Bundle Health Board - Public 16 November 2017

Bundle Health Board - public 16 November 2017

1 B17/12 Joint Chairs' Welcome and Introductions 2 B17/13 Apologies 3 B17/14 Declarations of Interest 4 B17/15 Minutes of Meeting Held on 24.3.17 for Accuracy, Matters Arising and Review of Actions B17.15 Minutes CHC Board to Board 24.3.17 v0.03.doc 5 B17/16 Special Measures Update - Mr Gary Doherty (Verbal) 6 B17/17 Financial Position Month 6 and Financial Recovery - Mr Russ Favager B17.17 Finance report Month 6.docx 7 B17/18 Living Healthier Staying Well Update - Mr Geoff Lang B17.18a LHSW coversheet v2 12.10.17.docx B17.18b LHSW paper v3 12.10.17.docx B17.18c LHSW App 1 priorities paper.docx B17.18d LHSW App 2 Schedule of engagement events.docx B17.18e LHSW App 3 Phase 3 Engagement Plan V8.docx 8 B17/19 Seasonal Plan / Winter Resillience - Mr Geoff Lang / Ms Morag Olsen B17.19 Seasonal Plan 2017-18 FINAL v6_updated.pdf 9 B17/20 Welsh Government White Paper 'Services Fit for the Future' - Mr Gary Doherty B17.20a NWCHC White Paper Response (FINAL 092017 - E) inc appendices.pdf B17.20b White Paper Board Response BCUHB V1.0 Final Submitted 29 September 2017.docx 10 B17/21 Complaints Management : Update on Performance - Mrs Gill Harris B17.21a Complaints Management coversheet.docx B17.21b Complaints Management amended 7.11.17.docx 11 B17/22 Dementia Strategy : Progress Update - Mrs Gill Harris (Verbal) 12 B17/23 Recruitment and Retention of Medical and Nursing Staff - Dr Evan Moore / Mrs Gill Harris (Verbal) 13 B17/24 Date of Next Meeting Tuesday 10th April 2018 10.00am

4 B17/15 Minutes of Meeting Held on 24.3.17 for Accuracy, Matters Arising and Review of Actions 1 B17.15 Minutes CHC Board to Board 24.3.17 v0.03.doc

Minutes Board to Board CHC 24.3.17 v0.03 draft Page 1 of 6

Betsi Cadwaladr University Health Board (BCU) and North Wales Community Health Council (NWCHC)

Joint Board Meeting

Minutes of the meeting held on 24.3.17 in Neuadd Pendre, Tywyn

Present:

Health Board Community Health Council

Dr Peter Higson, Chairman Ms Jackie Allen, Chair - NWCHC Mr Gary Doherty, Chief Executive Mr Geoff Ryall-Harvey, Chief Officer - NWCHC Mr John Cunliffe, Independent Member Miss Joy Baker, Member - Conwy Ms Jenie Dean, Independent Member Ms Eleanor Burnham, Chair - Wrexham Cllr Phil Edwards, Chair, Stakeholder Reference Group Miss Christine Evans, Member - Denbighshire Mr Russell Favager, Executive Director of Finance Mr Colin Herbert, Chair - Flintshire Cllr Bobby Feeley, Independent Member Cllr Eryl Jones-Williams, Member -Gwynedd Mrs Margaret Hanson, Vice Chair Mr Mark Thornton, Vice-Chair NWCHC Mrs Gill Harris, Executive Director of Nursing & Midwifery Mr Geoff Lang, Executive Director of Strategy Mrs Grace Lewis-Parry, Board Secretary Mrs Lyn Meadows, Independent Member Dr Evan Moore, Executive Medical Director Prof Michael Rees, Chair, Healthcare Professionals Forum (part meeting) Mr Andy Roach, Director of Mental Health & Learning Disabilites Mr Ceri Stradling, Independent Member Mr Adrian Thomas, Executive Director of Therapies & Health Science Mr Chris Wright, Director of Corporate Services

In Attendance: Mrs Kate Dunn, Acting Head of Corporate Affairs Translator/Observers

Agenda Item Action

B17/1 Welcome and Apologies

Mrs Allen and Dr Higson opened the meeting and welcomed those present.

Apologies were received on behalf of the Health Board from Cllr Cheryl Carlisle, Mrs Marian Wyn Jones, Mr Martin Jones, Ms Morag Olsen, Miss Teresa Owen, Mrs Bethan Russell-Williams, Prof Jo Rycroft-Malone, and Mrs Nicola Stubbins Minutes Board to Board CHC 24.3.17 v0.03 draft Page 2 of 6 Apologies were received on behalf of the Community Health Council from Mr John G Williams.

B17/2 Minutes of the previous meeting held on 10.10.16

The draft minutes were approved as a correct record pending correction to show Mrs KD Eleanor Burnham’s title as Vice Chair.

B17/3.1 Matter Arising – Social Services and Well-Being (SSWB) Act

B17/3.1.1 Mr Lang presented the paper which provided an update on the development of the North Wales Population Assessment as a requirement of the SSWB Act which was due for publication by the 1st April 2017. He noted that the Act set out guidance in terms of themes that Welsh Government would expect the population assessment to cover, and that the respective partners in health and social care were currently receiving the assessment at their Board meetings for approval. Mr Lang indicated that the next step would be to produce Area Plans with Local Authorities and other partners.

B17/3.1.2 Mr Lang indicated that the SSWB Act was separate legislation to the Future Generation & Well-Being Act, however, there was a need for alignment. It was noted that each of the four Public Service Boards in North Wales also had to undertake their own health and well being assessment by May 2018, and there would need to be a coherent approach to minimise duplication and overlap with the population assessment. The range of assessments would in turn inform any strategy development in North Wales.

B17/3.1.3 As part of the discussion which it ensued it was confirmed that an audit of progress against requirements of the Act would be undertaken by Wales Audit Office towards the end of 2017-18. It was also noted that the population assessment had been developed through engagement with communities. CHC members raised concerns over the availability of some social care services at weekends, and availability of residential care home placements particularly for mental health. It was noted that a piece of work had been undertaken within Denbighshire around the care home economy. It was acknowledged there were different challenges across the different areas but there were opportunities to share good practice and for public bodies to work more cohesively.

B17/3.1.4 The point was made that the population assessment should lead onto identifying solutions and a way forward - particularly responding to the restrictions on resources. It was noted that this was the challenge for the Area Plans to support different ways of working on an integrated basis.

[Prof M Rees joined the meeting]

B17/3.1.5 With regards to the status of the document, Mr Lang confirmed that the Health Board was required to publish the population assessment but it would be subject to approval and updating on an ongoing basis.

B17/4 Special Measures End of Phase 2 Report

B17/4.1 Mr Doherty presented the detailed report covering Phase 2 of Special Measures, noting that the report was further supported by a whole range of documentary evidence across all the areas identified under Special Measures. He indicated that members would be able to identify a range of actions that had been completed and also areas where work Minutes Board to Board CHC 24.3.17 v0.03 draft Page 3 of 6 remained in progress and that feedback was awaited from Welsh Government on the submission. Mr Doherty also confirmed that there was a programme of reporting in detail on the individual Special Measures areas to the Health Board in public session

B17/4.2 The issue of response times to concerns and complaints was raised, with a specific example given of delays in the provision of a specialist wheelchair. Mr Doherty clarified that this particular service was commissioned through the Welsh Health Specialised Services Committee however he accepted that individual health care needs must be met irrespective of the element of the service it pertained to, and that any complaints should be dealt with in a timely manner. Mr A Thomas would be happy to AT follow up the specific wheelchair issue with Cllr Jones-Williams. It was confirmed that the Health Board was meeting the requirements regarding acknowledgement of complaints and there was an improved position in terms of response times but the overall performance was still not where the Board would wish to be.

B17/4.3 A discussion ensued regarding the nature of complaints in that people raised concerns for different reasons ie; not always to receive recompense, but to try and ensure that lessons were learnt and improvements made. It was acknowledged that the complaints process could be complex and lengthy and that the implementation of a PALS model (Patient Advice & Liaison Service) would help guide patients and families through the process, improving response rates and ensuring a better experience. Mr Wright indicated it was hoped to launch PALS within BCUHB in June. The question was asked whether being in Special Measures had affected recruitment opportunities for medical staff, and Mr Doherty felt this would be difficult to evidence, but the Board were not aware of this being the case. He did note there would be wider benefits associated with the removal of Special Measures such as improved public confidence. With regards to mental health, Mr Thornton noted the work that was ongoing to improve capacity and capability and sought assurance that effort would be sustained to ensure a positive impact on patients. Mr Roach confirmed that the draft Mental Health Strategy would be presented to the Health Board in April, and had been developed in conjunction with service users. Mr Thornton also raised the importance of improving appraisal rates which would support the workforce strategic priorities. Mr Doherty indicated that appraisal paperwork had been refreshed and re-launched to make the process smoother whilst retaining the relevance of the conversation between the individual and line manager.

B17/5 Urology

B17/5.1 Mrs Allen outlined the background to this agenda item in that the CHC were concerned over the length of time that patients were being fitted with catheters, and that a meeting was being sought with clinicians to discuss these concerns. Mr Lang indicated that the Health Board had welcomed the report from the CHC which highlighted a number of important issues and had been the impetus for a range of actions including raising awareness. Dr Moore also welcomed the report and noted there were challenges in addressing the issues raised through alternative ways of providing the service, increasing capacity and capability, and developing a consistent approach across the Health Board. Miss Evans outlined her concerns that catheterisation should not be seen as treatment, and she provided Dr Moore with a copy of a journal extract on the subject of urology costs. Mrs Allen also outlined that anecdotal evidence was being provided to the CHC that staff were sometimes nervous about treating urology patients and they felt that specialist skills within nursing teams was being lost.

Minutes Board to Board CHC 24.3.17 v0.03 draft Page 4 of 6 B17/5.2 Mrs Hanson confirmed that the Board’s Quality, Safety & Experience Committee had considered the CHC’s report on urology paper in January and a response from the clinical teams had been provided at that time. A discussion ensued regarding the timeliness of scheduling the report for discussion, and it was suggested that the route for GH the CHC to submit reports to the Health Board may need to be revisited.

B17/6 Joint Replacement / Orthopaedic Wait Times

B17/6.1 Mr Ryall-Harvey reported that CHCs nationally had agreed to make this area one of its work projects. He referred to some intelligence that some patients who had undergone the surgery subsequently felt it had not been worthwhile. Mr Doherty accepted that knee surgery was BCUHB’s largest challenge in terms of a single specialty with waiting time concerns, and that plans to address this would be taken to the Health Board meeting on 20th April. He also reminded members that there were opportunities to improve the situation at the pre-surgery stage, including falls prevention, exercise and weight management. Mr Doherty also noted that sometimes the outcome of surgery did not meet patient expectations, although it had been technically successful. Dr Higson suggested that the orthopaedic waiting list did tend to be fairly dynamic with patients moving up and down the list depending on their clinical need. He accepted the Health Board and CHC’s concerns about the total numbers of patients waiting.

B17/6.2 A discussion ensued. It was suggested that a proportion of people on the waiting list would benefit from lifestyle changes and physiotherapy, and that the human element must be recognised with pain being the key factor. Prof Rees noted that the Healthcare Professionals Forum had received a recent presentation which highlighted the developments within primary care and the benefits of multi disciplinary working amongst healthcare professionals.

B17/7 Older People in Community Hospitals : Avoiding Boredom and Loneliness in Hospital

B17/7.1 Mr Ryall-Harvey outlined the findings of the CHC report, summarising that there were notable variations in practice, sometimes even within the same hospitals, and that boredom and loneliness was a significant issue. The report highlighted a range of actions to improve patient experience, some of which would appear to be easily achieved – for example, better access to reading material. A key positive within the study was free access to wi-fi in the majority of BCUHB wards, and there were other examples of excellent practice but these were not consistent.

B17/7.2 Dr Higson welcomed the report and noted the importance of treating patients and both people and individuals, and ensuring their health and well-being needs were met whilst in the care of BCUHB. He suggested that where there were gaps in the provision of hospital radio, this could be met through listening online, and he also wished to recognise the arts in health project which had been well-supported.

B17/7.3 Mrs Harris acknowledged the importance of the report and was pleased to read of the good practice which had been identified whilst recognising the inconsistencies. She noted there was a need to listen to individuals to better identify what would help improve their experience. Mrs Harris outlined a range of actions which she would wish to see developed to respond to the report including flexibility around access to wards and visiting times, the normalisation of the ward environment for dementia patients, giving ward staff the ‘permission’ to respond to individual patient needs and the use of volunteer visitors. Minutes Board to Board CHC 24.3.17 v0.03 draft Page 5 of 6 B17/7.4 A discussion ensued around patients’ own electronic devices and the need for PAT testing of charging cables and plugs and it was felt that there must be acceptable workarounds to this issue. It was confirmed there were no infection prevention issues with regards to books and reading material.

B17/7.5 It was agreed that Mrs Harris would meet with Mrs Allen and Mr Ryall-Harvey to respond to the report and agree some priorities for the Health Board to progress. GH

[Mr Jack Evershed and Mrs Ruth Hall joined the meeting]

B17/8 Public Patient Engagement

B17/8.1 Mr Wright presented the paper which provided an update on public engagement issues including future planned activity. He highlighted that Hywel Dda Health Board were undertaking a continuous engagement pilot which would provide an opportunity to share best practice, expertise, skills and resources as well as helping address any common barriers and issues. The paper outlined a range of engagement events that had taken place as part of the Living Healthier Staying Well Strategy. The paper was welcomed the paper and the CHC acknowledged that the Board have moved on significantly in terms of public engagement over the past two to three years.

B17/9 Discussion with Joint Chairs of Mid Wales Healthcare Collaborative (MWHC)

B17/9.1 Mrs Hall and Mr Evershed gave an overview of the work of the MWHC, indicating that the first two years had been focused on improving communication across the respective partners and moving towards the shared intent of joint planning. The next phase would be to ensure collaborative delivery in conjunction with the three Health Boards, Ambulance Trust and the Local Authorities. The importance of ensuring that systems supported the mainstreaming of collaboration into core business was highlighted, as was Welsh language issues. Mr Thomas provided an update on telehealth and it was noted that the Cabinet Secretary had recently received a demonstration of consultations being undertaken via video link which had been well received. It was reported that broadband issues which could be a barrier to this work were being addressed through Offcom. Mr Lang gave an update on the palliative care briefing which had identified positive work but inconsistencies.

B17/9.2 In response to a question regarding the relationship of the MWHC to Public Service Boards (PSBs), it was reported that the MWHC had been launched by the Minister and was a new platform for engaging with the public about service delivery in this particular rurual geographical area which crossed organisational boundaries, and aimed to improve collaboration in clinical practice. PSBs were still emerging but were working at a different level.

B17/10 Any Other Business

Dr Higson invited Mr Morgan Vaughan to address the joint meeting. Mr Vaughan recorded his thanks as a resident of Tywyn and previous Chair of the Tywyn and District Memorial Hospital Appeal Fund Committee for the excellent working relationship that had been, and was still enjoyed.

B17/11 Date of Next Meeting Thursday 26.10.17 10am. Venue to be agreed. Minutes Board to Board CHC 24.3.17 v0.03 draft Page 6 of 6

Summary Action Plan Minute Action Agreed Officer(s) Ref Responsible B17/2 Amend and create approve version of previous minutes K Dunn COMPLETED B17/4.2 Follow up specific concerns re wheelchair provision with Cllr Jones- A Thomas Williams COMPLETED B17/5.2 Review and reflect on route / process for receipt of CHC reports into G Harris the Health Board COMPLETED B17/7.5 Meet with CHC Chair and Chief Officer to respond to report on older G Harris people in community hospitals COMPLETED

Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board North Wales Community Health Council is the operational name of the Betsi Cadwaladr Community Health Council

6 B17/17 Financial Position Month 6 and Financial Recovery - Mr Russ Favager 1 B17.17 Finance report Month 6.docx

Board to Board

16.11.17

To improve health and provide excellent care

Title: Finance Report Month 6

Author: Mrs Helen MacArthur, Head of Financial Services

Responsible Mr Russell Favager, Executive Director of Finance Director: Public or In Public Committee Strategic Goals 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS’ best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through ✓ innovation and research 7. Support, train and develop our staff to excel.

Approval / This report is subject to scrutiny by the Finance and Performance Scrutiny Route Committee prior to submission to the Board.

Purpose: The purpose of this report is to brief the Boards on the financial performance and position of the Health Board for the year to date and the forecast for the year.

Significant issues The Health Board approved an Interim Financial Plan on 16 March and risks which approved a deficit budget as a planning assumption of £26m; following a need to deliver savings of £35.4m.

As at Month 6, there is an adverse variance against plan of £12.0m. The variance relates to under delivery of savings and continued overspends within Secondary Care and Mental Health & Learning Disability Division (MHLD) due to unscheduled care pressures, out of area placements, nurse agency costs and Continuing Healthcare costs. Action is being taken in relation to known areas of pressure including the use of medical and agency nursing within the secondary care divisions and individual packages of care.

The forecast position is as stated in the Interim Financial Plan of £26m although this is extremely challenging and represents a significant risk at present. 1

A Financial Recovery Plan has been developed and approved at a special meeting of the Board on 7 September. The Financial Recovery Plan reduces the current run rate trajectory and if fully delivered reduces the forecast deficit to £33.4m. Further actions will be required to achieve the planned deficit of £26m. A Financial Recovery Group, chaired by the Health Board chairman and reporting directly to the Board has been established to oversee delivery, the group will meet fortnightly.

It is recognised that the changes necessary to achieve savings on a recurrent basis is a significant challenge both to achievement of this year’s budget plus the underlying financial position and will require a move from operational (improving what we currently do) to tactical (the way) and strategic (what we do) change. Special Measures Costs associated with implementing improvements arising from Special Improvement Measures are included within departmental budgets. Framework Theme/ Expectation addressed by this paper

Equality Impact Not applicable Assessment Recommendation/ It is asked that the report is noted. Action required by the Board

Executive Director of Finance Report Month 6 2017/18

Russell Favager

Executive Director of Finance Betsi Cadwaladr University Health Board

3 1. Executive Summary

1.1 Purpose

• The purpose of this report is to outline the financial position and performance for the year to date, confirm performance against financial savings targets and highlight the financial risks and outlook for the remainder of the year.

1.2 Context

• The Health Board has two statutory duties to achieve:

1 To ensure that its revenue and capital expenditure does not exceed the aggregate of the funding allocated to it over a rolling period of 3 financial years, the second of which commenced on 1st April 2015 and will end on 31st March 2018 and 2 To prepare a plan to secure compliance with the above duty, providing healthcare and improving the health of the population, and for that plan to be submitted to, and approved by the Cabinet Secretary. This was first required in 2014/15.

• The Health Board was placed in Special Measures in June 2015 and, in agreement with Welsh Government, has not submitted a three-year plan. As a result of this, the Health Board has been operating under Annual Operating Plan arrangements.

• The table below sets out the Health Board’s revenue performance against the first and second rolling three year period. On the 16 March, the Board approved the 2017/18 budget of a deficit of £26m.

17/18 Year 14/15 15/16 16/17 (budget) £’m 26.6 19.5 29.8 26.0 First rolling three year period 75.9 Second rolling three 75.3 year period

• The Minister for Health and Social Services placed the Health Board in Special Measures in June 2015. The implementation of the Special Measures Improvement Framework has resulted in additional costs for the Health Board, necessitated to address longstanding areas of concern. The Health Board received a specific allocation in 2015/16 and 2016/17 to support the additional costs incurred as part of Special Measures. Many of these costs still remain and are currently funded through the Health Board’s general revenue allocation.

1.3 Summary of key financial targets

Annual Year to Year to Forecast Key Target target date date Risk target actual Achievement against Revenue Resource Limit £’000 (26,000) (13,200) (25,161) (Performance against £26m budget deficit) Performance against identified savings £’000 31,715 13,374 11,050 (Internal target against ledger profile) Performance against unidentified savings £’000 3,685 1,842 0 (Internal target against ledger profile) Achievement against Capital Resource £’000 65,030 28,027 24,340 Limit

Compliance with the requirement to pay Non-NHS invoices within 30 days of receipt % 95.0 95.0 94.2 of a valid invoice

Cash balance at month-end £’000 7,300 7,300 5,004

1.4 Revenue position

• At Month 6, the Health Board has overspent by £25.2m (£3.5m in month 6). Of this, £13.2m (£2.2m in month) relates to the Health Board’s planned budget deficit and £12.0m (£1.6m in month) represents an adverse variance against the financial plan.

• The adverse variance reflects under delivery of savings across the Health Board and activity and cost pressures predominantly within the divisions of Secondary Care and Mental Health and Learning Disabilities. The monthly run rate improved in month by £0.9m but this was due to one-off non-recurring benefit with the underlying run rate, and consequential overspend, being consistent since month 2. There needs to be a sustainable improvement in the underlying run rate in order to develop confidence around recovering the financial position.

1.5 Cash releasing efficiency savings

• The Health Board set itself an ambitious savings target of £35.4m (3.5%). As at Month 5 savings of £32.3m (Month 5 - £32.0m) have been identified and recognised within this financial report. Of the identified savings £26.2m (60%) are reported to be recurring in nature.

• Savings delivery is generally profiled in the Health Board’s financial ledger in equal twelfths which spreads the risk of non-delivery equally across the Financial Year, although where more confidence and certainty in specific schemes is considered then they will follow a different profile. The approach adopted is considered prudent due to the value of unidentified schemes and those rated as high risk. A number of schemes are planned for operational delivery during the final quarters of the financial year which has resulted in a profile variance between the ledger and the manager expectations. The operational profile of schemes and the year to date impact between the two methodologies equates to £1.9m of the £12.2m variance.

1.6 Forecast revenue position and risk assessment

• The Health Board’s current expenditure (run rate) has been consistent in the first six months on the financial year with an average of £129.4m per month. It is pleasing to note an improvement in the deficit position in the current month, however, this improvement relates to one-off income receipt, funding assumptions around the Drugs Treatment Fund and performance delivery within external contracts. Without the significant intervention through the delivery of mitigating and recovery actions contained within the Financial Recovery Plan the deficit projection would be materially in excess of the original budget set and therefore delivery of the recovery plan is critical.

• The forecast remains for a £26m deficit for the year as a whole although the Board have previously been notified that, given the current run rate, this represents a significant challenge to achievement. Even if full delivery of the recovery actions this will only reduce the forecast deficit to £33.4m and further actions are still required to achieve the original budget deficit of £26m. Further work is on-going around closing the £8m gap

• The Financial Recovery Plan (FRP) approved by the Board meets bi-weekly to oversee and monitor delivery of the plan. The FRG is Chaired by the Health Board Chair and membership includes the Chairs of the Finance and Performance and Audit Committees, the Chief Executive, Executive Director of Nursing and Midwifery and Executive Director of Finance.

1.7 Balance sheet

• The Health Board is required to pay at least 95% of non-NHS invoices within 30 days of receipt of a valid invoice. As at Month 6, the Health Board has paid 94.2% of its non-NHS invoices within 30 days. This is below target mainly due to delays in the receipting of and pricing queries relating to nurse agency invoices, following the introduction of the All Wales Framework. Focussed work is in progress to address weaknesses to improve performance over the remaining six months of the financial year.

• The closing cash balance as at 31 August was £5.0m which is within the internal target set by the Health Board. As the Health Board has a set a deficit budget and the full year cash requirement will exceed its cash allocation, the management of cash remains a key priority.

1.8 Key Messages

• The Health Board’s financial position as at Month 6 is an adverse variance against plan of £12.0m. The in month deficit position of £3.5m reflects continued pressures arising from non-delivery of savings, pressures with Secondary Care and also within Mental Health and Learning Disabilities (MHLD). Despite all the additional work and controls put in place to date, there is little evidence of the overall underlying run rate changing. • Achievement of the forecast deficit of £26m is dependent on delivery of identified saving schemes and delivery of the Financial Recovery Plan. In addition to these

actions further recovery actions in the region of £8m are required to achieve the £26m.

• Delivery of the forecast will require continued implementation and compliance of the significant management grip and control actions and risk management identified throughout the organisation, full delivery of the Financial Recovery Plan and a reverse of some of the current trend trajectories shown in some divisions. Managers need to ensure that they are focussed on their entire budget portfolio and not only evident issues and savings in order to manage the risk of unsighted emerging issues.

1.9 Key actions being taken

• Financial Recovery Plan for £14.5m approved by the Board is overseen by a Board Financial Recovery Group chaired by the Health Board chairman.

• Further financial savings opportunities are being explored, led by the Chief Executive with the Executive Team.

• Further strengthening of the financial governance and accountability framework.

• Accountability Agreements are all signed, and kept up to date as staff move/change.

• Further strengthening of the financial reporting, through a weekly Intelligence Dashboard and a comprehensive Day 6 Flash Report.

• The ongoing costs of agency staff remains a key financial pressure. Stringent financial controls are being operated to ensure that there is an escalation process for high cost placements and approval mechanisms are robust, although assurance cannot be given that these are being followed consistently in all instances.

• The implementation of the Medical Agency Pay Cap is expected to result in improvements in the Health Board forecast position although the impact on services needs to be managed.

• The arrangements for procuring goods and services, including drugs, outside of the Health Board are a key focus during 2017/18 to ensure that proper contractual and management arrangements are in place.

• Underlying deficit position being assessed as part of planning cycle for 2018/19 and development of the IMTP.

7 2. Revenue position

2.1 Financial performance by division

The table below provides an analysis of the Month 6 budget to actual position for the Health Board’s operating divisions.

North Variances West Centre East Wales Total £m £m £m £m £m Area Teams (0.3) (0.0) 1.5 0.5 1.7 Contracts 0.6 0.6 Secondary Care 1.1 3.3 1.5 2.2 8.1 Mental Health 5.5 5.5 Corporate (0.5) (0.5) Reserves (2.2) (2.2) Variance from Plan 0.8 3.3 3.0 4.9 12.0 Planned Deficit 13.2 Total 0.8 3.3 3.0 4.9 25.2

Red: represents adverse variances in excess of 0.5% Amber: represents adverse variances equal to, or less than, 0.5% Green: represents favourable variances

2.1.1 Commentary by division

• The Area Teams are currently reporting an adverse variance of £1.7m due to pressures arising from undelivered savings, higher GP prescribing costs and growth in CHC placements. These are partially offset by underspends within the dental service and area management.

• Contracts are reporting a favourable variance due to activity with local providers, however, there are pressures within the WHSSC contract. The year to date position does not include costs associated with the new English treatment tariff known as HRG4+. These costs are being managed by WHSSC and are estimated to be circa £4m for the full year.

