales Performance Indicators
Authors: Mr Dean Phillips, Dr Rosemary Fox, Mr Rhys Blake on behalf of Executive Director of Public Health Services
Date: 12 June 2015 Version: 1.0
Distribution: Executive and Board members, Public Health Wales; Irfon Rees, Welsh Government
Review Date: N/A
Purpose and Summary of Document: This paper explains why the achievement of the round length standard by the Breast Screening Programme has proved challenging, reports on action being taken to address this as well as an appraisal of other options, and proposes some amendments to the current trajectory in the operational plan for the achievement of this service standard.
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1 Introduction
Converting technologies in Breast Screening, while conferring patient benefit from improved diagnostics, has proved a significant challenge. Concern has been raised about performance and although this has improved significantly in terms of screening capacity, results turnaround and cancer detection, improvement against the 36 month standard for the round length has been frustratingly slow. This paper explains why this is so, reports on action being taken to address this as well as an appraisal of other options, and proposes some amendments to the current trajectory in the operational plan for the achievement of this service standard.
2 Background
Following almost two years of significant technological change over the period 2011/12, Breast Test Wales became the first fully digital national breast screening programme in the United Kingdom in January 2013. Breast Test Wales measures itself against standards for effectiveness, acceptability and timeliness of its service. The implementation of digital mammography in Breast Test Wales substantially disrupted programme delivery. The impact has not been limited to the period of the technical upgrade alone; overall programme performance in relation to the timeliness of invitation continues to be heavily affected. Screening activity has recovered following the reduction seen in 2011/12 and is now higher than previously. Current activity (all referral sources) represents a 4.1% increase from the last full operational year pre digital with an additional 5000 women screened per year. The programme continues to seek additional ways to deliver a timely service to the eligible population in Wales, while maintaining its excellent cancer detection rates. The following definitions are used throughout this report (source: NHS Breast Screening Programme). Round Length The interval between the date of a woman’s previous screening mammogram and the date of her next first offered appointment. Uptake The percentage of women who have a test within six months of invitation. Coverage The percentage of women in the population who are eligible for screening at a particular time, who have had a test with a recorded result in the last three years. Prevalent screen A woman’s first screen. Incident Screen A woman’s second or subsequent screen. Recall rate The proportion of women recalled for assessment following their screening mammogram.
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3 Breast Test Wales pathway
Breast Test Wales is responsible for the entire breast screening pathway in Wales, from identification and invitation of eligible women, through screening mammography, image interpretation and assessment of women with potential abnormalities to the diagnosis of cancer in around 1% of women screened. Each stage in the pathway is a separate process with its own rate limiting steps. The stages are interlinked so that an increase in the number of women screened in turn requires an increase in reading, assessment and ultimately treatment capacity for the cancers diagnosed.
3.1 Screening and round length
3.1.1 Routine Screening
Around 416,000 women in Wales are eligible for breast screening now. Each woman is invited seven times between the ages of 50 and 70. To screen each woman every three years we must invite 138,000 women annually for screening and to achieve a 75% uptake, screen 104,000 women every year. These numbers will increase because of demographic change. The national standard requires that 90% of women should be invited for screening within 36 months of their previous screen (referred to as the round length standard). This standard will always be challenging and additional capacity must be created year on year within existing resources. Furthermore this challenge is not unique to Wales and it is known that 25% of breast screening programmes in England are currently outside the standard for round length. Being clear what is meant by round length is crucial to an understanding of the challenges in achieving the standard. Round length records the interval between the date of a woman’s previous screening mammogram and the date of her next first offered appointment. Importantly it should not be confused with coverage, which is the proportion of eligible women screened in the last 36 months. The way that the standard is calculated means that once performance has slipped it takes a long time to recover. The screening programme (Breast Test Wales, BTW) only has one opportunity every three years to influence each woman’s invitation date. Thus a woman who should have been invited in October 2013 but who was invited three months late (ie in January 2014) will remain outside of standard until her next screening invitation in January 2017. Even if the programme were to invite her in October 2016, she would still be out of standard until the date of her appointment, when the three year clock is, in effect, reset. The
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programme would not want to invite the woman any earlier because of the risks associated with cumulative radiation dose.
3.1.2 Additional Groups
In addition to the population screening programme, Breast Test Wales screens two other groups of women: Women aged over 70 who request screening Women aged over 70 have always been able to be screened on request, although there is currently no evidence that screening is of benefit in this age group. BTW has no control over the numbers of women requesting screening or when they will contact the service, so planning for this group of women is difficult. Women aged over 70 who self refer are not included in round length calculations, but in effect are ‘fast tracked’ through the system as they tend to request screening when the mobile is in their area and must be screened before it can leave. Quite apart from the operational impact and potential consequential effect on the round length for women in the screening population, the absence of evidence of benefit from screening this self-referral group, and the continued provision of this service, appears contrary to the principles of prudent healthcare. Young women with a Family History of Breast Cancer, or who have been treated with mantle radiotherapy1. Breast Test Wales offers additional surveillance mammography to women in both these groups. Again the numbers are rising and will continue to do so. As screening is annual for this group the impact on screening capacity is amplified. The table below illustrates the scale of these activities. Table 1: Activity by referral source 2009/10-2014/15
Source / Year 2009/10 2010/11 2011/12* 2012/13* 2013/14 2014/15 Routine 101,691 101,926 76,750 86,397 107,959 103,736 Self-referrals (all ages) 7206 6886 6039 6924 8996 9848 Non-routine 91 46 66 49 99 77 FH & Hodgkin’s 1870 1971 2012 2067 2006 1891 Total 110,858 110,829 84,867 95,437 119,060 115,552 *In all tables, the years of digital implementation (2011-12 and 12-13) are shaded blue
In 2010-11 (the last full year before digital implementation), Breast Test Wales screened 110,829 women, 101,926 in the routine 50-70 age range,
1 A type of extended field radiation used to treat Hodgkin’s lymphoma, which exposes the breasts to radiation and is known to be associated with an increased incidence of breast cancer
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along with an additional 8903 from self referrals and the Family History programme. In 2014-15, BTW screened 115,552 women, 103,736 in the routine age range and 11,816 from other sources. The overall increase in screening activity was 4.3%. However, referrals from other sources rose by 32.8%. Thus a substantial amount of the increased capacity developed by Breast Test Wales to recover the round length has been absorbed by increased demand from women self-referring. This activity is not reflected in the round length statistic. The trend in self–referrals is expected to grow in 2015/16 secondary to planned cancer awareness initiatives.
3.2 Image reading and reporting
Each image is independently read by two specialists. Where either reader indicates an abnormality, it is reviewed by a third reader for a final decision on whether to recall the woman. Women with no abnormality on their films (approx 95%) are informed by letter. Women with an identified abnormality (approx 5%) are invited to attend an assessment clinic for further investigation. The digital implementation significantly altered the processes and technology associated with film reporting (see below).
3.3 Assessment
Women whose mammograms are suspicious of abnormality (about 6000 women per year) are invited to assessment clinics held in the BTW Centres in Swansea, Cardiff, Llandudno and Wrexham. Each woman is seen by a team consisting of a surgeon, radiologist (or breast clinician/ consultant radiographer), diagnostic radiographers and breast care nurse. Further images, including breast tomography and ultrasound, as well as biopsies are taken as required. Cases where a biopsy has been taken are discussed at a weekly Multidisciplinary Team (MDT) meeting in each centre, before women are given their results and women with a cancer diagnosis referred for treatment. Digital implementation had major implications for assessment and diagnosis within the programme.
4 Impact of digital implementation
Digital technology has had a major impact on the functioning of Breast Test Wales, both as a result of the disruption to the service at the time of implementation, and also in adapting the programme to the different operational requirements of the new equipment.
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Breast Test Wales converted the whole programme to digital technology region by region over a period of approximately 21 months. During implementation, many factors combined to produce delays to screening, image reading and assessment. Some of these were predictable and the service had made plans to mitigate their effects as far as possible. Others were not predictable, or were not amenable to mitigation. A detailed appraisal of the impact of digital implementation is set out in Appendix A.
4.1 Timeliness
The impact of the implementation was most keenly felt over the period from 2011 to 2013 when activity was at its lowest and none of the indicators for timeliness were achieved.
5 Performance against standards
Key Performance Indicators against UK NHS Breast Screening Programme quality standards are summarised in table 2 below. This shows that meeting timeliness standards (screening reporting and assessment) were challenging even prior to digital implementation
Table 2: Performance against Key Indicators, 2009/10-2014/15 Standard 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Uptake >=70% 75.6% 74.3% 73.2% 71.2% 71.9% TBC%* Coverage >=70% 73.8% 74.6% 70.5% 66.1% 67.0% TBC%* Invasive cancer detection rate (prevalent round) - per 1000 women >=2.7 screened 5.3 5.9 7.8 5.4 6.8 6.3** Invasive cancer detection rate (incident round) - per 1000 women >=3.1 screened 6.8 7.5 6.9 8.2 7.6 7.7** Normal results within 2 weeks >=90% 68.1% 54.8% 63.9% 54.0% 78.7% 93.3% Assessment within 3 weeks >=90% 53.3% 31.1% 35.4% 20.3% 32.4% 31.7% Recall rate (prevalent round) <10% 8.9% 9.0% 9.9% 9.8% 9.4% 9.5% Recall rate (incident round) <7% 3.8% 3.9% 4.1% 4.3% 3.9% 4.3% Recall rate (overall) N/A 4.9% 5.0% 5.2% 5.5% 5.0% 5.4% Round length (36mths) >=90% 66.8% 79.1% 56.4% 8.3% 5.3% 16.4% Round length (38mths) >=90%* 80.8% 97.9% 81.5% 30.0% 22.6% 34.8%
* The final position for the year 2014/15 (ending 1 April 2015) will not be known until September 2015 ** The lag in receipt of full pathology means that the figures in the last column (given at the time of writing) almost certainly understate the final position
Since the beginning of 2013, following the last region going “live” with the digital upgrade, there has been improvement in overall activity and report turnaround times, which now sustainably exceed pre digital performance levels and cancer detection rates.
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However, challenges remain, namely delivering round length performance and assessment waits that must improve on pre digital levels. We have developed substantial additional assessment clinic capacity to meet the increased demand arising out of increases in activity, referral and cancer detection rates, but performance against the standard remains poor, reflecting these longstanding difficulties.
5.1 Cancer detection
Limited national comparative data on screen detected cancer is collated by the English NHS Breast Screening Programme. Wales has consistently had the highest cancer detection rate over the past five years i.e. both pre and post digital phases. The most recent figures available at national level are 2013-14, when Wales had the highest cancer detection rate/1,000 women screened at 10.6/1,000 (compared with England 8.4 and Scotland 6.8). Cancer Research UK publishes comparative cancer incidence and mortality statistics for the four UK home nations on its website. The data is not broken down into screen or symptomatically detected. This was until recently updated annually. However the most recent data available is from 2011. In 2011, there was no significant difference between the age standardised breast cancer incidence or mortality rates in the four UK home nations although confidence intervals for Wales, Scotland and Northern Ireland are wide.
5.2 Interval cancer
Breast Test Wales receives notifications of all breast cancers diagnosed in between screening examinations as a measure of programme effectiveness. Early indications suggest that interval cancer rates may have reduced following digital implementation but this is not confirmed. Short timeframes mean that case ascertainment is likely to be incomplete and rates may rise over time, particularly in North Wales.
Fig 1: Interval cancer rates West Wales 2006-14
2.00 n
e 1.50 m o 0-12 w
0 1.00 0 13-24 0 1
r
e 0.50 25-36 p
0.00 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14
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Fig 2: Interval cancer rates South East Wales 2006-14
1.60 1.40 n
e 1.20 m
o 1.00 0-12 w
0 0.80 0 13-24 0
1 0.60
r
e 0.40 25-36 p 0.20 0.00 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14
Fig 3: Interval cancer rates North Wales 2006-14
2.00 n
e 1.50 m
o 0-12 w
0 1.00 0 13-24 0 1
r
e 0.50 25-36 p
0.00 06-07 07-08 08-09 09-10 10-11 11-12 12-13 13-14
Note that there is a lag time in the registration of cancers and therefore these graphs do not represent the results of full case ascertainment. It is not yet possible to confirm whether this is a real trend.
6 Actions taken to recover round length
The screening schedule is planned regionally. A planning tool calculates the number of days required to screen eligible women registered with any particular GP practice based on historic levels of: • Uptake by eligible women, and • Additional activity from self referrals (women aged over 70). We compare this against the previous round to assess if we are going to arrive early, on time or late (>36 months) in any given location. Unplanned downtime, inclement weather, high levels of self referrals or staffing issues extend the time taken to screen particular sites introducing delays and extending round length for the next scheduled site. Action taken to reduce extended waits in sites includes: • Split shifts allowing more women to be booked in a day;
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• Redeployment of mobile units (two units on one site if logistically possible); • Weekend working, increasing overall capacity so sites to finish on schedule. Actions considered to increase throughput but not progressed were: • Suspension of screening for women self referring in the >70 age range; • Move to issuing a single mammographic report rather than the current double reporting system; • Increase rate of screening by hiring / buying additional mobile units; • Suspension of the family history screening programme; • Waiting list initiatives for assessment clinics; • Consideration of a proposal to narrow the eligible age range; • Rationalise number of mobile sites visited across Wales; • Operate a 7 day a week service. An assessment of each of these options is set out in Appendix B. The screening service is always open to reconsideration of any of these options. As already stated the national standard requires that 90% of women should be invited for screening within 36 months of their previous screen (referred to as the round length standard).
6.1.1 Current performance
The programme is seeing a steady increase in round length as West and South East Wales enter their second screening round post digital. This can be seen in Table 3 and Figure 4, which shows significant recovery in West and South East Wales, the first and second regions to convert. At the end of May 2015, 46% women across Wales were being invited within 36 months of their previous screen. The digital conversion in North Wales was not completed until January 2013, and significant recovery will thus not be seen before January 2016.
Table 3: Performance against 36m round length target, by region 2014/15 2014/15 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May North 4.0 10.2 6.5 2.8 0.7 1.2 7.1 4.0 3.3 1.2 0.8 2.3 South 4.5 7.2 14.3 18.6 24.4 34.8 35.5 41.1 50.8 44.1 40.0 71.0 West 1.6 1.3 1.3 2.7 2.4 2.0 4.3 62.7 55.9 7.4 44.6 35.5 Wales 3.8 6.9 8.9 11.0 12.0 17.0 23.1 35.7 36.2 22.2 31.1 45.8
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Fig 4: Performance against 36 round length target, by region 2014/15
BTW-009A: Round Length (36 months)
100 90 80 e 70 North g
a 60 t South
n 50 e West c 40 r
e 30 Wales P 20 standard 10 0 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
The trend towards recovery can be seen more clearly when looking at the proportion of women whose most recent screening invitation was within thirty eight months of their previous invitation Table 4 and Figure 5). Over 80% women in Wales, and nearly 100% of women in West and South East Wales are now being invited within 38 months of their previous invitation. Table 4: Performance against 38 month round length by region 2014/14 2014/15 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May North 37.4 35.9 39.1 15.5 4.1 10.3 10.7 15.4 22.6 31.7 5.7 24.4 South 29.9 22.4 33.0 34.4 40.7 45.0 36.1 41.7 71.3 81.9 88.7 97.5 West 3.0 1.8 1.5 4.0 7.4 41.5 34.1 81.5 88.2 42.8 84.9 97.8 Wales 26.6 22.2 25.2 22.5 21.8 34.4 31.8 44.1 58.5 57.3 67.0 82.4
Average round length shows a similar pattern of improvement as shown in Table 5 and Figure 6, which shows that the average round length was 36.5 months in May 2015, broken down into 34.8 and 37.0 months in South East and West Wales respectively. Again the data for North Wales is indicative of the fact that recovery has yet to start in this region reflecting the fact that this was the last part of Wales to implement digital technology. Fig 5: Performance against 38 month round length by region 2014/14
BTW-009B: Round Length (38 months)
100 90 80 e North
g 70 a
t 60 South
n 50 e West
c 40 r
e 30 Wales
P 20 standard 10 0 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
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Table 5: Average round length 2014-15 2014/15 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May North 39.1 38.8 39.1 39.5 39.9 39.6 39.6 39.6 39.5 39.7 40.1 39.6 South 39.4 39.5 38.7 38.4 37.9 37.3 37.7 37.4 36.0 36.3 36.3 34.8 West 41.3 41.7 42.4 41.6 41.3 39.3 39.3 36.0 35.7 39.0 37.3 37.0 Wales 39.7 39.8 39.8 39.4 39.5 38.5 38.4 37.7 37.1 38.0 37.5 36.5
Fig 6: Average round length 2014-15
BTW-009D: Round Length (average months)
44
) 43 s d h n 42 t u 41 n North o o r 40 South m e 39 ( g 38
a West h r
t 37 e g 36 Wales v n 35 A e l 34 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May
6.1.2 Future performance
Incorporating the dependencies described in this paper into a forecast the following trajectory is anticipated in 2015 (see Table 6 below). Table 6: Projected performance against 36 month round length target (all Wales 2015/16 Q1 Q2 Q3 Q4 35 45 55 65
North Wales accounts for 25% of the round length performance figure. Full correction of the round length in North Wales is not expected until early 2016 when it commences its second round using digital imaging. Therefore overall round length in Wales will not achieve a correction greater than 75% until at least 2016.
The trajectories set out below (Table 7 and Figure 7) assume there will be no disruption to screening caused by impacts from health boards, for example, failing to deliver necessary staffing to read films or assess women. The screening plan will continue to be reviewed and mobiles deployed to areas of longest wait within Wales to minimise regional variations in round length.
Table 7: Projected round length trajectory by region 2014-17 2014-15 2015-16 2016-17 West 40 90 90 South East 33 85 90 North 5 68 83 Wales 26 68 83
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Fig 7: Projected round length trajectory by region 2014-17
100
80
60
40
20
0 2014/15 2015/16 2016/17
W SE N Wales
6.2 Assessment Waits
Waits to assessment are a key priority and challenge for the programme. The standard of >=90% for assessment invitations being given within 3 weeks of the screen was not being achieved even before digital implementation, which has resulted in greater demand for assessments as result of the increased sensitivity of the imaging equipment. Current waits for assessment average 3.9 weeks. The challenges around meeting this standard are numerous and differ by region within Wales. A workshop facilitated by 1000 Lives+ identified the following issues in common across Wales. These have formed the basis of a series of work streams. • MDT constraints – right people, right place, right time. • Workforce – medical, nursing, radiography, administrative and support staff. • Workforce / assessment model – evaluate current model and alternatives. • Clinic cancellation rates - attendance and monitoring. • Robust management of contracts with Health Boards specifically in relation to surgical attendance. • Review and adjustment of booking templates. It is difficult to give a firm quantitative indication of the correction to assessment waits. It is anticipated that work streams around surgical attendance and cross cover will lead to reduced clinic cancelation in the short term and ongoing. The work streams around workforce will provide medium term and long term stability for clinic waits. Table 8 summarises the trajectory for assessment waits in 2015.
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Table 8: Projected performance against assessment waits target 2015-16 2015 Q1 Q2 Q3 Q4 Invited within 3 weeks for assessment 50 60 70 80
This performance indicator will prove very challenging to achieve because there are so many dependencies, many outside the direct control of Public Health Wales. • All Health Boards meeting the provision of the LTA’s with BTW. • Surgical engagement and improved attendance rates. • No unforeseen staffing shortages for the entire workforce involved in the pathway. • No long-term equipment failure over the period. • No significant increase in the recall rate to assessment. • No significant increase in self referrals to screening. • No significant increase in the rate of micro-calcification detected. • A steady state of overall screening activity. • Relevant previous images are available for arbitration within short timescales. • No reduction in current average numbers seen in individual clinics. • No change in current national clinical guidelines for breast assessment extending the length of the time slot required. • No detrimental change in pathology provision to the programme. • Sufficient MDT capacity and attendance. Should the current work streams fail to achieve the trajectory, a more fundamental shift in the workforce model will need to be considered. This would take a significant time to realise and implement, would have significant training and recruitment requirements and implications, and may attract political and public attention. Risks and mitigation are set out in Appendix C.
7 Summary and Key Messages
Overall screening activity exceeds that recorded pre digital. Report turnaround time is excellent and exceeds that recorded pre digital and exceeds the standard. Full round length correction (90% seen within 36 months) will not be achieved until North Wales completes its second round of digital screening in 2016. The programme is optimising available capacity and screening site locations and significant recovery has been seen in West and South East Wales. Improvement will continue month on month.
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Assessment waits remain challenging. BTW has developed a task and finish group to specifically oversee service improvement work required to reduce assessment waits; the current average waiting time is 3.9 weeks against a 3 week standard. Service delivery risks have been recognised. These include critical dependencies with health boards. They are being managed via the appropriate work stream and monitored by the Breast Test Wales Programme Board, Screening Division Senior Management Team and Public Health Wales Executive Team.
______
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APPENDIX A: Impact of Digital Implementation
7.1 Implementation.
Schedule of Conversion Region Screening Slowed Full capacity regained West April 2011 April 2012 South East July 2011 June 2012 North May 2012 January 2013
West Wales converted first. Screening slowed in April 2011 to allow all analogue images to be reported before the viewing equipment was removed. South East and finally North Wales followed over the next 21 months. It was not possible to convert more gradually (eg one mammography set at a time) in order to mitigate the impact because the film processing equipment we were using was obsolete, so we could not continue to provide a film based service of any description. Additionally, once one digital image is created, a Picture Archiving Communications System (PACS) is required for image handling and storage. Acquisition and installation of the PACS was a major component of the digital implementation, and in order to ensure that it was used efficiently, we converted across Wales as a national project. Conversely, we opted not to convert all the centres simultaneously (this would have had less of an impact on the round length statistic in the ensuing years) as: • Neither Breast Test Wales nor the suppliers had the organisational capacity to manage three simultaneous implementations; • Capital funding available was spread over two financial years; and • We could learn from each regional implementation. The major elements of the implementation can be summarised as: • Replacement of mobile mammography units with new units accessible to wheelchair users; • Replacement of mammography sets with digital equipment; • Replacement of physical film storage with a digital PACS. • Building works to centres to remove processing equipment, remodel layouts (including installation of static screening suites in three centres) and installation of digital equipment; • Replacement of roller viewers for analogue image viewing with digital reading stations;
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• Development of image transfer between Breast Test Wales and Welsh Local Health Board (LHB) PACS systems for women diagnosed with cancer; • Development of administrative processes to ensure all images are processed and the correct results issued in the absence of a physical film package; • Redeployment of staff whose roles within the programme had ceased to exist (in particular, radiography helpers); and • Training of staff to use new equipment.
7.1.1 Impact on screening
Table 2 describes the period in each region in which screening was slowed or stopped. The impact was most keenly felt in West Wales, as the first region to convert, requiring the installation of the PACS for handling digital images. While it would have been possible to continue to screen women on the newly commissioned mobiles, preserving performance against the round length standard, it would not have been possible to do anything with the resultant images, resulting in a large backlog of women waiting several months for results. Screening in West Wales stopped altogether for two months at the start of the implementation. Screening in South East Wales could continue at (at much reduced capacity) during the building works as the PACS was already installed and a temporary reading room was created in one of the BTW centre’s meeting rooms. In North Wales, screening continued (at a reduced capacity) during implementation as the two centres converted sequentially and it was possible to decant work between them. In the long term, maximum screening capacity in BTW is increased as a result of digital, as the process of taking the image has fewer steps than with analogue equipment.
7.1.2 Impact on image reading
Digital implementation had major implications for image reading within the programme. • Significant initial problems with the viewing equipment supplied resulted in BTW rejecting Swansea’s new viewing stations as below quality specifications. This introduced an additional delay of several weeks in restarting screening as women could not be screened until the images could be read. • The PACS process of handling the images was very slow initially, particularly in Cardiff where the largest volume of images is produced. The proprietary software had to be rewritten, as did some of the
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supporting NHS software (the National Breast Screening System, NBSS) used across England and Wales. This slowed the recovery in West and South East Wales. • Reading images is slower than using film as individual images must be called up by the reader rather than being displayed on bulk roller viewers. The cumulative impact of a few second’s delay in each image is substantial in a service reading over 500,000 images each year. • The need to compare the current image with those taken previously also slows the reading process as comparison of digital and analogue images is time consuming. • The improved clarity of the digital image compared to analogue means that film readers are more likely to rate films as abnormal, resulting in an increased referral rate to the third reader (the arbitrator). Despite all these issues, and the increased number of women being screened, we have invested in additional image reading capacity and successfully implemented new pathways which mean that reporting time standards are now sustainably being met, which had not been the case previously.
7.1.3 Impact on assessment and diagnosis
Digital implementation had major implications for assessment and diagnosis within the programme. Issues slowing assessment during implementation phase but now resolved • During implementation, it was not physically possible to hold assessment clinics and MDT meetings on BTW premises. We continued to provide some assessments by using facilities in Local Health Boards, although transfer of digital images to the clinics was very problematic and only small numbers of women could be assessed. • The need for staff to familiarise themselves with the new equipment, particularly when taking biopsies, meant that numbers in each clinic were restricted for some time after implementation. • The new biopsy equipment (particularly in Cardiff) required intensive calibration over several weeks to achieve the required accuracy. Issues with an ongoing impact on assessment capacity: The increased sensitivity of the digital mammograms referred to in the section on image reading affected clinics in two ways: • Increased numbers of women referred to assessment, many with very subtle lesions which are challenging to biopsy, reducing effective clinic capacity; • Increased cancer detection rate over and above that expected from assessing larger numbers of women with the digital equipment. This
Date: 12 June 2015 Version: 1.0 Page: 17 of 22 Public Health Wales BTW digital impact appraisal
resulted in a sustained increase in the need for assessment, MDT and results sessions. It can be seen from the above that implementation of digital mammography has had a profound effect on all elements of the breast screening programme (table 3).
Breast Test Wales Workload 2009-15
2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 Women screened 110,858 110,829 84,867 95,437 119,060 115,552 Women recalled for assessment 5,384 5,523 4,379 5,170 5,971 6,166 Biopsies performed 2,034 2,046 1,663 2,015 2,452 2,470* Cancers diagnosed (number) 989 1051 816 956 1,235 N/A Cancers diagnosed (rate/ 10,000 women screened) 9.1 9.6 9.8 10.2 10.6 N/A *incomplete data at time of writing
Date: 12 June 2015 Version: 1.0 Page: 18 of 22 APPENDIX B: Appraisal of recovery options
Decision log of options considered to recover round length and reasons
k
e s y / l i l
d l b ) y R e a l
a t l n t c c p i i a / p l t o c i y e i b l ( d c n u o i c A l P Financial risks P a Suggested Action Benefits C /benefits Comment /Risk
Increase rate of Greater Coverage, No Significant revenue Yes Temporarily hiring mobile units is expensive; there will still be No screening by hiring/ Faster screening, investment required issues in obtaining appropriately qualified staff to operate buying additional Mobile them. Technical compatibility issues (PACS) would need to be Units with necessary staff addressed. Additional reporting and assessment would be generated that would require further staffing with potential substantial revenue consequences. In practice it is unlikely we would be able to recruit to these short term positions. It should also be remembered that any ‘hump’ in numbers of women screened will be replicated every three years thereafter, creating peaks and troughs in workload that would be difficult to manage on a long term basis. .