• Secondary Care teams have a total overspend of £8.1m due to undelivered savings and other cost pressures within pay related expenditure. The use of medical and nurse agency remains a significant factor some of which is being incurred to deliver improved waiting time performance.

• Mental Health and Learning Disabilities (MHLD) has a year to date overspend of £5.5m which is due to out of area placements, pressures with individual packages of care, agency costs and undelivered savings.

• Further analysis by operating division is provided in Appendix 2.

2. Revenue position 2.2 Cumulative revenue position by expenditure category Spend Variance In month Subjective trend YTD YTD variance 13 Month Trend Narrative analysis £'m £'m £'m

The year to date variance reflects signficant pressures arising Pay (Health Board from the use of agency staff due to vacancies. This is most 250.6 3.7 0.0 provided) evident within the Medical and Dental, Nursing and Admin and Clerical staff groups.

Action is being taken across the Health Board to manage costs Clinical Supplies associted with clincial supplies and services. This includes 32.0 0.2 0.1 (excluding drugs) actions to improve consistency across the Health Board to ensure that cost savings are achieved.

Cost pressures are being experienced in a range of areas including high cost drugs for cancer patients, care of the elderly, Clinical Supplies - 29.5 0.4 0.2 dermatology and sexual health. The impact has been partially drugs mitigated through anticipated additional funding from the all Wales Treatment Fund.

This includes a range of expenditure headings including premises costs, utilities, travel costs and losses. Significant Other non pay 55.8 22.2 2.8 management action is taken to identify opportunities to manage costs. The year to date and in month variances reflect the phasing of savings schemes.

The in month variance reflects an increase in prescribed drugs Primary Care 141.7 (2.7) 1.2 which remains a key risk for the full year. The year to date underspend includes dental slippage.

Spend Variance In month Subjective trend YTD YTD variance 13 Month Trend Narrative analysis £'m £'m £'m

This area of expenditure includes services with other NHS bodies including WHSSC. The in month variance includes an Contracted underspend on locally managed contracts. This remains a key 121.9 1.5 (1.0) services area of risk for the remainder of the financial year. No provision has been made for costs associated with HRG4+ which is being managed by WHSSC.

This area of expenditure is subject to signficant activity and cost pressures. The variance relates to Mental Health and CHC 46.5 2.0 1.1 Learning Disabilities schemes. Action is being taken to manage costs although this remains a key risk area.

The level of income received by the Health Board includes Other Income (63.3) (2.1) (0.9) additional income from other public sector bodies including HMP Berwyn.

WG Allocation (689.4) 0.0 0.0

Total (74.9) 25.2 3.5

10 2. Revenue position

2.2.1 Pay

• Payroll expenditure year to date is £350.6m (including Health Board staff within primary care functions). The year to date variance on payroll expenditure is £4.5m which includes agency pressures, expenditure in Primary Care managed practices and non delivery of payroll savings schemes.

62,000

60,000

58,000

56,000

54,000

£'000 52,000

50,000

48,000

46,000

44,000 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Substantive Bank Overtime Agency Average Substantive Average Bank Average Overtime Average Agency

• The Health Board has fully implemented the changes to the regulations for the taxation treatment of off payroll workers (agency and locum staff) which became effective on 6th April and requires that payments are taxed at source. These changes are mandated across the public sector. Work is now ongoing to ensure that contractual arrangements are updated to reflect the new arrangements.

• The year to date expenditure on agency staff is £19.6m which is an average of £3.3m per month. This is a reduction against the monthly average of £3.8m for 2016/17. The expenditure represents 5.6% of the total pay expenditure for the Health Board

• The table below provides the trend on agency costs for the previous thirteen months and demonstrates the variability in this area of expenditure. Excluding Managed Practices, Medical and Dental Pay is £1.9m overspend year to date which includes an overspend in relation to agency doctors. While it is pleasing to report the trend for medical agency is in a positive direction this needs to be treated with some caution as increases in substantive appointments should result in a corresponding reduction in agency usage. The Health Board recovery actions include reductions in agency expenditure so a significant reduction in the current run rate of these costs is required.

• Monthly expenditure on substantive staff amounted to £54.9m including overtime and bank nursing.

3,000 2,500 2,000 1,500

1,000 Cost £000sCost 500 0

Agency Medical Agency Nursing Agency Other

12 3. Cash Releasing Efficiency Savings & Recovery Plans

3.1 Savings requirement

• The Health Board has a challenging savings target of £35.4m for 2017/18. This includes £30.4m (3%) for cash releasing savings and a further £5.0m (0.5%) for cost avoidance schemes.

• All saving schemes have a service lead and are required to have a project initiation document (PID) which includes the need to undertake a quality impact assessment to ensure that quality and safety are appropriately considered.

3.2 Identified Savings

• A total of £32.3m of schemes have been identified leaving an unidentified balance of £3.1m. Work has been ongoing since the start of the financial year to reduce the impact of the gap although there has been little progress on this and this gap has been surpassed by the Financial Recovery Plan

• Of the identified saving schemes planned it is anticipated that £26.2m (81%) are recurring in nature. The reliance on non-recurring schemes remains a significant financial risk for future years.

• Identified savings have increased in Month 6, by £0.3m. This is due to the addition of two new schemes since last month.

• All savings schemes are subject to scrutiny to ensure that there is a robust approach supported by a project brief and appropriate quality and equality impact assessments. This work is being overseen by the PMO Steering Group which is chaired by the Chief Executive, additionally given the critical importance around delivery of the savings target this is a standing item on the weekly Executive Team meetings.

• Information sharing opportunities have been and continue to be shared with all divisions, including work under the Value agenda; the Opportunities Menu derived from NHS England, and sharing of schemes from across the Health Board with peers

3.3 Financial Recovery Plans

• The Board has approved a Financial Recovery Plan which includes additional recovery actions for implementation in this financial year. To date recovery opportunities of £14.5m have been identified which are expected to reduce the current run rate outturn projection to £33.4m.Delivery of these savings will also be managed using the PMO methodology.

• Delivery in Month 6 was £1.2m which is £0.5m ahead of profile and relates to profiling of local commissioning arrangements with English NHS bodies. The full year delivery remains in line with target.

• Further opportunities continue to be explored to reduce this figure to the £26m planned deficit budget set by the Board.

• Further strengthening of the financial governance and accountability framework will be required in order to provide resilience needed to deliver the financial plans; especially given the additional risks of delivering these recovery actions in addition to a challenging savings programme

3.4 Performance

• Savings delivery is generally profiled in the Health Board’s financial ledger in equal twelfths which spreads the risk of non-delivery equally across the Financial Year, although certain specific schemes follow a different profile. The approach adopted is considered prudent due to the value of unidentified schemes and those rated as high risk. A number of schemes are planned for operational delivery during the final quarters of the financial year which has resulted in a profile variance between the ledger and the manager expectations. Appendix 1 confirms the operational profile of schemes and the year to date impact between the two methodologies, including the phasing of the recovery plans, equates to £1.9m of the £12.2m variance.

• The risk profile and anticipated delivery of schemes will continue to be critically reviewed over the forthcoming months to further strengthen the arrangements. The performance to-date against the manager's profile is an under delivery of £2.3m, this is of significant concern..

• It is essential that assurance is gained through the PMO Steering Group and the Financial Recovery Plan that planned savings will be delivered in accordance with the delivery profiled

14 4. Revenue Forecast Position

4.1 Financial year forecast revenue position

• A financial risk assessment was undertaken as part of the budget setting process to understand the underlying assumptions and risks faced by the Health Board. The planned deficit of £26m has been reviewed, in conjunction with the Financial Recovery Plan that has been developed.

• Whilst at this stage the forecast position remains at the planned deficit of £26m achievement of this is extremely challenging. This will require the identification of further recovery actions of circa £8m and full delivery of these identified to date.

• The table outlines the key risks to delivering the original budget deficit of £26m.

Worst Risk Explanation case level

£’000 Original planned 26.0 budget deficit Unidentified/under 7.5 The Health Board was required to delivery £35.4m of delivery of savings to achieve the original budget deficit of £26m. savings Continuing 3.1 The Health Board is experiencing significant ongoing Healthcare pressures in relation to both the underlying number and Packages (CHC) cost of care packages. These are being monitored on a weekly basis.

Secondary Care 3.0 There are risks to the secondary care position which Risks includes additional drugs costs and non delivery of expected savings due to activity and demand pressures. This includes not being able to close escalation beds and non delivery of agency reductions. High risk 5.0 All schemes have been risk assessed and are being schemes within carefully monitored. the Recovery Plan Change in tariff 4.0 The current working assumption is that the HRG4+ risks methodology in will be resolved through negotiation between WHSSC and England (HRG4+) NHS England. The WSSC contain is subject to detailed and risks to the scrutiny and is being actively managed. WHSSC contract Other external 0.5 The Health Board is actively managing all external contracts contracts although a demand risk remains. Managed Practice 0.5 The number of Managed Practices continues to increase and action is being taken to contain cost pressures. Enhanced 1.0 The provision of additional services within Primary Care services within remains a risk the forecast. Primary Care Estates and 0.5 There are cost pressures arising from catering costs and Facilities costs associated with the Estates survey Worst case 51.0 scenario

• The outcome of the Supreme Court Judgment in relation to Continuing Healthcare fees has not been factored into the Health Board’s financial projections. Work is ongoing to estimate the potential impact with colleagues across Wales to ensure a consistent approach. A verbal update will be given at the Board meeting.

16 5. Balance Sheet

5.1 Cash

• The closing cash balance as at 30 September was £5.0m which is within the internal target set by the Health Board.

• The Health Board has a set a deficit budget and therefore the full year cash requirement will exceed its cash allocation. The management of cash remains a key priority.

5.1.1 Accounts Payable

• The Health Board is required to pay at least 95% of non-NHS invoices within 30 days of receipt of a valid invoice. As at Month 6, the Health Board has paid 94.2% of its non-NHS invoices within 30 days. This is below target due to the ongoing delays in the processing and receipting of nurse agency invoices, following the introduction of the All Wales Framework. Focussed work is in progress to address weaknesses to improve performance.

Trade Aged Payables 14,000 12,000 10,000 8,000

£'000 6,000 4,000 2,000

Jul

Oct Apr

Jan Jun

Mar

Feb

Nov Dec Aug

May

Sep-16 Sep-17

< 30 days 31 - 60 days 61 - 90 days > 90 days >60 days

5.1.2 Accounts Receivable

• The management of amounts due to the Health Board is a key focus of the cash management arrangements. The increase in Monthly monitoring of amounts outstanding is undertaken to ensure that recovery is in place with a quarterly report to the Audit Committee. Debts over 90 days are a particular focus and include staff salary overpayments for which instalments are agreed.

Trade Aged Receivables

12,000

10,000

8,000

6,000 £'000

4,000

2,000

Apr

Jan

Feb Mar

Dec

Oct

May

Nov

June

Jul-17

Sep 16 Sep

Aug-17 Sep-17

< 30 days 31 - 60 days 61 - 90 days > 90 days Total >60 days

5.2 Capital expenditure

• The Capital Resource Limit at Month 6 is £65.03m. There is significant investment in a number of key projects including the YGC redevelopment, the SURNICC, the redevelopment of the Emergency Department in YG and primary care health centre developments. In addition, the Health Board has received a number of allocations for upgrades across the Health Board estate and IT.

• Year to date expenditure is £24.3m against the plan of £28.2m. The year to date slippage of £3.9m will be recovered over the remainder of the financial year subject to risks associated with any funding adjustments.

18 6. Conclusions and Recommendations

6.1 Conclusions

• The Health Board has agreed on an interim Financial Plan which includes a deficit of £26m. At month 6 it is clear that the Health Board is running significantly behind its planned financial position with an underlying operational run rate which has broadly remained consistent throughout the first half of the financial year. Thus achieving the original plan set will be an extremely challenging achievement for the Health Board that will require material mitigating actions to reduce the current expenditure run rate and also to recover year to date overspends. This is being actioned through a Financial Recovery Plan which the Board approved on the 7 September and is overseen by the Financial Recovery Group. Full delivery of the Financial Recovery Plan will, however, only reduce the trajectory to a deficit of £33.4m and further actions are still required to achieve the £26m planned deficit.

• As at Month 6 the deficit position is £25.2m against a planned deficit of £13.2m. The adverse variance includes unidentified savings, under delivery of planned savings and cost pressures. The variances include significant pressures within Mental Health and Learning Disabilities and Secondary Care divisions. Significant action is being taken in relation to known areas of pressure including the use of medical and agency nursing and out of area placements. A sustained focus remains on the procurement arrangements for goods and services including healthcare contracts.

• Financial Recovery Plans totalling £14.5m have been identified which includes an anticipated funding assumption of a further £3.4m in relation to the Drugs Treatment Fund. Recovery actions of £1.2m were delivered in Month 6. Emerging pressures are being experienced within Continuing Healthcare and Primary Care Prescribing costs.

• The Board need to be sighted on the potential significant financial impact of HRG4+ on WHSSC commissioned services. This relates to the new HRG tariff in England which has seen material increases in some specialised service tariffs. The Health Board are currently working with other Health Boards and Welsh Government to assess the implications and impact but for this Health Board it could be in the region of £4m, this has not been factored into the current forecast and is, therefore, a significant financial risk.

• Similarly the outcome of the Supreme Court Judgment in relation to Continuing Healthcare fees has not been factored into the Health Board’s financial projections. Work is ongoing to estimate the potential impact with colleagues across Wales to ensure a consistent approach.

• Achieving the financial plan, while not compromising the quality and safety of its services, is an important element in developing trust with Welsh Government, the Wales Audit Office, Health Inspectorate Wales and the public.

In order to deliver the required improvements in the financial position to achieve the original financial plan set, the Health Board needs to ensure that the series of controls and processes that flow through the organisation are complied with. Similarly there is a clear scheme of financial delegation through Standing Financial Instructions (SFIs) that need to robustly adhered to. Management focus needs to be on continued implementation and compliance of the significant grip and control actions put in place 19

and managers need to concentrate on their entire budget and not just on the current overspending areas as lack of focus can lead to unsighted emerging issues

6.2 Recommendation

• It is asked that the report is noted, recognising the significant risks to the financial position which are outlined in Section 4.

20 Appendix 1 Savings Analysis

Savings Excess / Identified Manager Savings (deficit) of YTD Ledger 2017/18 (including YTD Variance requirement savings Delivered Planned recovery Planned identified actions)

£'000 £'000 £'000 £'000 £'000 £'000 £'000 Ysbyty Gwynedd 3,100 3,024 (76) 1,356 1,200 (156) 1,550 Ysbyty Glan Clwyd 3,517 2,659 (858) 788 436 (353) 1,759 Ysbyty Wrexham Maelor 3,100 3,305 205 792 966 174 1,550 North Wales Managed Services 3,000 3,548 548 1,333 1,022 (311) 1,500 Womens Services 1,200 1,200 0 275 844 569 600 Secondary Care 13,917 13,736 (181) 4,544 4,468 (76) 6,959

Area – West 3,500 4,691 1,191 1,473 996 (477) 1,473 Area – Centre 4,783 4,858 75 1,782 1,818 36 2,392 Area – East 5,200 5,747 547 1,994 1,574 (420) 2,600 Area – Other 800 750 (50) 100 40 (60) 400 Area Teams 14,283 16,046 1,763 5,349 4,428 (921) 6,865

West Economy 0 575 575 192 0 (192) 192 Centre Economy 0 100 100 50 36 (14) 0 East Economy 0 0 0 0 0 0 0 Health Economy 0 675 675 242 36 (205) 192

MHLD 3,400 7,580 4,180 1,989 959 (1,030) 1,700 Corporate 3,800 5,143 1,343 1,250 1,160 (90) 1,900 Total 35,400 43,180 7,780 13,374 11,050 (2,324) 17,615

Appendix 2 – Commentary by Division

Spend Operational YTD Variance Divisions £'m YTD £'m Year to date summary Actions being taken East Area 110.6 1.5 The variance movement this month • Fortnightly review of financial matters and relates to higher GP prescribing costs savings delivery by Senior Management Team. compared to budget level. Growth in • Increased scrutiny of CHC activity and CHC placements exceeded the impact expenditure. Weekly monitoring reports and of savings schemes to date. East Area enhanced forecast modelling being shows the total North Wales CHC over- undertaken. spend. Continued pressures within • A paper submitted to EMG on new workforce Children’s Services and Community model for managed practices, with one aim to Medicine. These pressures are being reduce the current expenditure rates and partially mitigated by underspending pursue opportunities for further cost within the dental service and GMS. containment.

Central 95.1 (0.0) The variance mainly relates to an under • Continued focus on the delivery of identified Area spend within the dental service and non- saving schemes and development of additional recurrent slippage from vacancies within schemes to achieve financial balance. the year to date. • A specific project is in place with regards to the Dressing issues. However the key pressures and • Monthly performance reviews are held with financial risks are being experienced each Assistant Area Director with an emphasis within Medicines Management (with a on Finance and Performance. £0.3m adverse movement in-month) due to high cost dressings within District Nursing, growth in Primary care Prescribing, NCSO price increase, and other drug expenditure within the care of the elderly, sexual health and dermatology.

West Area 74.0 (0.4) The variance movement relates mainly • Continual review of Agency spend and

22 Appendix 2 – Commentary by Division to £0.1m GP planning in place to reduce this, with the Pressures exist predominantly in expectations of further reductions from January secondary care drugs, overtime spend with the appointment of middle grades in and medical agency, although due these Children’s services. are reducing. • New manager is in place in Eryri hospital, which has seen continuous overspend to date, The Dental underspend is £0.4m year to spend is now slowly reducing as new rotas and date with a full year forecast of £0.8m cost reductions are put in place. • Further work is being implemented to reduce Dermatology drugs spend and a phototherapy service will reduce spent on biologics. Equipment has been purchased, but we are awaiting some estates work to be able to implement this service. • VCP continues to scrutinise all posts and challenge need and skill mix. Other North 10.1 0.3 The variances relate to growth in the • The Assistant Area Director of Children's Wales use of out of area placements within Services receives weekly updates of all OOA CAMHS due to an increase in activity, Children, clearly showing all of the clinical although the position for Month 6 reviews and activities that are being showed a small improvement. undertaken to reduce the length of stay and Out of area Neonatal activity is higher return the Child to North Wales as soon as is than plan this month, although with the clinically appropriate. full opening of the SuRNICC it is • Staffing on the North Wales Unit is monitored anticipated that this will be brought back closely, including the use of agency, to ensure on plan by the end of the financial year. that the Unit is open for admissions. • The SuRNICC project Board receives a financial report of both the internal budget and costs and the external contract costs.

Commission 87.9 (0.6) The locally managed contracts are • Continue to pursue resolution of the English ed Services reporting an underspend of £0.5m to Treatment Tariff funding issue (HRG4+). month 6 this relates mainly to • Continue to validate and actively challenging underperformance in the Countess of Non Contracted Activity that does not have

23 Appendix 2 – Commentary by Division Chester contract on elective activity and prior approval critical care and through the write back • Further scrutiny of remaining provisions. of old year provisions. WHSSC specific actions: • Review all WHSSC contracts where BCU has The WHSSC month 6 initial reported a significant level of non-specialised elective position is an over performance of activity going through and split contracts so £1.9m of which £1.8m relates to the that only specialised activity can go via the impact of HRG4+. There are currently WHSSC contract. BCU to then determine if ongoing discussions between WG and local contracts are required for non specialised NHS England to resolve this issue, the activity year to date position excludes the • WHSSC to review any remaining reserves and impact of this and it remains a risk for ensure reflected in the Month 7 position. the Health Board. Provider (9.2) 0.2 Variance has improved slightly due to • Ensure all chargeable activity is identified and Income increased NCA activity, but is still invoiced. adverse due to the £0.2m underachievement on RTA income. MHLD 59.4 5.5 The variance relates to pressures within • Increased weekly package costs particular for Continuing Healthcare due to cost and community rehab teams and learning activity pressures, Out of Area difficulties. Growth outstripping cost placements, under delivery of savings projections. Quality improvement work is being and drugs costs. undertaken in relation to CHC and action plan in place to address review of packages, repatriation and commissioning opportunities and price negotiation. • A review of OOA Governance arrangements is in progress including patient flow work and delayed transfer of care to reduce out of area placements. OOA costs have reduced significantly and are below recovery plan trajectory • Savings schemes and recovery plan off trajectory mainly due to workforce issues which are being progressed via the Senior

24 Appendix 2 – Commentary by Division Management Team. Mitigating actions / schemes are discussed via weekly Efficiency Group (subgroup of Senior Management Team). • Drugs expenditure is being reviewed and closely monitored.

Ysybyty 46.3 1.2 The variance relates to overspends • Theatre capacity review being undertaken with Gwynedd within pay. These primarily relate to a review of specialty medical rotas to ensure medical agency costs incurred in that both elective and non elective activity is covering vacancies and increased maximised efficiently. nursing costs due to one to one nursing • Monthly audits of the effectiveness of ward E- cover. The impact of the pay pressure Rostering are being undertaken. is being partially mitigated through drugs • Continued recruitment to vacant medical posts underspend. whilst ensuring that both the hours and rates of agency cover are minimised. Ysbyty Glan 55.1 3.2 The variance relates to pressures in pay Clwyd caused by the high level of vacancies • Successful recruitment of 3 Consultants in the within Medical Staffing, slippage in Emergency Department. delivery of savings schemes and • Recruitment and sickness management additional expenditure relating to initiatives across nursing staff within increased activity within Theatres. Emergency Department. Staffing issues are most noticeable • Review of Medical to ensure compliance to within the Emergency Department which reduce reliance on Agency Staff and minimise has a high level of agency usage due to the use of internal locums. staff vacancies across all grades. AMD • Action is being taken to progress savings plans drugs usage has seen increase with the and identify further options for curtailment of number of injections up by 58% costs. compared to last year. • Review of processes for management of One to One patients • Review of all nursing rotas to ensure efficient use of nursing resource is fully utilised. • Review of Oracle orders to ensure business critical spend only being incurred. 25 Appendix 2 – Commentary by Division Wrexham 48.7 1.5 The variance relates to pressures on • Successful recruitment to fill most of the Maelor pay costs. These reflects high levels of Surgical medical vacancies nursing vacancies and the use of • Review of Medical to ensure compliance to escalation beds, leading to increasing reduce reliance on Agency Staff and minimise use of agency nursing. There have also the use of internal locums been vacancies in medical posts, • Increased scrutiny of rotas for the Emergency particularly in ED. Whilst the run rate in Department and acute ward nursing to tackle the use of medical agency has reduced areas of high sickness and ineffective rostering the use of nurse agency is increasing • Recruitment campaign for both Registered due to the opening of escalation beds. nurses and Health Care Support Workers

Womens 18.9 0.2 The variance relates to additional costs • Directorate F&P re-introduced associated with equipment, legal costs • Weekly meetings to monitor Birth Choices and medical staffing. contract in place • Admin & Clerical Review in progress NW 47.4 1.9 The variance relates high usage of • Continued recruitment to vacant posts with Services medical agency due to recruitment stringent controls on the use of agency staff to difficulties, high cost drugs approved by minimise actual hours worked and remove long NICE and overspends within managed term locums. contracts and laboratory equipment. • Action is being taken to progress savings plans CRES slippage is a contributing factor to and identify further schemes. the year to date position. • Drugs expenditure is being reviewed to identify options for utilising biosimilar and delivery via homecare

Corporate 55.0 0.5 Corporate Departments are in the main • A review of cook/freeze catering provisions is under spent, with the exception of planned in light on new ways of working at Estates & Facilities. Facilities are over Ysbyty Glan Clwyd and a change in supplier. spent, notably with Catering Other (3.0) The underlying position is being supported by reserves Total 12.0

26 7 B17/18 Living Healthier Staying Well Update - Mr Geoff Lang 1 B17.18a LHSW coversheet v2 12.10.17.docx

Board to Board

16.11.17

To improve health and provide excellent care

Title: Living Healthier, Staying Well : Strategy programme update

Author: Mrs Sally Baxter, Assistant Director – Health Strategy

Responsible Mr Geoff Lang, Executive Director of Strategy Director:

Public or In Public Committee Strategic Goals (Indicate how the subject matter of this paper supports the achievement of BCUHB’s strategic goals –tick all that apply)

1. Improve health and wellbeing for all and reduce health ✓ inequalities 2. Work in partnership to design and deliver more care ✓ closer to home 3. Improve the safety and outcomes of care to match the ✓ NHS’s best 4. Respect individuals and maintain dignity in care ✓ 5. Listen to and learn from the experiences of individuals ✓ 6. Use resources wisely, transforming services through ✓ innovation and research 7. Support, train and develop our staff to excel. ✓

Approval / The Strategy Programme is overseen by the Programme Executive Scrutiny Route Group (PEG) and reports into the Strategy, Partnerships & Population Health (SPPH) Committee. An update on the Programme was presented to Board briefing on 20 September and to SPPH workshop on 28 September 2017.

Purpose: To provide an update to the Joint Boards on progress with the Living Healthier, Staying Well strategy development programme.

Significant issues A detailed risks and issues log is being maintained by the Programme and risks Office and any risks or issues requiring escalation are reported on a regular basis to the Programme Executive Group. The PEG will escalate any risks or issues as necessary for inclusion in the overall Programme Risk identified as CRR 08 on the Corporate Risk Register.

Equality Impact A summary of the approach to embedding equality and human rights in Assessment the strategy programme is set out in the paper together with a narrative regarding the ongoing impact assessment work. Recommendation/ The Boards are asked to note the report

Action required by the Board Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

1 B17.18b LHSW paper v3 12.10.17.docx

Living Healthier, Staying Well Strategy Programme: Developing our priorities

1. Purpose of report

The purpose of the report is to present to the Board the emerging proposals from the work of the Living Healthier, Staying Well strategy programme.

The report has been produced to provide an overview of the work of the programme, and to share our proposals for transformation of the way we work with our population, service users and carers, partner organisations, the third sector and community groups, and our staff.

The paper attached as Appendix 1 describes the proposed long term strategic direction for the Health Board the next ten years. It also sets out the initial priority areas which have been identified for the first three years of the strategy. These in turn, following further discussion and refinement, will inform the Integrated Medium Term Plan to be developed for 2018 - 2021.

We intend this paper to provide an opportunity for further discussion about the future of health, well-being and healthcare services in North Wales. Included with the paper is an engagement and communication plan which sets out a range of opportunities for people to get involved with this work and tell us their views.

2. Introduction and background

Having a clear and well thought out strategy will help achieve the vision, principles and values of the NHS in North Wales and contribute to sustaining safe, effective patient care.