Suspend Family History Slight reduction in Yes Cost neutral No This is politically controversial and publicly would not be well No Screening temporarily workload which received. There would undoubtedly be a clinical risk- but to put allows faster that into context, in its first ten years of operation the FH throughput of core programme diagnosed 43 cancers-Suspension for a year might cohort delay the diagnosis of 5 or 6 cancers- which is substantially less than are being delayed by the current situation (we diagnose 1,000 cancers per year, so an average delay in screening of three months means that at any one time there are probably around 250 women whose diagnosis has been delayed by three months. .
Suspend Self referral in Significant Yes Cost neutral No This is politically controversial and publicly would not be well No the >70s temporarily reduction in received. No evidence to show that is would increase mortality, workload that but morbidity needs to be considered Alternatively one could allows faster argue that morbidity should be looked at from the perspective throughput of core of over diagnosis also. From the point of view of over or under cohort diagnosis,, this is a controversial work stream to pursue
Date: 12 June 2015 Version: 1.0 Page: 19 of 22 Public Health Wales BTW digital impact appraisal
k
e s y / l i l
d l b ) y R e a l
a t l n t c c p i i a / p l t o c i y e i b l ( d c n u o i c A l P Financial risks P a Suggested Action Benefits C /benefits Comment /Risk
Additional reporting staff Increased report No Significant revenue Yes Recruitment is a rate limiting step to this option, however it is Yes turnaround time, investment required currently being pursued as part of the current operational plan supports faster to support the current service need. Funding has been screening rate identified for additional reporting staff.
Additional assessment Supports faster No Significant revenue Yes Recruitment is a rate limiting step to this option, however it is Yes staffing screening rate investment required currently being pursued as part of the current operational plan. Funding has been identified for additional assessment staff.
Adopt English BSP Relaxing or No Needs to be costed Yes No clinical risk, assumption based on English BSP model, Under assessment clinic model removing the although this could have significant implications for LHBs that consider /or Hybrid requirement for currently do not allow capacity for such a model in their ation breast surgeons in planning assumptions. Other options may include a model that (2015) clinic would continues to run clinics if surgeons are unavailable. We would reduce the number need to increase levels of other grades of staff eg nurses, of cancelled clinics, breast clinicians, radiographers in clinics to carry out the role thereby supporting currently performed by surgeons. We may wish to introduce an faster throughput LTA whereby funding is withheld if surgical attendance at BTW to support clinics falls below a certain threshold, to allow for this additional increased cost variations on the English BSP model should be explored. screening and reporting rate
Waiting list initiatives for Increased report No Significant revenue Yes Staff appetite would have to be measured. We have previously Yes, but reporting and turnaround time investment required failed to implement lists on request. This solution is pay limited assessment and subsequent sensitive in terms of being able to implement this additional staff assessment, activity. This is currently being undertaken in a limited appetite supports faster capacity. screening rate
Single read Potentially doubles Yes Cost neutral Yes Likely to have a very adverse impact on cancer detection and No mammography reporting capacity service quality. Potential increase in False Positives and False and reporting Negatives, further work would be required to assess the actual throughput outcomes in terms of sensitivity, accuracy and specificity. This would deviate significantly from NHSBSP reporting practices, and would be vigorously resisted by clinical staff and management
Date: 12 June 2015 Version: 1.0 Page: 20 of 22 Public Health Wales BTW digital impact appraisal
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d l b ) y R e a l
a t l n t c c p i i a / p l t o c i y e i b l ( d c n u o i c A l P Financial risks P a Suggested Action Benefits C /benefits Comment /Risk
Narrow current age Reduced overall Yes N/A No Not in line with evidence based practice. No range to reduce eligible workload, allows population quicker moves for Inequitable. Would deny an evidence based service to women mobiles and who would benefit from it. recovers round length faster
Reduce number of mobile More efficient use No Needs to be costed, No Would require additional radiography staff to staff extended Limited screening sites across of resource and potentially cheaper screening time. Wales (and/or see option staff. Fewer days below) lost to moves, Potential to reduce uptake and increase inequalities. Work potentially cheaper previously undertaken suggests current geographical model is service delivery best fit for population in terms of travel time and accessibility. model
Operate existing sites More efficient use No Needs to be costed, Yes Service model would need to be established and costed, this No over 7 day week with of resource. potentially more option could possibly be combined with a reduction in the extended days expensive number of mobile locations, the issue of reduced uptake would still need to be considered, as would impact on film reading and assessment from increased numbers images/ women and reduced staffing available
Re-deploy all Advanced Faster screening No Additional revenue No Creates further delays in the reporting and assessing. Would No Practitioners from throughput required require more Medical cover. assessment and film reading to mobile and static mammography units
Remove results from all Greater capacity to No Needs to be costed, Yes Implications for LHBs that currently do not allow capacity for No BTW assessment clinics see 'New Patients', potentially cheaper such a model in their planning assumptions and deliver in LHB,s greater clinic throughput
Date: 12 June 2015 Version: 1.0 Page: 21 of 22 Appendix C: Risks and mitigation
# Risk Description Mitigation Responsibility
1 Screening Current activity does not Increased utilisation of new Radiography Managers / capacity/ meet the minimum number static centres, reassignment of Head of Programme activity of screens required to certain post codes to static deliver a 36 month centres to allow shorter mobile screening cycle to deployments. Developing population further rationalisation of mobile sites to call larger geographic areas to single points of screening 2 Clinical Increased round length Plan in place to reduce round Head of Programme. leading to greater number length. of interval cancers 3 Clinic Up to 33% of clinic Enforce leave policy, revisit Clinical / Leads / Head Capacity capacity is lost in certain LTA and backfill arrangements of Programme regions. with LHB. Training support for Nurse / Radiographer breast examination course. Revisit service delivery model for assessment. 4 Reporting Increased screening will Continue to provide funding for Clinical Leads / Head of Capacity lead to greater pressure Radiographer reporting Programme on reporting workload, any courses. Actively appoint to significant backlog in Consultant Radiologist reporting has historically vacancy. led to a reduction in screening activity 5 Financial Increased activity will Agree realistic budgets and Budget Holders / increase overall spend monitor in month spend. Business Manager within pay and non pay Identify cost pressures early. cost centres 6 Staff Staff vacancy Fast track replacement Head of Programme / vacancy / business cases, actively Business Manager Sickness appoint to vacancy. Agree backfill for long terms sickness. 7 Increased Increased BTW activity will Monitor detection rates. Liaise Head of Programme demand on lead to a greater number with LHB’s surgical services /BTW Breast Surgeons LHB of women requiring access surgical to LHB surgical services services 8 Public There is a potential risk Engagement strategy to be Lead Screening engagement that uptake will decline in aligned with recovery plan. A Engagement Officer / areas reassigned to static number of engagement events Head of Programme centres or this could be planned over recovery period perceived as a reduction in service level
Date: 12 June 2015 Version: 1.0 Page: 22 of 22 39.12
Month 2 2015/16 Finance Performance Report Author: Tamira Rolls, Deputy Director and Head of Finance
Date: 12 June 2015 Version: 1
Sponsoring Executive Director: Huw George, Deputy Chief Executive/Executive Director of Operations and Finance
Who will present: Huw George, Deputy Chief Executive/Executive Director of Operations and Finance
Date of Board / Committee meeting: 25 June 2015
Committee/Groups that have received or considered this paper:Executive Team
The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper X Discuss and scrutinise the paper and provide feedback and comments Receive the paper for information only
Link to Public Health Wales commitment and priorities for action:
(please tick which commitment(s) is/are relevant) X X X X
Date: 14 May 2015 Version: 1 Page: 1 of 8 Public Health Wales Month 2 Finance Performance Report – May 2015 1. Introduction
The content of this report reflects the Director of Finance commentary that was formally submitted to Welsh Government 11 June 2015 as part of the full financial monitoring return for month 2 (31 May 2015).
The report will cover the following areas: • Financial Position and variance report (section 2) • Key Financial Performance Indicators (Section 3) • Key Risks (Section 4) • Capital Programme (Section 5)
2. Financial Position
The month 2 for 2015/16 is a surplus of £56k and this is summarised in the tables below. Further information is given in the appendix.
Table 1a: Overall Trust Position
Annual Cumulative Cumulative Cumulative Budget Budget Actual Variance Type £000s £000s £000s £000s Income -107,142 -17,714 -17,649 65 Pay 66,928 11,044 10,691 -353 Non Pay 40,214 6,670 6,902 232 Grand Total 0 0 -56 -56
Table 1b: Net Financial Position by Directorate:
Annual Cumulative Cumulative Cunulative Budget Budget Actual Variance Directorate £000s £000s £000s £000s Public Health Services 41,952 6,983 6,956 -27 Health and Wellbeing 24,487 4,081 4,004 -77 Policy, Research & International Dvt 1,588 265 246 -18 Quality Improvement and Patient Safety 3,507 580 580 -0 Quality Nursing and Other Allied Profs 1,386 231 229 -2 Operations and Finance 4,304 604 672 68 Workforce and OD 1,938 323 319 -4 Core Income -81,953 -13,526 -13,526 0 Board and Corporate 1,616 269 281 12 Hosted Organisations 1,175 190 183 -7 Total 0 0 -56 -56
Note: -ve figures indicate underspend (of expenditure) / over-recovery (of income) +ve indicate overspend (of expenditure) / uner-recovery (of income)
Date: 12 June 2015 Version: 1 Page: 2 of 10 Public Health Wales Month 2 Finance Performance Report – May 2015
The reasons for any significant directorate variances are given below. Further details are provided in the individual directorate financial reports.
2.1 Public Health Services (£27k underspent)
Microbiology (£10k overspent):
There has been slippage on the implementation of the Managed Service Contracts (Serology, Chlamydia and Blood Culture) resulting in a £128k overspend. This is partially offset by an underspend on lab consumables (£70k) and maintenance and accreditation (£43k). The LHB SLA income is under achieved by £50k as a result of uplifted 2015/16 SLAs not yet having been agreed with Health Boards.
There has been an overachievement against the vacancy turnover target of £55k
Screening (£4k over spent)
There has been an overspend on consumables (£116k) as a result of bulk buying, primarily on Liquid Based Cytology consumables. This is a timing issue and no overspend is anticipated at year end. An overspend on postage (£24k) has been more than offset by various underspends across other areas of non pay primarily in Screening Management and Bowel Screening Wales (£90k). Several vacant posts, including consultant vacancies in Breast Test Wales have resulted in an overachievement against the turnover budget of £57k
Health Protection (£41k under spent)
Several consultant and other senior level vacancies have resulted in an overachievement against the turnover budget (£77k). This has been partially offset by additional recruitment and additional non pay costs within the non core programmes (£35k).
2.2 Health and Wellbeing (£77k underspent)
Health Improvement is underspent by £52k as a result of slippage against several programmes making up the Transforming Health in Wales review.
Health Intelligence is underspent by £29k mainly due to staff vacancies and acting up arrangements.
Date: 12 June 2015 Version: 1 Page: 3 of 10 Public Health Wales Month 2 Finance Performance Report – May 2015
2.3 Policy Research and International Development (£18k underspent)
The majority of the underspent is within pay and is a result of several vacant posts. Plans have been submitted for recruiting to these vacancies, and the underspend is anticipated to reduce as a result.
2.4 Operations and Finance (£68k underspent)
Estates is overspent by £57k due to unbudgeted costs relating to current accommodation and the Our Space project.
2.5 Workforce and Organisational Development (£4k underspent)
Pay is overspent by £30k as a result of agency costs and additional hours worked. This is offset by an underspend within non pay of £34k.
2.6 Board and Corporate (£12k overspent)
The overspent is a result of a provision for the recruitment costs associated with several Board and tier 3 level posts.
3. Public Sector Payment Policy (PSPP) Compliance
3.1 The PSPP figures for April and May are summarised in Table 2 below.
Table 2: PSPP for April and May 2015:
Non NHS NHS % Number % Value % Number % Value April 89.50% 90.80% 97.40% 96.66% May 95.24% 93.34% 92.81% 98.51% YTD 91.78% 91.58% 95.68% 97.88% Previous Month YTD 89.50% 90.80% 97.40% 96.66%
In Month movement 5.74% 2.55% -4.60% 1.85% Cumulative Movement 2.28% 0.78% -1.73% 1.21%
3.2 We continue to work with NWSSP to improve the performance against the PSPP target of 95%, and there has been an improvement in month for all categories except NHS invoice number.
Date: 12 June 2015 Version: 1 Page: 4 of 10 Public Health Wales Month 2 Finance Performance Report – May 2015
3.3 The Trust also undertakes a monthly review of all invoices that fail the 30 day payment target in order to understand the issues causing the failures. In month 2, 72 non NHS invoices failed the 30 day target with the majority failing as a result of no bank details on the system. As a result, controls within Shared Services have been improved to ensure that this does not hold up payment in future months.
3.4 We are also hopeful that the new All Wales Director of Finance subgroup for Procurement, which met for the first time on 3rd June will help identify the issues around the performance against the PSPP target. One of the purposes of the group is to discuss and agree common operating procedures, key performance measures and process improvements which should increase the PSPP levels across NHS Wales.
4 Risks
4.1 The Managed Service Contracts slippage is a risk for future months and could cause further cost pressures within the Microbiology Division.
4.2 Robust 2014/15 Microbiology activity outturn is not yet available resulting in delays and risks associated with uplifting Health Board SLAs, activity reporting to Health Boards and over activity invoicing.
4.3 Slippage on posts across the organisation due to delays in the recruitment process may result in unplanned underspends.
4.4 There are a number of key contracts between PHW and other NHS organisations where no there is no signed SLA in place. This will include agreements with BCU with respect to savings as a result of the centralisation and automation in North Wales
5 Capital Programme
5.1 Table 3 overleaf shows the Trust’s final discretionary capital programme as at May 31st 2015.
5.2 PHW’s recurrent discretionary capital funding baseline has been increased from 2015-16 onwards to £1.053m.
Date: 12 June 2015 Version: 1 Page: 5 of 10 Public Health Wales Month 2 Finance Performance Report – May 2015
Table 3: 2015/16 Capital Programme
Division £000s IT General IM&T 200 Toxoplasma - various replacements Microbiology 22 BTW Swansea Electrical infrastructure Screening 40 Enabling works for Managed Service Contract Microbiology 30 Our Space Estates 500 HP Case Management System Health Protection 119 Molecular Extraction Platform Microbiology 28 BD FX40 Microbiology 15 Rotor Gene Microbiology 32 ARU microscope Microbiology 15 Mobile generators Screening 25 Unallocated 27 Capital Programme Total 1,053
Reserve Ultrasound Scanners x 2 Screening 180
6 Conclusion
The Trust forecasts a breakeven position in accordance with its financial strategy.
Appendix: Month 2 Position by Directorate
Annual Cumulative Cumulative Cumulative Dir Division Acc Class Budget Budget Actual Variance PH Services Microbiology Income -15,194,778 -2,532,466 -2,449,320 83,146 Pay 15,441,268 2,576,300 2,521,038 -55,262 Non Pay 6,261,704 1,043,530 1,025,799 -17,731 Microbiology Total 6,508,194 1,087,364 1,097,516 10,152 Health Protection Income -1,191,326 -164,954 -177,682 -12,728 Pay 4,668,128 783,118 705,744 -77,374 Non Pay 636,307 65,758 114,891 49,133 Health Protection Total 4,113,109 683,922 642,953 -40,969 Screening Income -269,336 -44,896 -50,905 -6,009 Pay 13,784,346 2,297,406 2,239,988 -57,418 Non Pay 17,815,599 2,959,460 3,026,683 67,223 Screening Total 31,330,609 5,211,970 5,215,765 3,796 PH Services Total 41,951,912 6,983,256 6,956,235 -27,021 Health and Wellbeing H&W Mgt & Admin Income -145,596 -24,266 -4,468 19,798 Pay 1,529,002 254,834 251,628 -3,206 Non Pay 64,758 10,792 24,386 13,594 H&W Mgt & Admin Total 1,448,164 241,360 271,546 30,186 Hlth Improvement Income -1,117,894 -209,868 -165,011 44,857 Date: 12 June 2015 Version: 1 Page: 6 of 10 Public Health Wales Month 2 Finance Performance Report – May 2015
Pay 3,873,920 653,431 636,056 -17,375 Non Pay 6,595,182 1,114,982 1,005,903 -109,079 Hlth Improvement Total 9,351,208 1,558,545 1,476,948 -81,597 Primary Community and Income -251,836 -41,974 -31,686 10,288 Integrated Care Pay 2,163,183 360,531 311,409 -49,122 Non Pay 58,456 9,744 48,578 38,834 Primary Community & Int Care Total 1,969,803 328,301 328,301 -0 Health Intelligence Income -75,740 -12,624 -19,352 -6,728 Pay 3,215,991 536,003 513,692 -22,311 Non Pay 451,566 75,270 78,313 3,043 Hwalth Intelligence Total 3,591,817 598,650 572,653 -25,996 LPH Teams Income -1,137,732 -189,622 -92,263 97,359 Pay 8,342,279 1,390,375 1,337,147 -53,228 Non Pay 920,984 153,501 109,359 -44,142 LPH Teams Total 8,125,531 1,354,254 1,354,242 -12 Health and Wellbeing Total 24,486,523 4,081,109 4,003,691 -77,418 Policy, Research & International Development Income -266,612 -44,436 -47,125 -2,689 Pay 1,602,054 267,012 254,113 -12,899 Non Pay 252,287 42,052 39,180 -2,872 Policy, Research & International Development Total 1,587,729 264,628 246,168 -18,460 Quality Nursing and Other Allied Health Profs Income -69,707 -11,618 -7,600 4,018 Pay 1,389,925 231,656 228,686 -2,970 Non Pay 66,174 11,030 8,220 -2,810 Quality Nursing and Other Allied Health Profs Total 1,386,392 231,068 229,305 -1,762 Quality Improvement and Patient Safety Income -316,682 -52,780 -52,780 0 Pay 2,555,637 425,940 425,940 0 Non Pay 1,267,659 207,064 207,064 -0 Quality Improvement and Patient Safety Total 3,506,614 580,224 580,224 -0 Annual YTD Dir Division Acc Class Budget YTD Budget YTD Actual Variance Ops and Finance Estates Income -16,368 -2,728 0 2,728 Pay 35,454 5,910 5,934 24 Non Pay 938,298 156,383 211,073 54,690 Estates Total 957,384 159,565 217,007 57,441 Finance Income -120,560 -20,094 -22,259 -2,165 Pay 975,669 159,280 155,233 -4,048 Non Pay 708,969 118,162 121,568 3,406 Finance Total 1,564,078 257,348 254,542 -2,807 Prog Management Pay 178,596 29,766 27,279 -2,488 Non Pay 0 0 -284 -284 Prog Management Total 178,596 29,766 26,994 -2,772 Comms Pay 455,799 75,966 80,079 4,113 Non Pay 45,888 7,648 13,749 6,101 Comms Total 501,687 83,614 93,828 10,214 Planning and Performance Pay 78,711 13,119 15,791 2,672 Non Pay 10,040 1,674 1,022 -652 Planning and Performance Total 88,751 14,793 16,813 2,020 IM&T Pay 186,245 35,250 36,532 1,282 Non Pay 91,280 15,214 14,408 -806 IM&T Total 277,525 50,464 50,940 476
Date: 12 June 2015 Version: 1 Page: 7 of 10 Public Health Wales Month 2 Finance Performance Report – May 2015
Capital Charges Income -2,849,862 -474,978 -474,978 0 Non Pay 2,849,862 474,978 474,978 0 Capital Charges Total 0 0 0 0 WRP Income 0 0 -176,701 -176,701 Non Pay 50,000 8,334 188,415 180,081 WRP Total 50,000 8,334 11,714 3,380 investments Pay 686,952 -0 0 0 investments Total 686,952 -0 0 0 Ops and Finance 4,304,973 603,885 671,837 67,952 WorkforceTotal and OD Workforce and OD Pay 1,255,867 209,312 239,405 30,092 Non Pay 681,812 113,640 79,650 -33,990 Workforce and OD 1,937,679 322,952 319,055 -3,897 BoardTotal and Corp Board and Corp Income -178,093 -29,682 -8,834 20,848 Pay 1,543,972 257,329 229,285 -28,044 Non Pay -174,983 -29,164 -13,838 15,326 Board and Corp Total 1,190,896 198,483 206,614 8,131 SpRs SpRs Income -801,724 -133,620 -133,620 0 Pay 1,215,767 202,628 202,628 -0 Non Pay 10,760 1,794 5,630 3,836 SpRs Total 424,803 70,802 74,637 3,835 Core Income Core Income Income -81,952,602 -13,526,083 -13,526,083 0 Core Income Total -81,952,602 -13,526,083 -13,526,083 0 Hosted Collaborative Income -1,035,852 -172,641 -170,836 1,805 Pay 1,619,660 263,771 245,284 -18,487 Non Pay 591,272 98,546 108,242 9,696 Collaboratives Total 1,175,080 189,676 182,689 -6,987 Bevan Income -150,000 -25,000 -25,000 0 Pay 130,000 15,605 15,605 -0 Non Pay 20,000 9,395 9,395 0 Bevan Total 0 0 0 0 Hosted Total 1,175,080 189,676 182,690 -6,986 Grand Total 0 -1 -55,627 -55,627
Date: 12 June 2015 Version: 1 Page: 8 of 10 39.14
Healthcare Inspectorate Wales annual report for
Public Health Wales Author: Darren Hatton, Relationship Manager, Healthcare Inspectorate Wales Date: 15 June 2015 Version: 1 Sponsoring Executive Director: Keith Cox, Board Secretary Who will present: Darren Hatton, Relationship Manager, Healthcare Inspectorate Wales Date of Board / Committee meeting: 25 June 2015 Committee/Groups that have received or considered this paper: Executive Team
The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper Discuss and scrutinise the paper and provide feedback and X comments Receive the paper for information only
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) X
Date: 15 June 2015 Version: v1 Page: 1 of 6
Public Health Wales HIW annual report for Public Health Wales
1 Introduction
Healthcare Inspectorate Wales (HIW) has produced the attached annual report as a summary of the activity HIW has carried out between 1 April 2014 and 31 March 2015 in Public Health Wales.
2 Background
Healthcare Inspectorate Wales (HIW) is the lead independent inspectorate for healthcare in Wales. Its purpose is to provide independent and objective assurance on the quality, safety and effectiveness of healthcare services making recommendations to healthcare organisations to promote improvements.
3 Timing
The Board is asked to discuss and scrutinise the annual report at the formal Board meeting on 25 June 2015.
4 Description
During 2014-15, HIW has not conducted any inspections to Public Health Wales.
5 Financial Implications
None.
6 Recommendation(s)
The Board is asked to discuss and scrutinise the annual report from HIW.
Date: 15 June 2015 Version: v1 Page: 2 of 6
Public Health Wales HIW annual report for Public Health Wales
Public Health Wales Annual Relationship Manager: Darren Hatton Report from Healthcare Healthcare Inspectorate Wales Tel: 0300 062 8402 Inspectorate Wales 2014-15
Purpose
Healthcare Inspectorate Wales (HIW) is the lead independent inspectorate for healthcare in Wales. Its purpose is to provide independent and objective assurance on the quality, safety and effectiveness of healthcare services making recommendations to healthcare organisations to promote improvements.
This annual report has been produced by HIW as a summary of the activity that HIW carried out between 1 April 2014 and 31 March 2015 in Public Health Wales.
The outcomes we seek to influence as a result of our activity within this and other health boards/trusts are that:
Citizen experience of healthcare is improved Citizens are able to access clear and timely information on the quality, safety and effectiveness of healthcare services in Wales Citizens are confident that inspection and regulation of the healthcare sector in Wales is sufficient, proportionate, professional, co-ordinated, and adds value.
Overview
During 2014-15, HIW has not conducted any inspections to Public Health Wales.
Key Themes
HIW conducted 46 Dignity and Essential Care inspections across the 7 health boards during 2014-15 and in a small number of inspections we found infection control issues by both medical and non-medical staff on wards. Examples included:
Barrier nursed patients being assisted by non-medical staff without appropriate protective gloves and apron and non-medical staff clothing increasing risk of infection control issues Medical staff not wearing gloves or washing hands as required.
HIW conducted 77 Dental inspections across the 7 health boards during 2014-15 and in some health board areas we found areas for improvements in infection control arrangements and other issues that are relevant to Public Health Wales. Examples included:
Date: 15 June 2015 Version: v1 Page: 3 of 6
Public Health Wales HIW annual report for Public Health Wales
The need to ensure patients are provided with further health promotion information, including smoking cessation and mouth cancer awareness/prevention (Aneurin Bevan UHB) Decontamination of equipment and storage – The need to ensure the effectiveness of decontamination arrangements and that equipment is appropriately stored to maintain its sterility (Aneurin Bevan and Hywel Dda UHBs) Infection control – The need to ensure the effectiveness of infection control arrangements, including the training of staff in this area (Aneurin Bevan UHB and Powys Teaching HB) There were some health and safety issues highlighted such as; inappropriate disposal of dental casts; mercury handling; disposal of single use instruments; insufficient quantities of hand pieces (Hywel Dda UHB).
Governance and Accountability
The self assessment conducted and submitted by Public Health Wales for 2013-14 indicated the organisation’s evaluation of its governance arrangements as being effective. The self assessment conducted and submitted to HIW by Public Health Wales for 2013-14 indicated the following:
Under all three themes: Setting the Direction, Enabling Delivery and Delivering Results, Achieving Excellence, the organisation believed that they had demonstrated level 3 maturity – the trust are developing plans and processes and can demonstrate progress with some of our key areas for improvement.
Under Setting the Direction theme, the trust has an established board and governance arrangements. The trust refreshed its strategies to provide a clear purpose. The trust identified a requirement to strengthen learning from service users and stakeholders to inform service improvement.
Under the Enabling Delivery theme, the trust continued to achieve high quality, safe and accessible services within budget for 2013-14. The trust aimed to improve accommodation and ways of work, for a workforce spread across a number of different locations. It has also identified low compliance rates for statutory and mandatory training as a risk to the organisation.
Under the Delivering Results, Achieving Excellence theme, the trust developed and revised performance and planning arrangements during the year, and as with the theme Setting the Direction, the trust needed to improve learning from service user engagement.
In addition, conclusions from the Wales Audit Office’s Annual Audit Report indicated the trust has improved its focus on its strategic and operational priorities, and related risks, and its governance arrangements, though there is scope to accelerate further improvements.
Engagement Date: 15 June 2015 Version: v1 Page: 4 of 6
Public Health Wales HIW annual report for Public Health Wales
In 2014-15, HIW’s Chief Executive, Kate Chamberlain, along with the Relationship Manager met with the Chief Executive and Chair in January 2015. This visit was part of a programme of liaison meetings, where HIW raised any issues with health boards and trusts, discussed future programmes of work and gained feedback on any issues relating to the way HIW conducts its work.
HIW continues to work closely with PHW in development and delivery of dental inspections. PHW is an active member of HIW's Dental Stakeholder Group, and regularly provides advice where appropriate on inspection findings. PHW also manages and reports to HIW on a Quality Assurance Self-Assessment (QAS) process for all practitioners delivering only private dentistry in Wales. This process is managed via a Service Level Agreement. The QAS process was completed successfully for the first time in 2014, and a second QAS is planned for 2015.
HIW continues to engage with other stakeholders in relation to Public Health Wales via the Healthcare Summit process and the NHS Escalation and Intervention framework.
Date: 15 June 2015 Version: v1 Page: 5 of 6
Public Health Wales HIW annual report for Public Health Wales
Inspection Activity
Inspection Location Date Link to report Type Amman 13/08/2014 http://www.hiw.org.uk/opendoc/251981 Royal Glamorgan 10/09/2014 http://www.hiw.org.uk/opendoc/255086 Hospital Dignity and Montgomery Essential County Care 04/12/2014 http://www.hiw.org.uk/opendoc/260507 Infirmary, Inspections Newtown Royal Glamorgan 14/01/2015 http://www.hiw.org.uk/opendoc/263631 Hospital
Date produced: April 2015
Date: 15 June 2015 Version: v1 Page: 6 of 6
39.15
Targeted intervention review of Betsi Cadwaladr University Health Board Author: Ann Lloyd, Chair of Review Date: 16 June 2015 Version: 1 Sponsoring Executive Director: Professor Sir Mansel Aylward CB Who will present: Professor Sir Mansel Aylward CB Date of Board / Committee meeting: 25 June 2015 Committee/Groups that have received or considered this paper: N/A
The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper Discuss and scrutinise the paper and provide feedback and comments Receive the paper for information only X
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) X
Date: 15 June 2015 Version: v1 Page: 1 of 2 Public Health Wales Targeted intervention review of Betsi Cadwaladr University Health Board
1 Introduction
The attached Targeted Intervention Review for Betsi Cadwaladr University Health Board is being brought to the attention of the Public Health Wales Board. A discussion will be held at the informal Board meeting on 28 July 2015 which will focus on the implications the report has on Public Health Wales and whether there are any lessons which Public Health Wales can learn from the report.
2 Background
In November 2014 the Welsh Government escalated Betsi Cadwaladr University Health Board to ‘targeted intervention’ under the NHS Wales Escalation and Intervention Arrangements protocol. The decision was based on a discussion between Welsh Government, the Wales Audit Office and Healthcare Inspectorate Wales. Under this protocol a review was undertaken to look at how the organisation made decisions and the capacity and capability of the organisation to deliver its key priorities. This report outlines the outcome of the first stage of targeted intervention – namely the diagnostic review.
3 Timing
The Board will discuss the report in more detail at the informal Board meeting on 28 July 2015.
4 Financial Implications
None.
5 Recommendation(s)
The Board is asked to note the report and further discussions will take place on 28 July 2015.
Date: 15 June 2015 Version: v1 Page: 2 of 2 "%43) #!$7!,!$2 5.)6%23)49 (%!,4( "/!2$
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1. INTRODUCTION.
The Welsh Government decided in November 2014 to escalate BC UHB to —targeted intervention“ under the NHS Wales Escalation and Intervention arrangements protocol, March 2014. This decision was based on a discussion between the Welsh Government, the WAO and HIW. The aim of the protocol is to identify potentially serious issues affecting NHS Wales and to ensure that appropriate action is taken. Targeted intervention is action designed to strengthen the capacity and capability of the NHS body to drive improvements. The reasons for the increased concerns relating to BC UHB were: • Significant changes in the financial plan for 2014/15 and concerns about the ability of the organisation to deliver a revised plan. • Significantconcerns around the delivery, safety and quality of the mental health services • The management and control of capital schemes, capital planning and capital cash control
In addition, concerns were raised about the performance of the organisation against Welsh Government service performance targets. The aim of the intervention was to provide support to help the Health Board to succeed by ensuring that there was a clear understanding of the challenges they faced, that plans were developed which addressed those concerns with urgency and that the capacity to deliver the necessary action was put into place urgently.The reviewer was as to look at how the organisation made decisions and the capacity and capability of the organisation to deliver its key priorities. This report outlines the outcome of the first stage of targeted intervention œ namely the diagnostic review. The work was undertaken during December 2014 and January 2015 , led by Ann Lloyd CBE, independent advisor, assisted by Margaret Pratt who undertook the forensic financial and governance review. Lesley Law, Welsh Government and Llinos Roberts BCUHB provided invaluable help in tracking down and analysing the necessary documentation. The leaders of the organisation were interviewed in depth during the course of the review and the intervention team is very grateful for those open, frank and illuminating discussions and the information provided. The intervention lead will report to the Chair, Mr. Peter Higson OBEwhose help in facilitating
/hbCL59bÇL![ Lb /haaLÇÇ99 2 access to all material information and individuals has been greatly appreciated. The review covers the following areas: • An assessment as to why the Boards plans have not been delivered as intended, why the financial situation has deteriorated and an assessment of the financial and performance prospects for 2015/16. • An assurance review into the new controls in respect of the management of capital schemes • Governance and controls with specific reference to those that impact on the quality, performance and financial position of the organisation • An assurance review of the actions being planned and taken to address quality concerns in the mental health services • The 3 year plan and the operational plans and strategies • The functioning, scrutiny and decision making processes of the Board • An assessment of the capacity and capability of the organisations leadership to deliver.
Criteria for de-escalation will be determined at the end of Stage 1. As the aim of the intervention is to support the organisation the reporting line will be to the BC UHB Chair who will be accountable for taking the appropriate action. The DG/CEO NHS Wales will be copied into all correspondence and reports generated by Stage 1 (diagnostic review).
2. FINANCE and control. Analysis. The organisation has a history of failure to address an escalating cost base œ clearly outlined in the independent review undertaken by Alison Lord of Allegra in 2012. The IMs over time became increasingly frustrated about their inability to effectively hold the executives to account to gain the necessary assurance due to the absence of quality information. This culminated in the former Finance Director, the Chair of Audit and the Chair of Finance —whistle blowing“ their concerns to the Welsh Audit Office in September 2012. There was a change of leadership at Board level in 2013/14.
2014/15 financial plan. An incremental approach was adopted to budget setting by rolling forward the 2013/14 budget allocations adjusted for known cost pressures. The budget was based on there being no change in demand for services during the year. The Board adopted an outline plan which defined cost improvement proposals to fit the resource envelope of £1.3 bn.
/hbCL59bÇL![ Lb /haaLÇÇ99 3 An underlying deficit of £20.2m was brought forward from 2013/14. Cost pressures of £17.8m were identified. Savings targets of £76.3m were identified which included service disinvestments of £33.7m. (It is disappointing to note that a report commissioned from Deloittes, December 2013 into the efficiency of their services which recommended that the organisation could save approximately £107m was never actioned at the time. It is now being used by the new PMO.) The annual operational plan was adopted in May 2014 and gave assurance about the risks to the achievement of statutory financial duties. At that time IMs identified the following risks to delivery œ the need for disinvestment and in which areas, savings plans representing 73% of the whole had yet to be identified, additional savings could be required as part of the national pay negotiations, the degree to which the CPGs were committed to make the necessary savings, the accountability mechanisms for delivery, that no payback of the overspend covered by the Welsh Government in 2013/14 would be required. They also identified specifically the risk of weak integration between finance, workforce and service planning and the exercising of accountability generally.
It became clear by July 2014 that, despite the assurances in the operational plan, the savings plans required from the CPGs were not being delivered to full effect and additional expenditure on locum and agency staff was required to maintain safe services. No firm plans for significant service disinvestment to deliver £33m had been agreed. The reported position at the July 2014 Finance committee was that planned savings should have been running at £4.1m per month and were in fact at £3.5m; the adverse variance at the end of June was £15.259m with a monthly run rate over allocation of £5m. The forecast deficit for the year was identified at that time as £35m. Causes for concern were the cost of drugs and agency and locum costs. The IMs asked for the timescale and mechanisms for disinvestment and for assurance that the savings would be made. However at the same Finance committee, it was recognised that the capacity planning tool used was seriously flawed and that a further £17.236m was required to reach tier 1 RTT targets.
The adverse variances against plan identified in July 2014 have continued and the Board has not been able to realise a balanced plan.
A new FD came into post in August 2014.
In December he presented to the Board a suite of additional costs savingsin order the try to mitigate the increasing escalation of the run rate, with a year
/hbCL59bÇL![ Lb /haaLÇÇ99 4 end forecast of £76m œ less £37m assistance from Welsh Government œ leaving a potential year end deficit of £39m. These costs savings were clearly identified in terms of the potential risk of being achieved. The new FD has clearly risk assessed the proposals and reported to the Board those that are of particularly high risk, which at the February confidential Board session,stood at £5.4m of the agreed additional measures. He does not believe that these can be achieved.
Some improvement has been secured through these measures and the increasing grip being exercised through the FD and the new COO, who came into post at the end of September 2014 and via a new PMO which started operating in November 2014. By the end of Month 10 the run rate has reduced to £4.1m over plan (or £1.2 m with WG assistance) and the cumulative deficit stands at £58.6m(or £29.4m with WG assistance). However this picture is skewed because of an adverse variance caused through a WHSSC in month adverse variance of £1.2m in February 2015. The Health Board does not directly control the WHSSC expenditure. It is therefore vital that there should be an improvement in the communication and forecasting between the Health Boards and WHSSC to ensure that there is absolute control and clarity about the performance and financial management of the specialist contracts and the consequences for the bottom line for the individual Health Boards.
The forecast deficit to the end of the year remains at £27.5m This will be a challenging target to achieve. Much hope is being placed in the effectiveness of the PMO to provide assurance and support to deliver the required savings. The organisation acknowledges that it needs to influence provider behaviour in the areas of CHC, GP prescribing and WHSSC commissioning and control. The organisation is also assuming that it does not have to repay the previous year‘s brokerage.
Cash. Of considerable concern is the fact that the organisation will run out of cash in March. The gross year end cash shortfall is £33.0m; they will receive additional working capital cash from WG of £6.3m and there are other net changes to forecast which equate to £0.7m. To overcome the estimated £26m cash shortfall the Board agreed in February 2015 to delay HMRC payments of £11.5m and to delay paying the NHS pensions agency at £9.1m This still left them with a net cash shortfall of £5.4m for which there are no proposals.However this problem has now been resolved by Welsh Government providing the necessary cover. It is important that steps are taken to ensure that such a cash shortfall does not occur again.
/hbCL59bÇL![ Lb /haaLÇÇ99 5
Summary. The financial situation is very serious this year œ and the achievability of breakeven in 2015/16 is even more serious and remote. Indeed the prospects for the coming three years are exceptionally difficult. (See the section on the strategy and the three year plan.) The new FD has exercised a grip on the management of money and reports the issues to the Board and the Finance Committee in a clear and concise way but he cannot achieve success alone. He has indicated to the Board and the corporate directors group the very grave difficulties with which they are faced. It is of concern that within the Board there is a sense of inevitability about the results. A question to the Chair would be whether or not he considers that the current Board is able as constituted to make the radical decisions required to balance safe services and resources effectively. It is also of concern that the Chair could not gain sufficient assurance about the performance of the organisation in his first six months to have enabled him to have instituted a recovery programme at an earlier date. There is also a real need to ensure that the executive team and senior staff are very clear about the priorities they need to pursue, priority setting having been seen to be very variable in the recent past. Much hope and expectation is being invested in the new management team as it comes into post together with the effectiveness of the PMO œ but the management of the resources available remains an issue for the whole of the organisation and a radical change in culture and accountability is needed together with a very clear strategy to deliver safe and sustainable services. To date all the action and responsibility seems to be vested in the FD and the COO; action appears not to be regarded as a responsibility for the whole of the executive team (excluding the MD and ND who are wrestling with the safey and sustainability of services). This is neither a desirable nor sustainable position.
The prevalent culture of —bail out“ from the Welsh Government must change. Additional money from the Welsh Government should be used to improve health and care systems, not to cover the —bottom line“, especially as the CEO considers that there is sufficient resource within the organisation to run the services required for the population; he considers that much of the resource is currently being wasted through duplication and a lack of efficiency.
A summary of the financial review undertaken by Margaret Pratt is found as Appendix A.
/hbCL59bÇL![ Lb /haaLÇÇ99 6 Action required. • As a matter of urgency the Board needs to agree its clinical and service strategy to ensure that the organisation can deliver safe and sustainable cost effective services from within its resource envelope. • The strategy needs to be underpinned by a sound three year plan which clearly indicates the accountability for delivery and the steps to be taken in financial and service recovery. • The CEO should ensure that the financial plans presented to the committees and the Board are fully worked up, owned and risk assessed. • The Board should be firm in declining to adopt financial plans until it is assured that they are fully aligned with agreed strategies and plans œ workforce, estates, services etc., are practical, realistic and achievable, are underpinned by agreed and realistic timescales and action plans and are underpinned by risk and sensitivity analyses. • It is imperative that the Board sets plans for 2015 œ 16 that are practical, realistic and achievable. The CEO and his team need to ensure that the financial plans presented to the Board for approval in March 2015 are owned by the service leaders charged with their delivery, are backed by definitive plans for delivery within timescales and metrics for achievement, are subject to a clear accountability framework and a system of effective incentives and sanctions and have been comprehensively risk assessed. They must be underpinned by action plans to manage and mitigate emerging risks. • The FD is undertaking zero based budgeting for 2015/16. However this approach can only be effective if supported by clear and accurate clinical service, workforce, performance and estates plans. The Board must assure itself that these are in place and are deliverable. • The CEO and FD should consider the level of reserves to be held for 2015/16, taking into account experience in 2014/15 and the knock on effect of the additional savings required.
CONTROL OF CAPITAL SCHEMES and the management of capital schemes and spend.
Analysis. Considerable control problems have been experienced over the management of capital schemes and until the Welsh Government is satisfied that better controls have been instituted then this area will remain the subject of intervention.
/hbCL59bÇL![ Lb /haaLÇÇ99 7 In the light of the criticisms and concerns engendered by the lack of controls the Health Board Commissioned Capita to undertake an independent review. Capita reported their conclusions and recommendations to the Corporate Directors group in December 2014. The report is sound and achievable.
The concerns about control have a knock on effect with the Welsh Government approval of capital schemes; capital resource is granted to the Health Board by Welsh Government on the basis of approved business cases; recent business cases have been rejected on the basis that benefits have not been demonstrated.
Action required. • An action plan for the implementation of the recommendations contained within the Capita report should be developed by the end of March 2015 and responsibility for its implementation is assigned to a relevant corporate director. • The action plan should set out clear dates and governance arrangements for ensuring the delivery of specific actions. • Other Health Boards in Wales should review their arrangements against the Capita recommendations to ensure best practice is implemented throughout Wales. • Relevant training should be given to those staff charged with the development to ensure that business cases in future meet the requirements of the Welsh Government. • The capital plan should form an integral part of the service plan œ any capital bid should clearly be able to show where and how it fits into the strategic direction for the organisation.
Recommendation. If assurances can be provided by the organisation that they have a worked up an implementation plan for the Capita recommendations and a competent director has been assigned the responsibility to implement and monitor that plan, then the Welsh Government should allow a further six months review to ensure that the agreed action is being taken before lifting the intervention level on this element.
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Analysis.
The performance of the organisation, excluding financial performance, is measured against the 7 domains of the Welsh national framework. The
/hbCL59bÇL![ Lb /haaLÇÇ99 8 quality of the service delivery is overseen by the Quality, Safety and Experience committee and performance is overseen by the newly established Finance and Performance committee. The seven domains are: Staying healthy Safe care Effective care Dignified care Individual care Timely care Our staff and resources.
The Board is also in the process of developing a suite of local indicators œ including measures of Nursing quality, other key performance standards, which include —I want great care“, PMO efficiency, C section rates, staff turnover, cancelled procedures, follow up waiting list, OOH data, appraisals for medical staff, hand hygiene rates, and contract performance activity.
Intervention was required as there had been a continued deterioration of performance against a number of key performance measures and resulting safety concerns arising from the inability of the Health Board to provide consistent timely access to clinical care, including unscheduled care and planned care. (Meeting WG, WAO, HIW 31 st October 2014)
A number of reviews have been undertaken in the past 18 months which have indicated a lack of grip and accountability to deliver the required improvements. Over the past 12 months, the new Nurse Director and Medical Director have made significant efforts to improve the quality of the service provided and the accountability of the clinical staff for the care delivered. Considerable progress has been made by the Nurse Director in resolving the long delays and very poor handling of complaints and concerns within the Health Board. It is of concern that this function has been moved to the Corporate Services Director who is not clinically qualified and who might not be able to exercise the same influence with clinical staff and complainants that the Nurse Director has clearly demonstrated. The Medical Director has undertaken the RAG rating of all clinical services œ it is important that the results of this assessment are included in the 3 year plan, in order of priority for action, to further improve clinical and patient safety risks.
In terms of service improvement the new CEO has set personal targets for the new COO for 2014/15 covering key tier 1 targets: • Delivery of the stroke pathway
/hbCL59bÇL![ Lb /haaLÇÇ99 9 • Delivery of the cancer minimum 62 day wait target • Delivery of ambulance category A response times • Delivery of 8 week maximum diagnostic waits • No over 52 week RTT waiting times.
The COO considers that these targets will be achieved by the end of March 2015.
At December 2014 the organisation remained at escalation level 4 on a number of high priority delivery areas and was showing —red“ i.e. a continued failure to improve performance or failure to engage with the national process in the following areas: • Staying healthy œ smoking cessation • Safe Care œ pressure sores/ C. Difficile/ MRSA/ Serious incidents • Dignified care œ postponed procedures • Timely care œ Referral to treatment/diagnostic waits / emergency departments/ ambulance/ cancer/ stoke • Use of staff and resources œ sickness rates/ appraisals/ finance.
Safe Care: Pressure sores œ the preliminary outcomes for Nov 14 indicate a significant rise in the number of hospital acquired pressure sores œ and action is being taken; the progress to date has not been as positive as desired. The Nurse Director is monitoring the implementation and effectiveness of the action rigorously. Safe Care: C. Diff and MRSA - this still remains very difficult to control especially on the Glan Clwyd site œ again the Nurse Director is putting considerable energy into ensuring the action being taken is effective. Safe Care: Serious Incidents œ there has been a significant rise in the reporting of serious incidents in Nov 14 œ however this might be due to the fact that additional investigating staff have commenced in the past 2 months to both investigate trends and to help the clinical teams with quality improvement. Dignified care: the numbers of postponed procedures has increased, which might be expected during the winter months because of other pressures œ but this is being monitored and managed rigorously by the COO and her staff. However the concern must be the impact of the growing burdens on the elective service to deliver during 2015/16 in the light of increasing delays and numbers. A sound capacity:demand model will need to be used for 2015/16 to ensure that there is absolute clarity about the workload to be delivered to avoid breaches. Timely care: breaches œ the situation is deteriorating with both the 52 week and 36 week performance being behind plan. However the Health Board maintains that it remains on profile to deliver its yearend target of no-one waiting over 52 weeks with outsourcing being a key part of year end delivery œ but this needs to be monitored with rigour to ensure that this is achievable and affordable.
/hbCL59bÇL![ Lb /haaLÇÇ99 10 Timely care: 4 hour A & E target œ this is declining œ action is being taken to increase the management grip on this service and also to introduce Primary Care —in reach“ in all DGHs œ but there is no clarity about how much this will cost and what alteration in the pattern of service delivery and volume will result. This is being combined with effecting reduce lengths of stay. 12 hours waits in A & E have been very variable and have increased significantly over the past year. Timely care: Cancer within 31 days œ it is good to see that although performance has fluctuated considerably over the past 18 months, the target for non urgent cancers is being maintained. However the target for urgent cancers slipped back in December having improved greatly in November. Timely care: Stroke œ although this remained red for bundle 2 there have been significant improvements in performance largely due to the staff redesigning the care pathway. This improvement should be maintained. Resources: Staff sickness œ this remains high and no definitive action to manage and reduce these levels has been agreed. A meeting is shortly being held with the staff side to discuss management of sickness but this is very late in the day. Summary. It will take a mammoth effort on behalf of the whole of the executive team to enable the organisation to improve this performance, especially as this is a period of the year that always experiences real pressure. Every effort is being made by the teams to meet the priorities identified by the CEO but a concern is that the knock on effects for 2015/16 will be very difficult to manage. Failure to achieve these targets will have a demoralising effect on the new team.
Action required. • The Board must assure itself that it has the appropriate demand and capacity models to formulate a firm and reliable plan to manage performance in 2015/16 and that it allocates resources effectively to meet the needs and demands of its population. • The quality of the information reported to the Board has improved but the Board must continue to seek regular progress reports from named officers accountable for the delivery of the priorities of the Health Board. • The Board and its subcommittees must also be very clear about what is required to deliver safe and effective services to its population for the future and must be very thorough in its monitoring to ensure that the recommendations from officers are delivering the required results and can be maintained. They must be clear about the resources required to deliver and ensure that they are sufficient and yet do not increase the financial burdens within the organisation. Priority setting is of paramount importance for the Board if it is going to succeed in its task.
/hbCL59bÇL![ Lb /haaLÇÇ99 11 • It is essential to ensure that for the three year plan period a structured programme is developed and implemented at pace and with grip to deliver cost effective and safe services and to use every opportunity to close the financial and safety gaps that exists at present. This means that the three year plan must be very clear about the future shape of services and how the Board will engage with the wider staff and public to deliver the changes necessary. • Referrals and waiting lists need to be thoroughly scrutinised to ensure that they are valid and a soundly based demand/capacity model must be implemented. Associated with this, job plans must be revised and scrutinised to ensure that they fit the requirements of the capacity model and as a matter of urgency a practical and evidenced based workforce plan must be agreed. Staff appraisal rates, which are currently poor, must improve to ensure that staff are developed effectively. Every resource within this organisation must be used to effect an improvement in the quality and sustainability of the services provided and the Board must be prepared to make difficult decisions. Very effective and early communication and engagement with the communities and key stakeholders will be needed. • The Board needs to be mindful of the April/May —dip“ that can result following significant effort to reach year end targets and ensure that this does not occur. • The performance indicators against which the organisation is held to account are basic œ not world class; the performance of the organisation should not only be compared with other part of Wales (and there is a tendency displayed to be part of the —pack“) but should seek out the best providers of services and compare their performance with those.
5. Mental Health Services.
Analysis. A number of reports and incidents within adult and older people‘s mental health services have been produced over the past 2 years. These collectively and individually give rise to very considerable concerns about the quality and safety of care provided in the units. Reports from HIW regarding adult services identified a number of areas for improvement in record keeping, basic quality of care, the environment, training and development for staff, medicines management, the range and mix of patients and the clinical relationships which required concentrated and energetic action to be taken to improve and secure the services. Action has
/hbCL59bÇL![ Lb /haaLÇÇ99 12 been taken to close those areas where improvement could not be guaranteed. The RCP was invited in by the Health Board to review the service œ their observations complemented the reports of HIW.
An Interim Director of mental health has been seconded into the Health Board for one year from 1 st September 2014 to provide leadership and direction to the service. He has brought focus to the services but it is of concern that the Wrexham adult mental health unit has recently been the subject of concerns relating to its HIW spot check.
There is a great deal of work needed to bring the services up to the standard required. The Interim Director produced a report on the improvements made and needed for the Board in March 2015 but this remains to be quantified in terms of the consequences of the actions necessary. It provides evidence of the changes that have been delivered but it is clear that more time and effort will be required to enable this service to reach its maximum potential and probably a change in the design of the whole service is going to be required.
Of concern is the fact that on the measures of performance used in Wales, these services are —green“. The evaluation of the quality and safety of mental health services will need more thought in order to enable any issues of concern to be highlighted at an early stage to Health Boards.
Action required.
• The Interim Director must continue to provide a full report against action required arising from the critical reports to provide assurance and direction to the Board and confidence to patients and carers that the services are improving. This should be presented to the March Board meeting. • To provide this service with the focus and leadership required to make long term sustainable improvements in the quality and design of the mental health services, a top quality team of Director, Medical Director and Nurse Director dedicated solely to mental health services, which could include CAMHS, should beappointed with a proven track record in the delivery of high quality services and the management of change to lead and drive improvements in this service over the next 3 years. (It is noted that an interim director for Primary, community and mental health services has recently been appointed to replace the previous Director who has been moved to manage strategic planning.) The new Mental Health director should be held personally to account by the CEO
/hbCL59bÇL![ Lb /haaLÇÇ99 13 œ this responsibility should not be delegated. In discussionsthe Health Board directors are unclear in their views about where mental health might sit within their management structure with some believing that its component parts might be split between various service groups. This would be a very insecure move. It hasalso been envisaged that the COO would assume responsibility for the services œ this again would be unwise as it could distract the COO from the not inconsiderable task that she has of turning around the culture and performance of the acute and primary care operational elements of the organisation. • The Board needs to manage its Board cycle to ensure that the improvement in the quality and sustainability of these services is given top priority. • Alternative measurements of quality and safety need to be included in the Board papers to allow theBoard to obtain more assurance about their mental health services in general. (Copies of suggested measures can be provided if required.)