“Strategy is a set of choices and principles designed to help an organisation achieve long-term goals. It will influence how resources are allocated and how staff prioritise their time. If leaders communicate their strategy successfully, it will help employees understand the organisation’s direction. Whether or not the organisation achieves its aims will depend on the strategy’s quality. Through strategic planning, board members can shape patient care into the future.”1

NHS Wales planning guidance has confirmed the requirement for every NHS organisation to have a long-term strategy which should “set out the organisation’s strategic goals; outline the ‘roadmap’ which the organisation will follow and describe how it will address any key strategic challenges or opportunities.” The development

1 Monitor, Strategy Development Toolkit

2 of a clear and comprehensive strategy for the Health Board is also one of the key elements of the Special Measures Improvement Framework.

The LHSW programme was established in for this purpose in 2016 and work has been undertaken through a governance structure approved by the Board in July that year. The Programme Executive Group was established in August 2016 and includes membership of a number of executive directors, the Health Board Vice-chair and Chair of the SPPH Committee, chairs of the Health Board Advisory Forums, staff side, UNISON and LNC chairs, and Community Health Council representation. The Programme Executive Group reports into the Strategy, Partnerships and Population Health Committee. The work has been supported by a core programme team which meets on a fortnightly basis.

Regular updates on the LHSW Programme have been given to SPPH Committee and to the Stakeholder Reference Group, Healthcare Professionals Forum and Local Partnership Forum, and to the Service Planning Committee of the Community Health Council.

3. Development of the strategy

The strategy has been taken forward through a number of workstreams reporting into the core team and Programme Executive Group.

• Health Improvement, Health Inequalities • Care Closer to Home • Acute Hospital Care

Alongside the three core programme groups there have been workstreams established for Children and Young People and Older People. The lifecourse approach to health recognises the importance of those key stages in people’s lives which have particular relevance for their health.

The lifecourse approach offers a more integrated perspective, with opportunities for long term health gain, placing emphasis on education and early intervention. It views health as an integrated continuum rather than as disconnected and unrelated stages in life. The workstreams for Children and Young People and Older People, as well as identifying specific initiatives within their scope, have identified links with the other strategy programmes and will contribute to ensure that relevant needs are addressed.

The work on the Mental Health Strategy which was approved by the Board in April 2017 has also been linked into the strategy programme.

The strategy has been driven by a common set of strategic questions, which were considered by the Board in November 2016 (Living Healthier, Staying Well November 2016) and an agreed and clear framework of principles. The principles are described below.

3.1 Focusing on achieving population health and well-being outcomes

The strategy programme has been developed in the context of the increasing recognition of the importance of delivering sustainable health and well-being outcomes for the population. The figure below, taken from Measuring the health and well-being of a nation (Welsh Government and Public Health Wales, March 2016) illustrates the broad context and links between strategic, policy and operational strands.

Our strategy has adopted an outcomes-based approach that shows clearly how we will contribute to achieving population health outcomes, using the Public Health Outcomes Framework and linked to the national Well-being of Future Generations indicators. To support this, each strategy programme area has developed a high level Logic Model summarising the key elements of the pathway that will deliver the defined population health outcomes. A Logic Model is a simple method used to articulate and convey on a single page the theory of change driving our thinking, and providing a summary of our prioritised actions.

Once the Logic Model is developed, it will inform the subsequent more detailed plans which in turn will be developed to inform annual operational priorities.

3.2 Enabling principles -

Underpinning this approach to developing our Living Healthier, Staying Well strategy are two sets of enabling principles. These are –

The five ways of working which support the sustainable development principle described in the Well-being of Future Generations (Wales) Act 2015:

• Long term – balancing short term need with long term needs and planning for the future

• Prevention – putting resources into preventing problems occurring, or getting worse • Integration – considering the impact on all well-being goals together and on other bodies • Collaboration – working together with other parties to deliver objectives • Involvement – involving those with an interest and seeking their views

The four principles of Prudent Healthcare:

• Public and professionals become equal partners through the principles of co- production • Care for those with the greatest health need first • Do only what is needed and do no harm • Reduce inappropriate variation through evidence based approaches

These principles have been used to test scenarios that are being developed through the strategy programme work and will also be applied to support formal options appraisal where needed.

3.3 Listening to and learning from what people tell us

The programme has been supported throughout by continuous engagement and involvement of representatives of partner organisations, stakeholders, community groups, people with experience of our services and carers.

In 2014/15 an extensive listening exercise was undertaken across North Wales in which we took time to stop and listen to what is important to people in relation to their health and healthcare, what works well in North Wales and what we need to do better.

During 2015, we also undertook a major formal consultation on the future of women’s and maternity services, which gave the Board a clear understanding of the views and needs of women and their families on these important services.

In 2016 we continued to connect with local groups and partnerships in establishing the strategy process. In the autumn, this was further enhanced by the Welsh Government’s engagement exercise, Delivering a Healthier North Wales.

During 2017, we have held a series of targeted events to inform specific issues within the strategy programme and more general discussions with a wider range of groups. This has included staff involvement via the targeted events and also a series of world café style discussions specifically for staff.

A schedule of the engagement events undertaken is attached as Appendix 2.

3.4 Equalities and human rights

There are profound inequalities between different groups and communities across North Wales. Our understanding of inequalities, which arise as a consequence of socio-economic deprivation is reasonably well established. We know, for example,

5 that there are significant differences in life expectancy and in the prevalence of limiting long-term illness, disability and poor health between different socio-economic groups (The Deprivation Profile of North Wales). We are not defined by any singular characteristic; social determinants such as ethnicity, gender, disability, and sexual orientation combine and intersect to affect health and well-being, often varying across the lifecourse. We recognise that we have a significant amount of work to do with individuals, communities and other agencies to better understand the impact of the inequalities, which arise as a consequence of socio-economic differences including those related to the protected characteristics.

In recognition of this, and to support our fulfilment of the general and specific duties under the Equality Act 2010, the strategy programme made an explicit commitment to this work from the outset. This was set out within the baseline document produced in March 2017.

The Programme Executive Group for the Strategy received a presentation on the statutory duties under the Equality Act 2010 and best practice approaches to impact assessment. The Group will ensure that proposals coming forward under the Strategy are made with due regard to equality and human rights. Individual Programme Groups have also received presentations on the statutory duties and discussed best practice approaches. Regular updates have been provided to the Strategy and Planning Equality Scrutiny Group of the Health Board to provide support, scrutiny and challenge throughout the process. The Equality duties and potential risks have been identified and managed within the overarching risk and issues log established to support the strategy development. This is overseen by the Programme Executive Group Ongoing involvement with people and groups who share protected characteristics is continuing and has helped shape the emerging proposals from the strategy. As the initial priorities become more defined, equality and broader impact assessment will be undertaken to inform any recommendations to the Board.

3.5 Health needs and health inequalities

Improving health and well-being for all and reducing avoidable health inequalities is the first well-being objective adopted by the Health Board. In this we must encompass physical, mental and emotional health and well-being. Feedback to the Board has suggested that we make this explicit in our objectives. “Health inequalities are differences between people or groups due to social, geographical, biological or other factors. These differences have a huge impact, because they result in people who are worst off experiencing poorer health and shorter lives.”2 We know there are inequalities in health outcomes across North Wales and between specific groups or communities. Male life expectancy is higher than the Wales average;

2 NICE guidelines, Health inequalities and population health, 2012

6 however, there is a gap of 8 years between life expectancy in the most deprived and the least deprived areas. For women, life expectancy is similar to the Wales average, but there is a gap of 6 years between the most deprived and least deprived areas.

There are difference in the years of healthy life experienced also. Males living in the least deprived areas are likely to live 13 years longer in better health than those living in most deprived areas; and females living in the least deprived areas are likely to live almost 14 years longer in better health than those living in most deprived areas We also need to recognise that more equal societies and countries have better health outcomes overall – so reducing inequalities is of benefit to all our population. It is important that we address these inequalities and seek to improve the health of those with the greatest need most quickly; working closely with communities to understand and address their needs; and working in partnership to improve health and well-being. To support this we will target our priorities to support these parts of our population. Each of the programme workstreams will include plans to show how they contribute to tackling inequalities. Overall, the evidence suggests that preventing ill health across the population is more effective at reducing inequalities than clinical interventions; and that a focus on the early years – the first 1,000 days – is critical. We are developing initiatives to address this.

4. Emerging priorities and next steps

The Health Board described its overall strategic vision for the future in the strategic narrative presented to the Board in April 2017. This summary document can be found within the LHSW update report at Living Healthier, Staying Well - our vision. Over the summer, the key messages from this strategic narrative document have been shared through meetings with different groups and more open public engagement sessions. Population health is at the heart of the strategy. The vision for the future is focused on:

• Improving health and achieving better outcomes • Becoming a wellness service • Giving children the best start in life • Supporting everyone in staying fit and healthy • Enabling a healthy and meaningful older age • Supporting the right choices at end of life • Narrowing the gap in life expectancy

To do this we will target our efforts and resources to support those with the poorest health to improve the fastest. We will work in partnership with the people of North Wales and others – statutory organisations, the third sector, the independent sector - to do this.

Programme workstreams have been developing their response to the population health needs, the evidence of what works, and quality standards and indicators.

As described earlier in this report, each workstream has developed a Logic Model with a clear set of outcomes, taking account of what people have told us is important. The work has also begun to identify the initial priority areas for service transformation in the first three years for each key area of the strategy programme.

The paper attached also sets out the outcomes for each programme area, shaped by feedback from our engagement work, together with the initial priorities identified for the first three years.

We need to develop these into a more detailed plan that clearly articulates how these will be taken forward, by whom and by when, and the resource implications (workforce, financial, estates and infrastructure.) First, however, we want to seek the views of our population, service users and carers, partner organisations, third sector and community groups, and our staff on the overall shape of the proposals. This will build on the extensive engagement work undertaken to date.

During the next 6 weeks we will share the strategic outline widely. A programme of activities has been put together to allow people to take part in conversations about the strategic direction and about the priority areas we have identified to date. This is intended to allow anyone who may not have had an opportunity already to hear about the work we have been doing and the proposals we are developing.

We will review and refine the strategic outline based on what we hear from people, before developing our draft strategy which will be submitted to the Board in January 2018.

5. Assessment of risk and key impacts

The potential consequences of failure to develop a comprehensive strategy and subsequently an IMTP for the Health Board are significant. Failure to deliver in these areas will compromise the Board’s ability to address the health needs of the population and to deliver improvements in health, wellbeing and service delivery. Furthermore, failure to produce an IMTP would result in a breach of the Board’s statutory responsibilities under the NHS Finance (Wales) Act 2014.

The continuous engagement approach which has been taken in the strategy programme has been designed to fulfil the requirements of the Welsh Government’s Guidance for Engagement and Consultation on Changes to Health Services. There is a risk that failure to follow the guidance may lead to inadequate involvement, risk to effective delivery of the strategy and potentially challenge to the approach.

The Living Healthier, Staying Well strategy programme has established a risk and issues log in accordance to identify and manage risks to strategy development which will be overseen by the Programme Executive Group.

The Corporate Risk Register reflects the risks relating to both the strategy development and the IMTP (CRR8).

As the strategy moves forward into the implementation phase, a revised risk and issues log will be developed to recognise risks associated with failure to deliver, or to achieve the required outcomes.

6. Equality Impact Assessment

The baseline assessment document referred to above was produced to set out an understanding of the needs of the population we serve, principles and outcomes to shape the strategy, current challenges, priorities and the context within which we are working.

Within the LHSW strategy programme, there has been an explicit commitment to meeting the equality duties from the outset. This includes recognition that whilst our understanding of inequalities which arise as a consequence of socio-economic deprivation is reasonably well established, we have a significant amount of work to do with individuals, communities and other agencies to understand better the inequalities which arise as a consequence of differences including those identified as protected characteristics. Sometimes the data is not available at all, and it is often impossible to undertake a more sophisticated assessment of key areas of disadvantage, for example, where people’s characteristics intersect. Some small groups of people such as those aged over the age of 80, transgender people, Gypsies and Travellers, children and young people affected by abuse and exploitation, are often invisible in the data. The baseline document is supported by more detailed work for each workstream and can be accessed via http://www.bcugetinvolved.wales/key-documents/

The broader perspective of the local population with regard to well-being has been gathered in partnership through the engagement work supporting the SSWB Population Assessment and also the WFG Well-being Assessments. Each of these has contributed a rich source of data. As part of the strategy development a mix of larger scale deliberative events and engagement activity with smaller local community groups has taken place. In North Wales, we need to understand how the national experiences of inequalities and human rights abuses are reflected in our population, we have been working with representatives of groups of people who share protected characteristics to collect information to help inform this, our work includes targeted engagement with protected characteristic groups. Social media has been used to host online discussion forums and staff engagement workshops have also been facilitated.

Good progress has been made on consideration of equality and human rights matter and includes the following: • Regular updates have been provided to the Strategy and Planning Equality Scrutiny Group of the Health Board to provide support, scrutiny and challenge throughout the process • The Equality duties and potential risks have been identified and managed within the overarching risk and issues log established to support the strategy development. This is overseen by the Programme Executive Group • A more integrated approach to impact assessment is being progressed, which will streamline the evidence gathering and involvement process so that best use

is made of the valuable contributions of people who might be affected by proposals under the strategy. • Development of an Equality Evidence Document which brings together relevant evidence from national and local research and local engagement activity • The PHW equality profiles for North Wales have been refreshed and updated • Extensive engagement has been facilitated including equality monitoring of attendees to identify areas for targeted engagement with protected characteristic groups • Provision of information in local community languages • A targeted LHSW Equality Engagement Event has been facilitated as part of our ongoing equality engagement work with people locally who have an interest in equality issues and/ or represent individuals with protected characteristics to gather views, experiences and ideas from everyone with a focus on equality. A report of the findings has been complied and will inform the strategy and EqIA • Facilitation of a focus group to identify and discuss BME health inequalities • Meetings with seldom heard groups, including for example Unique Transgender Network, VIVA young people’s LGBT Network, the Portuguese Community in Wrexham, the Minority Ethnic Elders Advocacy Group in Bangor . A full equality impact assessment will be undertaken on the strategy programme as future scenarios emerge. This work will be informed by the evidence we have gathered during the strategy development, outlined above, in regards to equality and human rights issues.

7. Conclusions / Next Steps

The strategic outline document and supporting public-facing materials will be made widely available as described in the draft engagement and communications plan attached at Appendix 3. Additional activities and dates will be added to the plan as they are confirmed.

Opportunities for direct conversations through targeted sessions and attendance at specific groups are being arranged as identified and will allow more in-depth discussion of the issues raised.

Feedback gained through the process will be conscientiously considered and taken into account in the process of developing the draft strategy further for presentation to the Board in January 2018.

8. Recommendations

The Boards are asked to note the report.

1 B17.18c LHSW App 1 priorities paper.docx

1 Appendix 1

Developing our strategy for health, well-being and healthcare for the future

1. Introduction

In North Wales we are facing a number of challenges which mean we will need to change how we support the health and well-being of our population, and how we provide healthcare services now and in the future.

We are living longer – average life expectancy is now 78 years for males and 82 years for females. The good news is that many people stay in good health for much of their lives. However, we need to do more to help everyone to have an active, happy and healthy life and to stay well as long as possible. Many more people will have long-term conditions such as diabetes or complex health needs. There will also be many more people living with dementia.

There are also unacceptable differences in how long people live, and how many years of good health they will have.

➢ In areas which are better off, men can live up to 8 years longer than those who live in the poorest areas. For women, the difference can be up to 5 years. ➢ Men living in areas which are better off can have up to 13 years of better health than those in the poorest areas, while women can have almost 14 years of better health.

More people are experiencing mental health issues – one in four of us will be affected at some time during our lives. We need to do more to promote well-being, support people with long term mental health needs when care is needed, and facilitate recovery.

2 Appendix 1

At the moment, many people are waiting too long for the help they need from healthcare services – people have told us it can sometimes be difficult to get an appointment with a GP; pressures on our Emergency Departments mean that we cannot always see patients as quickly as we would like; and waiting times for a number of operations such as surgery on hip and knee joints, or eye surgery, are too long.

As well as this, we have significant financial challenges. In 2017/18, we are facing a shortfall of at least £26million and we need to make sure we work efficiently and spend wisely, making the best use of our resources to improve health.

People in North Wales may be aware that over recent years, the Health Board has experienced problems in responding to health needs and coping with changes in demand. In 2015, the Health Board was placed in “special measures” by the Welsh Government. Since that time we have been working hard to make improvements and have made progress in many areas:

✓ We have invested in the redevelopment of Glan Clwyd Hospital to strip out asbestos and create a hospital environment that is fresh, modern and fit for purpose – this work will continue into 2018 ✓ We have secured funding and are redeveloping the Emergency Department at Ysbyty Gwynedd in Bangor ✓ We have opened new community facilities in Tywyn, and will be opening new healthcare centres in Flint and Blaenau Ffestiniog ✓ We have invested in new primary care services – in North Denbighshire the Healthy Prestatyn Iach and Healthy Rhuddlan Iach services are providing support to local people through a new and innovative model which provides better access, focusses on well-being and makes best use of skilled staff ✓ In Gwynedd, the Ffordd Gwynedd initiative is developing integrated teams with Social Services to support people in the community ✓ Waiting times for diagnostic tests have reduced and are meeting national targets ✓ The Sub-regional Neonatal Intensive Care Centre will open in Glan Clwyd in 2018, enabling more of the most poorly babies to be cared for in North Wales ✓ We have recruited consultant doctors for the very specialist vascular surgery services and also for the Emergency Department in Glan Clwyd ✓ We have recruited additional staff – doctors and midwives – to our maternity services, having heard clear messages through consultation about the importance people place on this service.

However, there is more to do to consistently meet the standards that our population should be able to expect. We recognise that this will take time. There are some areas where we need to get the basics right before we can develop and innovate; in other areas we can - and will - be more ambitious in pursuing transformational change.

We are developing our strategy for the next ten years which will describe how we will change the way we work – to improve the health and well- being of the population of North Wales and provide better healthcare services. We have talked to many people over the last year about our

3 Appendix 1 strategy. Their views have helped shape the outcomes we describe in this paper and contributed to the draft priorities which we think will help achieve those outcomes. This paper isn’t our finished strategy – we want to make sure that everyone has a chance to see what we are developing and tell us their views on our proposals before we take our ideas any further.

4 Appendix 1

2. The context for our strategy

In April 2016, the Social Services and Well-being (Wales) Act 2014 and the Well-being of Future Generations (Wales) Act 2015 came into effect. Both Acts have major implications for the Health Board and the way that we plan and deliver services – and both create the opportunity to think differently and to give new emphasis to improving the well-being of current and future generations.

The Social Services and Well-being Act focuses on individuals and carers who need support. The Well-being of Future Generations Act requires us to contribute to improving well-being for the whole population, contributing to the seven national well-being goals. We need to change the way we work, adopting the Sustainable Development principle and following the five ways of working that support this. To do this, we need to find ways to meet current needs without compromising our ability to meet the needs of future generations.

Five ways of working

5 Appendix 1

3. Our well-being objectives

One of the other requirements of the Well-being of Future Generations Act is to set well-being objectives for the Health Board. These should form part of our corporate plans.

We have already identified a series of strategic goals for the Board, which had been developed in discussion with our advisory groups (Stakeholder Reference Group, Healthcare Professionals Forum and Local Partnership Forum.) We also took account of feedback from the work undertaken during 2015/16 to listen to what’s important to people about their health and healthcare. The goals are:

• Improve health and well-being for all and reduce inequalities • Work in partnership to design and deliver more care closer to home • Improve the safety and outcomes of care to match the NHS’s best • Respect individuals and maintain dignity in care • Listen to and learn from the experience of individuals • Use resources wisely, transforming services through innovation and research • Support, train and develop our staff to excel

Because we are in the process of developing a new strategy, we decided to adopt these strategic goals as interim well-being objectives. We felt that it was important to wait until we had completed work on our strategy and then review and confirm the objectives.

During this time, as we have involved people in developing our strategy, there are some issues that have been raised frequently and which could improve our well-being objectives, as set out below.

• We need to be clear that we will work with others to improve physical, emotional and mental health and well-being for all, and reduce inequalities • We should include the need to support children to have the best start in life, and promote life-long well-being, given the importance of protecting and meeting the needs of our future generations • We need to help enable people to take control over their own health and well-being, working with people and communities, supporting capacity and resilience.

6 Appendix 1

4. Principles supporting the strategy development

We have been working for some time to develop our draft strategy. From the outset we identified a series of principles that we have sought to follow in developing our initial proposals.

✓ Taking an outcomes based approach focusing on population health and well-being outcomes, and how we will contribute to improving these

✓ Proposals are based on evidence… using evidence of what works to identify the priorities for transformation in our strategy

✓ …including what we have learned from involving people taking account of the evidence of people’s own experiences and their views on health and well-being

✓ Demonstrate prudent healthcare following the prudent healthcare principles in developing strategy proposals

✓ Address what matters to the individual involving people in decisions about their health and healthcare

✓ Address equality and human rights matters an explicit commitment to address the inequalities that can be experienced by specific groups

7 Appendix 1

8 Appendix 1

Working together with our partners

It is important to recognise that we cannot deliver the improved outcomes we are aiming for without working closely with our partners. Partnership working spans a wide range of activity and many different partners. We share collective legal responsibilities with some, including Public Health Wales; other NHS organisations; the Community Health Council; Local Authorities; North Wales Police; the Police and Crime Commissioner; North Wales Fire and Rescue Service; Natural Resources Wales; the third sector and the independent sector.

There are other partners including town and community councils, community groups, businesses, and many other groups who also have an important role to play – including our population themselves.

Our requirement, under the NHS Wales planning guidance and to meet the Special Measures Improvement Framework actions, is to develop a strategy for the Health Board. Having a clear and well thought out strategy will help achieve our vision, building on our principles and values. Implementing this strategy will contribute to sustaining safe, effective patient care. It will help transform our services to make them fit for the future. Although this is a strategy for the Health Board, in many areas we have undertaken joint work to develop priorities and are developing this in other areas as the strategy matures. • We have collaborated in the development of the Population Assessment for North Wales under the Social Services and Well-being Act and will be looking to build an action plan to address the findings of the assessment • We have taken a significant role in the new Public Services Boards established under the Well-being of Future Generations Act, with our Area teams closely involved. The well-being assessments produced by each PSB have influenced our priorities. • The outcomes and priorities we identify for children and young people have been developed through a partnership approach with strong input for our Local Authority colleagues and other partners and stakeholders • The Together for Mental Health Partnership Board has committed to taking forward a joint approach for the mental health strategy for North Wales • We are considering how we can confirm a shared set of values for older people with colleagues in Local Authorities, the third sector and other partners, working through the Regional Partnership Board • The programme areas of Health Improvement, Health Inequalities and Care Closer to Home have recognised many partnership initiatives and will seek to learn from successes in these areas • We are working with partners in the Welsh Ambulance Services Trust to develop our plans for improving support to patients with emergency and acute care needs.

9 Appendix 1

We recognise there is further work to be done to strengthen and develop partnership working as we develop our strategy, which will bring benefits for our population, and are firmly committed to this. Our Quality Improvement Strategy

Our Quality Improvement Strategy (QIS) was approved by the Health Board in June 2017. The QIS emphasises the outcomes-focussed approach which is described within the Living Healthier, Staying Well principles and identifies five main aims. Our proposals within the strategy will seek to support the aims of the QIS.

5 main aims: Leadership & culture

Reduce Our community mortality “Choose Wisely” The outcome we want to achieve:

Reduce harm Person People are protected from harm and centredness supported to protect themselves from known harm Deliver what Quality matters most ✓ People are listened to and services are Improvement based on “what matters” Capability & ✓ Proposals are based on evidence Measurement Improve ….including what people have told us reliability of ✓ We will seek to achieve quality care Learning improvement standards within all service systems models ✓ Proposals will be based on safe staffing levels and robust education and training Deliver ✓ Safeguarding and protection are important integrated Suite of quality elements of the proposals care improvement projects 10 Appendix 1

5. Taking an outcomes-based approach

The proposals within our strategy are designed to help us deliver better outcomes for people. By this, we mean improvements in health and well- being. These will be measured by the indicators in the Public Health Outcomes Framework (published by Public Health Wales NHS Trust.). Many of these indicators are also National Indicators for the Well-being of Future Generations Act and will therefore help us measure the delivery of our commitments under this Act. The highest level, longer term outcomes describe changes in population health outcomes over time and are particularly important for assessing progress in reducing inequalities over the ten years of our strategy. The intermediate outcomes describe changes in behaviour, practice and environments which contribute towards this.

Longer term outcomes – changes in Years of Life and years of health population health Mental well-being Intermediate status outcomes – A fair chance for health changes in behavior, practice or Living conditions that environment Ways of living that Health throughout support and contribute improve health the lifecourse to health

✓ Children have the best opportunity for a ✓ Health in the early years and healthy start childhood ✓ Families and Individuals have the ✓ Healthy actions ✓ Good health in working age resources to live fulfilled, healthy lives ✓ Healthy ageing ✓ Resilient empowered communities ✓ Healthy starts ✓ Minimising avoidable ill- ✓ Natural and built environment that health supports health and well-being

11 Appendix 1

Within each area of our strategy we have identified the outcomes we will seek to achieve, which will contribute towards achievement of the population health outcomes.

What influences health and well-being? The diagram below shows the factors1 that influence health and well-being for people, their families and carers, and communities. (The factors are adapted from the Dahlgren-Whitehead model of the broader determinants of health.)

Our strategy recognises that there are some areas which we can only influence indirectly; some areas we can affect through commissioning services or working in partnership; and some areas where we can directly provide services and support.

We will influence…. We will commission and We will provide…. work in partnership….

Socio-economic

factors Living & working

conditions Social & community networks Lifestyle

Health and well-being Care closer to home

Care for more serious health needs People, their families and carers and communities

Age, sex and hereditary factors

1 Dahlgren G, Whitehead M. 1991. Policies and Strategies to Promote Social Equity in Health

12 Appendix 1

More focus on maintaining independence

More focus on health and well-being – physical, emotional and mental When we develop the detailed action plan for our strategy, we will consider in collaboration with others how we can best deliver the actions. We will provide some services or initiatives ourselves. In other areas we may seek to develop joint work with partner organisations. We may also commission third sector or independent organisations to deliver on our behalf. We will seek to influence others to maximise their impact on health and well-being for the people of North Wales, for example, through our work with colleagues on Public Services Boards.

13 Appendix 1

6. Health improvement and health inequalities

Our aim is to become more of a “wellness” service rather than an “illness” service and to work with you and our partners, including local authorities, other public services and third sector to plan for the future needs of people living in North Wales.

We will do more to give children the best start in life, taking action to help prevent problems for children and families and to tackle problems that do occur as soon as possible, before they become more difficult to resolve.