6. Strategy and the current 3 year plan. Analysis. The Health Board failed to produce an acceptable 3 year plan for 2014/15; it has worked hard to produce a sound 3 year plan for 2015/16 œ the first draft of which was submitted to the Welsh Government for consideration on 31 st January 2015. The Health Board went to some length to ensure that this was a credible plan, employing help from Deloittes. Latterly the Director of Primary care, mental health and community has been moved to take up the post of Director of Strategy to strengthen the planning team. The plan has not been accepted by the Welsh Government as the Welsh Government considered it to be incomplete with significant work remaining to address current gaps, service, resource and performance challenges. The Government wishes to understand more fully the Health Boards intentions in respect of national and local priorities. The organisation has been asked to prepare a detailed one year operational plan.(Appendix B)
The Board faces a significant handicap in the absence of an agreed service strategy. It formulated a strategy for North Wales back in 2011 but little action was taken to implement this, largely due to a major public outcry about the suggested actions to be taken. Little action has been taken subsequently to review the strategy to take account of increasing clinical risk and safety issues and the difficult financial position.
/hbCL59bÇL![ Lb /haaLÇÇ99 14 The three year plan that has been produced does not clearly describe the changes to the services that are required and the timescale or the shape of the future community services. It is broad in its description of the direction of strategic travel and the action proposed under the enablers that it has identified but it is very light on the actual change in service delivery that will be needed œ in particular the description of the primary and community service that should be available, costed to included workforce consequences and change and a description of what in the next 3 years will and will not be provided on hospital sites in order to achieve their vision of —cash out and shift left“ (an unfortunate slogan.) Much thought and effort has gone into this plan in respect of visions and aspirations for the future; this work should not be lost but now the hard task of describing exactly what has to happen needs to be delivered. They need to test their plans against their described key design principles of reinvigorating primary care and partnerships and of delivery closer to home. A questionmustsurround the detail of who has been engaged in developing the strategy and how they have influenced the design of solutions suggested in this plan. If key staff and stakeholders œ including communities œ have not been involved then there will remain a considerable danger of more mistrust developing and an overreaction which has caused inaction in the past.
The financial summary for the 3 year plan also raises significant concerns. Without a clear and definitive way forward being described, the FD has had to use his best endeavours to develop this. There is a statutory requirement to deliver financial balance year on year but this currently cannot be achieved by the plan. The cost pressures summarised at the end of February 2015 for each year were œ • £66.4m 2015/16 • £30.3m 2016/17 œ thus creating a cost pressure of £96.7m • £32.1m 2017/18 œ thus creating a total cost pressure over the 3 years of £128.8m
The pressures include pay inflation, pension changes, non pay inflation, demand and service growth, and include the underlying deficit for 2014/15 of £62.5m offset by additional WG funding of £42.5m. Plans are being debated by the Board which outline ways in which these challenges are to be managed and overcome.
Action required. • As a matter of urgency the Board needs to decide upon a clear strategy and the real action that needs to take place to change services over the next three years. The Medical Director has RAG rated the services and action needs to be taken on these results. A clear
/hbCL59bÇL![ Lb /haaLÇÇ99 15 practical plan for designing and delivering the future primary care services needs to be developed without delay so that in 12 months‘ time the next three year plan iteration can have concrete plans for service provision that is safe, sustainable, affordable and meets the needs of the population and that have been developed with users and the clinical staff and relevant stakeholders. It has to be capable of being implemented fully. This is a formidable task but is essential. The detailed explanations of vision are in this three year plan but they need translation and action to implement. • The Board has had considerable difficulty in making difficult decisions relating to clinical services, but these now need to be pursued and implemented without delay. • The immediate strengthening of the strategic planning experience within the organisation is needed œ with very senior and experienced staff employed to work with the key stakeholders œ clinicians, partners and users and the executive team œ to plan in detail the changes needed and to bring about their implementation. • The organisation needs to redefine its communications and engagement strategy to avoid some of the problems that can be encountered by public resistance to service change.
7. Leadership and governance. Analysis. a) The Board. The Board currently consists of 11 independent members, including the Chair, following the model determined for Wales and up to 9 executive or other directors, all of whom are entitled to speak. This is a very large Board, the size of which will have a consequences for the ways in which it can operate. The Board is polite and supportive but, because of the history of the organisation, consistently probe the detail of the information providedin order to receive assurance. I would recommend that the IMs continue to press the executive on issues of strategy and delivery. Thefull range of skills and competencies that might be expected from non executives on health boards is incomplete at present e.g. there is no one with a legal, estates or financial background and no-one thatcomes from a purely commercial background. However the IMs have a sound range of knowledge and have used their individual skills to undertake their responsibilities. Because of the absence of some specialist skills a suite of Board Advisors has been appointed to strengthen the governance arrangements at subcommittee level œ in HR and finance and audit. A number of IMs are coming to the end of their terms of office within the next 3 months.
/hbCL59bÇL![ Lb /haaLÇÇ99 16
The Board has previously been described as —adding no value to the organisation“ (GGI review April 2014) œ this is possibly because they have been seen as being distant from the organisation; their actions have not been communicated well. There is now a far more realistic understanding at Board level of the situation in which the organisation finds itself and the difficult decisions that it will have to make. The Board has not been very successful at making difficult decisions, in part because of a lack of the necessary evidence on which to base a decision. This situation is improving. The Board IMs have taken action in the past to draw attention to the position of the organisation and its services e.g. the Audit chair and the Finance chair —blew the whistle“ to HIW and the WAO in September 2012 about the deficiencies they perceived that were notbeing addressed by the management.
Those IMs whose appointment preceded the joint WAO/HIW reviews of the governance of the organisation have been severely shaken by the concerns uncovered. They remain very frustrated that they have been unable to obtain the assurance they required from the executives about key performance measuresin the recent past. They continue to question the detail of the evidence presented in order to restore their confidence that they understand fully the problems presented to them and that effective action is being taken to rectify the situation. The situation is improving with the appointment of the new executives in operational and financial management. Additionally,since their appointment, the new Nurse Director and the new Medical Director have instilled confidence into the IMs about their understanding of quality and safety issues within the organisation and that the necessary action to improve the safety and quality of care action is being taken. However the IMs are very aware that they have no strategy for the future shape of services and that much remains to be achieved in improving the quality of services, in service redesign andin stakeholder management. They are cautious in taking decisions to reform clinical services, having been conditioned by past history and the mistrust expressed by the population and the stakeholders about their previous decisions. The Chair and the new Vice Chair have taken on a role to test the status quo and to challenge the delivery of services.
A governance review was undertaken by GGI in April 2014 at the instigation of the new Chair. The headline findings were as follows: • There has been a clear lack of strategy and agreed m easurable objectives
/hbCL59bÇL![ Lb /haaLÇÇ99 17 • The response to reviews has been defensive • The need to demonstrate reduced risk may have had the damaging effect of preventing certain risk issues from being escalated or discussed at the Board • There has been considerable work put into the development of the quality improvement plan • Structural concerns persist around the CPG structure • There is a need to strengthen the contracting process and its governance • The nature and scale of support on corporate quality and governance to the front line operations needs to be described and delivered • Engagement with neighbours, support agencies and WG is critical.
Arising from the lack of a strategic direction and measurable objectives the GGI found that: • The Board was not seen as adding value to the organisation • Reports and information to the Board are not prioritised and —work arounds“ fill the vacuum e.g. departments setting their own objectives and timescales • Risk management and governance structures —float“ within BCU and are not grounded to achieve common goals • It is difficult for Board members to be assured on the key priorities in a planned and structured way • Competing issues cannot be prioritised in respect of their impact on the organisation so Board and Committee papers lack focus and are repeated in a number of places. This leads to lengthy and discursive meetings. • Without a clear strategy with SMART defined corporate objectives the corporate risk register and the Board assurance framework are unconnected to the corporate strategic view of the organisation, a commitment to delivery and an understanding of risks that could compromise the achievement of objectives.
A number of objectives arose from those observations and the quality of the information to the Board has improved. Steps have also been taken to improve and rationalise the subcommittee structure from a system of committees dealing with: • Quality and safety • Audit • Information governance
/hbCL59bÇL![ Lb /haaLÇÇ99 18 • Charitable funds • Remuneration and terms of service • Mental health act requirements • Finance • Workforce and organisational development
to committees dealing with: • Integrated governance œ with finance and performance, quality safety and patient experience and strategy planning and partnerships reporting to it • Audit • Mental health act • Remuneration and terms of service • Charitable funds.
This new system came into operation in January; the GGI will return to refresh their previous findings in April 2015 so that progress in improving the governance of the organisation can be tracked.
Summary:IMs In discussion with the existing IMs it is clear that they all perceive there to be an issue with the business and focus of the Board. The Board is polite and although IMs challenge they do not necessarily receive the assurance that they seek. The Chair is particularly exercised by this feature of executive behaviour and constantly pushes for answers and timescales for action. The IMs have had to push hard for answers in the past and this has meant that they have had little scope to develop their strategy and make decisions about the future shape of services. They appreciate that they do not have a workforce plan which matches the quality requirements of the organisation and are unsighted on the best ways in which to redesign services. They need to press the executives for this information. They believe that past clinical modelling has failed, it being too parochial and they believe that external communication is very poor. They describe the organisation as being —very bad at making things happen“ and they believe that the executives are forced into a position of firefighting too often. They are frustrated that little has been actioned from externally commissioned reports and recommendations and that there is a lack of progress and purpose within the organisation. They have been worn down by criticisms. Their confidence has increased with the appointment of the new MD, ND, COO and FD but they will need to continue to test the information provided to them to ensure that the BAF remains clear and accurate and that the quality of the information continues to improve. They will also have to ensure that the executives deliver on the key priorities for the organisation. The Board has recently made a decision on a change in the services provided in the light of safety concerns but were very exercised about the ways in which this decision might be made and the consequences. The reaction to the
/hbCL59bÇL![ Lb /haaLÇÇ99 19 decision they took œ and they individually clearly stated in public their view that change had to occur in the interests of the safety of the patients concerned - was mixed, with someinappropriate behaviour being exhibited by some stakeholders. The Board must change its focus for action to drive forward service change and development and to ensure that they can deliver appropriate high quality and sustainable services for the future. This will require stron leadership with courage and determination, very sound communications, a good early warning system and sound evidence from the executive. They have to start operating as a collective enterprise focussed on change; they need to increase the pace at which decisions about changes in services and the delivery of the future model of care are made and be clear about how implementation has to be handled. They need to engage key stakeholders more effectively. The Board has undertaken a Board development programme over the past year and has reflected on the position in which it finds itself. The members have agreed a suite of —commitments“ as a Board to the population they serve œ see appendix 2. The future agenda for Board development should be reviewed to ensure that it reflects the current and strategic challenges facing the Board.
b) Executive management and delivery. The Executive leadership model and style is in the process of change. The previous Chief Executive exercised control via a system of Clinical Programme Groups with a number of directors taking corporate and service responsibility. This appears to have been flawed in terms of accountability. This model is being scrapped by the new CEO. He wishes to replace it by a matrix model for operational delivery where —the main axis of accountability for line management, service and budgetary performance will be vertically through area teams and secondary care services with horizontal pan Board responsibilities held by clinical divisions assigned to the various teams for standard setting, quality assurance and ensuring consistency of service.“ Such matrix management can be complex to administer and can obscure responsibility. The Board has asked for assurance on the effectiveness of accountability within this structure. The rationale behind the decision to move standard setting etc. for the clinical services away from the direct control of the MD and ND is not fully understood and again the Board has asked for assurance on this element of management and control. The 3 new area teams are accountable for the operational management and commissioning of all community health services, the effective engagement of primary care practitioners and for commissioning secondary care services. This is the former England PCT model œ and the Board will have to monitor whether or not variations in commissioning practice arise, particularly as they affect secondary care services, to ensure that there are quality standards of equal value across all communities. However the power of the area teams to
/hbCL59bÇL![ Lb /haaLÇÇ99 20 innovate and drive improvements in primary and relevant secondary care to lead to a reduction in inequalities and an improvement in quality and value for money is to be welcomed.
The operational model has been consulted upon within the organisation and has been approved by the Board œ but it appears that no costings were available for its implementation at the time of agreement.In a paper dated January 2015, the FD estimated that the new management structure would cost an additional £2.06m but the 3 year plan indicates that an additional £5m will be required.The wiring diagram and the scheme of delegation are not yet available but the GGI has commenced this work. The responsibilities of the COO œ who heads this complex organisation œ are considerable and care will have to be taken that she has the support required to manage these complexities.
The Executives have not yet agreed on a scheme to manage mental health services œ my advice in section 5 should be considered before a final decision is made. CAMHS should ideally not be split away from mental health services, particularly as there are a number of problems arising with this service throughout the UK.
Currently, there is no agreed future corporate executive management structure although the Board has received an update on the possibilities. Specifically in a paper dated December 2014 a Director of Primary, mental health and community services is included whose functions will include the strategic direction for primary care and community services, partnership development and integration. However a Director of Strategy is also included to be responsible for overall strategic planning and commissioning. A revised corporate executive structure has the potential for improving control within the organisation whilst reducing the current number of executive directors. Some changes have however been made, which might need to be revisited e.g. the new Director of corporate affairs has recently picked up the portfolio of concerns and complaints and PPI from the Director of Nursing. The ND had improved performance considerably from the time of her appointment and had taken personal responsibility for the reputation of the organisation in proactively managing concerns and taking on the communications role in respect of SIs, inquests etc. The decision to move the responsibility from the ND should be fully risk assessed.
The executive team: conclusions. The COO has been appointed to apply grip to the organisations performance and delivery; however much of her success will depend on the quality and
/hbCL59bÇL![ Lb /haaLÇÇ99 21 capability of the candidates appointed for the 4 new roles within secondary care and the area teams. It is to be hoped that those clinical leaders who have helped develop the organisation are not disaffected by a more managerially driven structure and that their expertise and influence are retained. The MD and ND have shown sound leadership qualities in the face of considerable adversity. They will have only a dotted line responsibility for clinical standards etc. in the new structure œ this is possibly too tenuous a link and could well blur accountability The wiring diagram that is to be produced will be vital in bringing clarity to the situation. The FD has brought clarity and openness to the reporting of the financial situation and he needs to be able to continue to work in a constructive relationship with his colleague executives to influence the organisation to deliver value for money from its services. The Director of Primary, community and mental health services has been moved into the post of Strategy director in order to complete the first cut of the 3 year plan and the post of the Corporate director/Board secretary seems to have been split. The HR and workforce Director needs to refocus his attention to the consequences of the 3 year plan and the work of the area teams to ensure that the plan and subsequent training and development and relevant HR policies are available to ensure staff remain fit for purpose for the future model.
Currently the Executives and Directors meet collectively weekly as the Corporate Directors Group with an informal session weekly to discuss the politics and other all Wales issues that they need to be aware of. The purpose of this group appears confused in terms of whether or not it is a decision making body. This needs clarifying urgently otherwise the confusion will be perpetuated and will militate against corporate responsibility and will undermine the effective governance of the organisation. And if they do not make decisions who does and how do items for decision get channelled to the Board? The executives wish for more responsibility for decision making to be delegated to them by the Board; the Board will need to assure itself that any increased delegation levels are appropriate. In order to have any chance of succeeding this team needs to be strong, challenging, focussed, contain the right skills to ensure success, be united and well led. It does not yet give the impression that it is a team with some members appearing to opt out of collective responsibility. The executives must at all times be seen to be adding value to the organisation. Of concern is the fact that the team appears to have resorted over the past year to —buying its way out of trouble“ and bringing in consultancies to fill
/hbCL59bÇL![ Lb /haaLÇÇ99 22 gaps in the skills set of the team. With a full team in place it should be unnecessary to continue in this way.
The Chair and the CEO.
Chair. The chair has been in post for 16 months. He recognises the very difficult issues that face the Board over the next 2 years. Hepromoted to the Board development session in January 2015 a very long list of issues that would have to be addressed. See appendix C. He understands very clearly that the Board needs to demonstrate visible and engaged leadership, to increase the pace of change and set a challenging yet achievable agenda.He recognises that the Board needs to be well led, to be decisive and candid, honest and open, to be cohesive and resilient, to scrutinise and support, to be authoritative and decisive and to enhance the reputation of the organisation and its services. He wants to see very clear and active leadership and for the Board to have a compelling vision for the future of care in North Wales underpinned by a map for achievement and action. He appreciates well that the politics have to be handled and he has spent considerable time in talking to and working with key stakeholders to gain a common understanding of the agenda. He wants grip, pace, visibility, honesty and bravery within the organisation. He is very concerned about the lack of creativity within the organisation and considers that the organisation has a rigid, overly bureaucratic and bullying culture. He appreciates and is frustrated by the fact that the three year plan contains no clear vision for the future and that there is no accompanying OD and workforce plan. He believes that the organisation has not actioned the decisions of the Board adequately enough. He has changed the governance arrangements with the view to ensuring that the subcommittees are able to scrutinisemore effectively œ and for this they will need good information and evidence. He considers that the executives find him dogged and challenging. Indeed, from observation, he has to play a major role in challenging at the Board meetings rather than being able at all times to steer the Board to oversee the setting of strategy and direction.
CEO: The CEO joined the organisation from Hywel Dda UHB in June 2014. He presented his analysis of the problems within the organisationto the Board in September 2014 œ see appendix D. He set about changing the management structure to getting a better grip on delivery. Although the operational structure is not yet complete and needs clarity in relation to delegation and accountability, the operational structure should improve the control within the
/hbCL59bÇL![ Lb /haaLÇÇ99 23 services. He now needs to be as clear about the corporate services directorate structure œ and he certainly must strengthen strategic planning within the organisation and its associated clinical and workforce planning. Of concern is that an immediate grip was not exercised on the problems within the organisation (and the lack of accountability) which were clear in the reports to the Board and might have militated the position in which the organisation finds itself at year end.
The solution to the improvement in the reputation and clinical service quality and sustainability does not rest solely on the management structure œ which is an important enabler œ but on changing the culture of the organisation to one of delivery to its population. The CEO and Chair must be constantlyavailable and accountable within the organisation and with stakeholders, enunciating and leading change for the future. This needs a leadership that is visible, resilient and makes it clear to staff and the communities that services have to change, resources have to be managed well, performance has to improve and what will need to be done to achieve this. In terms of visibility within the organisation,( rather than with key stakeholders) the CEO seems to be required to be absent in Cardiff and other places exercising his representational responsibilities on a frequent basis. His visibility within the organisation needs to improve; this has started to happen through—100 top leaders“ meetings but needs to increase significantly. It is important that an agreement is reached with the Chair about the priorities that he should pursue to ensure that he is unencumbered and is able to devote all his time and energy to directly delivering results for the organisation.
Action required.
• The GGI review of the governance of the organisation need to be refreshed to ensure that the necessary action has been taken œ which should include a reformed BAF and a sound programme of Board business.
• The Board as part of its risk management and assurance processes ensure that it understands explicitly the consequences of inaction/and or delays on its financial, workforce and service quality/service sustainability, its workforce plan and financial plan.
• An opportunity should be taken to refresh the skills of the IMs on the Board at the next round of appointment and a good induction should be available to them to prepare them for their role.
/hbCL59bÇL![ Lb /haaLÇÇ99 24
• The corporate management structure for the Board needs to be completed and costed and the wiring diagram be completed so that accountabilities and delegations can be clear. The Board will need to assure itself that it is confident that the management structure can be effective and that accountabilities are clear and that it will start to change the culture and focus of the organisation. The CEO needs to assure the Board that he has prioritised strengthening the capacity and capability of the executive to deliver and to ensure that the Health Board is fit to deliver.
• An executive management team should be established without delay with a clear framework of delegation.
• The Board needs to determine the criteria against which the effectiveness of the new structure will be held to account; it must also assure itself that the cost of the structure represents good value for money.
• The Chair, CEO and Board need to move with pace to ensure that the Board is able to rely on executive assurances and the operation of the control systems; allowing the Board to focus on the identification, management and mitigation of strategic risk.
• Communications within the organisation and with stakeholders must improve; communities must be engaged effectively in the development and delivery of services. The Board needs to evidence clear and well- argued cases for change that enables the essential decisions on change to be made. The communications plan will need to promote a wider understanding of the interconnected drivers of service risk and the reasons for change including, service quality, workforce productivity and retention, financial impacts.
• As a matter of urgency the Board needs to revise and refresh its 3 year plan and develop it strategy for the future against which to measure development within the organisation.
!ÆÆ ,¨Øπ§ #"% March 2015.
/hbCL59bÇL![ Lb /haaLÇÇ99 25 Appendix A
BCUHB œ financial background and context. 2014 œ 15.
In the absence of an agreed three year strategic plan, the Health Board set an annual financial plan based on incremental budgeting in 2014 œ 15.
Key component of this approach were:
• An assessment of activity and demand based on the HB capacity planning tool. • Clinical programme groups and departments budgets that recognised cost pressures in key areas e.g. safe staffing, but assumed that all additional postswould be recruited to. Premium costs of locums and agency staff were not budgeted for • a workforce plan that did not alert the HB to intelligence about potential difficulties in recruiting to fragile specialties. The financial trajectory of recruitment challenge was not recognised. • Cost improvement programmes to be developed and owned by clinical programme groups.
The Board received assurance that the budget was —tough but achievable“ subject to underpinning cost improvement assumptions including £33m disinvestment.
In summer it became apparent that the finance, workforce and capacity assumptions that underpinned the 2014 œ 15 budget were fundamentally flawed:
1. Inability to recruit and retain staff led to high levels of unbudgeted premium costs being incurred 2. CPGs were unable to meet their cost improvement targets and live within their means 3. The Board did not pursue plans to disinvest. 4. Specialist services activity was above plan, leading to unbudgeted pressures on the HB plan 5. Capacity plans had to be revised upwards to achieve RTT. To support the achievement of tier 1 targets the Board invested additional money in RTT targets and maintained local services, despite their recognised clinical fragility, by extensive utilisation of locum medical staff. This increased 6. The HBs overspend and exposed services to greater clinical risk as well as further prejudicing the achievement of statutory financial duties.
26 27 28
Appendix C
Betsi Cadwaladr University Health Board
In discharging our roles and functions as Board members, we individually and collectively commit to assure ourselves and the population of North Wales that we:-
1. Keep the people of North Wales and their health and wellbeing at the heart of our agenda. 2. Provide a strong vision and clear strategic narrativ e. 3. Provide and foster a culture of quality improvement and safe, compassionate and confidential person centred care 4. Improve health outcomes, prioritising populations where health is particularly poor. 5. Emphasise the importance of prevention and early intervention in maintaining health, wellbeing and independence. 6. Listen to and learn from the experiences of our patients, their carers and our staff 7. To provide timely access to care throughout the patient journey 8. Act to safeguard the interests, health and wellbeing of the most vulnerable in our society. 9. Use all of our resources effectively to achieve our objectives. 10.Develop our staff to excel by fostering an approach of life-long learning across the Health Board 11.Collaborate and work effectively in partnership with other organisations, individuals and communities 12.Exercise our corporate social responsibilities with due diligence 13.Translate excellence in research and teaching into improvements in population health through innovative and distinctive partnership with academia. 14.Communicate openly and effectively with staff, partner organisations and the public.
29 Appendix D
List of priorities for BCUHB for 2015/16 devised by the Chair, March 2015
1. Financial management 2. Performance œ variability and efficiency 3. Quality, safety and standards 4. 3 year plan œ communication plan and briefing œ by end of March To deliver safe sustainable services that are affordable, to balance, to shift the services to primary care and the community, to tackle health inequalities and improve health 5. Better relationships with other NHS providers and find out where the best value might be for new alliances 6. Dealing with the independent sector and chc 7. Commissioning effectively 8. Joint working with local authorities, police fire and rescue 9. Relationships with the 3 rd sector œ housing œ adding complementary value 10. University links to be developed 11. Engaging effectively with the public and patients 12. —I want great care“ roll out œ patient feedback and the active management of concerns 13. No more endless action plans œ but action instead 14. Demonstrate that this is a learning organisation 15. Demand on unscheduled care œ links with ooh and wast 16. Overhaul the mental health services œ need a psychosocial model 17. Protect the most vulnerable of the patients 18. Workforce issues and better support for staff œ manage agency and locums 19. Ensure that concerns can be raised 20. Dealing with the legacy e.g. Tawel Fan 21. Develop the IT capacity 22. Manage the estates issues 23. Challenge the new management and governance systems.
What the Board needs to do is:-
• Demonstrate visible and engaged leadership • Increase the pace of change œ set a challenging agenda • Be decisive and determined • Be candid open and honest œ and handle the politics • Be cohesive and resilient • Scrutinise and support • Be authoritative and decisive as a message to the staff and public.
The Board must be active in its leadership. It must develop a compelling vision, underpinned by detail and action.
30 Appendix E
Points for Anne …. 5 months in!! (from the CEO)
• Change to organisational structure consulted • Mental health CPG disestablished • Interim DoMHS appointed • Board of directors disestablished • CDG implemented • New appointments œ DOF/COO/DCS/DOS and office manager • Adverts next week for 3 AD and DOSC • RDL appointed for team development • GGI appointed to redesign the wiring diagram of governance and assurance • Directorate portfolios realigned • Directors scheme of delegation underway • New PMO established œ weekly performance management meetings with CPGs • Clarity given on key performance targets • Clarity on vision and strategy provided • Deloittes appointed to help the IMTP • True £ position highlighted to the DG in August 14 • Wider profile with LA/AMs/MPs and staff/partners • Greater focus on partnership working • New offices identified for team integration œ not a hospital • 100 feedback given to the Board • Future hospitals project won • I want great care rolled out • Simpler/MBI/ Capita appointed • Leadership forum established (top 100)
The Past
• No real leadership or clarity in direction • No vision of how to get there • Confusion over medical leadership with management • Competing cultures • Failed CPG model • Disempowered executive • No single medical consultant body for point of contact • Weak management structure • Little and variable capacity • Asset stripped of £6-7m
31 • No grip • Confused roles and responsibilities • Unsupported executive with little power • Isolationist mentality • Poor partnership relationships • Damaged confidence • Risk averse in taking real issues to decision • Poor communications and media management
Now
• Can see a step change in Q & S • Increasing both pace and confidence • Increasing focus on population growth • Rolling out locality management with dragonised PBC • Willing to embrace working differently • Appetite for change • Increasingly cohesive board • In the J curve
32
39.17
39.16
Emergency Planning arrangements in Public Health Wales Author: Dr Gwen Lowe, Consultant in Communicable Disease Control Date: 12 June 2015 Version: V1 Sponsoring Executive Director: Dr Quentin Sandifer Who will present: Dr Quentin Sandifer (If appropriate) Date of Board / Committee meeting: 25 June 2015 Committee/Groups that have received or considered this paper: Executive Team Purpose and Summary of Document: The purpose of this paper is to provide the Public Health Wales Executive Team and Board with a report on the organisational plans and processes for dealing with major incidents and emergencies. The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper. Discuss and scrutinise the paper and provide feedback and comments. Receive the paper for information only. x
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant)
x
Priorities for action include relevant priority for action(s)
Date: 12 June 2015 Version: v1 Page: 1 of 9 Public Health Wales Emergency Planning arrangements
1 Introduction
Public Health Wales is defined as a Category One Responder under the Civil Contingencies Act 2004. This places certain statutory duties on the organisation with regard to assessing the risk of emergencies occurring, warning and informing the public and having plans in place to deal with emergencies. There is also a requirement for multiagency collaboration.
This paper provides assurance to the Board that Public Health Wales has plans and arrangements in place to discharge these duties and appends the current emergency response plan for information (see Appendix 1).
2 Background
Planning for emergencies in Wales occurs as a co-ordinated multiagency collaboration. This involves other Category One Responder organisations such as the blue light services, health boards, Natural Resources Wales and local authorities. The Wales Resilience Forum heads this collaboration, but the main responsibility for developing collaborative emergency plans and arrangements lies with the four Local Resilience Forums. These are chaired by the police and co-terminus with police force boundaries. In addition there is a Welsh Government Health Emergency Planning Advisory Group and other ad hoc groups.
Public Health Wales is represented on all these external groups, with the Executive Director of Public Health Services representing the organisation at the Wales Resilience Forum and Consultant in Communicable Disease Control (CCDC) representation at the four Local Resilience Forums, their work subgroups and other ad hoc groups.
In an emergency the Local Resilience Forums convert into Strategic Co- ordinating Groups (SCG), the Gold command group overseeing the response. Within the Public Health Wales Emergency Response Plan there are well established protocols for how we fit into the SCG and all the response groups established underneath it. These have been activated previously in real incidents.
The planning for Local Resilience Forums and the plans developed are driven by the Cabinet Office National Risk Register of Civil Emergencies and the Local Resilience Forums’ own risk registers. These resemble the national risk register but also include major local risks. The major risks identified on the National Risk Register 2015 are pandemic flu, catastrophic terrorist attack, widespread electricity failure and coastal flooding. Newly identified risks on the risk register of relevance to Public Health Wales include poor quality air events and antimicrobial resistance. Date: 12 June 2015 Version: v1 Page: 2 of 9 Public Health Wales Emergency Planning arrangements
Internally, Public Health Wales has an executive lead for emergency planning (Director of Public Health Services) and well established structures to co-ordinate and deliver on the emergency planning process. The work is resourced by the notational two sessions of a CCDC and a full time Emergency Response Support Officer.
There are quarterly emergency planning meetings attended by everyone across the organisation representing Public Health Wales at external meetings. These meetings drive the emergency planning work agenda and ensure that plans and processes and training are all in place. However, there are some gaps recently identified in the arrangements that are now being addressed. 3 Assessment
In general our internal established plans and arrangements work well and were tested and strengthened in preparation for NATO and potential Ebola cases. Formal debriefs of these events have not identified any changes needed to the existing Public Health Wales emergency response plan or arrangements. A copy of the self-reported annual return to Welsh Government and the summary response from Welsh Government is attached as Appendix 2.
In addition we run yearly exercises and communication cascade tests to test our resilience arrangements and plans. Any deficiencies noted in these lead to amendments to the emergency response plan.
This plan has a generic core structure with specific appendices as bolt on separate plans. The arrangements already in place would allow us to mount a response to most of the highest identified risks in the National Risk Register (pandemic flu, catastrophic terrorist attack, and coastal flooding) in collaboration with our multiagency partners. However the sheer scale of such incidents may leave any organisation overwhelmed despite surge capacity arrangements.
Widespread electricity failure would pose immense challenges to Public Health Wales in terms of business continuity and also ability to respond to incidents. The health protection service functions as an all Wales service so would still be able to deliver an emergency response if only a part of Wales was affected, but if most of Wales suffered a failure we would not be able to deliver a service.
Whilst the plan has been well-tested, on-going scrutiny of our overall emergency planning processes has identified gaps. At the start of the process to audit our organisation against the Cabinet Office Expectation Set for emergency planning, we identified that although we discharge most of our requirements under the Civil Contingencies Act through our Local Resilience Forum arrangements, there is also a need for us to
Date: 12 June 2015 Version: v1 Page: 3 of 9 Public Health Wales Emergency Planning arrangements develop our own risk register to formally identify the risks linked to the functions of Public Health Wales or that would prevent the organisation discharging its public health responsibilities.
Although there would be significant overlap with the corporate risk register, this is about the risks to our population and the plans we have to mitigate against these.
In practice most of these risks are on the national and local multiagency risk registers and we already have plans in place against these risks already. Nevertheless, we need to demonstrate as an organisation that we have formally considered these risks. This work is now underway and once completed we can continue with the Expectation Set audit.
Another gap identified is that although we participate in formal evaluation and review of outbreaks and incidents, there is no structured organisational process to take the recommendations from these reviews and ensure that the ones relevant to our organisation are implemented. In addition the lessons learned from exercises are not always fed back into the emergency planning process to allow action to be taken. Again work is underway this year to address these issues and develop such a process under the remit of the quarterly emergency planning group.
The other major gap identified is around training for the surge capacity from the wider organisation. Plans are in place to address this. As a first step, non health protection staff involved in incidents in the last two years will be identified and asked about their training needs so that we can develop a package to address their requirements to enable them to provide effect rapid support if required. Our on-going challenge for training is to develop surge capacity that can be used in major incidents or for a very prolonged incident such as pandemic flu.
In addition, the number of specialist advisors who could respond to specific incidents such as chemical attacks is very small. Keeping a large pool of public health consultants trained and participating on the on-call rota is a major step in maintaining specialist surge capacity if health protection staff are overwhelmed. 4 Financial Implications
There are no additional financial implications with regard to this paper. 5 Conclusion
Public Health Wales’ organisational plans and processes for dealing with major incidents and emergencies are generally robust and would provide some mitigation against most of the major risks identified in the National Risk Register. However, catastrophic scale events or widespread electrical failure may prevent delivery of an emergency response. In addition
Date: 12 June 2015 Version: v1 Page: 4 of 9 Public Health Wales Emergency Planning arrangements improvements to planning processes and procedures have already been identified as needed and are included as actions in the organisation’s 2015-16 operational plan. 6 Recommendation
The Executive Group and Board are asked to note the above and the attached emergency response plan and Welsh Government Emergency Planning report for information.
Date: 12 June 2015 Version: v1 Page: 5 of 9 Public Health Wales Emergency Planning arrangements
Appendix 1 The Public Health Wales Emergency Response Plan
27th February 2014 Emergency Response Plan Version 2c Final.pdf
This document provides the overarching operational plan for the Public Health Wales response to incidents and outbreaks where escalation is required to mobilise additional capacities beyond the norm.
Pages 1-39 covers: Purpose Relationship to other guidance Types of incidents, outbreaks and emergencies to which Public Health Wales may respond Response levels and response required Criteria for assessment of impact on Public Health Wales resources and for convening a Public Health Wales Senior Response Team Public Health Wales Senior Response Team – Membership and Tasks, When and How convened, Command structure Leadership and direction – description of key roles Response at different incident levels and Lead Responsibilities The Public Health Wales National Co-ordination and Advisory Centre (NCAC) Public Health Wales’ representation at external emergency response groups The relationships between emergency response groups during a major incident in Wales Specific Responsibilities at different response levels
Pages 40-111 include 52 action cards for specific roles or specific tasks.
The Emergency Response Plan is supported by a separate, confidential, Telephone Directory with contact details for all staff who might need to be reached, both Public Health Wales and external agencies.
Date: 12 June 2015 Version: v1 Page: 6 of 9 Public Health Wales Emergency Planning arrangements
Appendix 2 Health Emergency Planning Annual Report 2014
Welsh Government – Summary of responses from all NHS organisations
• All organisations have named Executive level leads for civil contingency/emergency planning arrangements; Executive level leads for business continuity, Emergency Planning Officers and officers responsible for contributing to the Prevent aspects of the Counter Terrorism Strategy. • All organisations have identified posts and services critical to the delivery of emergency plans and all were able to confirm they have suitably trained and dedicated staff and resources to manage their organisations response to a major incident or emergency. • 9 out of 10 organisations indicated that their business continuity planning addressed the resilience of all posts and services critical to delivery and said they were satisfied with their emergency preparedness and business continuity arrangements. • All organisations indicated that their emergency plans were updated during the last 12 months. • 9 out of 10 organisations implemented their emergency plans in response to an emergency situation during 2014. • There has been an improvement on 2013 Annual Report with 9 out of 10 organisations now indicating they have identified all posts and services critical to the delivery of emergency plans. • All 10 organisations were able to provide dates when they met the requirement for carrying out a live or simulated test of their major incident plans. • All 10 organisations were satisfied with their level of emergency preparedness and 9 out of 10 Chief Executives were able to sign off that their organisation met its requirements under the Civil Contingencies Act 2004.
Y% N% 1 Please provide the name and position of your nominated Executive level lead for the organisation’s civil contingency/emergency 100% 0% planning arrangements.
Please provide the name and position of your nominated Executive 2 100% 0% level business continuity lead if different from the above.
Date: 12 June 2015 Version: v1 Page: 7 of 9 Public Health Wales Emergency Planning arrangements
3 Please provide the name and position of your emergency planning officer(s) who has day to day responsibilities for civil 100% 0% contingencies/emergency planning/business continuity arrangements.
Do you have an officer responsible for your organisation’s 4 100% 0% contribution to the Counter Terrorism (Prevent) Strategy?
Have you identified all posts and services critical to delivery of your 5 90% 10% emergency plans?
Does your business continuity planning address the resilience of all 6 90% 10% posts and services critical to delivery of your key functions?
7 Have you suitably trained and dedicated staff, resources and facilities available at all times to effectively manage your 100% 0% organisations response to a major incident/emergency?
When was your organisations risk assessment of hazards, threats 8 100% 0% and vulnerabilities last updated?
When were your emergency plans for a major incident/emergency 9 100% 0% last considered and formally adopted by your Executive Board?
10 When were your emergency plans last updated to reflect 100% 0% organisational and contact changes?
11 Please provide the dates when your organisation has met the 100% 0% requirement for testing its plans through:
a. Carrying out a communications/activation test every six 90% 10% months b. Carrying out a table top exercise within the last year 90% 10%
c. Carrying out a major live or simulated exercise within the last 100% 0% three years Have you implemented any of your emergency plans in response to 12 90% 10% an incident in 2014?
Have you undertaken an assessment of staff training needs in 13 90% 10% relation to your emergency plans?
Do you have a training programme relating to your emergency 14 100% 0% plans?
Have all relevant NHS organisations and partner agencies been 15 100% 0% consulted about their role in your emergency plans?
Date: 12 June 2015 Version: v1 Page: 8 of 9 Public Health Wales Emergency Planning arrangements
16 Is there a mechanism for discussing and co-ordinating health emergency planning arrangements internally within your 100% 0% organisation?
17 Is there a mechanism for discussing and co-ordinating health emergency planning with the emergency plans of other 100% 0% organisations serving the Local Resilience Forum area?
Who represents your organisation at meetings of the Local 18 100% 0% Resilience Forum?
19 Are you satisfied with your organisation’s emergency preparedness 100% 0% and business continuity arrangements? Are you satisfied that your organisation is fulfilling its requirements 20 90% 10% under the Civil Contingencies Act 2004?
2014 Nominated Executive Level Lead for Civil Contingency / Emergency Planning
Public Health Wales – Quentin Sandifer
2014 Nominated Executive Level Officer Responsible for the Counter Terrorism (Prevent) Strategy
Public Health Wales – Rhiannon Beaumont-Wood
2014 Nominated Executive Level Officer Responsible for Business Continuity
Public Health Wales – Huw George
Public Health Wales return for 2014
2015-01-12 - Health Emergency Planning Annual Report 2014 Signed off 060215.pdf
Date: 12 June 2015 Version: v1 Page: 9 of 9
39.17
Audit Committee annual report Author: Terence Rose, Chair, Audit Committee and Eleanor Higgins, Corporate Governance Manager Date: 9 June 2015 Version: 1 Sponsoring Executive Director: Keith Cox, Board Secretary Who will present: Terence Rose, Chair, Audit Committee Date of Board / Committee meeting: 25 June 2015 Committee/Groups that have received or considered this paper: N/A
The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper. Discuss and scrutinise the paper and provide feedback and comments. Receive the paper for information only. X
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) X
Date: 9 June 2015 Version: 1 Page: 1 of 15 Public Health Wales Audit Committee Annual Report
1 Introduction
The main purpose of the Audit Committee annual report is to provide assurance to the Board that the system of assurance is fit for purpose and operating effectively.
2 Background
This Report summarises the key areas of business activity undertaken by the Audit Committee over the past year and highlights some of the key issues which the Committee intend to give further consideration to over the next 12 months.
The Committee approved the report at its meeting on 4 June 2015. . 3 Timing
The Audit Committee annual report forms part of the year-end annual reporting process. 4 Financial Implications
None. 5 Recommendation(s)
The Board is asked to receive the annual report from the audit Committee.
Date: 9 June 2015 Version: 1 Page: 2 of 15 Public Health Wales Audit Committee Annual Report
Audit Committee Annual report 2014/15 Author: Terence Rose, Chair, Audit Committee and Eleanor Higgins, Corporate Governance Manager Date: 9 June 2015 Version: 1 Purpose and Summary of Document:
This Report summarises the key areas of business activity undertaken by the Audit Committee over the past year and highlights some of the key issues which the Committee intend to give further consideration to over the next 12 months.
Date: 9 June 2015 Version: 1 Page: 3 of 15 Public Health Wales Audit Committee Annual Report
Contents Foreword ...... 5 1 Introduction ...... 6 2 Role and Responsibilities ...... 6 3 Committee structure...... 7 3.1 Membership of Committee ...... 7 3.2 Others in attendance...... 7 3.3 Meeting frequency ...... 8 4 Assurance ...... 8 4.1 Risk assurance ...... 9 4.2 Implementation of Electronic Staff Record (ESR) ...... 9 5 Audit Committee Activity 2014/15 ...... 9 5.1 External audit ...... 9 5.2 Internal audit ...... 10 5.3 Financial reporting ...... 13 5.4 Counter-fraud ...... 13 5.5 Other Committee work ...... 13 6 Relationship with other Committees...... 14 7 Actions for next year 2015/16...... 14 8 Conclusions and Way forward ...... 15
Date: 9 June 2015 Version: 1 Page: 4 of 15 Public Health Wales Audit Committee Annual Report
Foreword
I am pleased to present on behalf of the Committee the fifth annual Public Health Wales Audit Committee report.
The report summarises the key areas of business activity undertaken by the Audit Committee over the past year.
Throughout the year the Committee has continued to provide assurance to the Board on the governance and systems of assurance of Public Health Wales, with a prime focus, but not entirely, on the financial systems.
The Committee has an important role in taking timely action when there are indications that all is not well or we believe improvements can be made in our governance and management arrangements. For example this year, action has been taken to review our risk management policies, to improve clarity of responsibilities and presentation of our risk register, and to take a special look at the implementation of Electronic Staff Records because of its criticality to the management of some of our most important risks.
Finally I would like to thank all the members of Committee and all those who have supported and contributed to its work from within Public Health Wales, from internal audit, the Wales Audit Office and counter-fraud. In particular I would like to thank the whole Finance team of Public Health Wales for their professionalism and commitment in meeting important targets and deadlines.
Terence Rose Audit Committee Chair June 2015
Date: 9 June 2015 Version: 1 Page: 5 of 15 Public Health Wales Audit Committee Annual Report
1 Introduction
This Report summarises the key areas of business activity undertaken by the Audit Committee over the past year and highlights some of the key issues which the Committee intend to give further consideration to over the next 12 months.
The Audit Committee’s annual ‘business cycle’ ends on 30 June following the closure and audit of the Trust’s annual accounts and reflects the Committee’s key role in the development and monitoring of the Trust’s Governance and Assurance framework, the production of the Trust’s Annual Governance Statement and the relevant Financial Statements.
2 Role and Responsibilities
The primary purpose of the Audit Committee is to provide advice and assurance to the Trust Board on whether effective arrangements are in place - through the design and operation of the Trust’s assurance framework - to support the Board in its decision taking and in discharging its accountability for achieving the Trust’s objectives, in accordance with standards of good governance determined for NHS Wales.
Where appropriate, the Committee will advise the Board and the Accountable Officer on where, and how, its assurance framework may be strengthened and developed further.
The core functions of the Audit Committee are as follows;
• Consider the effectiveness of risk management arrangements, the control environment, and the related anti-fraud and anti- corruption arrangements;
• Seek assurances that action is being taken on risk related issues identified by auditors, by regulatory bodies and by the Trust itself;
• Be satisfied that the assurance statements properly reflect the risk environment and any action required to improve it;
• Approve the Internal Audit strategy, plan and monitor performance; review Internal Audit reports and the main issues arising; seek assurance that action has been taken where necessary; receive and consider the Annual Report from Internal Audit;
Date: 9 June 2015 Version: 1 Page: 6 of 15 Public Health Wales Audit Committee Annual Report
• Review the reports of External Audit and other Regularity Bodies and the main issues arising; seek assurance that action has been taken where necessary; receive and consider the Annual External Audit Report;
• Approve the Local Counter-fraud Services (LCS) strategy, plan and monitor performance; review LCS reports and the main issues arising; seek assurance that action has been taken where necessary; receive and consider the Annual Report from LCS;
• Review the financial statements and, acting under delegated powers, approve the adoption of the accounts;
• Consider the results of audit and assurance work specific to the Trust and the implications of the findings of wider audit and assurance activity relevant to the Trust’s operations to secure the ongoing development and improvement of the Organisation’s governance arrangements; and
• Ensure an effective relationship with the Quality and Safety Committee and any other Committees or sub-Committees of the Board so that it can understand the system of assurance for the Board as a whole.
3 Committee structure
A key element of the Committee is that the membership comprises Non Executive Directors only, this provides a basis for it to operate independently of any decision making process and to apply an objective approach to the conduct of its business. Executive Directors and other members of staff are invited to attend meetings to provide assurances and explanations to the Committee on specific issues.
3.1 Membership of Committee
The membership of the Committee during 2014/15 included:
Mr Terence Rose Chair and independent Non Executive Director Mr John Spence independent Non Executive Director Dr Carl Clowes third sector Non Executive Director
3.2 Others in attendance During 2014/15 the meetings were also regularly attended by the following:
Date: 9 June 2015 Version: 1 Page: 7 of 15 Public Health Wales Audit Committee Annual Report
Dr Tracey Cooper Chief Executive and Accountable Officer (from 1 June 2014) Mr Huw George Interim Chief Executive (until 31 May 2014) Executive Director of Finance (from 1 June 2014) Ms Tamira Rolls Interim Director of Finance (until 31 May 2014) Assistant Director of Finance (from 1 June 2014) Mr Keith Cox Board Secretary Mr James Johns Internal audit, NHS Wales Shared Services Partnership Ms Jayne Gibbon Internal audit, NHS Wales Shared Services Partnership Mr Matthew Coe Wales Audit Office Mr Jeremy Saunders Wales Audit Office Ms Gabby Smith Wales Audit Office Mr Craig Greenstock Local Counter Fraud Service, Cardiff and Vale University Health Board
3.3 Meeting frequency
The terms of reference for the Committee require meetings to be held no less than quarterly and otherwise as the Chair of the Committee deems necessary – consistent with the Trust’s annual plan of Board Business. During 2014/15 the Committee met five times and was quorate on four occasions. Where the meeting was inquorate the Committee Chair ensured that escalation arrangements were in place to ensure that any matters of significant concern that could not be brought to the attention of the Committee could be raised with the Trust Chair.
4 Assurance
The work of the Audit Committee, through scrutiny of external audit, internal audit, counter-fraud and other pieces of work, enable the Committee to provide reliable assurances to the Board and the Accountable Officer. The Committee has reviewed the system of assurance and concluded that it is fit for purpose. There are no areas of significant duplication or omissions in the systems of governance in the organisation that have come to the attention of the Committee or which have not been adequately resolved.
The Committee has, on occasion, requested further information on particular items to allow further scrutiny of the issues and to enable them to provide robust assurance to the Board and Accountable Officer. Examples of this include:
Date: 9 June 2015 Version: 1 Page: 8 of 15 Public Health Wales Audit Committee Annual Report
4.1 Risk assurance
The Committee receives the risk register at each meeting and seeks assurance on the actions being taken to mitigate against the risk. During the year the Committee requested that the process surrounding the risk management system be strengthened. This also involved a review of the presentation of the risk register with a request to simplify the information displayed on the register. The Committee received an in depth review of each risk from the responsible Executive Director. This gave the Committee the opportunity to explore the risks and any actions being taken to mitigate the risks in greater detail.
4.2 Implementation of Electronic Staff Record (ESR)
The Committee has been monitoring a number of actions from historic internal audit reports which will be complete once the implementation of the Electronic Staff Record has been completed. The Committee was concerned that some of these actions were outstanding from 2012 and requested further information on the issues the organisation was experiencing with the implementation of ESR, and the benefits the system will offer once implementation is completed. The Committee received assurance that progress was being made against the outstanding actions and that some actions had now been superseded by other pieces of work.
5 Audit Committee Activity 2014/15
The Audit Committee fulfilled its work plan for 2014/15 covering a wide range of activity. This work can be summarised under the following headings:
• External audit; • Internal audit; • Financial reporting; • Counter-fraud; and • Other Committee work.
5.1 External audit
External audit services are provided to Public Health Wales by the Wales Audit Office. The Committee received and agreed the Wales Audit Office annual plan for 2014/15 which set out specific areas to be covered in relation to both the audit of financial systems and performance audit assignments. The plan of work was developed in consultation with Executive Directors to ensure it was aligned to the organisational priorities and financial and operational risks facing the
Date: 9 June 2015 Version: 1 Page: 9 of 15 Public Health Wales Audit Committee Annual Report organisation. The Committee received progress reports from the Wales Audit Office at each meeting in relation to this work. These reports also give details of reviews undertaken at a national level.
The Wales Audit Office final accounts memorandum was received by the Committee in June 2015 and summarised the findings from the work carried out during 2014/15 as follows:
It is the Auditor General’s intention to issue an unqualified audit report on the financial statements
The Wales Audit Office performance audit work forms the structured assessment for the organisation. The report for 2014 concluded that:
• Sound financial management continues to ensure the Trust breaks even and to meeting savings targets • The Trust has improved its focus on its strategic and operational priorities, and related risks, and its governance arrangements, though some aspects are improving too slowly • Arrangements for seeking and responding to service user feedback are improving
Some recommendations were made relating to identifying and recording divisional risks; service user experience; and information governance. The Committee was able to provide assurance to the Board that the recommendations would be monitored closely by the Committee throughout the year. In addition the Quality and Safety Committee would monitor the service user experience recommendations and the Information Governance Committee would to monitor the Information Governance recommendations.
The actions agreed by Public Health Wales in response to the recommendations in Wales Audit Office reports are recorded in an action log and the Committee continues to monitor progress in addressing them.
5.2 Internal audit
Internal audit services are provided to Public Health Wales by NHS Wales Shared Services Partnership. The Audit Committee approved the Internal Audit Plan for 2014/15 at the start of the year, ensuring that the plan was robust and specifically targeted to risks identified within the organisation. The Committee also approved the revised internal audit strategy.
The work completed by internal audit provides assurance that risks are managed and controls and governance arrangements are in place. The
Date: 9 June 2015 Version: 1 Page: 10 of 15 Public Health Wales Audit Committee Annual Report internal audit plan was developed in consultation with the Executive Directors and reflected the key risks and strategic objectives identified by the Board.
During the year the Committee received nine assurance reviews. The following levels of assurance were awarded:
Substantial assurance 1. Sustainability reporting The Board can take substantial assurance that arrangements to 2. Annual Quality secure governance, risk Statement management and internal control, within those areas under review, 3. Main financial systems are suitably designed and applied effectively. Few 4. Asbestos management matters require attention and are compliance or advisory in nature with low impact on residual (follow up) risk exposure. 5. Claims management 6. Incident management 7. Standards for health services
Reasonable assurance 8. Performance reporting The Board can take reasonable assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Some matters require management attention in control design or compliance with low to moderate impact on residual risk exposure until resolved.
Limited assurance 9. Risk management The Board can take limited assurance that arrangements to 10. Appointment and secure governance, risk management and internal control, management of within those areas under review, temporary staff are suitably designed and applied effectively. More significant matters require management attention with moderate impact on residual risk exposure until resolved.
Where limited assurance was provided the Committee took the following action:
Date: 9 June 2015 Version: 1 Page: 11 of 15 Public Health Wales Audit Committee Annual Report
Risk Management: • Review of risk management arrangements with responsibility for risk management moving from Board Secretary to Executive Director of Quality, Nursing and Allied Health Professionals • Risk register has been redesigned into a clearer format • Board has received risk management training and a training programme for staff is being prepared for rollout across the organisation • The risk management policy has been reviewed and updated
Appointment and management of temporary staff: • Recruitment to a Selection specialist role has been approved • Attraction and selection policy will be developed • A procedure will be developed for obtaining agency staff • All Directors have been asked to sign off any temporary staff appointments for a duration of more than three months
The Head of Internal Audit has concluded:
“In my opinion the Board can take reasonable assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Some matters require management attention in control design or compliance with low to moderate impact on residual risk exposure until resolved.”
In reaching this opinion the Head of Internal Audit has identified that the majority of reviews during the year concluded positively, with the only exceptions being risk management and the appointment and management of temporary staff. The Audit Committee has responded to the exceptions noted by the Head of Internal Audit and has ensured that action has been taken at Board level to improve the situation and work continues to monitor the improvements.
The Committee is also scheduled to receive reports during the course of the year on the audits of financial systems operated by NHS Wales Shared Services partnership, processing transactions on behalf of Public Health Wales. There were no reports of this nature presented to the Committee during 2014/15.
Any areas identified for improvement by the reviews above are recorded on the internal audit action log which is received by the Committee at each meeting. It is closely monitored and each action is allocated to an Executive lead and allocated an overseeing Committee.
Date: 9 June 2015 Version: 1 Page: 12 of 15 Public Health Wales Audit Committee Annual Report
5.3 Financial reporting
The Audit Committee considered the annual accounts for 2014/15 in May 2015, including the organisation’s Annual Governance Statement. The Committee subsequently approved the annual accounts and Annual Governance Statement in June 2015, on behalf of the Board. In doing so, the Committee confirmed that the Annual Government Statement was consistent with the Committee’s view on Public Health Wales’ system of internal control. The Committee did not identify any reasonable limitations to draw to the attention of the Board.