We will work in partnership to support everyone in staying fit and healthy throughout life. In particular, we will work with partners in the Public Services Boards to develop and deliver local Well-being Plans to address the well-being of the whole population and meet the needs of current and future generations.

Our ambition is to improve life expectancy for all, and particularly to narrow the gap in life expectancy between those who live the longest in the better off areas of North Wales and those living in our more deprived communities.

We will target our efforts and resource to support people with the poorest health to improve the fastest. We will also work with seldom heard groups and people with different protected characteristics (as defined by the Equality Act 2010) to ensure we adapt the initiatives we develop to meet the needs of those groups better. This work has already started, but we need to do more.

Why invest in health improvement?

Benjamin Franklin once famously stated that an ounce of prevention is worth a pound of cure, and it is now widely acknowledged that investing in prevention saves lives as well as money2. We are facing increasing pressures to make efficient use of resources whilst improving outcomes. These pressures, coupled with a growing, ageing population mean that we have to reconsider our system wide approach to achieving and maintaining optimum health throughout the life-course.

This will not be a quick win. The National Institute for Health and Care Excellence (NICE) states that whilst “generally, the upfront costs of most preventive interventions will not be repaid for a number of years. However, these costs will usually be small in comparison with the future health benefits and the long-term cost savings from reductions in type 2 diabetes, cardiovascular disease and some cancers.”3 We must aim to achieve

2 Public Health Wales, 2016. Making a Difference: investing in sustainable health and well-being for the people of Wales 3 NICR 2013. Preventing obesity and helping people to manage their weight

14 Appendix 1 this long term gain, if we are to secure better health for future generations. Evidence shows that not only does this have direct benefits for people, but it also helps reduce the long term costs of healthcare. Some examples are shown below.

15 Appendix 1

Return on Investment

Smoking causes 27,700 adult hospital admissions across Wales each year – that’s 5% of admissions – and 5,450 adult deaths (18 %.) Each 25 year old smoker who quits saves £1,592 to the NHS over their lifetime.

Healthy weight

The majority of adults and a large proportion of children in North Wales are overweight or obese – this is expected to increase over time. Almost 3 in 4 adults are predicted to be overweight or obese by 2035.

Across Wales, this could lead to an additional 221,700 cases of type 2 diabetes; 78,200 cases of coronary heart disease, and 32,300 cases of cancer.

16 Appendix 1

Physical Activity

The cost to the NHS of people not being physically active enough is estimated to be £450 million per year – approximately £800,000 per 100,000 people.

Overall Return on Investment

The overall return on investment from public health interventions equates to around £14 gained for each £1 spent. 14:1

17 Appendix 1

Anticipating changes in demand

We know that our healthcare system is under pressure and that we are not using our resources in the most effective way to support health improvement.

2017 – smoking rates 22%, rising obesity and overweight, poor levels of physical

activity, rising levels of diabetes, significant older population, high inequality

Prev. Primary Care Secondary Care Specialist Care

The diagrams below show the changes that could be made if we shift our resources to support health improvement, taking account of the evidence of return on investment (for illustrative purposes only.)

2027 20:1– smoking rates declining2:1 slowly, levels of obesity and overweight still rising,

greater older population, inequalities still high

Without investment

Spec. Prev. Primary Care Secondary Care Care

18 Appendix 1

With investment

Spec. Prevention Social Prescribing Primary Care Secondary Care Care In considering our approach to health improvement and health inequalities, we have also looked at the feedback that people have given through consultation processes with and by partner organisations. During 2016 there was a consultation on the Population Assessment under the Social Services and Well-being Act. The four Public Services Boards (Anglesey & Gwynedd; Conwy & Denbighshire; Flintshire; and Wrexham) also asked people their views on the Well-being Assessments which were carried out under the Well-being of Future Generations Act. We have looked at the feedback and the information from these assessments when shaping our strategy and will be contributing to joint work to develop plans for these two sets of assessments.

What people have told us is important to them

Lifestyle issues – weight management, exercise, diet, sport, smoking

Enjoying the environment (outdoor space, allotments, walking, using the natural environment)

Social and community participation

Taking responsibility for your own health and well-being

Better education and support

Participation in activities such as the arts, singing, physical activity

More investment in prevention

The importance of mental well-being

More support for children and young people (and their families)

Transport and travel are important issues for some, including people with mental health needs, people with a learning disability, people with a physical or sensory impairment

All our services should improve how they respond to the needs of people who have protected characteristics – 19 Appendix 1

20 Appendix 1

7.1 Health improvement and health inequalities –the outcomes we will aim to achieve We have considered the evidence of what works, including what people have told us, to identify the initial outcomes we will aim to achieve.

People are healthy, active and do things to keep Interventions to improve people’s health are based themselves healthy on good quality and timely research and best practice

People have access to information and advice Through smoking prevention measures and about services and opportunities that enable smoking cessation, people have minimal risk of them to maximise their health & well-being developing smoking related diseases

People are well supported in managing and People are aware of the importance of tobacco and protecting their physical, mental and social well- alcohol consumption, and poor diet and lack of being physical activity as risk factors for chronic conditions and cancers

Inequalities that may prevent people from leading People are supported to identify cancer at an early a healthy life are reduced through programmes stage through screening, education and awareness tailored and designed to meet needs programmes

21 Appendix 1

7.2 Our initial priorities

7.2.1 Healthy lifestyles: What we will do in the first three years

Develop further our smoking cessation services, including providing support in our hospitals

Launch suicide & self-harm prevention strategy with our partners

Develop joint framework and strategic plan with partners in the creative arts

Develop and implement the obesity pathway for children and adults – to promote healthy weight

Improve alcohol awareness and help reduce alcohol use to safer levels

Develop and implement an action plan to support the 5 ways to well-being

Further develop the Get North Wales Moving programme which promotes physical activity

Further development of health & well-being centres in community health facilities and other community resources Equip more of our frontline staff with the knowledge, confidence and skills needed to Make Every Contact Count (using day to day contact to support people in making changes to improve health and well-being)

22 Appendix 1

23 Appendix 1

7.2.2 Health inequalities:

What we will do in the first three years

Submit a Lottery bid to develop the Well North Wales initiatives (projects in Llangefni, Denbigh, Wrexham) Support community development initiatives in Bangor, Parc Eirias and Shotton

Launch the social prescribing initiative “Made in North Wales” and roll this out (enabling referrals to a range of non-clinical services) Feasibility study on food poverty initiatives, working with external partners

Implement initiatives to address food poverty, such as the Flint Food Poverty scheme

Develop further work with a range of housing initiatives, linked into care closer to home and health & well- being hubs Develop our contribution to the homelessness agenda, including joint working with initiatives such as Denbigh Hwb, and Housing Associations proposals e.g. community café and homelessness outreach Develop a framework to ensure we use resources to the best effect, targeting investments that have the greatest impact on health and well-being and generate the greatest value for the people of North Wales

24 Appendix 1

7.2.3 Staff health and well-being:

What we will do in the first three years

Develop our detailed staff health & well-being strategy and implement this

Develop our strategy and action plan for supporting the older workforce

Undertake the corporate health standard platinum health assessment

Understand and respond to the detailed needs of our staff in relation to nutrition & obesity, physical activity, tobacco Implement the Time to Change action plan to promote mental well-being

Develop best practice to assist those with protected characteristics* into employment Develop support for staff with protected characteristics* who are already employed

*Note: by “protected characteristics”, we mean the protected characteristics defined within the Equality Act 2010 ✓ Age ✓ Disability ✓ Gender reassignment ✓ Marriage and civil partnership ✓ Pregnancy and maternity ✓ Race ✓ Religion and belief ✓ Sex ✓ Sexual orientation

25 Appendix 1

7.3 Health improvement and health inequalities – our initial priorities

The diagram below shows the main priority areas for the first three years and how they address the factors that influence health.

Socio-economic factors Living & working conditions Social & community Housing and networks homelessness Lifestyle Well North Wales Healthy Health and well-being lifestyles

Preventative services in (Age, sex and Best practice partnership Health & well- in employment being centres hereditary factors)

Staff health & Build prevention well-being into care pathways Arts in health & well-being

26 Appendix 1

8. Care Closer to Home

When you need health care or support to stay healthy, we will seek to provide as much of this close to your home as it is safe and effective to do so. People have told us they want to stay independent as long as possible, helped by good family and community networks. We want to help this to happen. Below is a description of what care closer to home will mean to people, shaped by discussions with stakeholders.

What Care Closer to Home will mean to me:

As many services as possible Services will be will be delivered in my local provided in person or community or my own home in through a virtual team partnership with me, my family,

my carers and other I will know where to go organisations and am able to access services when I need them

In order to prevent I will be put at the centre of services that will hospital admissions you will work with me to prevent, detect support and coordinate what I need around me, in order to early and manage any keep me healthy and deterioration to my physical or independent mental health

27 Appendix 1

The services offered by your GP’s practice will remain central in providing healthcare close to where you live. We will build on the work we have already done to introduce a broader range of health and social care professionals – including specialist nurses, pharmacists and therapists, optometrists (eye care specialists) – to work with GPs and their teams. This will mean that you will see the health care professional who is best placed to meet your needs. We will have introduced new roles in the workforce, such as the newly introduced Physician Associates, who support doctors in the diagnosis and management of people’s health needs. More help will be provided for carers, recognising their individual needs as well as those of the person they care for.

Through these means, we will improve access to primary care, reducing waiting times, and develop a more robust and resilient model of primary care services.

We will develop our Care Closer to Home services around the 14 primary care “clusters” – local areas based on an average of 50,000 people – which will form the building blocks of future planning and provision of services. We will provide the same level and range of services for all communities in North Wales, although the way they are delivered may vary to meet local circumstances or geography. Many services will be provided within each cluster, with some shared across more than one cluster where this is more effective. A map of the 14 clusters is included below.

We will expand services provided by our community teams who work together to care for people in their community and their own home where this is needed. There will be a single point of contact to arrange for the right healthcare professional to go to people when they need them. We will provide these services in an integrated team model, working closely with Local Authorities, which will focus on delivering “What matters” for each individual.

We have already started some of this work through the “Healthy Prestatyn Iach” primary care service; Advanced Physiotherapy Practitioners working on the Llŷn Peninsula; and health and social care teams working together more closely in Gwynedd (the Ffordd Gwynedd initiative.)

We will maximise our use of technology to prevent people from having to travel for appointments – particularly when they have a long term health condition. We are already doing this in the West area to connect patients via rural community hospitals with doctors in Bangor. We will also develop the use of apps – such as the app which gives real time information for tracking appointments; enhancing the app for waiting times at Emergency Departments and Minor Injuries Units; supporting information for treatment programmes; and apps such as “Doctor in my Pocket”, which provides access to medical advice.

28 Appendix 1

We will invest in modern, purpose-built facilities that bring together community teams under one roof to offer a range of services for local people. Together with the recent purpose-built health centres and redeveloped GP premises, we will identify other areas for development with our public sector and third sector partners, and deliver a programme of improved community services across the region.

We will use our community hospitals, GP premises and other facilities to develop health and well-being centres in every cluster. We will work with cluster teams and local communities to assess the local needs and determine how to develop the model of care appropriately in the light of that assessment.

We have involved many people in discussions about care closer to home to help us understand what is important and to help define the actions we will take to improve care.

What people have told us is important to them

Knowing where to go and who to go to for information

Seeing the right person first time

Not being asked the same questions multiple times

Having appointments and tests on the same day in the same place

Understanding where they are in any queue for services

Only being assessed once

29 Appendix 1

8.1 Care closer to home - the outcomes we will aim to achieve

We have considered the evidence of what works, including what people have told us, to identify the initial outcomes we will aim to achieve.

People can access the right information, when they need it, in People have easy and timely the way that they want it and use access to primary care services this to improve their well-being

Health and care support is delivered People know and understand what at or as close to people’s homes as care, support and opportunities are possible available and use these to help them achieve health and well-being

To ensure the best possible Interventions to improve people’s outcome, people will have their health are based on good quality condition diagnosed early and and timely research and best treated in accordance with clinical practice need

People are safe and protected from harm through high quality care, treatment and support

30 Appendix 1

8.2 What future services will look like - Example service model serving a cluster population of around 50,000 We have looked at the services currently provided in our communities and how these might develop in the future. The mature cluster will provide a full range of services for their community by offering the full range of appropriate skills in-house and bringing specialist skills into the team when needed. The model supports co-ordinated care for the entire population, making referrals to hospital services only when necessary and returning people to the care of the primary care and community team as soon as possible. New professional roles, therefore, have the potential to not only contribute significantly to the sustainability of primary care, but also to help to manage the unprecedented demand and pressures currently faced by our acute hospitals.

Expected No. of GPsBased = 25 on list sizes – 2,000 Secondary patients per care beds – to Primary GP be confirmed care Model teamCluster serving Supported a population of 50,000 Living = 200 On average – (based on ratio 1 x Level 1 H&WB* Community resource of 4 per 1000)

Centres and team for children and 2 x Level 2 H&WB adults, physical and Centres mental health Approx. 6

Health & Well-being opticians

assessment Approx. 7 *H&WB Centres = dental Health and Well-being Centres Diagnostics Approx. 11 surgeries pharmacies

31 Appendix 1

The 14 clusters in North Wales

32 Appendix 1

33 Appendix 1

What are Health and Well-being Centres?

Health and Well-being Centres will offer a range of services, bringing together both healthcare and other providers. This will include the full range of primary care services. These could include minor injuries and treatment services; step up and step down beds; therapy services and many others. The potential model for Health and Well-being Centres has been further developed following engagement into three levels

Level 1: Health & Well-being Centre

- Medium to large local campus, based on the footprint of existing Primary Care practices, Health Centres or Community Hospitals

Level 2: Health & Well-being Hub

- Provision of access points to health and well-being services in primary care settings.

Level 3: Well-being and Health Access Points

- Local points where health and well-being advice and information services are provided in community facilities.

We have discussed what services might be provided at the Level 1 and Level 2 centres described above with stakeholders as part of the development of our proposals and the table below summarises this work.

34 Appendix 1

H&WB Centre Services Level 1 Level 2

Higher level services including advanced diagnostics i.e. x-ray ✓

Rehabilitation and reablement providing both inpatient and day facilities ✓

Minor Injuries and Illness services. ✓

Outpatient / Assessment appointments ✓

GP services will have additional wrap around from community services ✓ ✓

Access to multidisciplinary team ✓ ✓

Access to information and advice ✓ ✓

Telehealth facility ✓ ✓

Access to consultant expertise through a Virtual Ward Round ✓ ✓

Navigation and Triage service ✓ ✓

Social prescribing ✓ ✓

35 Appendix 1

Health promotion ✓ ✓

Providing this range of services will require our staff to work in different ways, with a broader range of professions working in the community. This will bring their expertise to patients and reduce the need to travel to our main hospitals for services. The table below sets out a description of the core team who could operate within the Level 1 and 2 Health and Well-being Centres and the virtual team who will support them.

Core Team Virtual Team

36 Appendix 1

GPs Optometrists General Practice Nurses Dentists Community Nurses Consultants Clinical Pharmacists Paediatricians Physiotherapists School Nurses Physician Associates Midwives Health Care Assistants SALT (Speech and Language Therapy) Health Visitors Dietetics Primary Care Mental Health Practitioner Podiatry Audiology Third Sector Occupational Therapy Independent Sector Advanced Nurse Practitioners Psychology Social Workers Psychiatry Paramedics Child & Adolescent Mental Health Navigator Community Mental Health Team Social Prescriber

37 Appendix 1

8.3 What will be the impact of these proposals? We know there is evidence from elsewhere of the impact that similar initiatives have had. Supporting people to manage their own conditions, enabling resilience, preventing ill health and intervening early can all help improve people’s health and well-being and reduce demands on healthcare services. We are reviewing these initiatives and seeking to model the potential impact of introducing these for our population. As we develop this detail, we will build it into our business plans for the next three years. Some examples of the type of impact demonstrated in other areas are given below.

✓ Social prescribing ✓ Holistic care for high risk patients

Social prescribing has the potential to improve Targeting support to people with the highest level of risk can mental health and well-being, improve community result in a 31% lower length of stay (3.7 days compared to 5.2 well-being and resilience and reduce social days); and a 20% lower re-admission rate (14.7% compared to exclusion. Social prescribing programmes 18.4%) demonstrated a 20% reduction in the cost of managing patients with chronic conditions, and there (Powers and others 2016) could be a threefold return on the initial financial investment in services that are delivering positive Patients were found to need to use 63% fewer bed days when outcomes supported by this approach. (University of York – Centre for Reviews and Dissemination, Feb 2015) (Peterson and others 2011)

✓ Remote monitoring - telehealth

Monitoring patients with heart failure can help people stay in their homes, reducing heart-failure related hospitalisation by nearly 30%

(Inglis and others, 2015)

Support to care homes can help people avoid being taken to hospital: 35% reduction in emergency admissions and 50% reduction in attendances to Emergency Department (evidence from the telehealth model implemented in Airedale)

38 Appendix 1

8.4 Care Closer to Home: What we will do in the first three years

Further develop cluster profiles to include existing service provision based on the new model

Implement Social Prescribing across North Wales, monitor impact and develop our understanding of what works well Develop with clusters and individual practices an enhanced service agreement to include a training plan Develop Health and Well-being Centres with cluster teams Liaise with care homes and Local Authorities to introduce, evaluate and replicate the “Airedale telehealth model” in care homes Implement risk stratification in primary care in partnership with colleagues in Australia (an approach to make sure we target support towards those needing care with the highest level of risk) Roll out the Community Resource Team model across North Wales

Develop guidance and toolkit developed for managing GP practices when needed

Agree pathways for rapid assessment, and access to specialists for primary and community care teams in clusters

39 Appendix 1

Care Closer to Home – further priorities: What we will do in the first three years

Research the availability of technology and undertake analysis to inform the development of apps for appointment tracking, supporting treatment and information on where to go Implement and review the “Choose Well” and Minor Ailment Scheme across North Wales

Develop and implement the 6 children’s priority areas with partners

Develop a plan for women's services within the Health and Well-being Centres

Undertake dental health awareness campaigns for high risk groups and “Designed to Smile” will be extended across North Wales Increased access to OCT (Optical Coherence Tomography) scans in the community to support eye care and improve communication with hospital specialists, as part of implementing an improved care pathway for Wet Age-related Macular Degeneration (an eye condition which affects vision) Roll out and evaluate Audiology services across the clusters.

Integration of Primary Care Mental Health teams into clusters

Active promotion of discussion about death, dying and bereavement; introduction of tools and guidance for end of life care across care settings

40 Appendix 1

8.4 Care Closer to Home – our initial priorities

Socio-economic Clusters factors Living & working conditions Social Social & community prescribing networks Lifestyle

Well North Health & well- Primary Wales being centres Care model

Care closer to home GMS Technology & Plus* digital Community (Age, sex and healthcare Resource Team hereditary factors)

Care pathways

Rehabilitation

* GMS Plus – enhancing the model of General Medical Services (the term used for services provided under the GP practice contract

41 Appendix 1

9. Care when your health needs are more serious

We have three main hospitals in North Wales – Ysbyty Gwynedd in Bangor, Ysbyty Glan Clwyd in Bodelwyddan and Wrexham Maelor Hospital. Each of our hospitals will play an important part in meeting future healthcare needs.

We have heard from people that they value the care provided by their local hospital and in particular, the safety net of emergency care.

We have committed therefore to maintain a core set of services at each acute hospital:

• An Emergency Department able to respond to urgent and emergency needs • Consultant-led maternity and children’s services • Admission for medical care for people who are unwell • Admission for people who need an operation • Outpatient clinics, day case surgery and diagnostic services

This means that when people need hospital care, they can be assessed in any of our Emergency Departments. Most people will be treated at the hospital they attend, but some might need to be transferred to the most appropriate hospital for more specialised care. If the patient is being taken by an emergency ambulance, they may go straight to the appropriate hospital.

The relationship with hospitals outside North Wales is also important to people living in North Wales. People living in south Gwynedd often use Bronglais Hospital and those living in Deeside use the Countess of Chester Hospital. We will continue to work in partnership with these hospitals. People from North Wales also use specialist hospital services in England, such as at the Walton Neurological Centre and Alder Hey Children’s Hospital for specialist children’s surgery. In ten years’ time, we will have increased the care we can provide in North Wales so that people travel to English hospitals less frequently. Some people from outside North Wales currently use our services – including people from north Powys and Shropshire – and we will ensure we are aware of their needs in our planning.

However, it is well known that our Emergency Departments are struggling to meet the level of demand that is being experienced. People are often waiting too long to be seen. Demand can also put pressure on the ambulance service, with ambulances sometimes having to wait to hand over a patient to the hospital. This is not unique to North Wales – hospitals across the UK are experiencing similar difficulties.

Working with external experts, we are beginning a major programme of action to tackle these problems, which have proved so challenging, and to develop more detailed proposals for the ten year strategy.

42 Appendix 1

With the support of Welsh Government we are investing in our buildings to bring them up to 21st century standards. This includes the major redevelopment at Ysbyty Glan Clwyd and the new Emergency Department at Ysbyty Gwynedd. We are also developing plans for the redevelopment of the Wrexham Maelor Hospital campus.

In future, people will have information to help them find the right care instead of always having to go to the Emergency Department – this will include use of technology, from our app which gives information on waiting times and opening hours through to telemedicine which will help hospital doctors and nurses give better advice to people at remote sites.

Working with GPs and community resource teams, the ambulance service, local authority social services, the police and third sector, we will help more people to remain at home instead of admitting them to hospital. The table below shows areas which the evidence says are effective in preventing avoidable admissions and helping maintain people’s independence. Many of these services are described in our model for care closer to home, earlier in this paper.

43 Appendix 1

9.1 Making the shift from acute hospitals to care closer to home

Prevent unnecessary admissions and Reduce the number of people going Helping people get back home safely and reduce emergency admissions to Emergency Departments through as soon as possible support elsewhere

Risk stratification Risk stratification SAFER (a bundle of 5 elements of best practice in managing care)

Primary care team Primary care team Discharge to assess

24/7 Community Resource Team 24/7 Community Resource Team 24/7 Community Resource Team

Joint working with Welsh Ambulance Minor Injury Units Care homes Services Trust

Care homes Joint working with Welsh Ambulance Support for mental health needs Services Trust

Out of hours Care homes Access to diagnostics

Mental health services Out of hours Primary care team

End of life care Mental health services End of life care (including hospice care)

Health promotion initiatives End of life care

Health promotion initiatives

NHS Direct (national programmes)

44 Appendix 1

Care Call (national programmes)

9.2 What people have told us We have involved partners, stakeholders and patient and carer representatives in considering what is important to help us shape the priorities for hospital care.

What people have told us is important to them

Access to services as locally as possible - consider the impact of travel for patients, families and staff

Waiting times, particularly for orthopaedic and ophthalmology services, need to be improved

There needs to be improved communication between services and professions within health, social care, third sector and others

Workforce – there are concerns about future availability in some professions or certain specialties

Primary and community care capacity needs to be strengthened to prevent admission and improve safe, early discharge from hospital

We need to improve how the process works for patients - from the front door of the hospital, through the hospital system, and up to and after safe discharge out of hospital to home or the usual place of residence where possible

We need to make best use of our resources (apply the principles of prudent health care)

45 Appendix 1

9.3 Care when your needs are more serious:

Overall priorities for the first three years (Age, sex and hereditary factors) The following areas are priorities for the first three years and are developed in more detail in the sections which follow.

Full establishment of the Sub-Regional Neonatal Intensive Care Centre, providing more specialist care for more babies in North Wales Implementation of centralised complex arterial vascular surgery services

Develop and implement robust sustainability plans for acute care services when different ways of working are needed to sustain services Develop and implement sustainability plans for the urgent out of hours response for some services which are in less frequent demand, such as eye care and ENT (ear, nose and throat) Implement proposals for improving eye care services

Implement proposals for sustainable elective orthopaedics services

Confirm and implement proposals for the whole stroke care pathway

Develop and implement proposals for robotic assisted surgery and the broader model of care in urology services

Progress and implement plans for the longer term model for women’s and maternity services

46 Appendix 1

9.4 Further information - priority areas We have prioritised action to improve services where people are waiting long periods of time to receive treatment. We have looked in detail at how we can provide more timely orthopaedic surgery and eye care (provided by ophthalmology consultants and optometrists in the community). We will also be looking at how we deliver urology services more effectively, identify how we can introduce more specialised surgery in North Wales and reduce waiting times for patients.

Orthopaedic services

Orthopaedic services to treat a wide range of conditions of the musculoskeletal system – joints and bones.

The waiting times for planned orthopaedic surgery (not emergency) are too long. We have been working with the orthopaedic clinicians, other staff, and representatives of community groups to consider ways of improving our response.

At the Board meeting in September 2017 the Board agreed a proposal to improve and strengthen the planned orthopaedic services at each of the three acute hospitals. The following key steps will be taken:

• we will focus on developing preventative initiatives, including continued promotion of the Lifestyle Management programme, so that people are aware of healthy lifestyle choices and are supported to minimise the risk of disease and / or prevents the need for surgery. • a unified referral system will be used for North Wales (the CMATS system – Community Musculoskeletal Assessment Team)

• we will implement proposals for the clinicians to work together as an Orthopaedic Services Network for North Wales, to

improve collaboration and quality standards

• we will invest additional resources, with the support of Welsh Government, in developing extra capacity at each of the

three hospitals.

By doing this we will achieve national waiting time standards within the first three years and improve the quality of

outcomes and patient experience, based on individuals being supported to choose the right treatment for them.

47 Appendix 1

Eye care

Eye care is provided in community settings by optometrists, who are primary care practitioners. In hospital, services are provided through the ophthalmology services. Ophthalmologists provide specialist medical and surgical eye care.

Waiting times for hospital ophthalmology services have grown and we need to reduce these to ensure people have access to the care they need to help protect their sight and support them when problems arise.

We are developing an eye care plan to enable the improvements that are needed. The foundations of the plan are based on national vision strategies and are described below:

• Everyone in North Wales looks after their eyes and their sight • Everyone with an eye condition receives timely treatment (and if permanent sight loss occurs, early intervention and support is available to all) • A society in which people with sight loss can fully participate

The plan comprises four elements 1. Helping people stay healthy and active to maintain good eye health and avoid the need for any treatment in the future 2. Maximising the current and future use of appropriate alternatives to ophthalmology treatment 3. Using our existing ophthalmology capacity more efficiently 4. Increasing ophthalmology capacity

We will also be responsive to the needs of people with sight impairment or loss, improving the accessibility of healthcare and aiding independence.