5.4 Counter-fraud
The Committee approved the 2014/15 annual work plan of the Local Counter Fraud Specialist, provided to Public Health Wales by Cardiff and Vale Counter Fraud Services. Regular reports were received by the Committee to monitor progress against the plan. The reports advised the Committee about ongoing and concluded fraud investigations, policy and procedure reviews, and action being taken to deter and prevent fraud and to raise fraud awareness throughout the organisation.
The Committee also scrutinised the Counter Fraud qualitative assessment and self assessment risk tool which concluded an overall level of ‘green’ for risk against the contracts and standards. NHS Protect subsequently selected Public Health Wales for a further review of counter fraud arrangements.
A recommendation was issued that ‘regular evaluation should be undertaken to test staff knowledge of fraud related issues, including the Bribery Act. The Trust should then consider targeting specific areas of concern with awareness training. Following this, awareness levels should be retested to demonstrate improvements and feed into ongoing Fraud Awareness work’. The Committee received assurance from the Director of Finance and the Local Counter Fraud Specialist that a number of measures were being implemented to take action against this recommendation. This included a staff questionnaire to indicate where further knowledge and understanding is needed and awareness raising sessions.
The Committee noted that there had been no reported Counter Fraud cases during 2014/15.
5.5 Other Committee work
Date: 9 June 2015 Version: 1 Page: 13 of 15 Public Health Wales Audit Committee Annual Report
In addition to the work undertaken by Wales Audit Office, Internal Audit and Counter-fraud, the Committee completed the following pieces of work:
• Received and monitored a debtors report and noted good progress made;
• Received and reviewed the reporting of single tender contracts and procurement activity at each Committee meeting;
• The Audit Committee also received the formal report on the ongoing work on the register of interest and the register of gifts and hospitality and the register of common seal; and
• Reviewed the organisation’s second Annual Quality Statement.
6 Relationship with other Committees
The Audit Committee has continued to work closely with the Quality and Safety Committee during the year. Two members of the Audit Committee are also members of the Quality and Safety Committee. This common membership ensures continuity across the two Committees and provides the Chair of the Audit Committee with assurance that clinical quality and safety is being addressed appropriately by the Quality and Safety Committee. Performance data has been improved during the year and information flows relating to performance against Public Health Wales’ strategic objectives are improving. The Chair of Quality and Safety Committee has attended an Audit Committee meeting to observe the business discussed.
7 Actions for next year 2015/16
The Committee has identified the following areas to focus on during the forthcoming year:
• Continue to ensure that financial controls are operating effectively;
• Ensure continued development and improvement of effective risk management and governance arrangements;
• Continue to monitor progress against recommendations made in internal and external audit reports; and
• Ensure continued development and effectiveness of Audit Committee.
Date: 9 June 2015 Version: 1 Page: 14 of 15 Public Health Wales Audit Committee Annual Report
8 Conclusions and Way forward
The Audit Committee is now well established and has undertaken all of its core functions. The results of external reviews are pleasing and all recommendations are forming part of action plans which are actively monitored. The Committee has concluded that the above programme of work provides a comprehensive and reliable assurance to support the Board and Accountable Officer in discharging their accountability obligations.
The Audit Committee has established an active process which gives oversight of all internal and external recommendations and their timely implementation.
Good working relationships continue between the Committee Members and the colleagues from external and internal audit.
Date: 9 June 2015 Version: 1 Page: 15 of 15
30.18
Chair report – June 2015 Author: Professor Sir Mansel Aylward, Chair, Public Health Wales Date: 15 June 2015 Version: 1 Sponsoring Executive Director: Professor Sir Mansel Aylward Who will present: Professor Sir Mansel Aylward Date of Board / Committee meeting: 25 June 2015 Committee/Groups that have received or considered this paper: N/A
The Board / Committee are asked to: Approve the recommendation(s) proposed in the paper. Discuss and scrutinise the paper and provide feedback and X comments. Receive the paper for information only.
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) X X X X
Priorities for action Relevant to all priorities of action
Date: 15 June 2015 Version: 1 Page: 1 of 5 Public Health Wales Chair’s report – June 2015
1 Public Health Bill
The Minister for Health and Social Services introduced the Public Health Bill into the Assembly on 9 June 2015. The Bill included proposals to:
• Bring the use of e-cigarettes into line with the use of cigarettes by restricting their use in enclosed public places • Create a national register of retailers of tobacco and nicotine products • Creates a mandatory licensing system for businesses and practitioners who perform acupuncture, body piercing, electrolysis and tattooing • Prohibit intimate piercing of people under the age of 16 • Changes to the way in which pharmaceutical services are planned, through the use of pharmaceutical needs assessment • Place a duty on local authorities to prepare and publish strategies for the provision of toilets for public use within their area
Public Health Wales issued a statement welcoming the Bill.
The Board will be discussing the proposals set out in the Bill on 24 June 2015. The discussion will also focus on how the Public Health Bill links to the Wellbeing of Future Generations Act in ensuring health is reflected in all policies.
2 Bevan Commission
A joint event was held between the Bevan Commission and the Big Innovation Centre on the 13 May 2015. The event aimed to initiate discussions around the issue of sustainability within the NHS and what could be learned from others outside of health. The outputs of this meeting are currently being considered by the Bevan Commission.
A plenary session of the Bevan Commission was held on 14 May 2015. The Commission considered at length the area of a prudent workforce for the NHS, which will inform a submission commissioned by the Minister for Health and Social Services. The Commission also started to consider the areas of End of Life Care and remodelling the relationship between the citizen and the NHS. It was agreed that these areas will now be taken forward by the Commission.
The Bevan Commission work programme was formally agreed by the Minister for Health and Social Services on 20t May. The Bevan Commission secretariat is now finalising the programming of this work prior to establishing the necessary task and finish groups. Date: 15 June 2015 Version: 1 Page: 2 of 5 Public Health Wales Chair’s report – June 2015
The Bevan Commission is actively involved in the upcoming Prudent Healthcare conference on 9 July 2015. Commission members will be chairing the four afternoon panel sessions while others will be taking part in various panels throughout the day.
3 NHS Wales Chair’s meetings with Minister for Health and Social Services
A number of meetings between Chairs of NHS Wales organisations and the Minister for Health and Social Services have taken place since the last Board meeting. The following items have been discussed at these meetings:
• Prudent Healthcare • Choosing Wisely • NHS Wales Health Collaborative o The Chairs received a presentation from Bob Hudson, Director, NHS Wales Health Collaborative providing an update on the work being carried out by the Collaborative. The discussions which ensued were extensive and challenging • 111 project • Primary care • Mathematical modelling
The Chairs of NHS Wales organisations also had a meeting with Vaughan Gething AM, Deputy Minister for Health, which I attended on 2 June 2015. The meeting focused on initiatives and ideas for potential collaboration across health board and trusts.
4 NHS Wales Chair’s and Chief Executive’s meeting with Minister for Health and Social Services
I attended a meeting with NHS Wales Chair’s and Chief Executive and the Minister for Health and Social Services on 30 April 2015. The meeting focused on: • Unscheduled care • Approval process for Integrated Medium Term Plans • Primary care plans • 10 year workforce plan • Service change timetable
Date: 15 June 2015 Version: 1 Page: 3 of 5 Public Health Wales Chair’s report – June 2015
5 Meeting with Minister for Communities and Tackling Poverty
Dr Tracey Cooper and I met with Lesley Griffiths AM, Minister for Communities and Tackling Poverty on 2 June, 2015. During the meeting we discussed the following: • United in Improving Health in Wales • Public Health Wales’ strategic priorities • Early years and tackling poverty • Recruitment to senior Public Health Wales ositions
6 Recruitment to Senior Public Health Wales positions
Interviews for the Director of Health Improvement position took place on 26 May 2015 with Dr Julie Bishop being appointed as Director of Health Improvement. I would like to congratulate Julie on her new role within Public Health Wales.
The positions for Executive Director of Health and Wellbeing and Director of Quality Improvement and Patient Safety/Director of 1000 Lives Plus have been advertised.
Applications for the Director of Quality Improvement and Patient Safety/Director of 1000 Lives Plus closed on 04 June. Interviews for the position took place on 22 June 2015.
Applications for the Executive Director for Health and Wellbeing closed on 22 June 2015. Interviews for the position will take place on 22 July, 2015.
7 United in Improving Health in Wales
I attended the second workshop on United in Improving Health in Wales on 1 May 2015. A number of key stakeholders were invited to attend the meeting which was a follow-up to the United in Improving Health in Wales conference which took place in March 2015. A further meeting will take place on 16 July 2015.
8 Board development
A board development session will take place on 23 July 2015 in Bute Park Education Centre. The session was postponed from 8 May 2015, and will focus on the role and responsibilities of Board members in terms of scrutiny and challenge.
Date: 15 June 2015 Version: 1 Page: 4 of 5 Public Health Wales Chair’s report – June 2015
9 Conferences and events
9.1 United in Health – Developing a Social Model of Primary Care in Wales
I gave the keynote presentation at the United in Health – Developing a social model of primary care in Wales conference on 7 May 2015. My presentation focused on the models of sickness, disability and health.
9.2 Public Health Network Cymru
I attended a Public Health Network Cymru event in Merthyr Tydfil on 20 May 2015. The roadshow aimed to promote networking opportunities for professionals with an interest in public health.
During the event I presented the Good Practice Award to Nutrition Skills for Life.
9.3 Evening reception with Professor Richard Osborne
I chaired an evening reception with Professor Richard Osborne on 27 May 2015. The seminar was titled ‘reducing inequality through health literacy’. Professor Osborne recently developed ‘Ophelia’, which is a process for comprehensive health literacy needs assessment. It has been tailored for local, co-created intervention development, quality improvement, and has strong foundations of implementation science.
9.4 Joint Expert Seminar: Strategic Development and Decision Making
I attended a joint expert seminar on Strategic Development and Decision Making on 17 June 2015. Health board and trust Executive and Independent Board members, and Senior Executives attended the seminar. The seminar enabled Board members to: • Have the opportunity to review examples of good practice from leading UK healthcare providers, academia, researchers and organisational health and behavioural experts; • Develop their existing knowledge, skills and behaviours in relation to strategic development and decision making • Enhance organisations fitness for purpose in the delivery of safe and effective healthcare services for the communities they serve
9.5 1000 Lives Improvement National Learning event
On 17 June, 2015, I was chaired the 5x5 session at the 1000 Lives improvement National Learning event. An oral update will be provided. Date: 15 June 2015 Version: 1 Page: 5 of 5
39.19
Chief Executive report June 2015
Author: Tracey Cooper, Chief Executive
Date: 11 June 2015 Version: 1
Sponsoring Executive Director: Tracey Cooper, Chief Executive
Who will present: Tracey Cooper, Chief Executive
Date of Board / Committee meeting: 25 June 2015
Committee/Groups that have received or considered this paper:
Executive Team
The Board / Committee are asked to: (please select one only)
Approve the recommendation(s) proposed in the paper
Discuss and scrutinise the paper and provide feedback and comments
Receive the paper for information only X
Link to Public Health Wales commitment and priorities for action:
(please tick which commitment(s) is/are relevant) X Public Health Wales Chief Executive report April 2015
1 Recruitment of Senior Positions
The recruitment to senior positions is progressing and occupying a necessary amount of time to proceed to good appointments. Shortlisting has now taken place for the Director for NHS Quality Improvement and Patient Safety/Director of 1000 lives Improvement Service. Interviews for this position will take place on 23 June.
The Executive Director of Health and Wellbeing process has been rolled into July due to diary challenges and shortlisting for the position will take place on 29 June with interviews in mid July.
Julie Bishop was appointed as the Director of Health Improvement, which is a key role in driving improvements in health and wellbeing and reducing inequalities, and I would like to take the opportunity to congratulate Julie and wish her well in her exciting role.
2 Integrated Medium Term Plan and Operational Plan 2015/2016
I am delighted to say that our Integrated Medium term Plan (IMTP) has now been approved by the Minister for Health and Social Services. This is a significant development for us and will enable us to deliver excellent impact to improve the public’s health across all of our functions whilst developing our staff – both current and for the future.
I would like to thank everyone involved in the development of the Plan and particularly to our staff who contributed through our engagement events last year and who helped shape our strategic priorities and how we want to develop as an organisation. Also, a big thank you to those key people who led on the drawing together of each strategic priority and to Nathan Jones, our Assistant Director of Planning and Performance, and Huw George, Deputy Chief Executive/Director of Operations and Finance, for leading the process to a successful approval point.
Now the work really begins as we move to implementation of the Operational Plan for 2015/16 as our first year of the IMTP and I look forward to working with everyone in achieving our Mission Public Health Wales Chief Executive Report – June 2015
3 United in Improving Health in Wales
Following the United in Improving Health in Wales meeting which took place on 1 May 2015, there is a further meeting of the National Strategic Group on 14 July and a workshop on 29 June for the operational Expert Group, together with early years and communications experts. The purpose of the workshop is to shape a single brand for Wales and associated communications strategy, map the assets and resources currently available and begin to draft a delivery plan over the next year that covers across all sectors with the focus on early years and families in order to create positive futures.
This process is aligning closely with our internal approach in developing our systems approach in order for one to complement the other.
As part of developing our systems approach, the Well Communities Framework/Well London and Royal Society for Public Health team came to Cardiff on the 5 June to run a masterclass on their approach with colleagues from across Wales.
4 Meetings with our Teams
I have been fortunate to have a number of meetings with our teams over the last few weeks across Wales. These include: 1000 Lives Team meeting, Bridgend Maternal and Child programme Board, Screening Division, Cardiff Our Local Public Health Team, Wrexham Newborn Screening Team, Wrexham Our Local Public Health Team and Screening Team, Mold Microbiology Laboratory, Rhyl Microbiology Laboratory, Bangor Breast Test Wales Screening, Llandudno
Date: 11 June 2015 Version: 1 Page: 3 of 3
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Revalidation Annual Report 2014-15 Author: Dr Quentin Sandifer, Executive Director of Public Health Services, Medical Director and Responsible Officer Date: 12 May 2015 Version: 0a Sponsoring Executive Director: Executive Director of Public Health Services Who will present: Dr Quentin Sandifer, Executive Director of Public Health Services, Medical Director and Responsible Officer Date of Board / Committee meeting: 25 June 2015 Committee/Groups that have received or considered this paper: Public Health Wales Executive Team
The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper Discuss and scrutinise the paper and provide feedback and comments Receive the paper for information only X
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant)
Priorities for action include relevant priority for action(s)
Align our workforce to priorities and develop and maintain sufficient skills and knowledge Public Health Wales Revalidation Annual Report 2014-15
1 PURPOSE To provide the Executive Team with a report on the second year’s experience with medical revalidation in Public Health Wales.
2 BACKGROUND Revalidation for doctors has been introduced in the UK to assure patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practice. Revalidation is based on effective systems of appraisal and governance/quality assurance, the same ones which improve quality and safety. Revalidation is a by-product of these strengthened systems not the intended purpose of these systems.
Revalidation went ‘live’ on 3 December 2012 and the period to the end of March 2013 was described as year 0. In this period specified senior medical leaders underwent revalidation, which in Wales included the Chief Medical Officer and the Responsible Officers (RO’s) in the 10 health organisations (designated bodies) in Wales.
April 2014-March 2015 was the second full year of revalidation when it was expected that 40% of the medical workforce would undergo revalidation. March 2018 represents the end of the first 5 year cycle when all practicing doctors are expected to be revalidated.
3 REVALIDATION PROGRESS The Deanery asked all designated bodies to complete their second yearend Annual Report by 1 May 2015. The report submitted for Public Health Wales is appended to this report. The Executive Team is asked to receive the report before submission to the Board.
Public Health Wales is the responsible body for 79 Doctors registered with the GMC. In the year to the end of March 2015 35 doctors (44% of the medical workforce with a prescribed connection) underwent revalidation. All received a positive recommendation with no deferrals.
4 APPRAISAL PROGRESS Medical appraisal is a process of facilitated self-review supported by information gathered from the full scope of a doctor’s work. It has three primary purposes:
1. To enable doctors to discuss their practice and performance with their appraiser in order to demonstrate that they continue to meet the principles and values set out in Good Medical Practice and thus to inform the ROs revalidation recommendation to the GMC.
Date: 12 May 2014 Version: 0a Page: 2 of 21 39.20
2. To enable doctors to enhance the quality of their professional work by planning their professional development. 3. To enable doctors to consider their own needs in planning their professional development.
The requirements of an appraisal system are to:
• Ensure all doctors have an annual appraisal. • Cover all aspects of the doctor’s work. • Track appraisees through the system. • Ensure sufficient appraiser capacity. • Ensure appraisers are trained. • Ensure outputs of appraisal are of sufficient quality. • Understand reasons for missed or incomplete appraisal
The Medical Appraisal and Revalidation System managed by the Wales Deanery is a web-based system that has been adopted in Wales to support medical appraisal. All doctors with a prescribed connection to Public Health Wales are expected to register with and use MARS. At 31 March 2015 all doctors had registered with the MARS system.
In the year to 31 March 2015 73/79 (92%) doctors registered on the MARS system had completed a revalidation appraisal during the previous 12 months. Of the remaining 6, all had completed an appraisal in the previous 15 months.
The appended report provides details about the appraisal system in Public Health Wales.
5 RECOMMENDATION
The Board is asked to receive this report. Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report: 2015
Revalidation is the process by which doctors in the UK will have their licence to practise renewed. The purpose of revalidation is to assure patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practise. The Revalidation Progress Report is designed to enable designated bodies in Wales to report relevant figures relating to 2014-15, to carry out a self- assessment of the systems and processes they have in place to support medical revalidation and to provide assurances to their boards and to others that appropriate systems are in place. Completed reports will be analysed by the Wales Deanery on behalf of the Wales Revalidation Delivery Board (WRDB). Data relating to achievements in 2014-15 will be reported to the WRDB. Action plans arising from the self-assessment will be analysed at the All-Wales level. Areas where more than one organisation requires further support will be identified and reported to the Revalidation and Appraisal Implementation Group (RAIG). A plan will be developed highlighting areas where action / support at the Wales level may be beneficial.
The report is divided into three sections: Section 1: Details of designated body Section 2: Data reporting relating to 2014-15 Section 3: Effective governance to support revalidation: self-assessment
The form should be signed off by the responsible officer on behalf of the designated body, though completion of the form may be appropriately delegated. In all cases the responsible officer should confirm that they are happy with the content of the report. The deadline for completion of the report is detailed in the accompanying email. Following completion of this self-assessment exercise, it is recommended that designated bodies should produce a more detailed action plan to address the development needs identified within their specific organisation. Liaison with RAIG is advised prior to finalising action plans to ensure areas which are already being progressed at an All-Wales level are taken into account. Board-level accountability for the quality and effectiveness of these systems is important and this report, along with the resulting action plan, should be presented to the board, or an equivalent governance or executive group. The self-assessment process will also enable designated bodies to provide assurance to regulators, patients, the public, the profession and other interested bodies, that they are fulfilling their statutory obligations and their systems are sufficiently effective to support the responsible officer’s recommendations to the GMC. Page 4 of 21 Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report 2015
Section 1: Details of designated body - Please see guidance notes at the end of this document 1.1 Name of designated body: Public Health Wales Name of Responsible Officer: Dr Quentin Sandifer GMC 3019195 Name of person completing this report: Dr Brendan Mason GMC 3355875 Job title of person completing this report: Lead Revalidation Appraiser
Completed report authorised by Responsible Officer: Dr Quentin Sandifer Date: 27 April 2015
1.2 Type/sector of Local Health Boards designated body: Other NHS trust x (tick one) Other NHS organisation Deanery Independent/non-NHS Independent healthcare provider sector Locum agency (tick one) Government Department or executive agency, armed forces, public bodies Other non-NHS (please enter type)
Page 5 of 21 Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report 2015
NUMBER OF DOCTORS - Please see guidance notes at the end of this document 1.3 Number of doctors with whom the designated body has a prescribed connection as at 31 March 2015
IMPORTANT: ONLY DOCTORS WITH WHOM THE DESIGNATED BODY HAS A PRESCRIBED CONNECTION SHOULD BE INCLUDED IN THIS SECTION. EACH DOCTOR SHOULD BE INCLUDED IN ONLY ONE CATEGORY 1.3.1 Consultants (including honorary contract holders) 76 1.3.2 Staff grade, associate specialist, specialty doctor (including hospital practitioners, clinical assistants who do 3 not have a prescribed connection elsewhere) 1.3.3 General practitioners 0 1.3.4 Trainees: doctor on national postgraduate training scheme (for Deaneries only) N/A 1.3.5 Doctors with practising privileges (for independent healthcare providers only; all doctors with practising 0 privileges who have a prescribed connection should be included in this section, irrespective of their grade) 1.3.6 Temporary or short-term contract holders (including trust doctors, locums for service, clinical research 0 fellows, trainees not on national training schemes, doctors with fixed-term employment contracts) 1.3.7 Other (including some management/leadership roles, research, civil service, other employed or contracted 0 doctors, doctors in wholly independent practice, etc)
1.3.8 TOTAL 79
Page 6 of 21 Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report 2015
APPRAISALS - Please see guidance notes at the end of this document Section 2: Appraisal / revalidation data reporting relating to April 2014- March 2015 2.1 Numbers of doctors who had completed appraisal between 1 April 2014 and 31 March 2015 (with whom the designated body has a prescribed connection as at 31 March 2015) IMPORTANT: ONLY DOCTORS WITH WHOM THE DESIGNATED BODY HAS A PRESCRIBED CONNECTION SHOULD BE INCLUDED IN THIS SECTION. EACH DOCTOR SHOULD BE INCLUDED IN ONLY ONE CATEGORY NB 2.1.4 TRAINEES ARE NOT TO BE INCLUDED IN THIS SECTION NB: Where the answer is nil, please enter “0”. 2.1.1 Consultants (including honorary contract holders) 70 2.1.2 Staff grade, associate specialist, specialty doctors (including hospital practitioners, clinical assistants who do not 3 have a prescribed connection elsewhere) 2.1.3 General practitioners 0 2.1.4 Doctors with practising privileges (for independent healthcare providers only; all doctors with practising 0 privileges who have a prescribed connection should be included in this section, irrespective of their grade) 2.1.5 Temporary or short-term contract holders (including trust doctors, locums for service, clinical research 0 fellows, trainees not on national training schemes, doctors with fixed-term employment contracts) 2.1.6 Other (including some management/leadership roles, research, civil service, other employed or contracted 0 doctors, doctors in wholly independent practice, etc) 2.1.7 TOTAL 73
Page 7 of 21 Public Health Wales Revalidation Annual Report 2014-15
2.2 An audit has been performed to determine reasons for all missed or incomplete appraisals A missed or incomplete appraisal is an important occurrence which could indicate a problem with the appraisal system or a potential issue with an individual doctor which needs to be addressed. Missed appraisals are those which were due within the appraisal year but not performed or which were performed outside the 9 to 15 month window for ‘annual appraisal’. Incomplete appraisals are those Green where, for example, the appraisal discussion was not completed or where the personal development plan or appraisal summary have not been signed off within 28 days of the appraisal meeting. For this exercise to be valuable every missed or incomplete appraisal should be included in the audit and in a well-managed system this information should be monitored and tracked on a continuous basis.
Page 8 of 21 Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report 2015 To answer ‘Green’: An audit of all missed or incomplete appraisals for the appraisal year 2014/15 has been completed. Recommendations and improvements are enacted. To answer ‘Amber’: Information is available relating to some missed or incomplete appraisals but this is not audited in a systematic way To answer ‘Red’: No information is available relating to missed or incomplete appraisals
The 6 Doctors with appraisals that had not been completed in the past 12 months had all had a completed appraisal in the past 15 months, and had an appraisal booked but not yet completed within 15months since the last appraisal.
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Revalidation Progress Report 2015
APPRAISERS - Please see guidance notes at the end of this document
2.3 Number of active medical appraisers as at 31 March 2015: 11
2.3.1 Ratio of active medical appraisers to doctors (appraisers: doctors) 1:7 Ratio to be calculated as total number of doctors divided by number of appraisers i.e. 1000 doctors divided by 20 appraisers = 1:50 (appraisers : doctors)
REVALIDATION RECOMMENDATIONS - Please see guidance notes at the end of this document 2.4 Numbers of doctors with whom the designated body has a prescribed connection as at 31 March 2015 who have had a recommendation made to GMC between 3 December 2012 and 31 March 2015 Responsible officers should ensure recommendations are made to the GMC before the notified due date. This question relates to the number of recommendations completed by the responsible officer between the date revalidation started and the end of the year.
Number of recommendations to be split by year (Year 1: December 2012 – 31st March 2015. Year 2: 1st April 2013 – 31st 2012/ 2013/ 2014/ March 2014. Year 3: 1st April 2014 – 31st March 2015) 13 14 15 2.4.1 Positive recommendations 2 18 35 2.4.2 Deferral requests 0 0 0 2.4.3 Notification of non-engagement 0 0 0 2.4.4 TOTAL 2 18 35 2.4.5 Recommendations which were due between 3 December 2012 and 31 March 2015 but were not completed on time 0 0 0
Page 10 of 21 Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report 2015
Section 3: Effective governance to support medial revalidation: self-assessment
The following checklist is provided as an appendix to Effective governance to support medical revalidation: a handbook for boards and governing bodies. The full document can be accessed at http://www.gmc-uk.org/doctors/revalidation.asp (see “Governance handbook")
The document states that the checklist provides a list of questions that are relevant in the context of ongoing evaluating, demonstrating and reporting on governance of local systems and processes supporting patient safety and medical revalidation. These questions draw on well established principles that support quality improvement and medical revalidation objectives. They take account of the clinical governance and appraisal criteria followed in the various assessments of readiness to begin medical revalidation undertaken across the UK, for example the Organisational Readiness Self Assessment.
Each designated body should undertake a self assessment against the questions listed, awarding a Red / Amber / Green rating, outlining the justification for this rating and summarising key actions to be taken to address any issues identified.
Red – nothing in place
Amber – working towards meeting criteria
Green – criteria met
Question R/A/G Justification Action plan rating
1. There is corporate or organisation-wide commitment to creating an environment that fosters good professional practice
How does your organisation: An effective communication chain Green exists between the Responsible know that the governance of systems supporting the provision Officer, Public Health Wales of quality patient care and medical revalidation objectives is Appraisal Lead and medical staff. appropriately supported, managed and assured? The Responsible Officer works closely with the BMA. Public Health Wales
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Revalidation Progress Report 2015 Question R/A/G Justification Action plan rating appraisal/revalidation coordinator provides administrative support to this process. ensure the adequacy of resources to support all doctors in An effective process exists fulfilling their professional responsibilities, eg in relation to staff Green between the Responsible Officer, induction, appraisal, Continuing Professional Development Public Health Wales HR division, (CPD) and revalidation? Professional and Organisational Development Team and appraisal/revalidation coordinator to support Public Health Wales doctors with a prescribed connection. In what way: Public Health Wales reports 1.1 does the organisation’s governance strategy proactively Green through the Quality and Safety support the provision of quality patient care and medical Committee, a subcommittee of the revalidation objectives? Board, the Executive Group and to informal and formal Board meetings. 1.2 might reporting around quality patient care and Public Health Wales recognises medical revalidation objectives to the board/governing Amber that it has to do more to body be improved? understand service user experience 1.3 How transparent are the board/governing Policies are available on the body’s governance activities? Green Public Health Wales intranet and minutes of the Quality and Safety Committee, formal Executive Group meetings and public Board meetings are available on the Public Health Wales internet 1.4 How does the board/governing body regularly review Data relating to revalidation and data relating to revalidation and clinical practice? Green clinical practice is reported to the Public Health Wales Board on a six monthly basis.
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Revalidation Progress Report 2015 Question R/A/G Justification Action plan rating 2. Local governance is in place and monitored
How does your organisation ensure: Through meetings of a Green Revalidation Group including the 2.1 all information systems for monitoring the conduct and Responsible Officer, members of performance of doctors working in your organisation our Workforce Development/HR are operating effectively? and the Lead Appraiser.
2.2 the performance of locums, doctors in training and Public Health Wales rarely appoint temporarily appointed doctors is monitored and reported in Green locums and such appointments a way that contributes constructively to their revalidation? directly involve the Responsible Officer and HR. 2.3 pre-employment, and other pre-contract checks undertaken Public Health Wales workforce in keeping with statutory and other requirements, are Green directorate has in place effective comprehensive and accurate? measures to ensure that pre- employment, and other pre- contract checks undertaken are in keeping with statutory and other requirements, are comprehensive and accurate. 2.4 quality improvement activities undertaken have Through reports to our Quality been beneficial? Green and Safety Committee. The Responsible Officer works closely with the Risk Manager and other senior quality and safety managers in the various divisions of the organization. 2.5 it can and does respond quickly when things go wrong? As evidenced by our response to Green serious incidents, reported to our Quality and Safety Committee
3. Equality and diversity considerations are integrated into all of the organisation’s medical revalidation policies and practices
How does your organisation: Policies for equality and diversity exist and staff are required to 3.1 ensure its policies and practices supporting medical Page 13 of 21 Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report 2015 Question R/A/G Justification Action plan rating revalidation are fair and non-discriminatory, and comply Green undertake equality and diversity training. The Responsible Officer with legal requirements? last undertook this training in August 2013. 3.2 keep up to date with equality and diversity issues Public Health Wales keeps up to and policies? Green date with equality and diversity issues and policies through employees’ statutory and mandatory training provided by our Workforce and Organisational Development Team. 3.3 approach training in equality and diversity matters? Through employees’ statutory and Green mandatory training provided by our Workforce and Organisational Development Team. 3.4 How do your organisation’s policies and practices Through monitoring and support supporting quality patient care and medical revalidation Green provided by our Workforce and promote equality and diversity, eg for people with protected Organisational Development team. characteristics?
3.5 How does your organisation’s board/governance hierarchy Through monitoring and support engage with equality and diversity issues, and what Green provided by our Workforce and benefits does this bring? Organisational Development team.
4. Ongoing compliance with regulatory requirements and standards creates an environment where professionals can flourish
In what ways does your organization: Briefings to the Board by the 4.1 ensure ongoing familiarity with the organisational and Green Responsible Officer. The professional responsibilities set down in regulations Responsible Officer attends RAIG, and guidance? Revalidation Remediation and Responsible Officer Network meetings. Similarly the Lead Appraiser maintains his Page 14 of 21 Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report 2015 Question R/A/G Justification Action plan rating knowledge and experience through his active involvement in Faculty of Public Health affairs. 4.2 take patient and public views, complaints and Public Health Wales take patient compliments into account to support governance and Amber and public views, complaints and quality improvement? compliments seriously and these are reported to the Quality and Safety and Executive Team. The Responsible Officer has oversight responsibilities for complaints working closely with the Risk Manager. However, further work is required on service user experience. 4.3 know that relevant data are collected and distributed The Responsible Officer to doctors, including for doctors working in a range of, Green communicates directly with or remote, practice settings, in a way that supports all doctors with a prescribed their revalidation? connection to Public Health Wales. 4.4 monitor the quality of data supporting your RO in their Through regular meetings of the role, including making revalidation recommendations to Green Revalidation Group. the GMC?
4.5 What was the outcome of your last review of data needs Further work required to to support quality improvement and monitoring? Amber strengthen appraisal assurance and checks on medical professional registration. How does your organisation: The HR Medical Workforce lead 4.6 ensure the identity, qualifications, references Green continuously reviews the GMC and experience of your doctors? list of doctors to assure the Responsible Officer that doctors with a prescribed connection do not have conditions or other
Page 15 of 21 Public Health Wales Revalidation Annual Report 2014-15
Revalidation Progress Report 2015 Question R/A/G Justification Action plan rating restrictions on their practice. Doctors are required to make specific declarations at each appraisal. Before a doctor is revalidated a check is undertaken that the doctor has no complaints and is not subject to any inquiries or investigations. 4.7 monitor the conduct and performance of doctors, including The HR Medical Workforce lead temporarily appointed doctors, locums and doctors in continuously reviews the GMC training, and ensure any issues arising are addressed? Green list of doctors to assure the Responsible Officer that doctors with a prescribed connection do not have conditions or other restrictions on their practice. Doctors are required to make specific declarations at each appraisal. 4.8 manage admission to the performers list, if relevant? Not relevant to Public Health Wales 4.9 know that the arrangements to grant and monitor The directors of the divisions that practising privileges for medical practitioners are robust? Green offer such practicing privileges undertake pre-employment checks with HR input.
5. Medical appraisal takes place in accordance with GMC guidance and organisational requirements
5.1 What is the practical effect of the integration of your This is still being evaluated. organisation’s appraisal policy with other governance Amber arrangements?
How does your organisation: Reference to MARS. Direct 5.2 know that all doctors requiring annual appraisal Green communication with the very few have participated? doctors that have yet to register.
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Revalidation Progress Report 2015 Question R/A/G Justification Action plan rating 5.3 manage the situation where doctors requiring appraisal By direct communication from the have not been appraised? Green Lead Appraiser and Responsible Officer. 5.4 know all doctors are familiar with your organisation’s The Responsible Officer and The appraisal policy and system? Green Wales Deanery and the Appraisal Lead communicate regularly with our Designated Doctors to ensure understanding and familiarity is maintained. How does your organisation ensure: The structure of the MARS 5.5 the focus of appraisal is on the GMC’s Good Green appraisal is consistent with the Medical Practice and other relevant guidance? GMC’s Good Medical Practice and other relevant guidance 5.6 appraisers are appropriately trained to conduct appraisals? All Public Health Wales Appraisers Green are required to complete The Wales Deanery Appraisal skills training module. 5.7 medical appraisers are supported in the role The Lead Appraiser liaises closely through leadership and peer support? Green with medical appraisers and the Responsible Officer supports as necessary. 5.8 adequate resources are available to support Public Health Wales has managed Need to appoint an Associate doctors’ appraisal, revalidation and CPD? Amber to this date within existing Medical Director to support RO resources but this could be and Lead Appraiser with medical challenged in year 3 as the revalidation (position agreed by number of doctors presenting for organization but currently vacant) revalidation increases and strict enforcement of annual appraisals takes effect. 5.9 the quality and completeness of information Monitored by the Lead Appraiser supporting appraisal? Green and Responsible Officer.
How does your organisation: Through the Lead Appraiser and 5.10 manage and monitor the performance of its appraisers in Green Responsible Officer roles.
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Revalidation Progress Report 2015 Question R/A/G Justification Action plan rating their role?
5.11 monitor the quality and robustness of appraisals and Through the Lead Appraiser and Appraisers have quality assured appraisal outputs? Amber Responsible Officer roles. Need anonymised appraisal summary for further work on appraisal using the all Wales standards. assurance acknowledged. This will be repeated in 2015/16. 5.12 review the annual appraisal process and put Through the Lead Appraiser and consequential learning into effect? Green Responsible Officer roles and in internal revalidation meetings. 5.13 monitor the outcomes of doctors’ participation in CPD? Through the Lead Appraiser and Green Responsible Officer roles. 5.14 How does your governance hierarchy oversee appraisal, Through briefings to the Executive and consider whether it is delivering anticipated benefits? Green Group and Board by the Responsible Officer.
GUIDANCE NOTES
NUMBER OF DOCTORS 1.3 Number of doctors with whom the designated body has a prescribed connection as at 31 March 2015 The responsible officer should keep an accurate record of all doctors with whom the designated body has a prescribed connection. The prescribed connection is defined in detail in the RO regulations and the responsible officer must be satisfied that the doctor has correctly identified their designated body. To do this the responsible officer will need to understand this section of the regulations and will need to know the other roles the doctor performs. A number of doctors, including locums, other employed or contracted doctors and doctors in wholly independent practice may not be included in these categories and should be entered under ‘other’. All general practitioners (GPs) including principals, salaried and locum GPs on the medical
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Revalidation Progress Report 2015 performers list should be entered under ‘general practitioner’. Trainees on national training schemes, including GP trainees, have a prescribed connection to the Deanery; trainees on independent schemes may have a prescribed connection to the employing trust. Academics with honorary clinical contracts will usually have their responsible officer in the Health Board or Trust where they perform their clinical work. Depending on their contractual status, secondary care locums may have a prescribed connection to a locum agency or an employer. Doctors with practising privileges may have a prescribed connection with the independent sector hospital depending on their other roles. The categories relate to current roles and job titles rather than qualifications or previous roles. The number of individual doctors in each category should be entered.
APPRAISALS Section 2: Appraisal / revalidation data reporting relating to April 2014- March 2015 The appraisal system is one of the cornerstones of revalidation and good quality appraisal is essential for the responsible officer to be assured that each medical practitioner is up to date and fit to practise. Appraisal must also provide a safe environment for personal development needs to be discussed and agreed. A good appraisal system is dependent on effective leadership and management, the quality of the supporting information and the quality and professionalism of the appraisers. For revalidation to fulfil its primary objectives it is essential that information from all the doctor’s roles is available at appraisal. The appraisal system must be set up to deliver annual appraisal for all the doctors who have a prescribed connection with the designated body. In order to ensure all doctors have an annual appraisal, it is necessary for the responsible officers to establish the reasons for missed or incomplete appraisals, to satisfy themselves that the appraisal system is functioning effectively and also that doctors are fulfilling their professional and contractual obligations. The responsible officer is responsible for the quality and effectiveness of the appraisal system even if this has been commissioned from an external provider organisation. In these circumstances, it is advisable for a service agreement to be drawn up defining the required quality standards and key indicators. For the purposes of this guidance the organisational appraisal year runs from 1 April to 31 March. The appraisal year is defined in this way to assist the management and monitoring of the appraisal system and to allow comparison and benchmarking between organisations and sectors. A completed annual appraisal is one where the appraisal meeting has taken place between 9 and 15 months of the date of the last appraisal and the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting. It is not suggested that these definitions, required for managing an effective organisational appraisal system, should be applied to revalidation recommendations for individual doctors. The audit will give a detailed understanding of what has happened in all missed or incomplete appraisals and the responsible officer will exercise judgement on a case by case basis if an appraisal falls outside the appraisal year for acceptable reasons. For doctors in training it has been agreed that revalidation recommendations will be based on the process of annual review of competence progression and therefore Deaneries do not need to complete this section. The role of medical appraiser is an important professional role and effective selection processes and structured initial training programmes are needed. Ongoing performance review, development and support of appraisers will also be necessary to maintain the skills of the appraiser and
Page 19 of 21 Public Health Wales Revalidation Annual Report 2014-15 Revalidation Progress Report 2015 assure the quality and consistency of appraisal. It has been agreed by the Wales Revalidation Delivery Board that, in order to further support revalidation, all NHS doctors will be required to access their appraisal via MARS from 1 April 2014. Therefore it is anticipated that NHS designated bodies will be taking steps to ensure this happens. 2.1 Numbers of doctors who had completed appraisal between 1 April 2014 and 31 March 2015 (with whom the designated body has a prescribed connection as at 31 March 2015) For the purposes of this guidance, a completed annual appraisal is one where the appraisal meeting has taken place between 9 and 15 months of the date of the last appraisal and the outputs of appraisal have been agreed and signed-off by the appraiser and the doctor within 28 days of the appraisal meeting. In most circumstances the final sign-off of the appraisal should occur within a few days of the appraisal meeting. Some organisations may require additional sign-off from a medical manager, clinical director or medical director. These additional processes should be described in the organisation’s appraisal policy with any necessary deadlines but the principle that should apply in all situations is that the appraiser and doctor should sign the agreed outputs within 28 days. The 28-day period is to allow for holidays and other absences and should be sufficient for agreement and sign-off in almost all circumstances. For example, an appraisal meeting taking place on 31 March would need to be signed off on 27 April for it to be included in the year. An appraisal that has not been signed-off within this period should be regarded as incomplete and included in the audit of missed/incomplete appraisals so the reason for the delay can be explored. In completing this self-assessment it is important to distinguish between the responsible officer’s responsibility to manage the quality and effectiveness of the appraisal system and their responsibility to make revalidation recommendations on individual doctors. To manage the system the responsible officer needs to know that every doctor has had an appraisal meeting and the sign-off has been completed. In making recommendations on individual doctors the responsible officer can use their judgement to allow flexibility for appraisals delayed by holidays, sickness absence, study leave, etc. There is no suggestion that an individual appraisal will be invalidated by delays, but in managing the appraisal system the organisation needs to set a reasonable expectation, track what’s happening and understand the reasons for delays. It would be unusual for a designated body to complete appraisals on all the doctors for whom it has responsibility within the appraisal year. There are many potential reasons for this and the main purpose of this section is to help the designated body establish the reasons for missed or incomplete appraisals so that the management of the appraisal system can be optimised. The same categories of doctors in section 1.3 are used in this section to identify those doctors who have had a completed appraisal in the year 2014/15. Comparing the numbers in sections 1.3 and 2.2.1 will give an indication of the additional organisational capacity and training required.
APPRAISERS
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Revalidation Progress Report 2015
2.3 Number of active medical appraisers as at 31 March 2015: 2.3.1 Active appraisers are those who have performed at least one appraisal in the appraisal year and undertaken revalidation ready training, as described in the Appraisal Policy and Operating Standards, should include: • Understanding of the purpose of appraisal and revalidation and the links between these processes and other systems for improving the quality of medical practice in the organisation and the wider healthcare system • Competency in assessing supporting information that informs the appraisal and revalidation process, speciality aspects of appraisal • Skills to conduct an effective appraisal discussion, including all the elements needed for revalidation • Ability to produce consistently high quality appraisal documentation, sufficient to inform the revalidation recommendation as well as inform personal development • Wales Medical Appraisal Policy in particular ethos of appraisal in Wales, integration with other quality improvement and patient safety processes, principles of delivery • Wales Whole Practice Appraisal policy • Wales Quality Indicators of Supporting Information policy • Concept of agreement at appraisal – and processes for resolving disputes • Quality criteria for appraisal summary and PDP • For those using MARS, managing the above through MARS
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39.21
Plan of Board business Author: Eleanor Higgins, Corporate Governance Manager Date: 15 June 2015 Version: 0a Sponsoring Executive Director: Keith Cox, Board Secretary Who will present: N/A paper for information only Date of Board / Committee meeting: 25 June 2015 Committee/Groups that have received or considered this paper: Executive Team
The Board / Committee are asked to: (please select one only) Approve the recommendation(s) proposed in the paper Discuss and scrutinise the paper and provide feedback and comments Receive the paper for information only X
Link to Public Health Wales commitment and priorities for action: (please tick which commitment(s) is/are relevant) X
Date: 15 June 2015 Version: v0a Page: 1 of 4 Public Health Wales Plan of Board business
1 Introduction
The Plan of Board business is presented to the Board for information only.
2 Background
The Plan of Board business provides an overview of activity due to be presented to the Board during 2014/15.
3 Timing
The plan of Board business will be updated on a quarterly basis and presented to the Board for information after each update.
4 Financial Implications
None.
5 Recommendation(s)
The Board is asked to note the plan of Board business for information.
Date: 15 June 2015 Version: v0a Page: 2 of 4 Public Health Wales Plan of Board business
Plan of Board Business 2015/16 Improve health and wellbeing and to reduce health Improve the quality, equityand effectiveness of healthcare services
Protect the publicfrom infectious and environmental hazards Corporate/Enablers
For y t i r
o d n i n r n o i o P a i
t s c y a i
Month Items s Presenter /Author Director n g i u m n t r e c o t s u o i i a r f s r i c D n t c I S S e D June Review of SO and SFI X 7(i) Keith Cox Keith Cox (Formal) Welsh Language monitoring report X 7(j) Ruth Davies Ruth Davies Governance and accountability module X 7(i) Keith Cox Keith Cox Our Space X 7(g) Huw George Huw George HIW annual report X 7(d) Darren Hatton, HIW relationship Rhiannon Beaumont Wood / Keith manager Cox Performance report X 7(i) Mark Dickinson Mark Dickinson Audit Committee update X 7(a),7(i) TerenceRose Terence Rose Information Governance Committee update X 7(i) John Spence John Spence Developing the Organisation Committee X 7(b),7(g), John Spence John Spence update 7(i) Liquid cytology procurement X 6(e) Quentin Sandifer Quentin Sandifer Emergency planning X 6(c) Quentin Sandifer Quentin Sandifer Policy, research and development update X 5(a) Mark Bellis Mark Bellis Local public health team X all Director of Public Health Director of Public Health priorities WEDINOS update X 6(b) Quentin Sandifer Quentin Sandifer July Understanding information presented to the X 7(i) Nathan Jones Huw George Board (Informal) Futureof public health system in Wales X 1(a) Tracey Cooper Tracey Cooper International health X 5(a) Quentin Sandifer Quentin Sandifer child flu and immunisation X 6(b) Quentin Sandifer Quentin Sandifer Microbiology programme update X 6(b) Quentin Sandifer Quentin Sandifer Transforming health improvement / systems X 1(a), 1(b) Judith Greenacre Judith Greenacre Older Person's Commissioner X all Sarah Rochira Mansel Aylward priorities August No Meeting
September Committee annual reports X 7(i) Keith Cox Keith Cox (AGM and Performance reports X 7(i) Huw George Huw George PHW Annual report X all Huw George / Keith Cox Huw George / Keith Cox priorities Trusted to careand Francis updateon 4, 6, 7 Rhiannon Beaumont Wood Rhiannon Beaumont Wood progress against recommendations Update on HCAIs X 4(c) Quentin Sandifer Quentin Sandifer Quality and Safety Committee update X 7(i) Simon Smail Simon Smail Audit Committee update X 7(i) Terence Rose Terence Rose Information Governance Committee update X 7(i) John Spence John Spence Declarations of interest X 7(i) Keith Cox Keith Cox Register of gifts and hospitality X 7(i) Keith Cox Keith Cox Register of Seal X 7(i) Keith Cox Keith Cox
Date: 15 June 2015 Version: v0a Page: 3 of 4 Public Health Wales Plan of Board business
October IMTP X all Huw George Huw George priorities (Informal) Health and safety training X 7 Nicola White Keith Cox WCVA Ruth Marks X all Ruth Marks Mansel Aylward Air quality X 6(c)priorities Huw Brunt Quentin Sandifer November Strategic priorities X all Huw George Huw George priorities (Formal) Quality and Safety Committee update X 7(i) Simon Smail Simon Smail Together for mental health X 1(b) Su Mably Judith Greenacre December IMTP X all Huw George Huw George priorities CARIS X 6(f) Judith Greenacre Judith Greenacre Welsh languageCommissioner X all Meri Huws Mansel Aylward priorities (Informal) IG training X all Rhiannon Beaumont Wood Rhiannon Beaumont Wood priorities January Microbiology modernisation programme X Quentin Sandifer Quentin Sandifer (Formal) Performance report X Huw George Huw George Wales AuditOfficeannual audit report X Wales Audit Office Huw George Draft Integrated Medium Term Plan X Huw George Huw George Audit Committee update X Terence Rose Terence Rose Quality and Safety Committee update X Simon Smail Simon Smail Information Governance Committee update X John Spence John Spence February Draft Integrated Medium Term Plan X Huw George Huw George (informal) March Integrated Medium Term Plan X Huw George Huw George (formal) Budget strategy X Huw George Huw George Draft operational plan X Huw George Huw George Audit Committee update X Terence Rose Terence Rose Information Governance Committee update X John Spence John Spence
Date: 15 June 2015 Version: v0a Page: 4 of 4 39.22
Minutes of the Public Health Wales Audit Committee Date of meeting: 27 March 2015 Time of meeting: 12:30 – 14.30 Venue for meeting: Boardroom, 14 Cathedral Road, Cardiff Version: 1
Present Terry Rose (Chair) (TeR) Board Member, Public Health Wales John Spence Board Member, Public Health Wales
In attendance Keith Cox Board Secretary, Public Health Wales Cerian Dovey Business Support Manager, Public Health Wales Huw George Director of Finance, Public Health Wales Jayne Gibbon NHS Wales Shared Services Partnership – Audit & Assurance Services Craig Greenstock (in part) Cardiff and Vale University Health Board – Counter Fraud Eleanor Higgins Corporate Governance Manager, Public Health Wales James Johns NHS Wales Shared Services Partnership – Audit & Assurance Services Lucy Jugessur Wales Audit Office Tamira Rolls (TaR) Assistant Director of Finance, Public Health Wales Jeremy Saunders Wales Audit Office Gabby Smith Wales Audit Office Ian Taylor Head of Financial Services and Control Ruth Davies (in part) Director of Workforce and Organisational Development, Public Health Wales Joe O’Brien (in part) Workforce Systems Development Manager, Public Health Wales
Date: 12 May 2015 Version: 1 Page: 1 Public Health Wales Minutes from Audit Committee 27 March 2015
Apologies Professor Peter Bradley Executive Director of Public Health Development, Public Health Wales Dr Carl Clowes Board Member, Public Health Wales Tracey Cooper Chief Executive, Public Health Wales Simon Cookson NHS Wales Shared Services Partnership – Audit & Assurance Services Anne-Marie Harkin Wales Audit Office
1. Welcome and apologies
The Chair welcomed all those in attendance to the meeting of the Public Health Wales Audit Committee. Joe O’Brien was in attendance for item 4 and Ruth Davies was in attendance for items 4 and 5.
Apologies were received from Dr Carl Clowes, Tracey Cooper, Simon Cookson and Anne-Marie Harkin. Professor Peter Bradley sent his apologies for item 5.
2. Declarations of interest
There were no declarations of interest to register.
3. Minutes and matters arising
The minutes from the previous meeting were received by the Committee and approved as an accurate account.
Matters arising There were no matters arising.
4. Internal Audit action log
The Committee members received and noted the above report for information. Mr Keith Cox presented the report (item 26.02) to the Committee.
The Committee discussed the system issues experienced during the NATO summit last year. Huw George confirmed that NWIS produced a report on this at the end of 2014, but it was not clear what the failings were. The Committee raised a concern that this is a potential risk. HG advised the Committee that he will be investigating the issue further with NWIS. Action: HG to provide an update for the Committee.
Date: 12 May 2015 Version: 1 Page: 2 Public Health Wales Minutes from Audit Committee 27 March 2015
Ruth Davies and Joe O’Brien joined the meeting.
a) Update on the implementation of ESR
Joe O’Brien presented the following update to the Committee.
Audit Committee 12th March 2015 - ESR Presentation.pptx
The Committee heard of the improvements made on business intelligence and analysis. For example, when Ruth Davies discovered that staff turnover was over 10 percent recently, she requested a report on the reasons for leaving, which she received within the hour. This data can now be used to update the questions asked at leaving interviews.
The Committee asked RD for an update on the internal audit actions for which she is the responsible manager. RD was able to provide an update for each, citing resource concerns or new system implementations for perceived delays. The implementation dates for many needed updating to reflect these issues. It was also agreed that some of the actions had been superseded by other audits or pieces of work and may, therefore, be able to be closed. It was agreed that Tamira Rolls and Ruth Davies should liaise with Internal Audit colleagues to agree which actions could be closed down.
Action: TaR and RD to liaise with Internal Audit to agree which actions could be closed down.
The Committee thanked JO and RD for the presentation and noted the improvements already made.
Joe O’Brien left the meeting.
5. Risk Assurance
a) Corporate Risk Register
The Committee members received and noted the above report for information. Keith Cox presented the register (item 26.12) to the Committee.
The Committee heard that the Executive Team has updated the format and identified corporate risks in line with the IMTP.
Date: 12 May 2015 Version: 1 Page: 3 Public Health Wales Minutes from Audit Committee 27 March 2015
The next stage will be to identify due dates for each risk.
It was noted that this version will be the one submitted for the Board on 26 March 2015.
KC confirmed that risks can be captured from across the organisation.
The Committee noted a significant improvement in the format of the risk register. Moving forward the Committee will be challenging the risks and scoring of those risks.
The Committee recommended that the risks should be ordered according to their current risk level.
KC confirmed that a cross referencing exercise has been completed with a supporting narrative explaining why certain risks on the previous version of the register have not transferred to the new register.
KC advised the Committee that some risks are managed at directorate level and will not be seen on this corporate level register. However, they can be escalated if necessary.
b) In depth review of specific risk: Public Health development
Apologies were received from Professor Peter Bradley. This item was therefore deferred.
c) Risk appetite
It was noted that the Committee and the Board will need to consider Public Health Wales’ risk appetite.
Ruth Davies left the meeting.
6. Audit Committee work plan
Eleanor Higgins presented the Audit Committee plan of business for 2015/16 (item 26.03) for approval.
EH noted that plan is rolling and can be updated throughout the year.
The Committee approved the plan of business for 2015/16.
Date: 12 May 2015 Version: 1 Page: 4 Public Health Wales Minutes from Audit Committee 27 March 2015
7. Wales Audit Office
a) Audit Position Statement
The Committee members received and noted the above document for information. Gabby Smith presented the report which provided an overview of the audit work planned or currently underway for the Trust and the status of the reports.
The outline of audit work for 2015/16 will be presented at the next Audit Committee meeting.
GS noted that a discussion with Huw George and Tracey Cooper on the local programme of works needs to take place before the final audit fee is agreed.