48 Appendix 1

We will treat as many people as possible in North Wales and continue to create specialist centres for treating more complex conditions, where it meets clinical standards and is safe to do so. We are currently developing the Sub-Regional Neonatal Intensive Care Centre at Ysbyty Glan Clwyd. This will mean that more poorly babies can stay in North Wales.

We have developed specialist services at Ysbyty Gwynedd for gynaecological cancer services. By having a specialist team which manages these conditions consistently, this means that outcomes are improved for women.

During 2018 all major surgery on arteries (vascular surgery) will be provided in a specialist centre at Ysbyty Glan Clwyd. This will ensure that we can provide treatment that meets the highest standards and attract and keep the specialist doctors we need to carry out these complex operations. Our plan for a specialist centre has already helped us to recruit surgeons to North Wales.

We are considering which other services could deliver better outcomes for patients by being developed into specialist centres. We are looking at modern technology for some cancer surgery – particularly pelvic cancer – which will need to be based in a specialist operating theatre.

Introducing innovation in technology

Urology services are a further area where waiting times have been too long and we need to consider how to provide the best service for our patients that will be effective and sustainable into the future.

We have begun a review of North Wales urology services and expect to conclude this in early 2018. The review will consider current service provision and make recommendations for the development of a sustainable service to meet the needs of the North Wales population.

As well as reviewing how we deliver current services, a business case is being developed for the introduction of Robotic Assisted Surgery to North Wales. This innovative development is of strategic importance and it is anticipated this will safeguard and future- proof the delivery of pelvic cancer surgery in North Wales, assisting with recruitment and retention of clinicians.

The robotic device is used by the surgeon to assist in a surgical procedure. The robot provides the surgeon with enhanced imaging, allows 360 degree rotation of surgical instruments, has ergonomic benefits and facilitates greater surgical precision. A robot could also be used for other specialties – such as colorectal surgery and gynaecology.

49 Appendix 1

We are also considering how we will improve the quality of services and support for people who have had a stroke.

Improving our stroke care services

Across North Wales, around 1,200 people will have a stroke each year. In general, survival rates for stroke and the quality of life after a stroke are improving. We know that the risk of a stroke can be reduced significantly through adopting healthy lifestyle choices. Many more people are now aware of the need for prompt action when symptoms of a stroke occur (using the well- publicised FAST checklist for symptoms.)

Our vision is that people of all ages are supported to reduce the risk of stroke, and when stroke does occur, to have an excellent chance of survival and return to independence as quickly as possible.

Together with clinicians, partner organisations and representatives of survivors of stroke, we have been considering what would be the best approach for North Wales. We want to achieve the best chances of survival and avoid or reduce disability after stroke for the population as a whole. This includes the whole range of care from prevention, through hospital care, to ongoing rehabilitation and support at home.

In the UK, there is evidence of improved survival rates and reduced disability rates after a stroke where specialist services have been set up as a hyperacute stroke unit – a unit dedicated to treatment of stroke for the critical first 72 hours. Such a unit would need recruitment of at least 6 specialist stroke consultants and other specialist clinical professionals. The evidence is stronger in urban areas where there is a greater concentration of the population. Nevertheless, there is also some evidence of improved outcomes in other, more rural areas.

We will need to test whether developing a specialist hyperacute stroke service for North Wales would work best; we need to consider the impact on the population if we were to concentrate these services in one place. We have not made any decision and are interested to hear your views before we take this work forward. 50 Appendix 1

Improving services for women

Women’s services include the care of pregnant women, their baby, and family; and services for women who need gynaecological care. We have learned from the feedback we have had from women, their partners and families over recent years and are aiming to address the issues that have been raised. We have confirmed our commitment to maintaining the safety net provided by the three consultant-led obstetric units at Ysbyty Gwynedd, Ysbyty Glan Clwyd and Wrexham Maelor Hospital.

We will achieve the best outcomes possible by co-designing and providing services in partnership with service users, staff and external partners. Our priorities include

• The best support in the First 1,000 days (from conception) • Preventing or reducing Adverse Childhood Experiences and mitigating their impact • Supporting Healthy Weight • Continuing to improve neonatal care • Addressing Peri-natal Mental Health for mothers (during the weeks immediately before and after birth) • Promoting healthy lifestyles and screening.

One of the requirements for providing expert, safe and sustainable care is having the right workforce. Progress has been made with the introduction of Resident Consultants which has reduced reliance on Locum and Agency Doctors. We have also maintained Birth Rate Plus compliance (having the right number of midwives) to provide safe care for women. We will continue to work on re-design and modernisation of our workforce, exploring the contribution of Academic Posts, Advanced Midwifery Practitioners, Surgical Practitioners and Physicians Associate posts.

We will provide a range of high quality choices of care and birth place choices as close to home as is safe and sustainable to do so, from midwife to consultant led care, provided from fit for purpose accommodation.

We will work with primary care to develop and implement gynaecology referral pathways.

For some more specialist services consideration will be given to consolidating services, for example pelvic cancer (Robotic Assisted Surgery), paediatric gynaecology, endometriosis services and fetal medicine.

51 Appendix 1

9.5 Care when your needs are more serious – our initial priorities

Socio-economic Psychiatric factors Living & working liaison services conditions Social & community

networks Emergency Women’sLifestyle services Departments, including trauma Vascular

Care for more serious Medicine & More specialised health needs surgery services (Age, sex and Eye care Electivehereditary factors) Stroke care - Orthopaedics acute & hyperacute

Innovation in technology Rehabilitation e.g. stroke, e.g. robotics orthopaedics

52 Appendix 1

10. Mental health and well-being

Our commitment to promoting mental health and well-being is at the heart of our plans to improve and develop our mental health services. The Five Ways to Well-being are based upon the New Economics Foundation [2008] review of the most up to date evidence of individual actions that promote well-being.

“Evidence indicates that each action theme positively enhances well-being and mental capital by interacting at the level of ‘functioning’. According to the evidence

base to date, the 5 Ways To Well-being play an essential role in satisfying needs for positive relationships, autonomy, competency and security” New Economics Foundation

In April 2017 the Health Board approved a new strategy for mental health and well-being in North Wales. This is an all-age strategy, which has been co-produced with service user and staff involvement. The strategy sets out the clear aims of promoting health and well-being for everyone; preventing mental ill health and early intervention when required; and delivering joined-up and recovery-focused care. The strategy is being

53 Appendix 1 taken forward through the re-established Together for Mental Health In North Wales partnership board. The full strategy can be found on our website at BCU HB April 2017 Mental Health Strategy

10.1 Mental health and well-being - the outcomes we will aim to achieve

Our strategy was developed in partnership with people with lived experience of mental health services, carers, partner organisations and stakeholders. The six high level outcomes identified in Together for Mental Health have been adopted as the overall outcomes we will aim to achieve.

The impact of mental health problems and/or mental illness on individuals of all ages, their families and The mental health and well-being of the whole carers, communities, and the economy more widely population is improved is better recognised and reduced

Inequalities, stigma and discrimination suffered by Individuals have a better experience of the support people experiencing mental health problems and and treatment they receive and have an increased mental illness are reduced feeing of input and control over related decisions

Access to, and the quality of, preventative measures, The values, attitudes and skill of those treating or

early intervention and treatment services is improved supporting individuals of all ages with mental health

and more people recover as a result problems are improved

54 Appendix 1

55 Appendix 1

10.2 Mental health and well-being:

What we will do in the first three years

Promotion of good mental health – including 5 ways to well-being; schools-based programmes; employer- based approaches; welfare rights and money advice Peer support and other services for people stepping down from community care

Integrated teams to manage very common co-morbidities between physical and mental health, for example anxiety and COPD (Chronic Obstructive Pulmonary Disease, a respiratory condition) Eating Disorder Pathway for young people, which focuses on early intervention and the family

Roll out and implement across North Wales the self-harm pathway for young people developed in partnership with Education services Improve the availability of a range of psychological therapies, including online therapeutic interventions

People experiencing first episode psychosis have access to the full range of NICE-approved interventions (joint model, Adult Mental Health & Child & Adolescent Mental Health Services for young people aged 14 – 25 years) Support people who are able to manage safely by enhancing community based services, which are accessible and responsive to changing needs and available 24/7 All ward environments will be fit for purpose, safe and humane

Deliver all care in North Wales for all ages unless clinical needs require more specialised out of area care

Confirm our strategy for supporting people living with dementia and their carers, and develop a robust action plan to implement this Work with partners to develop and improve support for people with a learning difficulty or disability

56 Appendix 1

11. Children and young people

Through our strategy, we will do more to give children the best start in life, taking action as soon as possible to address problems for children and families before they become more difficult to address.

We know the chances of good – or poor – health are influenced by what happens in-utero (before birth) and in early childhood. Disadvantages are likely to have a cumulative impact throughout childhood and onwards into adulthood. What we do to support families and children will have a direct impact on the health of future generations.

We have worked in partnership with other organisations working to meet the needs of children and young people, and have asked children and young people themselves directly, to find out what is important and develop our priorities for this strategy.

Many of the priorities we have identified are cross-cutting and appear in other themes. We intend for children’s services to be better integrated with Local Authority and third sector services, and closely linked into the developments described within the Care Closer to Home priorities – including the Community Resource Teams, and Health and Well-being Centres.

What people have told us is important to them

• I mproving outcomes and reducing inequalities in the First 1000 days (focus on low birth weight, immunisations, nurturing etc.) • Prevention and mitigation of Adverse Childhood Experiences • Lifestyle Choices, including breastfeeding initiation and maintenance, healthy weight in pregnancy and childhood, smoking cessation • Emotional health, resilience and well-being of children and families including more specialist services e.g. CAMHS, Perinatal Mental Health. • Better access and services for families with children with Complex Needs / Disabilities / children in crisis • Children who are Looked After have improved health and emotional health wellbeing outcomes • Young Carers have improved physical health and emotional well-being

• Timely access to services when needed including primary, community, acute and specialist care

• Acknowledgement of the contribution of the Third sector in providing services and support to children and families

57 Appendix 1

11.1 Children and young people – the outcomes we will aim to achieve

Listening to what people have told us we have identified the following initial outcomes -

Children’s rights are met in line Children are listened to and with the requirements set out in Children are cared for, services are planned and the United Nations Convention supported and valued provided based on what is on the Rights of the Child important to them

All children in early years do All children in early years are, All children in early years learn not live in, and are not and feel safe and develop disadvantaged by poverty

Children at raised risk of poor emotional well- Children are resilient, being are quickly identified and early capable and caring intervention and preventative action is tailored to their needs

Services are age appropriate Children are supported in (with particular reference to transition (adult services and teenagers) between services)

58 Appendix 1

11.2 Children and young people:

What we will do in the first three years

Fully establish the Sub-regional Neonatal Intensive Care Centre and provide more care for more babies in North Wales Take action to improve outcomes in the First 1,000 days of life

Improve the emotional health, mental well-being and resilience of children and young people

Promote healthy weight and prevent childhood obesity

Review crisis intervention services for children and young people who are experiencing an urgent perceived mental health crisis Prevention and mitigation of Adverse Childhood Experiences – delivering trauma informed services

Improve services for children with complex needs due to disability or illness

Improve engagement with children, young people and families

With partners develop a joint framework and strategic plan for the 6 Children’s Partnership priorities

59 Appendix 1

60 Appendix 1

12. Healthy ageing

Through our strategy, we will place greater emphasis on promoting good health, and providing appropriate support for older people. Many people will be in paid employment or the early years of retirement within this age range and we will focus on promoting well-being and healthy lifestyles for all, and where needed, enabling people to maintain active and independent lives.

For others, the age at which support needs may emerge will vary. For people from areas with greater social and economic needs, the impact of the process of ageing can begin much sooner. The preventative approach will focus on enabling people to maintain their independence or enabling them to regain it at any age.

We will address the needs of those people who begin to find it more difficult to continue with the life that they may have enjoyed pre-retirement. We will anticipate longer term care needs, facilitating reablement or rehabilitation where necessary to encourage and promote independence either closer to home or within people’s own home. We will seek to reduce inappropriate hospital or care home admissions.

We will also seek to support preventive interventions such as those promoting exercise and physical activity, healthy eating, lifestyle change, disease management, integrated models of care and telehealth / telemedicine.

The priorities we have identified for people are threaded through the work of the other programme areas. What is important is that the specific needs and perspective of older people is taken into account throughout. We want to be sure that older people have a voice that is heard, and feel they have control over their health, well-being and healthcare.

61 Appendix 1

What people have told us is important to them

Timely access to GPs - improved appointment systems, extended opening hours

Improved waiting times for hospital appointments (particularly orthopaedics and Emergency Departments)

Use of telemedicine – however we need education in new ways of working and smart technology

Living independently – for as long as they’re able to do so

Support network to provide good basic local care and information about available services People want to feel in control of their lives and their choices

Provision of a key worker to help people and carers navigate the system

Information - help and care available; raise awareness of SPOA (Single Point of Access) and DEWIS (DEWIS is the website with information and advice about well-being – www.dewis.wales)

Dignity and respect – there are examples of excellent, dedicated care and support which need to be consistent

Well-being – impact of social isolation; the need to shift to a more psycho-social model of health

Health promotion – people having the opportunity to take more control and responsibility over their own health

Joint working – health, social care, and third sector services to work more collaboratively, improved co- ordination and integration of multi-agency care 62 Appendix 1

12.1 Healthy Ageing – the outcomes we will aim to achieve Through our engagement work we have confirmed the following initial outcomes:

People aged 50+ and carers have access to People aged 50+ and carers live in environments information and advice about services & that are sensitive to their needs, support healthy opportunities that enable them to maximise their ageing and enable them to be socially connected health & well-being

People aged 50+ and carers have access to People aged 50+ and carers have personalised integrated services to enable appropriate access to high quality them to manage long-term conditions, primary & community services within dementia and mental well-being and their local area complex needs

People aged 50+ and carers are People aged 50+ and carers have proactively supported to regain their Quality of end of life care is proactive community based clinical or motivation following an adverse life optimised for people aged 50+ social care interventions which avoid event / period of poor health / and later in life unnecessary admission to hospital admission to hospital

63 Appendix 1

12.2 Healthy Ageing - What we will do in the first three years

Develop key evidence-based health promotion interventions for older people

Develop senior health mentor roles / health volunteers within the work environment and community settings Plan whole system initiatives that maximise the health and well-being of older people

Staff who can communicate effectively with older people i.e. appropriate interpersonal skills, behaviours and sensitive to needs Deliver improvements in end of life and palliative care including - Active promotion of initiatives to encourage discussion of experiences of the end of life, to help promote and provide support for dying well - Easily accessible information & advice for patients receiving end of life and palliative care services - A training and education plan for staff developed in conjunction with academic partners - A skilled, knowledgeable workforce that can respond efficiently and effectively - Tools & guidance for end of life care in place across all settings i.e. Treatment Escalation Plans and Care Decisions, and work in partnership with the hospice movement

Workshop session with partners to agree a joint action plan under the Regional Partnership Board to align Health Board plans with the Local Authorities’ ageing well plans

64 Appendix 1

13. What next – how people can get involved

The approach to our strategy, and the priorities we have outlined in this paper, have been built on our involvement with a wide range of people – individuals, groups and organisations, including our own staff – which has contributed significantly to reshaping the way we think we should work for the future. The paper has been produced to provide an overview of the work to date, and to share our proposals for transformation of the way we work with our population, service users and carers, partner organisations and third sector and community groups, and importantly, our staff. We want to be certain that anyone who wants to give their views on the developing strategy has the opportunity to do so. We want to continue the conversation about what we do next for health, well-being and healthcare in North Wales. We will consider the further feedback we receive and review our proposals, before producing the draft strategy in January 2018.

To enable this to happen, we will circulate this paper widely to our staff, partners, key stakeholders and publish it on our website. We will provide simple, summary information which will be easily accessible and draw attention to the proposals we are considering. We will particularly seek views on

• whether, with the amendments we have proposed, Our well-being objectives are the right ones or whether there are other objectives that people think should be included. • our proposals for transforming the way we work to improve physical, mental and emotional health and well-being are appropriate and people recognise the need for change • whether we have identified the right outcomes to work towards and the right priorities in the first three years.

To facilitate this, we have produced a draft engagement and communications plan. We will add to this as activities and dates are confirmed and will welcome any further suggestions of how to share the messages and gain views from people before we finalise the proposals.

July – September October – November December January Development of scenarios Further engagement Review and refine Draft strategy to Board

1 B17.18d LHSW App 2 Schedule of engagement events.docx

APPENDIX 2 Schedule of engagement events

Date Event Venue 29/09/2016 International Day of Older Persons Wrexham Maelor 01/10/2016 Eagles Meadow Engagement Event Wrexham Shopping Precinct 16/01/2017 Age Well Llangefni 19/01/2017 Age Well Dolgellau 03/02/2017 Care Closer To Home Big Ideas Event Oriel House Hotel, St Asaph 14/02/2017 Hubbub Llanrwst Trans people’s Experiences of Primary 16/02/2017 Healthcare; “Have your Say” Llandudno 25/02/2017 South Denbighshire Carers Group Ruthin 02/03/2017 Acute Hospital Care - Professionals The Interchange, Old Colwyn 03/03/2017 Children’s and Younger People Beaufort Park Hotel, Mold 06/03/2017 Maternity Services Liaison Committee Pontio Theatre, Bangor 08/03/2017 Older People's Stakeholder Event (East) Wrexham Memorial Hall, 09/03/2017 Maternity Services Liaison Committee Llandudno Glasdir Business centre - 09/03/2017 Children’s and Younger People Llanrwst Older People's Stakeholder Event 09/03/2017 (Central) The Interchange, Old Colwyn 10/03/2017 Maternity Services Liaison Committee Wrexham Memorial Hall, 10/03/2017 Care Closer to Home Workshop Carlton Court 13/03/2017 Children’s and Younger People Tre-Ysgawen Hall, Llangefni 14/03/2017 Older People's Stakeholder Event (West) Celtic Royal, Caernarfon 20/03/2017 Over 50+ Forum Flintshire 22/03/2017 The Lighthouse Group Mynydd Isa 23/03/2017 Hope & Caergwrle Ladies Group Hope 28/03/2017 Care Closer To Home Gallery The Interchange, Old Colwyn 29/03/2017 Morfa Bychan Y Ganolfan @Morfa Bychan Catrin Finch Centre, 30/03/2017 Care Closer To Home Gallery Wrexham 30/03/2017 Derby & Joan Club Holywell Trinity Community Centre, 31/03/2017 Deaf, Blind Cymru Engagement Event Llandudno 03/04/2017 Care Closer To Home Gallery Reichel Hall, Bangor Young people’s project and VIVA Rhyl 04/04/2017 06/04/2017 Women's Centre Rhyl 06/04/2017 League of Friends AGM Ysbyty Alltwen Date Event Venue 07/04/2017 Men’s shed meeting Colwyn Bay 07/04/2017 Dementia Go Porthmadog Leisure Centre 07/04/2017 The Amigos - Portuguese group Hightown, Wrexham Flint Health Centre - Information 12/04/2017 Session Flint Library, Flintshire 25/04/2017 Housing Meeting Noddfa 25/04/2017 Children’s and Younger People Morfa Hall, Rhyl 26/04/2017 Session at Opticians premises Llangefni 26/04/2017 Iorwerth Arms Pub Bryngwran, Anglesey 26/04/2017 Children’s and Younger People Galeri Caernarfon 03/05/2017 Children’s and Younger People Wrexham Memorial Hall, Conwy Business Centre, 10/05/2017 Acute Hospital Care - Clinical Summit Llandudno Junction Conwy Business Centre, 10/05/2017 Acute Hospital Care - Clinical Summit Llandudno Junction Acute Hospital Care - Focus Groups - 13/05/2017 Gynaecology Pen-y-Bryn Pub, Colwyn Bay 17/05/2017 Knit and Natter Group Cefn Mawr Library 22/05/2017 Extra Care Housing Plas Madoc, Wrexham 23/05/2017 Hyperacute Stroke Unit Roadshow The OpTic 01/06/2017 Survey of Patients attending ED YGC Children’s Workshop - SSWBA & Conwy Business Centre, 07/06/2017 Strategy Llandudno Junction Wrexham & Flintshire Town & Gwersyllt Community 07/06/2017 Community Councils' Forum Resource Centre Ruthin Community Hospital League of 09/06/2017 Friends Awelon, Ruthin 20/06/2017 Staff engagement, Ysbyty Gwynedd YG, Bangor 22/06/2017 Staff engagement - Abergele Hospital Abergele 24/06/2017 Denbigh Carnival Denbigh 26/06/2017 Staff engagement - Wrexham Maelor Wrexham Maelor 26/06/2017 Staff engagement - Wrexham Maelor Wrexham Maelor 03/07/2017 Staff engagement - Ysbyty Alltwen Ysbyty Alltwen 04/07/2017 Specialty Pathway Review Workshop OpTic Centre, St Asaph 04/07/2017 Staff engagement - Ysbyty Glan Clwyd Ysbyty Glan Clwyd 04/07/2017 Staff engagement - Ysbyty Glan Clwyd Ysbyty Glan Clwyd Conwy & Denbighshire Town & 05/07/2017 Community Councils' Forum Eirianfa, Denbigh 06/07/2017 Stroke Services workshop The Kinmel, Abergele 07/07/2017 Women's Service Leads - West Ysbyty Gwynedd Staff engagement - Mold Community 07/07/2017 Hospital Mold Community Hospital Date Event Venue 20/07/2017 Women's Service Leads - East WMH 20/07/2017 Equalities Stakeholder Workshop OpTic, St Asaph 28/07/2017 Women's Service Leads - Central Faenol Fawr, Bodelwyddan 01/08/2017 Staff Questionnaire North Wales 05/08 – 12/08/2017 National Eisteddfod Anglesey 08/08/2017 Elective Orthopaedics Workshop OpTic Centre, St Asaph 16/08 – 17/08//2017 The Anglesey Agricultural Show Anglesey 17/08/2017 Denbigh & Flint Show Denbigh 18/08/2017 Stroke Services Workshop OpTic Centre, St Asaph 01/09/2017 1 to 1 engagement with Surgeons Various 02/09/ - 03/09/2017 Beaumaris Food Festival Beaumaris 09/09/2017 Elective Orthopaedics Workshop OpTic Centre, St Asaph Arfon & Dwyfor Town & Community Town Council Chambers, 12/09/2017 Councils' Forum Pwllheli 15/09/2017 Opthalmology Workshop OpTic Centre, St Asaph 16/09 – 17/09/2017 Mold Food Festival Mold 25/09/2017 Stroke Services The Kinmel, Abergele Meirionnydd Town & Community 26/09/2017 Councils' Forum Free Library, Dolgellau 02/10/2017 Younger Older People Llanfair PG

1 B17.18e LHSW App 3 Phase 3 Engagement Plan V8.docx

1 Appendix 3

Living Healthier Staying Well Engagement Plan October – December 2017

Version 8

2 Appendix 3 LIVING HEALTHIER, STAYING WELL ENGAGEMENT AND COMMUNICATIONS PLAN

October - Planning / Pre Engagement Stage

Action Lead Completed by Progress

1. Publish vision document outlining strategic direction and drivers for change CW / GL May 2017 Complete

2. Produce public information leaflet for use during summer engagement KS / RC July 2017 Complete

3. Hold engagement planning workshop RC 2nd Oct Complete 4. Produce “Issues Paper” SB 11th Oct Complete

5. Board to agree the scale and scope of issues for engagement and key SB 19th Oct “audiences” to engage 6. Map previous engagement activity SD / RS 19th Oct 7. Finalise engagement feedback template and questions RC 19th Oct

8. Agree content for managers’ briefing notes and FAQ JT / KS 20th Oct 9. Develop and launch social media plan KS / RS 20th Oct 10. Review LHSW website pages in preparation for new content KS / RS 20th Oct

11. Inform key stakeholders about the strategy programme and engagement KS / SB 20th Oct opportunities 12. Encourage staff involvement/ feedback through promoting key messages and KS 20th Oct signposting to LHSW information in Team Brief/ My Week

October - Engagement Stage

Version 8

3 Appendix 3 Action Lead Completed by Progress 13. Women’s Group, Anglesey JT / WH 2nd Oct Complete

14. Carers Experience Workshops, Wrexham Hafal / KO TBA

15. Community Information Day, Prestatyn MV 7th Oct Complete

16. Health and Wellbeing Fayre, Rhyl MV 10th Oct Complete

17. World Mental Health Day, Glyndwr University KO 10th Oct Complete

18. Unllais ½ day workshop Wrexham JT/SO 11th Oct

19. Unllais ½ day workshop, Llandudno JT / SO 11th Oct

20. Unllais ½ day workshop Caernarfon JT / SO 12th Oct

21. North Wales Cancer Forum (West) quarterly meeting – Ysbyty Gwynedd EW 12th Oct

22. Mantell Gwynedd’s big Good Health event – Dolgellau Leisure Centre EW 13th Oct

23. Llangollen Food Festival KO 14th & 15th Oct

24. Older Persons Workshop, St Asaph WH 16th Oct

25. Finalise supporting material (e.g. leaflets) KS 19th Oct

26. Offer opportunities for engagement to Local Authorities as key partners SB 19th Oct

27. Confirm open (drop-in) sessions in all Local Authority areas RC / SB 19th Oct

October - Engagement Stage

Action Lead Completed by Progress

Version 8

4 Appendix 3 28. Confirm staff drop-in sessions across the Health Board SB 19th Oct

29. Motivate, Eirias Park MV 20th Oct

30. Agree dates/availability to lead web chats SB 23rd Oct

31. Flintshire PSB SB 25th Oct

32. Musculoskeletal Group, Bangor EW 25th Oct

33. Cross – Sector CEOs Meeting SB tbc

34. Modern Slavery Awareness Event, St Asaph MV 28th Oct

35. Amigos Group, Wrexham KO TBA

36. Techniquest Event, Wrexham, Glyndwr University KO 30 & 31st October

November - Engagement Stage

Action Lead Completed by Progress

Version 8

5 Appendix 3 1. Fairbourne Older People’s Partnership, Caernarfon EW 2nd Nov

2. Armed Forces event at the Ramada, Wrexham KO 2nd Nov

3. Launch PR to highlight engagement opportunities KS 3rd Nov

4. Ageing Well Event, Llandudno MV 3rd Nov

5. Gwynedd & Mon PSB 6th Nov SB 6. Respect Faith Conference, Wrexham KO 7th Nov

7. Llanrwst Older Peoples Forum MV 7th Nov

8. Regional Partnership Board SB tbc

9. Networking event for cancer support groups, St Asaph MV 9th Nov

10. 3 x Children and Young People focus Groups (11-18yrs) Denbighshire schools JT / MV TBC 11. Health & Wellbeing Network, Llay, Wrexham (AM) KO 9th Nov

12. Third Sector Communications Session, Llay, Wrexham (PM) KO 9th Nov

13. Recovery & Wellbeing Event at Civic Centre in Connah’s Quay KO 12th Nov

14. Carers Experience Workshops WO 15th Nov

November - Engagement Stage

Action Lead Completed by Progress Notes

Version 8

6 Appendix 3 15. Joint Engagement with Community Nurses, COPD awareness, Bangor EW 15th Nov

16. Armed Forces Information Event MV 18th Nov

17. Video camper/engagement Van (Rural Denbighshire) RC TBA

18. Ruthin Older Peoples Forum MV 21st Nov

19. National Carers Rights Day, Anglesey or Gwynedd TBC EW 24th Nov

20. Mantell Gwynedd community van at Llŷn Peninsula EW 27th Nov

21. Singing for Lung Health Group – Theatr Clwyd, Mold KO 27th Nov

22. Substance Misuse Promotion Group, Rhyl MV 29th Nov

23. LHSW public & staff Information stands at Ysbyty Gwynedd EW 30th Nov

24. Third Sector Network of Organisations Delivering Health and Social Care, MV 30th Nov Conwy 25. Conwy & Denbighshire PSB SB 30th Nov

December - Engagement Stage

Action Lead Completed by Progress Notes

Version 8

7 Appendix 3 1. Ysbyty Alltwen Xmas Coffee morning EW 1st Dec

2. Leadership Group SB 1st Dec

3. Joint MSK Group – Llys Castan CHC Offices, Bangor EW 5th Dec

4. Third Sector Network of Orgs Delivering Health and Social Care, Denbighshire MV 6th Dec

5. LHSW public & staff Information stands at Wrexham Maelor KO 7th Dec

6. Regional Partnership Board SB tbc

7. Maternity Services Liaison Committees (MSLC) St Asaph MV 14th Dec

8. Therapies Department engagement day EW TBA

9. 3 new Community Hubs on Anglesey (Llanfairpwll, Llangefni and Llanfaelog) EW TBA

10. Equality Stakeholder Group ST 14th Dec

Version 8

8 Appendix 3 December - January – Post-Engagement Stage

Action Lead Completed by Progress

1. Provide analysis of digital engagement KS / RS 15th Dec

2. Collation and analysis of feedback through engagement channels RC Ongoing during Dec

3. Review of feedback and identification of significant messages SB / GL 31st Dec

4. Revise draft proposals to respond to feedback and develop draft strategy SB / GL 12th Jan

5. Publish draft strategy document for submission to February Board GL 25th Jan

Version 8

8 B17/19 Seasonal Plan / Winter Resillience - Mr Geoff Lang / Ms Morag Olsen 1 B17.19 Seasonal Plan 2017-18 FINAL v6_updated.pdf

Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru Welsh Ambulance Services

North Wales Health and Social Care Integrated Winter Resilience Plan

2017-18

1. Introduction This document sets out the Betsi Cadwaladr University Health Board’s seasonal plan and delivery arrangements for 2017/18. The plan builds on learning from local risk assessments and lessons learnt from 2016/17 to inform the system changes that will ensure our unscheduled care system remains resilient over the winter period.

Pressures throughout the pathway within any unscheduled care system lead to delays in treating people in urgent need. It is, therefore, essential that an unscheduled care system works effectively at all times. Through working together with partner organisations, the Health Board aims to ensure residents of North Wales can access high quality, timely healthcare when in urgent need, throughout the winter.

Our local plans also align with the all Wales framework which utilises a patient-centred unscheduled health and care patient pathway, based on the 10-step model to support citizens requiring access to health and social care services in Wales.

Step 0 – Help to keep me independent Step 1 – Help me choose Step 2 – Answer my call Step 3 – Come to see me Step 4 – Give me treatment Step 5 – Take me to hospital Step 6 – Assess me Step 7 – Provide me with my diagnosis Step 8 – Give me treatment Step 9 – Discharge me from hospital Step 10 – Ensure my continuing care is effective

2. Key areas of focus The Health Board, working in partnership with Welsh Ambulance Services NHS Trust (WAST), North Wales Police, Local Authorities and the Third Sector, has identified the following 4 immediate priority areas to improve our un scheduled care system that will focus on; i) community; ii) escalation; iii) ring fenced capacity; iv) discharge processes

This is combined with Primary Care, as general practice, dental surgeries and community pharmacy all play a significant role in any unscheduled care system.

During the winter planning process, all plans were presented and approved by the Health Boards Winter Resilience Group; and discussed with the Strategy, Partnerships and Public Health Committee of the Board and the Health Board in October 2017. The plan will also go to the North Wales Partnership Board in November 2017.

The system wide Unscheduled Care Transformation Group will lead and oversee the programme management and delivery of this plan, supported by 4 sub-groups identified above. There will be multi-agency task and finish groups to deliver the projects.

The NHS Wales Delivery Unit has been providing targeted support for teams on managing escalation and acute care flow. This support continues with work focused on daily safety huddles to improve patient flow.

3. Developing the plan for 2017/18 Having understood the expected demand over the seasonal period and into quarter 4 it is imperative that both a local and regional approach to unscheduled care is achieved. The Health Board has worked closely with WAST, North Wales Police, North Wales Fire and Rescue Services, Local Authorities and the Third Sector to develop this plan. This has been undertaken both at area level and across the breadth of North Wales to ensure that all clinical, managerial and professional staff are actively involved. All parties are represented on the Unscheduled Care Transformational Group and this forum has been the driving force behind its development. This has developed and strengthened effective communications with partner agencies on a day to day basis and in response to managing times of increased demand and pressures across the whole system.

There has been comprehensive engagement with Primary Care and in particular, cluster leads, who until recently have been represented on the Unscheduled Care Transformation Group and working together with the Area Directors, they have contributed to the development of the Unscheduled Care Plan.

The Health Board also has good links with the third sector at Area level, where the learning from the initial focus on frequent attenders to Emergency Departments (EDs) has led to a more focused approach between the Health Board and the Third Sector specifically around Social Prescribing and the model moving forward. The Local Public Service Boards are working together to develop joint strategies to address gaps in provision with a particular focus on the long term. One of the priorities is to address the long term needs of the growing ageing population, addressing gaps in provision and focusing on individual resilience. There is also significant ongoing engagement with third sector agencies to support preventative measures in terms of the take-up of statutory services as well as support for people in their own communities and prevent hospital admissions.

Feedback in relation to patient experience and satisfaction is key to learning and informing development of services and is received from monitoring of complaints, claims and incidents as well as from service users, carers and the public via a real time feedback system (Viewpoint). In addition to this there are other mechanisms available such as comment cards left in public areas, e-mail address for feedback to Service User Experience Team and a Carers Feedback Survey that is in public areas and is issued by 3 rd Sector Carers Organisations. Any significant issues documented within patient feedback is escalated to the relevant area within 48 hours and actions followed up.

Future learning is also informed via the bi-monthly Listening and Learning from Experience meetings. All areas are asked to provide a report on key themes and trends identified from patient feedback and incidents and what learning has taken place.

3.1 Review of 2016/17 During Quarter 1 of 2017 the Health Board reviewed the impact of the seasonal plan for 16/17. This highlighted a number of areas of significant success but also areas where further focus was required specifically moving into the planning stages for the forthcoming winter.

Some of the areas of success were identified as; • Escalation planning • Community resource teams working to ensure patients stayed at home where appropriate • Admission avoidance scheme that focused on multidisciplinary teams assessing patients in ED and discharging home with support from the community teams • Whole system ad hoc GOLD meetings lead by North Wales Police that reviewed pressures across North Wales for all organisations • Locating office space within the Health Board for Local Authority staff during the Christmas period to reduce delays in packages of care and residential and nursing home placements. • Live Waiting Times APP for EDs and Minor Injury Units (MIUs)

Areas of further focus and development during the year included; • Health Care Professional calls directly to an admissions hub • Flu plan, whilst successful in parts both on the uptake of the flu vaccination for staff and the population, there was still more that could have been done. • Preparedness for patients with flu within the secondary care setting; • Infection Control spread at Wrexham Maelor significantly impacted on flow during Quarter 4 of 2016/17; • Ambulance handover times; • Workforce resilience to the ongoing unrelenting pressures throughout the winter months • Most common reasons for conveyance to an ED by WAST; • Mental Health pathway including North Wales Police and WAST elements as well as the Health Board; • Deterioration in the delivery of both 4 and 12 hr waiting times targets.

3.2 Analysis of the impact on increased demand during winter In order to develop a cohesive plan, a review and understanding of the activity flows is paramount to ensure that, as demand increases, the additional actions taken will have a positive impact on flow through the system. The waiting times at hospitals, measured by the 4 hour and 12 hour waiting times targets, as well as ambulance handover times, are good indicators of system resilience and ability to cope with demand. For individual patients, delays at hospital can cause distress and may, in some cases, affect treatment outcomes. The following graph at figure 1, highlights the day-to-day average variations in both activity and performance over a 4 year period. This clearly identifies the days throughout this period, when all organisations across North Wales are required to increase capacity to meet the expected historical demand.

Figure 1: 4 and 12 hour performance, ED attendance and admissions (4 year average October 2013 – March 2017)

The pattern and frequency of admissions is a factor with an increase of attendances on specific dates revealing pressure in the system. The following graph at figure 2 shows the number of ambulance arrivals by day.

Figure 2: Number of Ambulances – 4 year average 2013/14 – 2016/17)

Both graphs demonstrate, over a 4 year period, two distinct sharp peaks in ambulance arrivals, e.g. immediately after the Christmas and New Year periods, and the relevant impact on admissions and performance. These are predictable patterns of demand and the capacity to effectively manage them is clear within our plan to ensure that the Health Board, working with partners has the necessary resilience in place across the whole system to respond to this expected demand particularly during the period 27 th December to 9 th January.

Whilst both graphs demonstrate that demand is relatively consistent, there is no correlation between demand and performance. There is a strong perception within the hospitals that the acuity of patients is increasing, due to the success of admission avoidance programmes. There is no strong evidence to support this perception, however, whilst the number of attendances rises significantly between the Christmas and New Year period, it does demonstrate a return to normal levels once into January. This means that the focus on discharge planning becomes even more crucial to maintain flow within the system.

The following graph also demonstrates the impact of a different level of communication in the development of the Live Waiting Times APP and the increase in activity that the Health Board have seen through its minor injury units.

Figure 3: MIU attendance by Area and Week

In order to understand flow in a system, the number of discharges and length of stay of patients becomes far more informative . The following graphs show the number of discharges from the three acute hospitals over the winter of 2016/17 (Figure 4) and the average length of stay for each acute site over a 4 year period 2013 to 2017 (Figure 5).

Figure 4: Acute Hospital Discharges by Date throughout the winter of 2016/17

400 350 300 250 200 150 100 50 25th Dec 0 07-Jan 14-Jan 21-Jan 28-Jan 01-Oct 08-Oct 15-Oct 22-Oct 29-Oct 04-Feb 11-Feb 18-Feb 25-Feb 03-Dec 10-Dec 17-Dec 24-Dec 31-Dec 05-Nov 12-Nov 19-Nov 26-Nov 04-Mar 11-Mar 18-Mar 25-Mar

BCUHB 2016/17 Linear (BCUHB 2016/17)

There are two main messages from the graph at figure 4; i) the number of discharges significantly drops at the weekend, and ii) the average number of discharges reduces (even more) in the week between Christmas Day and New Year’s Day, however this is probably offset by the significant number of discharges just before Christmas day.

Figure 5: Average Length of Stay by Acute Site per Month

4. At Risk and Vulnerable Groups As part of the context for the seasonal plan, it is important to understand which of North Wales’ populations are most at risk from adverse winter conditions and ensure that service changes are targeted to support these sections of the population.

In seasonal planning, the term “vulnerable group” refers to sections of the population particularly those at risk, marginalised or under-provided for. During the winter, these groups may become more vulnerable as health and social care resources are more likely to be directed into mainstream efforts to meet the needs of the general population. Extremes in temperature have been shown to have a detrimental effect on health and wellbeing. Higher mortality, morbidity and hospital admissions occur both in the summer and winter months.

As an indicator, “excess winter deaths” is defined as the difference between the number of deaths in the four winter months (December – March) and the average number of deaths during the preceding four months and the following four months. In the UK as a whole, excess winter deaths represent 5% of all deaths per year and representing an average of 27,000 additional deaths in winter, as compared to other times of the year.

Although EWM is associated with low temperatures, conditions directly relating to cold, such as hypothermia, are not the main cause of excess winter mortality. The majority of additional winter deaths are caused by cerebrovascular diseases, ischaemic heart disease and respiratory diseases. Exposure to cold also increases an individual’s risk of injury from fires and falls, contributes to mental health problems, increases social isolation and has a negative impact on the education of children, if homes are not adequately heated.

Figure 6: Material deprivation across North Wales

4.1 Older People Some older people can be particularly vulnerable regardless of their social background. They may require ongoing specialised medical care or need end of life care. They may need specific support, in order to achieve or maintain independence, including access to medical supplies or equipment (e.g. oxygen); or accessing other assistance.

4.2 People with an underlying physical or mental health condition In Wales and across the UK, ‘flu vaccination is routinely offered to people considered to be more at risk of complications from flu. This includes those who: • Are aged 65 and over; • Have a chronic heart condition; • Have a chronic chest complaint, including asthma which requires regular medication; • Are pregnant; • Are living in long-term residential or nursing homes;

Individuals with morbid obesity (BMI >40) have also been found to be at higher risk of complications if they catch flu, so it is recommended this group also receive annual flu immunisation.

Frontline healthcare workers; social care workers; carers; volunteer carers; members of recognised voluntary organisations that provide planned emergency first aid at organised public events; members of the Welsh Ambulance Service Trust Community First Responder scheme are also offered vaccination against flu.

4.3 People living in poor housing or homeless people This group is largely those people living in older, energy inefficient or exposed properties. Excess winter mortality is linked to poorly heated homes and low household income. Those living in deprived communities are more likely to have many of the risk factors for seasonal excess deaths and ill health. Across the North Wales area, Conwy and Wrexham Local Authorities have the highest rate of homelessness, with over 100 per 10,000 households assessed as being homeless during 2016-17.

Figure 7: Homelessness: households assessed as homeless during 2016-17, rate per 100,000 households Source: Welsh Government

The estimated levels of fuel poverty across North Wales range from just under 22% in Flintshire to just over 27% in Gwynedd.

Table *: Estimated levels of fuel poverty, North Wales unitary authorities, 2012-2016 % Isle of Anglesey 24.2 Gwynedd 27.5 Conwy 23.9 Denbighshire 23.3 Flintshire 21.9 Wrexham 22.0 Source: Welsh Government

5. Betsi Cadwaladr Seasonal Plan

The following plan has been developed in partnership with our colleagues across all organisations within North Wales. This takes into account the lessons learnt from last year, the activity and demand that we would expect to see as outlined within the overview taken over the last five years, and the needs of our population.

The plan is not set out in any priority, as all actions identified will take equal priority due to the impact we believe that they will deliver to ensure that our system remains resilient.

5.1 Communication Communication with our population is really important, with the focus of our activity this winter being to support the national Choose Well campaign http://www.choosewellwales.org.uk/home, by promoting locally available services using the communications methods outlined below. The Health Board aims to reach 1 million people through an integrated approach taking in digital and media channels. The Health Board’s communications team are working with Welsh Government and NHS Wales to coordinate messaging where possible and this will include the distribution of fridge magnets and ‘My Winter Health Plan’ materials that are being supplied to all Health Boards.

Actions to be taken • The Health Board will use social media (Facebook and Twitter) to issue regular information promoting services such as pharmacies and minor injury units which provide accessible alternatives to the ED or GP. The Health Board will target this activity to specific geographical areas to maximise impact for example Norovirus management and handwashing messages in the East. This keeps the information in the public eye rather than relying on the traditional approach of putting up posters simply asking people not to go to ED in big red letters, which in fact does more to advertise ED services than anything else. • Promoting ways in which people can help to keep themselves well during the winter will be a key element of our plan and will include e.g. Choose Well’s symptom checker and the flu vacination campaign which includes a range of materials including videos of celebrities such as Rupert Moon, Derek Brockway (the Weatherman), Gareth Jones (Gaz Top) and Jules Peters to urge people to have their vaccinations. • Promote our Live Waits App through our website, Twitter and Facebook on a regular basis. • Direct public to the “winter” section of our website, which contains information about a variety of topics, such as self-care, norovirus and what to do in an emergency. • Use information videos to help people look after themselves for example how to ease symptoms of colds and coughs and access care in the most appropriate place. • Issue weather warnings so people can be prepared to look after themselves and their families. • Use paid advertising to signpost local services in prominent places e.g. local newspaper advertorials to support the winter campaign.

All of this will be supported by more traditional promotional material, such as posters and leaflets. Adding to this the Health Board will use media opportunities to highlight the options people have available to them when it comes to unscheduled care, both through proactive and reactive press releases and media statements. Last year, this activity led to a number

of local newspaper and regional broadcast pieces offering advice from clinicians to readers/viewers.

Co-ordinating the use of these various communications tools, for example scheduling updates through our website, Facebook and Twitter to coincide with the issue of press releases will be crucial in order not to bombard the population with different messages and therefore we maximise the opportunity we have to reach as large an audience as possible

Some of this work has already started, including: • Launch of the Flu vaccination campaign with more than 4,000 staff vaccinated to date. • BBC Wales has visited the Health Board and filmed a report for Norovirus, pushing the importance of hand hygiene and following our advice and guidance on Norovirus. A BBC reporter has filmed an interview with the Health Board’s Assistant Director for Infection Prevention, who gave expert advice on Norovirus, infection prevention and the importance of people following our advice. A demonstration was also filmed with the reporter showing how germs can be easily spread and can survive beyond cleaning techniques – highlighting the importance of following advice. • BBC Wales also filmed the Health Board’s use of UPVC machines to fight infections in hospital, which will also include expert advice from Bangor University and will be shown across BBC’s English and Welsh TV and radio during October. • The Health Board are also running paid-social media campaigns in the Wrexham area reiterating Norovirus advice. The posts have already reached almost 20,000 Facebook users in the first 24 hours and will continue to run during October. Activity data on the posts will be reviewed and the campaign adjusted accordingly going forward.

Expected Impact Through an integrated multi-channel approach, the Health Board are looking to reach 1 million residents in North Wales with our winter wellness messaging. This year’s communication plan is built on the successes of last year and is flexible enough to allow the team to be able to change the method of communication depending on the audience it is looking to inform.

5.2 Primary Care Access to all primary care services over the winter period for both those with chronic diseases but also seasonal illness will be paramount to ensuring the resilience of our whole system both in hours and out of hours.

General Practice Practices are responsible for providing access, including urgent access to their patients during normal working hours. Unregistered patients or patients requiring out-of-hours access are directed to NHS Direct or GP Out of Hours services where they are triaged, provided with advice or referred on to a minor injuries unit or ED as appropriate, either directly or via Welsh Ambulance Service.

Actions taken and to be taken over the winter period • Following the development of the primary care dashboard and IRIS, clusters and practices will be able to review frequent ED attenders, ED attendances and admissions, which will help them to plan the care needed to best support these patients in their own homes and communities wherever possible.

• Navigation training has been developed with the GP practices and local university to support GP practice receptionists to develop skills in communication and signposting. The first cohort have completed the course, and further training is being commissioned. • Out of hours workload analysis from previous years will inform the levels of anticipated demand over the winter period and workforce capacity will be linked to identified pressure periods. Where there are current vacancies, the teams are working to ensure staff are in post and available as soon as possible. • Completing the rotas for GPs within the out of hours service for the Christmas and New Year period commenced in October, with all nursing and administrative staff within the service being on fixed rotas • Flu vaccination within nursing and residential homes provided by either general practice or community teams will be essential and each Area Team with Local Authority colleagues are ensuring that all homes have access to this service. • Working with WAST, two Advanced Paramedic Practitioners will join the Out of Hours Team to see if this additional skill set will provide support to both the GPs, District Nurses and increase both response times and also hospital diversions.

Expected Impact The Health Board believe that the impact of these actions will enable GP practices to cope better with demand. In addition the OOH service will also be better placed to meet the expected increase in demand over the period.

Closer working between community teams and general practice to ensure that those patients who are at risk have the support they require will be crucial in reducing the number of ED attenders.

5.3 Pharmacy As the “Choose Pharmacy” platform is now available across 149 pharmacies within the Health Board, this now enables pharmacies to provide the Common Ailments scheme and the Emergency medicines scheme, thereby reducing pressure on OOH, GPs and ED. All community pharmacies have signed up to the Public Health campaign ‘Keep Well this Winter’. Access to community pharmacy information is also available on the Choose Well APP.

Actions to be taken • The communication plan as outlined above will commence in October to raise awareness of these schemes and how to access them. • Neo post envelopes embossed with Choose Pharmacy campaign will commence in November 2017. • My Health Online (MHOL) linked to repeat prescriptions will be a focus of attention for those patients who are not already using this service. • All community pharmacies across North Wales have been commissioned to administer flu vaccinations. • Signposting to opening times for all community pharmacies are available on NHS Direct, information to be displayed within pharmacy windows to signpost if closed where the next open pharmacy is, together with advertisements within local newspapers.

Expected Impact This work links directly with the Health Boards strategy of care closer to home and easy access to services locally.

Improving access to opening times of community pharmacies has been problematic and it is envisaged that this approach will reduce the numbers of patients attending ED departments for repeat prescriptions over the seasonal period.

5.4 Dental Services

Actions to be taken • Details of any dental practices opening hours and any variations over the holiday season will be available on the NHS Direct dental help line. This will include the additional emergency dental service (Out-of-hours) sessions arranged for the bank holidays. • Unregistered patients or patients requiring out-of-hours access are directed to NHS Direct where they are triaged, provided with advice and if clinically appropriate referred to the Health Board’s Emergency Dental Service (EDS).

Expected Impact • The Health Board has commissioned 16 additional emergency dental clinics per week at a variety of sites across North Wales for the provision of access to urgent treatment out-of-hours and for unregistered patients. It is believed that this will reduce patients attending the ED.

6. Reducing the impact of seasonal infections

6.1 Seasonal Influenza Plan The Health Board has comprehensive plans in place for the prevention of infection (including flu) and for coping with outbreaks of infections if they arise. The following key points raised in the Flu Protocol inform the Health Board’s seasonal plan:

• Vaccination of frontline healthcare workers and people in high risk groups is the most important measure in preventing seasonal influenza infection; • Standard precautions must be maintained at all times in all healthcare settings including when managing known or suspected cases of influenza; • Hand hygiene is a very important defence against acquisition of influenza; • Reinforce respiratory hygiene/cough etiquette with all patients; • Droplet precautions are required for all cases of known or suspected influenza, until either the diagnosis has been excluded or the patient is no longer deemed infectious.

The Health Board’s Seasonal Influenza Plan for 2017-18 centres around two main themes: i) vaccination of the public and ii) vaccination of staff. Promotion of these key messages is an essential action to prevent outbreaks in care settings during the winter months when the likelihood of outbreaks of Influenza and flu-like illness is higher.

Actions to be taken – Vaccination of the Public Raise awareness of the eligibility for all ‘at risk’ groups with primary and secondary care health professionals to:

• Improve the knowledge of health and social care and voluntary sector colleagues regarding flu to encourage a higher uptake of the vaccination from patients and the public; • Ensure the accuracy of flu vaccine uptake data from schools and GP practices; • Provide the necessary training to Health Care Support Workers (HCSW) to administer nasal flu vaccinations in schools to improve the flexibility of the service. • Each cluster area has identified a Flu Champion who will be the nominated lead for the winter planning process across the GP practices. All practices are in the process of identifying Flu Lead’s to liaise with the Flu champion’s. GP practices are planning extra access out of clinic hours to help increase the uptake of the flu vaccination. • District Nursing Teams will vaccinate their housebound patients and proactively offer the vaccine to appropriate carers within their homes and ensure they have sufficient vaccine to do so. • The community pharmacy influenza vaccination scheme has been offered to all community pharmacy contractors within North Wales. The individuals that can be vaccinated include all WG identified ‘at risk’ groups and BCUHB employees. . • The specification has also been updated to allow pharmacists within BCU approval to vaccinate in other locations, such as care homes or managed practices.

Actions to be taken – Vaccination of Staff The Health Board has increased the number of flu vaccinators and for the first time this will include Allied Health Professionals to improve access to the vaccine. Within the Health Board the following specific actions are being implemented: • Engagement with all levels in the organisation, including positive peer promotion, to ensure staff are vaccinated; • A ‘protect all’ approach with staff video and newsletters; • Specific actions targeted at lower uptake groups; • Trained vaccinators attached to District Nursing Teams and Community Hospital sites who will vaccinate staff. Any staff who decline the flu vaccination are being asked to record their reasons for this decision.

6.2 Treatment of Flu • Antiviral medicines If the levels of circulating flu reach a certain threshold, the Chief Medical Officer for Wales will announce that antivirals can be prescribed for patients in ‘at risk’ groups. The Assistant Director for Medicines Management for each Area will then: - Monitor and ensure there are sufficient amounts of antiviral medication available within each District General Hospital (DGH) Pharmacy Department and report any availability issues - Ensure that antiviral medicines are available for patients in ‘at-risk’ groups when Influenza A or B are circulating and there is a substantial likelihood that people presenting with an influenza-like illness are infected with influenza virus.

• Clinical management and infection control The Health Board has a protocol for main hospital sites, to managing individual cases, large outbreaks or the potential for a pandemic that are associated with influenza, to minimise the risk to patients, staff and service delivery. - The Health Board will ensure that all relevant staff have training in infection control, including fit testing of FFP3 respirator (face masks).

- The Health Board will ensure an adequate supply of equipment, such as FFP3 respirators, and availability of critical care beds during epidemic periods. - Plans are in place to increase its critical care capacity over the period of winter pressures. Each site will have the ability to increase their critical care capacity by 2 beds, with further surge capacity into theatre recovery areas should that be required. - The plans have been supported by the critical care network - Plans on creating isolation wards for periods of increased demand are currently in development, but each site has the ability to isolate high infection risk patients regardless of the type of infection presenting. In the event of a sudden surge in flu cases, each site will revert to the current isolation plans - This has been supported through the civil contingency group

Expected Impact • Launch of the Flu campaign in September 2017 with over 4,000 staff expected to be vaccinated within the first month • The Health Board’s aim of achieving 62% of staff vaccinated is monitored monthly and actions taken also monitored both at Board and local levels • Neo-post envelopes for all communications will be embossed with the flu campaign commencing in November

Winter Planning – Children

• The Health Board’s seasonal flu plan has prioritised actions to roll out the children’s flu vaccination programme and teams of immunisers are currently visiting schools across North Wales to immunise school aged children in all eligible age groups. All children aged 2 and 3 years are being invited into primary care. The Children’s Transformation Operational Plan identifies the need to address the seasonal peaks in demand for Acute Paediatrics. Development of a new service model in EDs has commenced in YGC with Consultant Paediatrician’s providing expert assessment and intervention which is preventing admissions and enabling parents to manage acute episodes of illness. The Paediatric ANP is also supporting the ED team with training. All 3 sites have paediatric assessment bays to enable children to be monitored and treated, not admitted.