8. Internal Audit
a) Internal Audit Progress Report
The Committee members received and noted the above report (item 26.05) for information. This progress report provides the Audit Committee with the current position regarding the work being undertaken by the NHS Wales Shared Services Audit and Assurance Service as part of the 2014/15 Internal Audit plan.
John Spence queried why there was a delay in management responses to the risk management audit. The delay has been due to an internal discussion regarding the accuracy and clarity of the first draft of the report. Following that feedback, the amended draft is now with the Executive Team to approve. KC noted that the overall marking is not being challenged. It was confirmed that this delay is not typical. This report had a greater number of recommendations and greater complexity as well.
b) Internal Audit charter
The Committee members received and noted the above document (item 26.06) for information. The Committee heard that charter was approved by the Board Secretaries group and the amendments from that group are highlighted in this updated version.
JJ confirmed that no changes to the reporting lines are required following the changes to the Executive Team structure.
Date: 12 May 2015 Version: 1 Page: 5 Public Health Wales Minutes from Audit Committee 27 March 2015
b) Claims reimbursement report
The Committee members received and noted the above report (item 26.07) for information.
It was noted that substantial assurance had been received and that there were no high priority issues identified during the review.
c) Asbestos Follow up report
The Committee members received and noted the above report (item 26.08) for information. Limited assurance had been received previously, but the follow up report shows significant progress and all actions have been addressed.
It was noted that substantial assurance has now been received and the Committee thanked all those involved for their hard work.
d) Main Financial Systems report
The Committee members received and noted the above report (item 26.09) for information. It was noted that substantial assurance had been received and that there were no high priority issues identified during the review.
9. Counter Fraud update
The Committee members received and noted the above report (item 26.10) for information.
a) PHW Focused Qualitative Assessment report
The Committee members received and noted the above report (item 26.11) for information.
This final report had been updated to reflect the recommendations from the assessor, who is now satisfied with the report. A review will take place in a few years.
It was also confirmed that most Counter Fraud incidents are related to staffing issues, such a fraudulent timesheets. The Committee can be assured that the risk is limited. Policies and procedures are robust and will identify any fraud.
The Committee heard that work is taking place to address those standards marked as amber.
Date: 12 May 2015 Version: 1 Page: 6 Public Health Wales Minutes from Audit Committee 27 March 2015
Craig Greenstock left the meeting.
10. Annual Report, Governance Statement and Quality Statement
The Committee members received and noted the above report (item 26.12) for information which provides an overview on how we plan on producing the annual report this year. It was confirmed that it follows a similar process to last year.
The Board heard that better collaborative working will take place this year to ensure that the formatting and language is more consistent.
a) Annual Governance Statement
The Committee members received and noted the above document (item 26.13) for information.
The Committee requested the following amendments: • Confirm that the Developing the Organisation Committee had been established during the year, but had not met • Amend the table highlighting the number of risks reviewed and added during the year • Make reference to the public health bill
It was noted that the Executive Team will be providing feedback by the end of March 2015.
The Committee were satisfied that the statement was on track.
Action: update Annual Governance Statement to reflect changes requested by the Committee
11. Annual Account timetable
The Committee members received and noted the above document (item 26.15) for information.
12. External Audit Action Log
The Committee members received and noted the above document (item 26.16) for information.
TR noted that actions that have passed their implementation dates were being picked up through other areas of work. There were other actions on hold until a new senior management has been recruited.
Date: 12 May 2015 Version: 1 Page: 7 Public Health Wales Minutes from Audit Committee 27 March 2015
13. Procurement Report
The above report (item 26.17) was received and noted by the Committee members for information.
14. Debtors Report
The above report (item 26.18) was received and noted by the Committee members for information. 15. Claims annual report
The above report (item 26.19) was received and noted by the Committee members for information.
16. Publication of papers
It was agreed that all the papers should be published except the Annual Audit Report.
The Procurement Report will be edited before being published.
17. Wales Audit Office Fee Scheme 2015
The above report (item 26.20) was received and noted by the Committee members for information.
18. Any Other Business
No any other business to report.
Date: 12 May 2015 Version: 1 Page: 8 Public Health Wales Minutes from Audit Committee 27 March 2015
Actions
No. Action Who Start End Status Revised implementation date 20.02 Arrange a development session for CO/EH 18.12.13 12.03.14 This action will be 28.04.15 Audit Committee, internal audit and addressed through the external audit to discuss findings of wider Board development the self assessment. work which is currently ongoing. 20.05 Board member survey and EH/CO 18.12.13 12.03.14 This action will be 28.04.15 recommendations from Structured addressed through the Assessment to be discussed at a wider Board development future informal Board meeting. work which is currently ongoing. 27.01 HG to provide an update from NWIS HG 12.03.15 07.05.15 on the system issues experienced during the NATO summit last year.
Completed actions
27.02 Tami Rolls, Ruth Davies and internal RD/JO/TR 12.03.15 07.05.15 Complete – internal audit audit liaise with internal audit to actions have been updated agree which internal audit actions can be closed down.
27.03 Update Annual Governance EH 12.03.15 07.05.15 Complete – updates Statement to reflect changes completed. requested by the Committee
Date: 12 May 2015 Version: 1 Page: 9
39.23
Minutes of the Public Health Wales Audit Committee Date of meeting: 7 May 2015 Time of meeting: 12:30 – 14.30 Venue for meeting: Boardroom, 14 Cathedral Road, Cardiff Version: 1
Present Terence Rose (Chair) (TeR) Board Member, Public Health Wales Dr Carl Clowes Board Member, Public Health Wales John Spence Board Member, Public Health Wales
In attendance Keith Cox Board Secretary, Public Health Wales Cerian Dovey Business Support Manager, Public Health Wales Huw George Director of Finance, Public Health Wales Jayne Gibbon NHS Wales Shared Services Partnership – Audit & Assurance Services Craig Greenstock Cardiff and Vale University Health Board – Counter Fraud Anne-Marie Harkin Wales Audit Office Lucy Jugessur Wales Audit Office Tamira Rolls (TaR) Assistant Director of Finance, Public Health Wales Jeremy Saunders Wales Audit Office Gabby Smith Wales Audit Office Ian Taylor Head of Financial Services and Control
Apologies Tracey Cooper Chief Executive, Public Health Wales Simon Cookson NHS Wales Shared Services Partnership – Audit & Assurance Services Eleanor Higgins Corporate Governance Manager, Public Health Wales James Johns NHS Wales Shared Services Partnership – Audit & Assurance Services
Date: 4 June 2015 Version: 1 Page: 1 Public Health Wales Minutes from Audit Committee 7 May 2015
1. Welcome and apologies
The Chair welcomed all those in attendance to the meeting of the Public Health Wales Audit Committee.
Terence Rose welcomed Anne-Marie Harkin to the Committee in her role as Engagement Director for Public Health Wales.
Apologies were received from Tracey Cooper, Eleanor Higgins, James John and Simon Cookson.
2. Declarations of interest
There were no declarations of interest to register.
3. Minutes and matters arising
The minutes from the previous meeting were received by the Committee and approved as an accurate account.
Matters arising
In the previous meeting, during the update on the implementation of ESR, Ruth Davies noted that staff turnover has been at ten percent recently. The Committee agreed that a report on the reasons why should be submitted to the Developing the Organisational Committee.
ACTION: Staff turnover to be discussed at the Developing the Organisation Committee.
The Committee noted that an update on Public Health Development risks could not take place at the last meeting and suggested that this should now take place at the Audit Committee meeting in September.
ACTION: Dr Judith Greenacre to be invited to the September meeting.
4. Wales Audit Office
a) Audit Position Statement
The Committee members received and noted the above document (27.02) for information.
Date: 4 June 2015 Version: 1 Page: 2 Public Health Wales Minutes from Audit Committee 7 May 2015
The staff survey for the diagnostic review of IM&T systems capacity and resources was circulated last week. The final report is expected at the September meeting.
The final report on the review of back up data arrangements will be presented at the June meeting.
The Committee noted that the audit position statement suggested that the local project work will be agreed in May. However, the Committee wish to review any proposals before they are agreed.
ACTION: The local project work to be agreed in June’s meeting.
Dr Carl Clowes noted his concern over the delay in the intended audit work on 1000 Lives. Huw George replied that an audit would be more effective once the Director for NHS Quality Improvement and Patient Safety/Director 1000 Lives is appointed and the new structure is established. Mr George reassured the Committee that the job description for the role has been carefully scrutinized and ensures that the new position will raise the profile nationally.
b) Audit Outline Plan 2015
The Committee members received and noted the above plan (item 27.03) for information.
5. Internal Audit
a) Internal Audit Progress Report
The Committee members received and noted the above report (27.04) for information.
b) Internal Audit plan 2015/16
The Committee heard that the agreed plan will be presented at June’s Audit Committee meeting.
c) Risk management report
The Committee members received and noted the above report (item 27.06) for information.
It was noted that limited assurance had been received. However, significant changes have been made since the audit. A follow up audit is planned during 2015/16.
Date: 4 June 2015 Version: 1 Page: 3 Public Health Wales Minutes from Audit Committee 7 May 2015
The Committee were satisfied that the recommendations are being addressed.
d) Appointment & Management of Temporary Staff report
The Committee members received and noted the above report (item 27.07) for information.
It was noted that limited assurance had been received, with two high priority issues identified.
The Committee heard that a number of policies were transferred from Velindre that required reviewing. The policies were prioritised for review and a timetable was agreed.
ACTION: A list of the Velindre policies requiring review to be presented to the Committee in a future meeting.
The Committee agreed that the recommendations from this audit and the Appointment & Management of Temporary Staff should be included in the annual report, along with the management responses.
ACTION: Terence Rose to include the limited assurance audits in the annual report to show the recommendations and the management responses.
e) Performance Reporting report
The Committee members received and noted the above report (item 27.08) for information.
It was noted that reasonable assurance had been received and that there were no high priority issues identified during the review.
It was noted that the recommendations will be addressed but not necessarily by following the processes outlined in the report.
f) Incident Management
The Committee members received and noted the above report (item 27.09) for information.
It was noted that substantial assurance had been received and that there were no high priority issues identified during the review.
Date: 4 June 2015 Version: 1 Page: 4 Public Health Wales Minutes from Audit Committee 7 May 2015
6. Draft Annual Accounts
Tami Rolls presented the draft annual accounts.
audit committee accounts presentation 1415 v2.pptx
Huw George noted his thanks to Tami Rolls, Ian Taylor and the team for submitting the draft annual accounts to the Welsh Government on time.
The final accounts will be submitted to the Committee in June, with a full reconciliation of adjustments.
The Committee noted that Public Health Wales had once again broken even and were pleased to hear that the Welsh Government has recognised this achievement.
Whilst the Committee acknowledged that most of the NHS organisations missed the public sector payment performance target (Public Health Wales achieved the third best result across Wales), the Committee nevertheless needed a better understanding as to why the performance target was not met again this year.
ACTION: Huw George and Tami Rolls to produce a report on the challenges faced in achieving the public sector payment performance target and the actions taken to date.
The Committee noted that the Public Health Wales is not a part of the carbon reduction commitment scheme due to its size.
ACTION: Tami Rolls to ensure that the draft accounts make reference to the reason why Public Health Wales is not part of the scheme.
The Committee thanked Huw George, Tami Rolls and Ian Taylor.
7. Annual Governance Statement
The Committee members received the above document (item 27.11) and were asked to approve the recommendations.
The Committee received a revised draft, which incorporated feedback from the formal Board meeting on 28 April 2015.
Date: 4 June 2015 Version: 1 Page: 5 Public Health Wales Minutes from Audit Committee 7 May 2015
The Committee heard that the Governance and Accountability Module will be reviewed by the Board on 21 May 2015.
The Committee noted that the recommendations from the audits that received limited assurance will be included in the report.
Jayne Gibbons confirmed that the Facilities Database audit will not take place in this financial year and therefore the Annual Governance Statement needed to amended to reflect this.
The Committee approved the draft Annual Governance Statement subject to the additions outlined in the paper and minor amendments made.
8. Audit Committee annual report
The Committee members received and noted the above report (item 26.12) for information.
Terence Rose noted the following additions he will be making to the report; narrative on the recent audits that received limited assurance and narrative on public sector payment performance and acknowledgement that there have been no fraud cases to report this year.
The Committee will be asked to approve the final draft in June.
9. Counter Fraud policy
The Committee members received the above policy (item 27.13) and were asked to approve the recommendations.
The Committee noted that the policy would not require staff consultation, due to only minor amendments being made.
The Committee approved the revised policy.
10. Counter Fraud progress report
The Committee members received and noted the above document (27.14) for information.
The final report on the focused quality assessment of compliance against NHS Protect standards for Fraud, Bribery and Corruption was received and noted as an appendix to the above report for information.
Date: 4 June 2015 Version: 1 Page: 6 Public Health Wales Minutes from Audit Committee 7 May 2015
The Counter Fraud annual report for 2014/15 will be received at the June’s Audit Committee meeting.
The Committee discussed whether the number of days allocated to for Counter Fraud work is excessive. The Committee requested a report on the trends of Counter Fraud for the next meeting.
ACTION: Craig Greenstock to produce report for the next meeting, including a comparison to other trusts across Wales.
11. Internal Audit action log
The Committee members received and noted the above document for information. Mr Keith Cox presented the report (item 27.15) to the Committee.
The Committee were asked to review those recommendations marked as complete, following a review by internal audit.
The Committee did not agree with the recommendation to close action 136 regarding statutory and mandatory training analysis, due to the ongoing issues reported with ESR.
ACTION: Jayne Gibbon to discuss whether action 136 should be closed with Keith Cox and Eleanor Higgins.
The Committee agreed that the update presented on ESR at the March’s Audit Committee meeting should be presented at other Committees.
12. External Audit action log
The Committee members received and noted the above document (item 27.16) for information.
It was suggested that a review of actions is required.
ACTION: Gabby Smith, Tami Rolls and Huw George to meet and discuss whether some recommendations may have been superseded by other work and produce an updated log at September’s Audit Committee meeting.
Date: 4 June 2015 Version: 1 Page: 7 Public Health Wales Minutes from Audit Committee 7 May 2015
13. Procurement report
The Committee members received and noted the above document (27.17) for information.
The Committee heard that from April 2015, all purchases over £30,000 need to be published.
14. Publication of papers
It was agreed that all except the Draft Annual Accounts, Annual Governance Statement, Audit Committee annual report and the procurement report could be published.
15. Any Other Business
The Committee heard of an incident of credit card fraud at the Temple of Peace. The card was cloned digitally. All fraudulent transactions had been refunded.
Date: 4 June 2015 Version: 1 Page: 8 Public Health Wales Minutes from Audit Committee 7 May 2015
Actions
No. Action Who Start End Status Revised implementation date 20.02 Arrange a development session for CO/EH 18.12.13 12.03.14 This action will be 31.07.15 Audit Committee, internal audit and addressed through the external audit to discuss findings of wider Board development the self assessment. work which is currently ongoing.
20.05 Board member survey and EH/CO 18.12.13 12.03.14 This action will be 31.07.15 recommendations from Structured addressed through the Assessment to be discussed at a wider Board development future informal Board meeting. work which is currently ongoing.
28.02 Dr Judith Greenacre to be invited to KC 07.05.15 10.09.15 provide an update on Public Health Development risks at the September meeting.
28.03 A list of the Velindre policies KC 07.05.15 10.09.15 requiring review to be presented to the Committee in a future meeting.
28.04 Terence Rose to include the limited TR/EH 07.05.15 04.06.15 assurance audits in the annual report to show the recommendations and the management responses.
28.05 Huw George and Tami Rolls to HG/TR 07.05.15 10.09.15 produce a report on the challenges faced in achieving the public sector payment performance target and the
Date: 4 June 2015 Version: 1 Page: 9 Public Health Wales Minutes from Audit Committee 7 May 2015
actions taken to date.
28.06 Tami Rolls to ensure that the draft TR 07.05.15 04.06.15 accounts make reference to the reason why Public Health Wales is not part of the scheme.
28.07 Craig Greenstock to produce report CG 07.05.15 04.06.15 on the Counter Fraud trends, including a comparison to other trusts across Wales.
28.08 Jayne Gibbon to discuss whether JG 07.05.15 10.091.15 action 136 should be closed with Keith Cox and Eleanor Higgins.
28.09 Gabby Smith, Tami Rolls and Huw GS/TR/HG 07.05.15 10.09.15 George to meet and discuss whether some recommendations may have been superseded by other work and produce an updated log at September’s meeting.
Completed actions
No. Action Who Start End Status Revised implementation date 27.01 HG to provide an update from NWIS HG 12.03.15 Information Governance on the system issues experienced Committee has also during the NATO summit last year. discussed this issue and an action has been agreed.
The Committee agreed to
Date: 4 June 2015 Version: 1 Page: 10 Public Health Wales Minutes from Audit Committee 7 May 2015
close this action. 28.01 Staff turnover to be discussed at the This is on the agenda for Developing the Organisation Developing the Committee. Organisation Committee on 28 May 2015.
Date: 4 June 2015 Version: 1 Page: 11
39.24
Minutes of the Public Health Wales Information Governance Committee Date of meeting: 27 March 2015 Time of meeting: 09:00 – 10.30 Venue for meeting: Boardroom, 14 Cathedral Road, Cardiff Version: v1
Present
Mr John Spence (Chair) Board Member, Public Health Wales Dr Carl Clowes Board Member, Public Health Wales Mr Terry Rose Board Member, Public Health Wales
In attendance
Mrs Rhiannon Beaumont-Wood Director of Nursing Mr Keith Cox Board Secretary Miss Cerian Dovey Business Support Manager Ms Jane Evans Information Governance Manager Ms Eleanor Higgins Corporate Governance Manager Mr John Morley Information Governance Manager
Apologies
Dr Tracey Cooper Chief Executive Dr Quentin Sandifer Executive Director of Public Health Services
Date: 5 June 2015 Version: 1 Page: 1 Public Health Wales Minutes Information Governance 27 March 2015
1. Welcome and apologies The Chair welcomed all those in attendance to the meeting of the Public Health Wales Information Governance Committee.
Ms Rhiannon Beaumont-Wood was welcomed to the Committee as the new Executive lead for Information Governance.
Apologies were received from Dr Tracey Cooper and Dr Quentin Sandifer.
2. Declarations of interest There were no declarations of interest to register.
3. Minutes and matters arising The minutes from the previous meeting were received by the Committee and approved as an accurate account.
Actions arising Ms Jane Evans provided an update on EU Data Protection legislation (action 18.04). A recent news article announced that the European Union has provisionally agreed to proposals meaning data can be shared without explicit consent for clinical purposes; for the provision of health or social care; for the treatment or management of health or social care systems and services; and for public health purposes.
The Committee heard that NWIS have also been drafting a Memorandum of Understanding to address Section 251 (action 19.02). This draft is currently with the Department of Health for comment.
Legal advice was being sought on whether a Memorandum of Understanding was required. The Committee agreed that regardless of the legal advice received, a Memorandum of Understanding would provide added assurance.
4. Information Governance incidents report The Committee members received and noted the above report for information. Mr John Morley presented the report (item 19.02) to the Committee.
The Committee discussed the presentation of the report.
Action: RBW/JM/JE to discuss how the results in the incidents report could be updated to represent trends better.
Date: 5 June 2015 Version: 1 Page: 2 Public Health Wales Minutes Information Governance 27 March 2015
The Committee also discussed the table outlining the details of incidents categorised as moderate and above.
Action: JE/JM to update the table to show whether it is the Health Board’s or Public Health Wales’ responsibility to resolve the incident.
The Committee discussed how some clinical incidents were being incorrectly classified in DATIX under “IG – records management”. However, the greatest risk to the patient was inappropriate case management / treatment because records were missing or mislaid. Therefore they should be reported under patient safety rather than Information Governance.
The committee discussed the relationship between Public Health Wales and Health Boards, where incidents are picked up through Public Health Wales systems but originate in a Health Board. There is a concern that it is not always known who should be contacted in the Health Board to take any actions forward.
Action: RBW and JE/JM to clarify the process of reporting clinical incidents.
The Committee were concerned over an incident regarding babies’ records. The Committee were advised that the allocation of NHS numbers is now completed by NWIS for babies born in Wales. The Committee requested further information regarding the Information Governance implications for Public Health Wales in relation to the new system for allocating NHS numbers.
Action: JE to produce a report on the process of allocating NHS numbers to babies, highlighting the number of Information Governance incidents before and after the function moved from England to NWIS.
5. Freedom of Information Act report The Committee members received and noted the above report (item 19.03) for information.
The Committee noted the improvements made in content of the report.
6. Information Governance training report The Committee members received and noted the above report for information. Ms Jane Evans presented the report (item 19.04) to the Committee.
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The Committee heard of a new induction package for new starters at Public Health Wales, which would provide information regarding statutory and mandatory training. Action: The draft induction pack to be circulated to the Committee for information. 7. Caldicott principles into practice (CPIP) The Committee members received and noted the above report for information. Mr John Morley presented the report (item 19.05) to the Committee.
It was noted that the compliance table should also demonstrate what is happening to address those areas of partial or non compliance. The Committee noted that they need assurances that mechanisms will be put in place to ensure future compliance.
Action: JM/JE to amend the table to show how the areas of partial compliance and non compliance are being addressed.
The Committee discussed their concerns that although there is a home working policy, compliance cannot be monitored. It was also noted that the Our Space project is expected to encourage more home working.
The Committee discussed the possibility of using a self-assessment tool where home workers will declare that they are following policy.
The Non-Executive Directors discussed their own home working arrangements and the need for encrypted laptops and lockable drawers.
The Committee requested a paper on the potential risks associated with home working and how they can be mitigated. This report should include the option of a self-assessment tool and the approach of the Our Space project to home working. The Committee will then be able to discuss their risk appetite on this topic.
Action: JE/JM to produce a report on the current situation and potential risks associated with home working for the Committee.
Action: RBW to add the risk associated with home working to the Information Governance risk register when produced.
The Committee discussed the need for a review of the implementation dates in the improvement plan.
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Action: JM to review the expected closure dates for actions in the Caldicott Improvement Plan for 2015/16.
8. Information Commissioners IG audit of Public Health Wales JE updated the Committee on the Information Commissioner’s audit of Information Governance arrangements in Public Health Wales.
The audit went well, with the only notable recommendation being the need for changing electronic door codes regularly.
An action plan is in place following the audit and the door codes have since been changed. RBW advised the Committee that the working group will be reviewing the audit in more detail.
9. Risk It was confirmed that the Information Governance group will be producing a register for the Committee.
10. Information Governance audits The above report (item 19.06) was received and noted by the Committee members for information.
11. Minutes from Information Governance Working Group The above minutes (item 19.07) were received and noted by the Committee members for information.
The Committee discussed the need for a one page update on the most recent working group meeting, along-side the approved minutes.
Action: A one page update on the most recent Information Governance working group meeting to be produced for the Committee.
12. Publication of papers It was agreed that all items can be published with the exception of the Caldicott principles into practice (CPIP) report.
13. Dates of future meetings 4 June 2015 10 September 2015 10 December 2015
14. Any Other Business With the changes to the Executive Team structure, the Committee noted the absence of a representative for informatics for this Committee.
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Actions in progress
No. Action Who Start End Status 16.02 Include an item on agenda for a CO 12.03.14 04.06.14 In progress – will be discussed by future meeting where risk refreshed Information Governance appetite can be reviewed Working Group and further update provided at Committee meeting in June.
19.02 Seek legal advice regarding JE 17.12.14 04.06.15 In progress - Legal advice has been content of Memorandum of received and is included in papers for Understanding for Section 251 the Committee held 4 June 2015.
19.03 JM/JE to make amendments to JM/JE 17.12.14 02.09.15 In progress - Generic Public Health leaflet and paper and work Wales and specific CDSC information towards gaining full compliance leaflets have been sent to the public by end of the financial year. user engagement panel for redrafting into a user friendly language used in the Screening divisions.
This panel meets in July.
19.04 HG to provide Committee with HG 17.12.14 04.06.15 HG to pick up this action with NWIS. progress updates on the NWIS outage incident.
20.01 RBW/JM/JE to discuss how the RBW/JM/JE 27.03.15 02.09.15 In progress - A draft report will be results in the incidents report reviewed by the working group. could be updated to represent trends better. 20.02 In the incidents report, JE/JM to JE/JM 27.03.15 02.09.15 In progress - The report has been update the table of incidents updated, however further work is
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categorised as moderate and required to improve the data. above to show whether it is the Health Board’s or Public Health A request has been made to have a Wales’ responsibility to resolve mandatory field in Datix for Health the incident. Board involvement.
20.03 RBW and JE/JM to clarify the RBW/JE 27.03.15 02.09.15 In progress - This action relates to process of reporting clinical 20.02. incidents. The requested change to Datix is needed to clarify the process.
COMPLETED ACTIONS
No. Action Who Start End Status 18.04 Continue to provide regular HG / RBW 27.10.14 17.12.14 Complete – There is no update from the (agenda updates to the Committee on the European Commission. However, it is item 6) progress of the EU Data expected to be adopted by the EU in Protection legislation. December 2015, with the UK be given two years to use the legislation, before roll out in December 2017.
20.04 JE to produce a report on the JE 27.03.15 Complete - This is included on the process of allocating NHS agenda for 4 June 2015. numbers to babies, highlighting the number of Information Governance incidents before and after the function moved from England to NWIS.
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20.05 The draft induction pack to be JM 27.03.15 Complete - A draft induction pack was circulated to the Committee. circulated 11 May 2015.
The draft will be discussed at the Leadership and Delivery meeting in June. 20.06 JM/JE to amend the compliance JM/JE 27.03.15 Complete - This is included on the table in the Caldicott Principles agenda for 4 June 2015. into Practice report to show how the areas of partial compliance and non compliance are being addressed.
20.07 JM/JE to produce a report on the JE/JM 27.03.15 Complete - This is included on the current situation and potential agenda for 4 June 2015. risks associated with home working for the Committee. Jane and John will continuing working with the Our Space project team to This report to include the option ensure risks are considered and a of a self-assessment tool and the privacy impact assessment is carried approach of the Our Space out. project to home working.
20.08 A risk to be added to the RBW 27.03.15 Complete - This has been added to the Information Governance risk risk register (risk 451). register, when produced, in relation to home working and the expected increase in homeworking with the introduction of Our Space.
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20.10 JM to review the expected JM 27.03.15 Complete - This is included on the closure dates for actions in the agenda for 4 June 2015. Caldicott Improvement Plan for 2015/16.
20.11 A one page update on the most RBW 27.03.15 Complete - This is included on the recent Information Governance agenda. working group meeting to be produced for each Committee meeting.
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