Actions to be taken • Performance in relation to the children’s flu campaign will be monitored by the Children’s Transformation group and the Health Board’s Strategic Immunisation Group. • The service is developing in line with Royal College of Paediatrics and Child Health - Facing the Future Standards to address the demand for example, by supporting Primary Care to provide care closer to home and manage risk effectively, named link Consultant Paediatricians for GP practices are being identified. • Ysbyty Gwynedd have initiated a pathway with WAST so that Children are brought directly to the ward when a site is at high escalation, this pathway is expected to be rolled out across the 3 sites.

Expected Impact Data from previous seasons has highlighted how effective the children’s flu programme is at protecting individual children and also in protecting the wider community and older/vulnerable adults. It is therefore a key aspect of our winter planning.

6.3 Norovirus A detailed Health Board Norovirus preparedness plan is being implemented that builds on the lessons learnt from last year, in particular building on the experience over last winter at the Wrexham Maelor DGH, but also all of the work undertaken throughout this year specifically with regard to Infection, Prevention and Control.

Actions to be taken • Site preparedness checklists. • Preparedness by Areas to support people in their own homes rather than admission to a hospital. • Targeted staff education. • Revision of the Norovirus procedure and documentation to support clinical staff. • New pop-up outbreak banner signs purchased and deployed ready for use on all sites. • An awareness campaign which will be led by the Communications Team, commencing September 2017. • Specific work at Wrexham Maelor on rapid assessment and admission to appropriate facilities. • Identification of a cohort facility which can be used if single rooms are not available. • Identification of the golden bed and golden single room, so staff are clear on the contingency if a single room is needed rapidly. • Review the cleaning standards and the implementation of 24/7 deep clean team.

Expected Impact The Health Board believes that with all of the work undertaken throughout the year both internally, with General Practice and WAST, from anti-microbial prescribing to the conveyancing of patients with diarrhoea and vomiting, to bare below the elbows and cleaning standards that the organisation is now better prepared to ensure individual patients are isolated quickly to reduce any spread through to the management of outbreak situations. It is therefore believed that this will improve the impact on flow through the acute sites specifically the Maelor over the winter period.

7. Community Resilience within our community provision is crucial to both hospital avoidance and early discharge, therefore this plan focuses on both elements and is based on care closer to patients’ homes. To support this and outlined within our communication strategy is the need for the population to ‘Choose Well’.

The Health Board will work closely with WAST, GPOOH, North Wales Police and Local Authorities to further develop call handling and care co-ordination model across North Wales, building on the roll out of the national 111 programme. This work will commence in quarter 4 of 2017/18.

7.1 Minor Injury Units Providing consistency of approach within our minor injury units across North Wales is fundamental. By the end of December the Health Board will deliver the following actions:

Actions to be taken • Review all MIUs both in terms of opening times and the services that they are able to offer to provide consistency;

• Work with WAST to ensure that, where appropriate, patients are conveyed to MIUs rather than EDs; • Communicate with the population, through our communication plan and the Choose Well campaign, to emphasise when attending an MIU is the correct course of action to take; • Continue with the waiting times information available on the APP.

Expected Impact • The Health Board has seen a growing number of patients attending MIUs (see Figure 3) over the course of the year, with consistency of service provision and opening times it believes that this will reduce the number of patients attending ED. • Providing a level of consistency will allow WAST to take more patients directly to MIU’s rather than to EDs and this will improve both handover times and reduce delays at the front doors of the EDs.

7.2 Reducing ambulance conveyances to EDs Analysis of the majority of ambulance conveyances fall into 4 main categories, those being breathlessness; chest pain; falls, mental illness. With a growing older population the number of patients transferring to ED’s over the last 5 years has increased and therefore these are some of the additional actions we are taking over the winter period.

Data illustrates that average monthly conveyances for the 4 main pathways over the previous 12 months are as follows; • Breathlessness – an average of 660 • Chest pain – an average of 700 • Falls – an average of 660 • Mental Illness – an average of 130

The data shows that of the above pathway areas, the number of conveyances relating to breathlessness significantly peaked over the December period with 820 conveyances. The other pathway areas peaked did not significantly increase over the winter period for 2016- 17. Actions to be taken • By the end of November all 4 pathways will have been reviewed by a cross organisational team from WAST, North Wales Police (where appropriate) and the Health Board to ensure that both alternatives to ED are clearly identified, but also that the management of patients leads to speedier and more responsive treatment. This will include the development of clear criteria, alternatives and clear links to the pathfinder system for WAST. • All attendances to patients’ homes and transfers to ED's will be audited to ensure compliance of all health staff with the new pathways and to ensure that these pathways continue to develop. • In the longer term it is expected that this review will become common practice through the weekly review within the Safety Huddles, this is described in more detail within Escalation. • A text alert system has been implemented for patients who are known to have chronic conditions, known to the palliative care service, or who are on a register of patients with indwelling catheters. If these patients attend ED, text alerts are sent to the appropriate teams so that the teams can respond, either advising ED staff, or patients to be “intercepted” and supported home from hospital.

• Specialist Nurses for Chronic Conditions and District Nurses are also encouraging patients on their caseloads to ring them first, not 999, where appropriate to do so, to enable patients to be responded to in their own home and avoid conveyance to hospital. • Monitor and review the impact of the Older Peoples Assessment Units across North Wales with extending services built on the impact to both hospital avoidance and earlier discharge. • Six Steps to Success is a palliative and end of life care training programme for health and social care across North Wales. Over the past year, the programme has been delivered to a number of Care Homes, the impact has seen that 86% of care home individuals remained in their preferred place of care, this programme will continue. • District Nurses will be based in ED to provide a 7 day service to proactively review the WAST prehospital stack and offer alternatives to attendance at the Emergency Department. This will include referrals to Intermediate care, enhanced care, and step up step down beds, referral to DN service, local authority pathways and local MIUs. It is expected that this will change over time and link more directly with the Clinical desk within WAST. • In addition they will provide advice to ED staff as to patients self-presenting at the ED that can more appropriately be seen elsewhere. They will act as a point of resource for the DN team to track and monitor patients known to the DN service on admission to hospitals to facilitate a discharge to assess model. • The role of GP OoH’s is helping to create an additional flow of patients from the ED’s. Both elderly and frail patients not requiring the level of care provided at ED are redirected to the appropriate Community Resource Team.

Expected Impact Whilst we are already seeing the impact of patients at the end of life staying in the place that they would prefer through a joint training programme, the Health Board is working with WAST to better understand the impact of the focus on the 4 main reasons for conveyance.

Monitoring of both attendances and admissions against the agreed pathways will commence as soon as the pathways have been agreed in late November with the baseline data already available to both WAST and the Health Board.

The presence of District Nurses consistently within the ED departments the Health Board believes will have an impact currently this is in place but this provides a further enhancement to the current model.

8. Escalation

8.1 Implementation of the Safety Huddle In order for the Health Boards system to move away from the concept of how many beds we have, to the overall risk within our system, a daily whole system ‘safety huddle’ meeting will be established across the three geographical areas of North Wales.

Actions to be taken • Three meetings will take place across North Wales linked to our 3 clearly defined geographical areas. They will take no longer than 30 minutes at 8.30 every day. • All meetings will have a common agenda that will include a review of the previous day, did the actions taken ensure system resilience and safety,

• What actions are needed today to continue to achieve flow within the system? • In order for these meetings to be successful they will be led by senior clinical staff from both the Area teams and Secondary care • Membership of the huddles will include both the Health Board, WAST, Local Authorities, North Wales Police and third sector as we move forward. • The Health Board wide conference calls will continue three times a daily to ensure whole system resilience and prevent any siloes impact. • To support this the relaunch of clinical standards for all medical staff will the undertaken by the end of October these include responsiveness and support to ED in times of greatest need. • These standards have already been developed in line with best practice and auditing of responsiveness will be monitored and fed back into the daily safety huddle to ensure all understand their role within our system. • Based on the beds required predictor tool each regional area will assess the number of additional beds required based on current demand through the Saftey Huddle meetings. These will be used flexibly throughout the winter period to ensure the focus remains on discharging patients home as quickly as they are medically fit.

Expected Impact From the work undertaken in NHS Scotland the impact of the Safety Huddles with all involved agreeing the actions for the day, they have seen greater resilience and safety within their system. The Health Board will monitor this through the Unscheduled Care Transformation Group to ensure the benefits to the safety and resilience of the system are delivered.

9. Ring fenced capacity Ensuring access to rapid diagnostics and specialist advice is crucial for our most vulnerable population.

Access for older people through our EDs has been the focus of work throughout the year with Older Peoples Assessment Units now in place, however it is acknowledged that all three are at different stages of implementation and this has allowed for greater learning to take place to enhance the service model. We will therefore continue to monitor and review impact to further develop and improve our clinical assessment units across North Wales.

Actions to be taken • Understand the impact of direct admission rather than through ED following the pathway development work across all 3 sites • The Wrexham Maelor unit opened in September and early data suggests the majority of patients are proactively assessed from within the ED and discharged to normal place of residence from the unit (58% Sept). • The Rapid Assessment Unit plus is operational in Ysbyty Glan Clwyd and data will be evaluated to understand the impact of this

Expected Impact • The COPA Unit in the West has already seen a 50% reduction in length of hospital stay and enabling early return to usual place of residence for patients moving through the pathway. • The Health Board will continue to monitor the impact of the service provision as it develops across North Wales over the next 6 months.

10. Discharge In order for a system to flow the discharge process needs to be both robust but also meet the needs of the patients, specifically those with complex needs. To achieve this the Health Board is implementing the SAFER model of care across North Wales by the end of November.

Actions to be taken • Full implementation of the SAFER model across the Health Board • Monitor the agreed metrics against the baseline activity to demonstrate the impact and further learning • Feedback through the Safety Huddles with the impact of the golden beds and really understand the impact of Red to Green will become a daily occurance. • To continue to work with Non-Emergency Patient Transport team to improve transportation for those eligible patients who require support • Links between Primary Care and Secondary Care through both the electronic prescription and the new Primary Care dashboard will become paramount and therefore regular meetings during the winter period between GP’s and Consultants will be established.

Expected Impact Feedback to date is that SAFER provides a simple methodology for teams to follow and combines many of the previous improvement methodologies together which is expected to enable prompt discharge and contribute to reduced pressures on beds.

11. Workforce Funding has been agreed for the overall plan and the recruitment processes are under way to ensure that sufficient numbers of trained staff are in post to deliver the plan.

There are potential risks to elements of the plan from either delays in recruitment processes and/or recruitment difficulties. Potential delays to processes are being mitigated through expediting the decision making and authority processes, so that recruitment could begin as soon as possible.

Mitigation of recruitment risks is more challenging and this should be considered within the context of the overall Health Board recruitment strategy. We will continue to mitigate risk across the health board by deployment of non-ward based clinical staff such as specialist nurses and outpatient nurses to areas of higher risk whilst retaining the specialist expertise and activity provided by these professionals. There are a range of initiatives in place aimed at improving the ability of the health board to recruit skilled staff and these will support recruitment for the seasonal plan. In the meantime, the actions in this plan are being prioritised in relation to the potential impact on performance within the staffing available.

The health and wellbeing of our staff during the winter period is really important to the Health Board and ensuring that all are resilient to the increasing demands on both their skills and time. The Health Board are therefore working through with Union representatives how we ensure that staff take their meal breaks, keep themselves hydrated and of course increase the uptake of the flu vaccination.

12. Financial Implications The Health Board has allocated a budget of £3.1m for the delivery of the Seasonal Plan. The overall plan will be delivered within this budget and, where appropriate, from within the Intermediate Care Fund (ICF) allocation.

13. Monitoring Impact The current metrics, set out below, were identified within the operational plan and the unscheduled care transformation group has monitored throughout the year. This will continue over the winter period to demonstrate the impact of the actions taken against the baseline already outlined.

• AvLoS – community • Discharges from acute to community • Discharged from Community • DTOC Acute (patients) • DTOC Acute (days) • ED 4 hour waits • Emergency Admissions • Readmission • Reduced detentions under s135/6

21 Action Tracker

Action Status

Communications – Step 1 • The Health Board will use social media (Facebook and Twitter) to issue regular information promoting services Established such as pharmacies and MIUs which provide accessible alternatives to the ED or GP. • Promoting Choose Well’s symptom checker and the flu vaccination campaign Established • Promote our Live Waits App through our website, Twitter and Facebook on a regular basis. Established • Direct public to the “winter” section of our website, which contains information about a variety of topics, such October 2017 as self-care, norovirus and what to do in an emergency. onwards • Use information videos to help people look after themselves for example how to ease symptoms of colds and November 2017 coughs and access care in the most appropriate place. onwards • Issue weather warnings so people can be prepared to look after themselves and their families. Established • Use paid advertising to signpost local services in prominent places e.g. local newspaper advertorials to support November and the winter campaign. December 2017 Primary Care – GP Practices – Steps 1 – 4 • Following the development of the primary care dashboard and IRIS, clusters and practices will be able Established to review frequent ED attenders, ED attendances and admissions, which will help them to plan the care needed to best support these patients in their own homes and communities wherever possible. • Navigation training has been developed with the GP practices and local university to support GP practice Established receptionists to develop skills in communication and signposting. The first cohort have completed the course, and further training is being commissioned. • Out of hours workload analysis from previous years will inform the levels of anticipated demand over the winter Established period and workforce capacity will be linked to identified pressure periods. Where there are current vacancies, the teams are working to ensure staff are in post and available as soon as possible. • Completing the rotas for GPs within the out of hours service for the Christmas and New Year period October 2017 commenced in October, with all nursing and administrative staff within the service being on fixed rotas • Flu vaccination within nursing and residential homes provided by either general practice or community teams October 2017 will be essential and each Area Team with Local Authority colleagues are ensuring that all homes have access to this service. • Working with WAST, two Advanced Paramedic Practitioners will join the Out of Hours Team to see if this December 2017 additional skill set will provide support to both the GPs, District Nurses and increase both response times and also hospital diversions

22 Action Tracker

Action Status

Primary Care – Pharmacy Steps 1 & 4 • The communication plan to raise awareness of these schemes and how to access them. October 2017 • Neo post envelopes embossed with Choose Pharmacy campaign November 2017 • My Health Online (MHOL) linked to repeat prescriptions will be a focus of attention for those patients Established who are not already using this service. • All community pharmacies across North Wales have been commissioned to administer flu vaccinations Established • Signposting to opening times for all community pharmacies are available on NHS Direct Completed • Information to be displayed within pharmacy windows to signpost if closed where the next open December 2017 pharmacy is, together with advertisements within local newspapers. Primary Care – Dental 1 & 4 • Details of any dental practices opening hours and any variations over the holiday season will be Established available on the NHS Direct dental help line. • This will include the additional emergency dental service (Out-of-hours) sessions arranged for the December 2017 bank holidays. • Unregistered patients or patients requiring out-of-hours access are directed to NHS Direct where they Established are triaged, provided with advice and if clinically appropriate referred to the Health Board’s EDS service Red ucing the Impact of Seasonal infections – Flu Vaccination of the Public – Step 0 • Raise awareness of the eligibility for all ‘at risk’ groups with primary and secondary care health Established professionals • Improve the knowledge of health and social care and voluntary sector colleagues regarding flu to encourage Established a higher uptake of the vaccination from patients and the public • Ensure the accuracy of flu vaccine uptake data from schools and GP practices Established • Provide the necessary training to HCSW to administer nasal flu vaccinations in schools to improve the flexibility Established of the service. • Each cluster area has identified a Flu Champion who will be the nominated lead for the winter planning process Established across the GP practices. • All practices are in the process of identifying Flu Lead’s to liaise with the Flu champion’s. October 2017 • GP practices are planning extra access out of clinic hours to help increase the uptake of the flu vaccination. October 2017 • District Nursing Teams will vaccinate their housebound patients and proactively offer the vaccine to Established appropriate carers within their homes and ensure they have sufficient vaccine to do so. 23 Action Tracker

Action Status

• The community pharmacy influenza vaccination scheme has been offered to all community pharmacy Established contractors within North Wales. • Update specification to enable pharmacists within BCU approval to vaccinate in other locations, such as care Established homes or managed practices. Reducing the Impact of S easonal infections – Flu Vaccination of the Public – Step 0 • Engagement with all levels in the organisation, including positive peer promotion, to ensure staff are Established vaccinated • A ‘protect all’ approach with staff video and newsletters; Established • Specific actions targeted at lower uptake groups. Established • Trained vaccinators attached to District Nursing Teams and Community Hospital sites who will Established vaccinate staff. • Performance of children’s flu campaign will be monitored by the Children’s Transformation group and the Health Board’s Strategic Immunisation Group. • Named link Consultant Paediatricians for GP practices are being identified. • Further roll out pathway across 3 sites, with WAST so that Children are brought directly to the ward when a site is at high escalation. Norovirus – Steps 0 – 8 • Preparedness by Areas to support people in their own homes rather than admission to a hospital. Established • Targeted staff education. Established • Revision of the Norovirus procedure and documentation to support clinical staff. Established • New pop-up outbreak banner signs purchased and deployed ready for use on all sites. Established • An awareness campaign which will be led by the Communications Team Established • Specific work at Wrexham Maelor on rapid assessment and admission to appropriate facilities. Established • Identification of a cohort facility which can be used if single rooms are not available. Completed • Identification of the golden bed and golden single room. November 2017 • Review the cleaning standards and the implementation of 24/7 deep clean team January 2017

24 Action Tracker

Action Status

Community – Steps 0 – 4 • Review all MIUs both in terms of opening times and the services that they are able to offer to provide Established consistency • The Health Board will work closely with WAST, GPOOH, North Wales Police, Local Authorities and the Third Commence March Sector to further develop call handling and care co-ordination model across North Wales, building on the roll 2018 out of the national 111 programme. • Work with WAST to ensure that, where appropriate, patients are conveyed to MIUs rather than EDs Established • Communicate with the population, through our communication plan and the Choose Well campaign, Established to emphasise when attending an MIU is the correct course of action to take • Continue with the waiting times information available on the APP. Established Reducing Ambulance Conveyance to EDs – Steps 0 – 4 • Review of all 4 pathways to be undertaken November 2017 • Audit of all attendances to patients’ homes and transfers to EDs February 2018 • Implement a text alert system for patients who are known to have chronic conditions, known to the Established palliative care service, or who are on a register of patients with indwelling catheters. • Specialist Nurses for Chronic Conditions and District Nurses to encourage patients on their caseloads Established to ring them first, rather than 999. • Undertake a review of the impact of the Older Peoples Clinical assessment Units across North Wales March 2018 • Full rollout of the Six Steps to Success palliative and end of life care training programme for health and Established social care across North Wales. • District Nurses will be based in ED to provide a 7 day service to proactively review the WAST Established prehospital stack and offer alternatives to attendance at the Emergency Department and to facilitate the discharge to assess model. Escalation • Implementation of the daily Safety Huddle across all 3 sites in NW with colleagues from WAST, Local November 2017 Authorities, North Wales Police and the third sector • Implementation of the predictor tool to assess the number of additional beds required Established Ring fenced capacity • Model impact of direct admission to established Older Persons Assessment Units at each of the acute March 2018 sites

25 Action Tracker

Action Status

Discharge Processes • Full implementation of the SAFER model across the Health Board November 017 • Monitor the agreed metrics against the baseline activity to demonstrate the impact and further learning Established • To continue to work with Non-Emergency Patient Transport team to improve transportation for those Established eligible patients who require support • Establish regular meetings with GPs and Consultants during the winter period to ensure robust links Established between Primary Care and Secondary Care supported by both the electronic prescription and the new Primary Care dashboard.

26 9 B17/20 Welsh Government White Paper 'Services Fit for the Future' - Mr Gary Doherty 1 B17.20a NWCHC White Paper Response (FINAL 092017 - E) inc appendices.pdf

White Paper: Services fit for the future A response from the North Wales Community Health Council September 2017

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Contents

Page no Foreword 3 Background 4 What others have said 6 Overview 7

Chapter 1: Board membership and composition 11 The role of the Board Secretary 12

Chapter 2: Duty of quality 13 Duty of candour 13

Chapter 3: Setting and meeting common standards 15 Joint investigation of health and social 15 care complaints

Chapter 4: Representing the citizen in health and 17 social care Why do we need a People’s Voice body at all? 18 What should a People’s Voice body do? 23 What should a People’s Voice body look like? 25 Service change 26 Inspection and regulation 27

Appendices

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Foreword

This response represents the collected views and concerns of the 85 members of North Wales Community Health Council. It was prepared following extensive debate and discussion, not only within the CHC, but after CHC members had the opportunity to discuss the White Paper with hundreds of members of the public at many events and meetings across North Wales during the consultation period.

The content of this document was finally agreed at a special meeting of the North Wales CHC Executive Committee on 26 September and we confirm that it is a true and correct representation of the views of North Wales CHC members and its six Local Committees. Mrs Jackie Allen Chair, North Wales CHC Mr Mark Thornton Vice Chair North Wales CHC Mr Roger Williams Chair Conwy Local Committee NWCHC Dr Garth Vice Chair Conwy Local Committee NWCHC Higginbotham Dr Tak Matsuda Chair Denbighshire Local Committee NWCHC Mrs Roma Goffett Chair Denbighshire Local Committee NWCHC Ms Linda Harper Chair Flintshire Local Committee NWCHC Mrs Stella Howard Vice Chair Flintshire Local Committee NWCHC Mrs Menna Williams Chair Gwynedd Local Committee NWCHC Mrs Vera Wilson Vice Chair Gwynedd Local Committee NWCHC Ms Eleanor Burnham Chair Wrexham Local Committee North NWCHC Mrs Nerys Jones Vice Chair Wrexham Local Committee NWCHC Mr Alan Dixon Chair Ynys Môn Local Committee NWCHC Mr Brace Griffiths Vice Chair Ynys Môn Local Committee NWCHC

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BACKGROUND

The North Wales Community Health Council welcomes the opportunity to respond to the Welsh Government’s White Paper: Services fit for the future. North Wales CHC has been closely involved in the preparation of the national response prepared by the Board of CHCs in Wales and fully supports the content of that document. This response represents our opportunity to be heard on these proposals and to highlight local concerns and place emphasis on issues unique to North Wales.

North Wales CHC is the independent watch-dog of NHS services within North Wales and we seek to encourage and enable members of the public to be actively involved in decisions affecting the design, development and delivery of healthcare for their families and local communities.

The CHC movement seeks to work with the NHS and inspection and regulatory bodies to provide the crucial link between those who plan and deliver the National Health Service in Wales, those who inspect and regulate it, and those who use it.

North Wales CHC maintains a continuous dialogue with the public through a wide range of community networks, direct contact with patients, families and carers through our enquiries service, complaints advocacy service, visiting activities and through public and patient engagement. By this means we are able to provide a highly integrated and coordinated service to patients, their families and carers.

Over the summer North Wales CHC has asked people what is important to them about the proposals and in partnership with the Board of CHCs and the other six CHCs in Wales we have looked at the different arrangements across the UK and

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beyond. We have considered in detail what others have said about the strengths and weaknesses of related arrangements in other UK countries.

North Wales CHC collected over 250 responses directly from individual members of the public which have been forwarded separately to the Welsh Government. People have told us that they want any future body to:

 be independent,  be able to hear directly from people including hearing directly from people whilst accessing care,  be responsive to what matters most to people locally, regionally and nationally and,  have the necessary powers to hold service providers to account.

Few people we talked to felt that the White Paper would provide them with the above. In our SMS survey on the White Paper proposals, 96% of respondents rejected the Welsh Government proposals.

Members of North Wales CHC are disappointed that the White Paper consultation failed to meet the standards of either the Gunning principles or Welsh Government’s own consultation guidelines. The timing of the consultation over the recess/summer holiday period gave it a low profile.

North Wales CHC has concerns about the eight “Engagement Workshops” that were hastily arranged (18th to 28th September) following criticism by the Consultation Institute. These sessions also had a low profile in North Wales. Information on the sessions was only available on the Welsh Government’s consultation website. Details of venues and times were provided on email request with a follow up phone

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call to confirm attendance; all fairly onerous on anyone wanting to attend an event arranged at short notice. The event at Caia Park, Wrexham was very poorly attended with 4 or 5 members of the public. We understand this reflects the experience across Wales.

The lack of any detail in the impact assessment regarding potential impact on the protected groups listed in the Equality Act is a serious cause for concern.

North Wales CHC believes the manner in which this consultation has been carried out risks bringing Welsh Government consultation methods into disrepute and that a review should be undertaken in order to learn lessons that must be applied in future.

Whilst North Wales CHC members support the creation of a citizens’ voice body, it was felt that the proposed changes are back to front i.e. changes to social care and health care should be made prior to any other changes with a successor body to CHCs being modelled at a later date.

What others have said

The White Paper suggests that a number of reports have made a case to replace Community Health Councils and they are listed as Footnotes 29, 30 and 31.

Footnote 29 refers to Marcus Longley’s review of CHCs. That review was conducted specifically on the premise that CHCs were needed in Wales, where the Government had implemented a Welsh healthcare model which rejected the “purchaser- provider split” and denied patients the right to choose their provider. At no point in his report did Marcus Longley challenge the continuation of CHCs.

Footnotes 30 & 31 reference the personal views of Ann Lloyd

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and Ruth Marks but fail to mention the many expressions of support for CHCs in response to the Welsh Government Green Paper, Our Health Our Services, consultation in November 2015.

The most serious error of fact in the White Paper is the misrepresentation of the OECD conclusions and recommendations. The OECD did not suggest that the CHCs should be replaced, as is implied in paragraph 14. The OECD did not recommend an alternative “Patient Voice”.

The proposal to abolish, rather than strengthen, the CHC movement does not appear in the OECD report. On the contrary, the OECD said;

“Community Health Councils are a key feature in the architecture of Wales, with a clear role to engage with and ensure that the patient voice is heard (Page 225)”.

The OECD's overall recommendation was one of evolution of existing institutions, not abolition. There was no recommendation to close down CHCs.

OVERVIEW

North Wales CHC strongly supports the Welsh Government’s aspirations for a health and social care system that enshrines good governance, candour and the delivery of high quality services which are independently checked by an effective inspection and regulation regime.

We particularly welcome the aspiration to strengthen the people’s voice across health and social care, and embedding the key principles of co-design and co-production. During the consultation period we have made substantial efforts to engage with the public and listen to what they have to say about the Welsh Government’s proposal. We used a wide variety of methods to engage: face to face discussion, email, social

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media, SMS, telephone and land mail.

North Wales CHC recognises that primary legislation can play an important role in achieving Welsh Government aspirations for a stronger citizen voice. However, there is little evidence to suggest that primary legislation alone would provide the catalyst to deliver real and longlasting change.

The entire CHC movement has concerns that the White Paper places an over-reliance on legislation to deliver its policy aspirations rather than looking at other ways of doing so. There is a real risk in overusing legislation in terms of the ability and flexibility of health and care services to deliver real cultural change and respond flexibly to future needs.

There is much to be learned from the English experience of radically transforming CHCs and this is well described in the Francis Report:

“Community Health Councils (CHCs) were almost invariably compared favourably in the evidence with the structures which succeeded them. It is now quite clear that what replaced them, two attempts at reorganisation in 10 years, failed to produce an improved voice for patients and the public, but achieved the opposite. The relatively representative and professional nature of CHCs was replaced by a system of small, virtually self- selected volunteer groups which were free to represent their own views without having to harvest and communicate the views of others. Neither of the systems which followed was likely to develop the means or the authority to provide an effective channel of communication through which the healthcare system could benefit from the enormous resource of patient and public experience waiting to be exploited.”

The Rt Hon Andy Burnham MP (former Chief Secretary to the

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Treasury, Health Minister from 5th June 2009 – 11th May 2010 and currently Mayor Greater Manchester) doubted in retrospect the wisdom of abolishing CHCs:

“the abolition of Community Health Councils was not the Government’s finest moment … it seems we failed to come up with something to replace CHCs that did the job well”.

The hands-on experience of those who worked in the organisations that followed CHCs is that effective monitoring and scrutiny was lost for a substantial period of time (in some cases as much as two years) on each occasion there was a reorganization. There have been three iterations since the abolition of CHCs in 2003; Patient Forums, LiNks and HealthWatch.

The greatest criticism of CHCs arises from within the NHS and from politicians when CHCs do not support plans for significant alteration to the provision of local healthcare (such as hospital closures) or when they use their powers to refer controversial plans to the Minister. At the highest levels there seems to be a failure to understand what CHCs at the grass roots know to be true: that the public is increasingly prepared to challenge policy makers over their decisions on health and social services provision and to resort to the law to pursue their rights. Politicians and NHS leaders can no longer decide what they consider to be in the public interest based on only token consultation and expect their decisions to remain unchallenged. Such perfunctory and minimal consultation is the reason for the increasing trend towards the challenging of decisions by the use of Judicial Review.

In the 2015 Green Paper Welsh Government said:

“The National Social Services Citizen Panel has been set up to

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secure a voice for service users and carers and we would wish to explore whether a similar arrangement should be put in place for health services”

The National Social Services Citizen Panel is a strange example to use. Although it was announced enthusiastically by Ministers in 2012, it still has no website, no record of proceedings available to citizens and the promised evaluation of its effectiveness has yet to be published. Its public profile is extremely low and few have heard of it. If this is an example of how the new Citizen Voice will operate it is clearly a massive step backwards.

We set out below our detailed response to each of the proposals.

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CHAPTER 1

Board membership and composition

We agree that the boards of both health boards and NHS trusts should share some core key principles including delivering in partnership to deliver person-centred care and a strong governance framework to enable boards to work effectively and meet their responsibilities. We also agree that all boards should have vice chairs, and that executive officer membership should include some key positions which are consistent across local health boards but also allow some flexibility in appointments.

In more detail:

 the proposals in the White Paper individually or collectively do not appear to address the issues about board culture identified in earlier governance reviews. The difficulties of changing Board culture are illustrated by the successive HIW/WAO annual reports setting out the shortcomings of the Betsi Cadwaladr University Health Board and the unacceptably slow pace of change (despite being in Special Measures with considerable Welsh Government support). The White Paper gives the impression that legislation alone will change Board culture – this is simply not the case.

 We do not agree with all the core key principles identified. Specifically, we cannot see that a re-titling of the role of ‘independent’ members would bring about a change in the perspective these members will bring – nor why such a change is needed. There is already a clear need for the whole board (and not just a re-titled public member) to understand and respond to the perspectives of the population in all board discussions and decisions. A system of rigorous selection against a person specification and skill set rather than political appointment would be a good starting point.

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 We consider that a re-titling of the current ‘independent members’ to ‘public members’ may cause confusion and give an impression that their role is to represent the public. It is our view that the public currently recognise and accept the governance and leadership role of all voting NHS board members.

We agree that a representative voice should be heard at NHS board level. Associate membership of boards could contribute to achieving this. However, care would be needed to ensure that any such associate member has a clear mandate from the wider population, e.g. a representative from a new, stronger, people’s voice body.

The role of the Board Secretary

We recognise the important role that Board Secretaries have within NHS organisations and welcome proposals to ensure this role is carried out consistently and not compromised through conflicting duties and responsibilities. We believe that the solution to the problems outlined in paragraphs 33 – 35 of the White Paper is to monitor and enforce compliance with existing regulation.

In order that board secretaries are able to carry out their role as principal advisors to their NHS boards on governance matters, and so that they can properly protect the organisation they serve, it is important that the role has sufficient status and protection. We believe that, on a practical day-to-day basis, it will be impossible to ensure the independence of the Board Secretary. Whistleblowers in the NHS rarely fare well, even when protected by the Public Interest Disclosure Act, and we foresee that the role of Board Secretary could become untenable in certain situations.

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CHAPTER 2

Duty of Quality

We consider that as the current duties and definitions of quality are set out differently in a variety of places, it is complex for both bodies and individuals to understand and measure.

We would want any new legislation to genuinely simplify and clarify what is expected of service providers and what quality means from a service user’s perspective.

We believe that the actions needed to deliver services that meet public expectations on quality must extend beyond introducing primary legislation. Legislation in itself will not bring about a shift in culture and behaviours.

Duty of Candour

In general terms, the public should and do expect that those responsible for providing their health and social care (both individuals and organisations) do so in a manner that is open, honest and frank.

We recognise that the current duty for NHS bodies to promote rather than require candour means that there is currently no sanction on bodies who fail to do so.

On this basis, we support in principle the introduction of a duty of candour for health and social care providers.

However, primary legislation in itself cannot bring about the cultural change necessary to embed this at every level in every organisation. We are concerned that the introduction of new legislation – if not done properly – could focus on the wrong things and distract from, rather than bring about, the change needed.

To date, we are unaware of any real evidence that the introduction of a duty of candour in England is benefitting

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patients by having a meaningful impact on organisational behaviour. Such progress as has been made is dependent on a system of fines and penalties that would not work well in the Welsh context.

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CHAPTER 3

Setting & meeting common standards

The public expects clear and meaningful standards that apply wherever and whoever provides their care. Any such standards should be informed by and reflect what is important to people.

We recognise that there may be a need to address the limitations within current regulations that specify what standards must be followed. In doing so, it is important that any new legislation is framed in a way that allows flexibility and adaptability to meet future expectations.

Joint investigation of health and social care complaints

We consider that people who have concerns about their health and social care should only need to raise these concerns once in order for them to be investigated thoroughly and in a timely manner. We agree that there should be a common complaints process across health and social care accessed through a single point. We consider that a single complaints advocacy service should form part of a new people’s voice body.

The focus of any new arrangements must be to ensure:

 easy access for people to raise concerns  timely and co-ordinated investigation and response  shared learning.

Any new arrangements must recognise the need to ensure co- ordination within health and care organisations/sectors and not just between them.

Based on our own advocacy caseload and on discussions with colleagues in Local Authority Social Services, North Wales CHC believes that the number of complaints that are about the

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interface between NHS and Social Services are currently very low. We recognise, however, that this may rise in future as the delivery of services changes but caution on introducing new systems and procedures that might further affect the ability of NHS Concerns Teams to provide timely responses.

The valuable role of the complaints advocacy service, as provided by CHCs, must not be diminished. In England the service has become one of leaflets and call centre advice rather than the hands on, personalized service currently available in Wales.

North Wales CHC has been working with other organisations to promote its independent advocacy service. Meetings with CADMHAS and Stroke Services to consider the independent complaints service have been held and have been positive.

Advocacy is a key element of the work undertaken by CHCs and should not be looked at in isolation. The proposals need to consider every aspect of work done by CHCs as a coherent whole, as the loss of any one aspect of work would weaken the others.

It is vital that a new representative body should offer a truly independent Complaints Advocacy Service. This must be completely independent of the health care provider with whom the patient has an issue. It is undeniable that health care providers have not been adequately responsive to concerns raised by families and patients about the quality of care provided.

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CHAPTER 4

Representing the citizen in health and social care

We welcome the Welsh Government’s intention to create a stronger people’s voice across health and social care. The White Paper provides a once in a generation opportunity to do this in a way that best serves the people of Wales in health and social care.

We are not convinced however that the proposals as outlined will achieve this and are concerned they will dilute rather than strengthen this voice in the NHS. Further, we are concerned that the evidence presented in support of the proposals is flawed in some key aspects.

Over the summer the CHC movement asked people and bodies who represent them what is important to them and looked at the different arrangements across the UK and beyond. CHCs considered in detail what others have said about the strengths and weaknesses of the different models. We have reflected on what works well in our current arrangements.

Given that the Welsh Government’s proposals are drawn, in large part, from the arrangements in place in Scotland, we paid particular attention to the role and remit of the Scottish Health Council. Rather than make a brief telephone call, the Board of CHCs visited the Scottish Health Council to hear from them directly about the current arrangements; the recent review which identified a clear case for change in their role and remit; and the on-going consultation about their future direction.

We are concerned that the White Paper proposals for a stronger citizens’ voice body in Wales are predicated on a model that is not, and does not, currently describe or consider itself to be a citizens’ voice body.

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The CHC movement has jointly agreed what we consider should be the key functions and principles underpinning the detailed design of a new people’s voice body for health and social care in Wales.

We recognise that legislation can provide for the introduction of a new people’s voice body with a range of functions and responsibilities. A change in structure and remit itself, however, cannot address all the challenges identified. Evidence suggests that some of these challenges, for example the level of public awareness and perceived independence of bodies set up to represent the interests of people in health and social care, are common across the UK.

We believe a new, strong and meaningful people’s voice body should be designed and developed with others in Wales, for Wales. We should learn from others’ approaches and experiences and build on what is valued within our own current arrangements.

We should grasp the opportunity to co-create a new and exciting people’s voice body with the capacity and capability to work with others to drive flexible and innovative ways of engaging and involving people of all ages - on the things that matter most to them and using their preferred ways of communicating.

Why do we need a people’s voice body at all?

We agree with the aspiration set out in the White Paper that health and social care bodies should get things right for themselves by continuously engaging with their communities. We also know that these bodies do not yet get this right every

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time – and we do not believe that new legislation alone will make this happen.

In Wales, by and large we don’t have a market-driven health and care system. It is therefore important that our services are created with and for the people that use them. Not only do those planning and delivering health and social care need to engage on the matters they are contemplating, but people must have the opportunity to have a collective voice on the things that matter most to them.

Health and care organisations have the responsibility to respond appropriately when concerns are raised with them. However, those people in the most vulnerable situations may not be in a position to raise their concerns without independent support.

We believe therefore that people in Wales deserve an independent, effective voice. This voice should be:

 working hard every day to make sure people’s views and experiences influence how their health and care services are designed and delivered  encouraging and valuing the diverse range of voices across Wales  capable of making sure service providers across health and social care are held to account for the services they provide to people and communities in Wales.

What should a people’s voice body do?

We consider the purpose of a new people’s voice body in Wales should be to: “reflect the views and represent the interests of people in their health and social care services”.

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We believe a new people’s voice body in Wales should have the following functions:

To encourage and support the involvement of people of all ages as individuals and communities in the design and delivery of services by:

• Engaging directly with individuals and communities on the things that matter most to them about their health and care services and engaging directly with people while they are accessing services. • Supporting, encouraging and facilitating engagement and involvement through a formal alliance with others to promote co-production and co- design (building on the Scottish Health Council’s model Our Voice). • Working collaboratively and across-boundaries to develop a creative, bilingual and accessible platform for individuals, communities, regions and the wider population to share their views and experiences and influence health and social care design and delivery on a local, regional and national level. • Informing the development of national standards and guidance for engagement and consultation. • Advising and supporting providers on involving people, including on engagement and consultation activity. • Monitoring and evaluating the effectiveness of involvement, engagement and consultation. Checking that people have had the opportunity to be heard and that their views are properly considered and responded to.

Whilst we do not consider a new people’s voice body should be checking compliance against standards (this sits better with others) it could and should refer concerns to responsible bodies if it appears standards for engagement and consultation have been breached.

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To represent the interests of people in health and social care by:

 Scrutinising health and care policy, plans and performance locally, regionally and nationally  Challenging service providers and policy makers where improvement is needed  Scrutinising the work of health and care regulators and inspectors  Sharing ideas, information and concerns about health and social care to support service improvement  Involvement in the co-design and development of services (including service change proposals)  Providing independent advocacy support and assistance to individuals raising a concern about health and care services

Currently all CHCs have a joint Services Planning Committee with their local health board. Any successor body must have a similar arrangement that also includes social care changes.

Services Planning Committees have oversight of a vast range of local healthcare issues at a very early stage. They are a forum where experienced and knowledgeable volunteers can debate with NHS professionals and help form forthcoming service developments. North Wales CHC members are seriously concerned that this power would not be held by any successor body.

It should have the following rights:

 Right to visit unannounced wherever health and social care is delivered (NB this would not extend to the homes of individuals)  Right to co-operation from care providers in contacting people on their behalf for the purpose of collecting independent feedback about care services  Right to be heard in health and social care (including on

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service change) by: . Policy makers . Service providers . Scrutiny bodies . Regulators  Right to a full, public and timely response from the above on concerns raised.

We do not consider a new people’s voice body should take on the following existing CHC functions, duties or powers:

 Provide advice and information on health and social care services

We believe the responsibility for this should be with health and social care bodies. The new people’s voice body must have the right to challenge services where the advice and information are not sufficient, clear, accessible or accurate.

 Inspect premises

We believe that the responsibility for formal inspections should sit with relevant regulators/inspectorates. However, the new body must have the current CHC right to visit, to report on its findings from the patient’s perspective and to have those reports acted upon.

Monitoring and scrutiny work undertaken by North Wales CHC has been developed collaboratively with BCUHB, meaning that real lessons can be learnt from CHC reports, which are received and considered at Director level. The development work has included setting out how BCUHB will act upon the recommendations and evidence where improvements have been made.

It is unfortunate that no Welsh Government representative has spoken to the North Wales CHC about CHC visiting and

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monitoring when preparing the White Paper (although they seem to have spoken to others at length). Without having had such discussions it is difficult to understand how they felt able to make the statements about CHC visiting practices and their value. CHCs already have many years of experience in effecting real change at ground level and the Government should be looking to take this skill, knowledge and experience into any new arrangements - not diluting and eventually eradicating this important safeguard.

We have attached evidence of the regard in which North Wales Visiting and Monitoring is held by NHS professionals. This includes:

• Our work around hospital hygiene and infection prevention - a letter of support from the Infection Prevention Team stating that the work of North Wales CHC has been key to changing staff culture • Support from the Director of Nursing for our “Lonely in Hospital” report • Support from the Mental Health Director for our “One Simple Thing” on improving NHS dementia care • Our report on urinary catheterization, revealing the pain, risk of infection and reduced quality of life arising from long waiting times for prostate care. The BCUHB Board were unaware of this situation until it was highlighted by the CHC.

All of this work is patient focused and outside the remit and capability of professional regulators who mainly focus on procedure, policy and statistics and whose presence in local NHS establishments is not as frequent as that of CHC visiting teams. It is wrong to view the roles of CHC visiting teams and HIW inspectors as duplication – they are different but very complementary activities.

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Earlier in this submission we have quoted Lord Justice Francis on the impact of the loss of CHCs in relation to the Mid-Staffs NHS Trust. We remind the Minister that, at the time, the Mid- Staff Trust was regarded as an exemplar by all the professional regulators.

In other areas of scrutiny, North Wales CHC has considerable influence. Members attend various high level committees i.e. Quality Safety & Experience as ‘observers with speaking rights’.

Additionally, CHC members participate in workshops to consider service delivery e.g. Hyper Acute Stroke Unit, Orthopaedic Services. The CHC also meets regularly at Chair to Chair level and has an open and transparent relationship with BCUHB, who value the contributions of the CHC.

Authors of the White Paper do not seem to understand the already close working between CHCs and HIW – with sharing of reports and information on a weekly basis PLUS the bi-annual Healthcare Summits to which CHCs make an invaluable contribution.

. Responsibility to develop alternative models to service change proposals where agreement cannot be reached

We believe any lay organisation would not be equipped to meet this responsibility.

. Right of referral to Ministers on service change proposals

We believe a new people’s voice body should not be the decision making body for a proposed service change. All service change proposals should be open to public scrutiny. Where decisions are not considered to be in the public interest, the appropriate challenge is through judicial review. There is a

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discussion to be had about whether the new body should have funding to initiate judicial review in appropriate cases.

What should a new people’s voice body look like?

So that a new people’s voice body is, and is seen to be, independent, it should be established as a single legal entity on a stand-alone basis. So that it is accessible and can respond quickly to what matters most to people and communities about their local services, it should have a strong local presence and focus. The organisational design of a new people’s voice body must:

 enshrine the principle of decisions being taken as close as possible to the people impacted We do not accept the White Paper claim that involving local people in decision making is “cumbersome”  provide for local determination of priorities according to evidence of local needs  provide for the agility to take decisions that impact locally, regionally and nationally  provide for clear lines of accountability within a strong standards & governance framework

Volunteers should be representative of the communities they serve and:

 be the lifeblood of a new people’s voice body  have the opportunity to contribute in different ways according to their skills and interests underpinned by a strong framework of modular and competency-based learning and development.  A new people’s voice body must be free to determine how it recruits its volunteers. Welsh Government, not CHCs, have had the power to recruit CHC members and they

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have steadfastly ignored advice from the CHC movement on how to improve the process of recruitment and make the movement better reflect local communities.

In summary, we believe our outline proposals for a new people’s voice body provide a strong framework on which to base future arrangements in Wales. However, the success of any future model will depend on the detailed arrangements being co-produced with partners and stakeholders. We ask that the Welsh Government looks to facilitate this approach over the 6-12 months following the consultation period.

Service change

We consider that there should be a single approach across health and social care to handle service change proposals and are concerned that the detail in the White Paper proposals around a new service change process does not provide for this.

Integrated service developments should be driven by communities whose contribution must be valued and utilised by decision makers in both health and social care. It makes no sense to develop a detailed service change process centred on NHS decision making alone.

We also have concerns that the detailed process described in the proposals is based upon current practice in the NHS in Scotland which has been subject to a recent review that recommends a move away from this approach in light of experience. Specifically, the review recommends a shift from defining service change as significant or otherwise. The review states “decisions as to whether something should be seen as

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‘major’ or ‘minor’……. have become divisive, confrontational and detrimental to public confidence in the NHS”.

Our experience is that, where service change has been successful, the level and nature of involvement, engagement and consultation were proportionate and responsive to the needs of those affected. We consider that all service change should be open to public scrutiny.

We agree with the proposals to revise existing guidance. We believe that the guidance needs to illustrate what effective engagement, based on co-production principles, looks like in health and social care. In revising and extending this guidance to social care, the Welsh Government should work with NHS bodies, social care providers, the people’s voice body and others with a role in helping communities to be heard.

The revised guidance should explicitly recognise that decisions taken nationally and regionally have a direct impact on how health and care services are designed and delivered locally and should provide greater clarity as to how co-production principles will be used to ensure people are engaged at all levels.

Inspection and regulation

We are not clear how the proposals to overhaul HIWs underpinning legislation would inevitably lead to more integration and common methodologies between the two existing inspectorates (CSSIW and HIW).

We recognise that removing the existing inspectorates from within Welsh Government and housing them within a Welsh Government Sponsored Body would bring more independence from government.

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However, it is difficult to see how the governance and accountability arrangements would work in a model that seeks to preserve the independence of three separate bodies within one Welsh Government Sponsored Body. The experience in Scotland, with its Healthcare Improvement Scotland model (which houses within it a range of distinctive groupings, including its inspectorate and the Scottish Health Council), illustrates the challenges of maintaining an individual and independent identity for each.

North Wales Community Health Council, September 2017

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Appendix 1

Ein cyf / Our ref: KB/KMW Eich cyf / Your ref:

Rhif Ysbyty / Hospital Number: Ext: 5744 : 01978 725203 Ext: 5744 Gofynnwch am / Ask for: Kathryn Boardman

Ffacs / Fax: E-bost / Email: [email protected] Dyddiad / Date: 11th July 2017

Dear All

We are grateful to the Community Health Council (CHC) for their continued support with the Bugwatch Survey across our acute hospitals. The survey provides an extremely helpful independent view of our infection prevention and cleanliness standards. We are equally delighted that our commitment to continuing improvement is visible to the CHC.

Following the last Bugwatch Survey, we took the following actions:

 Shared the results with staff, to ensure they understood the good practice identified, and the issues which could be improved. We are very pleased that many areas have improved their compliance with the standards following the previous survey.  Celebrated and praised staff for the high standards achieved in a number of areas.  Published a Health Board strategic framework and improvement plan for the prevention of infection to provide a clear structure and focus for outstanding areas of work.  Our focus on improving hand hygiene, and bare below the elbow continues. Monthly monitoring of hand hygiene practice is in place across all areas, and compliance is reported to public meetings of the Health Board. Patients and the public can be assured that we are committed to continuous improvement in this area.  Performed further review of the cleaning strategy and cleanliness standards including monitoring arrangements. We have put into place a number of improvements including increased capacity to deliver advanced cleaning technologies such as hydrogen peroxide vapour cleaning and ultra violet light cleaning which are globally considered the gold standard technologies, across all of our sites. We are keen to learn as an organisation so we are responsive to the needs of the people in our community. Going forward into 2017/18 we will be focussed on further improving our hospital and care facility environments. . We acknowledge there is more work to do on a number of issues, and we will progress improvement in these areas taking account of the specific recommendations in this report including:

 Bryn Beryl high and low dust noted, general storage and estates issues identified and now being addressed as far as possible whilst the outcome of a new capital bid is awaited.

Cyfeiriad Gohebiaeth ar gyfer y Cadeirydd a'r Prif Weithredwr / Correspondence address for Chairman and Chief Executive: Swyddfa'r Gweithredwyr / Executives’ Office, Ysbyty Gwynedd, Penrhosgarnedd Bangor, Gwynedd LL57 2PW Gwefan: www.pbc.cymru.nhs.uk / Web: www.bcu.wales.nhs.uk

Credits for cleaning scores are scrutinised and environmental spot check audits are currently being undertaken by the Locality Matrons, with support from the Infection Prevention Team, on a quarterly basis. A detailed response to Bugwatch West Area is attached with this response.  At Mold Hospital, issues noted with hand hygiene facilities, have been addressed by the East Area Director’s team and similarly at Deeside Hospital where the height of hand hygiene dispensers was noted to be incorrect for users in wheelchairs has now been addressed. Issues raised in relation to workmen entering Chirk Hospital without decontaminating their hands was addressed immediately and at corporate level all contractors are subject to induction training.  At Colwyn Bay Hospital there has equally been a keen focus on hand hygiene for visitors and staff with regular spot checks being undertaken by the Area team. Issues raised in relation to high level dust have been resolved following a planned cleaning focus. In addition the bathroom where stained enamel was noted has been taken out of use as planned and the fittings will be removed as part of a planned change of use. Patient information on a range of infections is now available on the ward.  All issues raised in relation to Denbigh and Holywell hospitals have been addressed and a detailed action plan for the Central Area is available with this report.  Specific actions to address the issues raised at Llandudno remain under focus and scrutiny with the Area team and Infection prevention Team to ensure they are fully completed.

Kind regards

Kat Boardman Uwch Nyrs: Tim Atal Heintiau Senior Nurse: Infection Prevention Team Bwrdd Iechyd Betsi Cadwaladr University Health Board

Ffon symudol/ mobile: 07717548259

Rhif uniongyrchol/ direct line (01978) 72 5744 [email protected]

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Older People in Community Hospitals: Avoiding Boredom and Loneliness

December 2016

OLDER PEOPLE IN COMMUNITY HOSPITALS: AVOIDING BOREDOM AND LONELINESS

Contents

Executive Summary ...... 3 Introduction ...... 6 What we did ...... 8 What we found ...... 9 Staying in touch through technology ...... 10 Television & radio ...... 12 Remote controls & headphones ...... 14 Newspapers, books, printed materials & games ...... 15 Arts, crafts & creativity ...... 17 Visiting...... 19 Encouraging & maximising socialisation ...... 21 Personal appearance & self esteem ...... 24 Our conclusions ...... 25

What health services can do to improve patients’ experience ..... 26

Next steps ...... 28

Appendices

1 The hospitals we visited ......

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Executive summary

“Older people in hospital need opportunities for social interaction, they need meaningful activities that stimulate 1 their minds and alleviate boredom.”

1The Older Persons Commissioner for Wales has highlighted how social isolation can have a negative effect on the health and wellbeing of older people. Studies have found that for many patients’ time passes very slowly in hospital, leading to feelings of loneliness and depression.

In late November and early December of this year, Community Health Council (CHC) members undertook a round of visits to local community hospitals across Wales. We spoke to older people who had been in hospital for some time to hear about their experience and find out what is provided to alleviate boredom, increase socialisation and reduce loneliness.

Overall, we found that the picture across Wales was varied. On the one hand we saw positive examples of wards that provided a wide range of activities to support interaction. On the other we saw many wards that were crowded, provided few or no activities and were described to us as barren and depressing.

1 Holloway, I.M. et al. (1998). Patients experienced a lack of control over their time in hospital. Journal of Clinical Nursing, Vol. 7, p460.

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We found that books, newspapers, crafts and use of hand held devices such as phones and tablets were popular ways for people to spend their time. However on many of the wards we visited some or all of these items were disallowed for reasons of ‘infection control’. There needs to be a clear, evidence based and proportionate approach adopted across community hospitals.

We found that access to television and radio was often limited as a result of lost, broken or inappropriate equipment. The people we spoke to were often very well used to using technology in their daily lives and this will only increase over coming years. More could be done to support the use of technology both to enable the use of personal devices and by exploring the use of Smart TV.

Maintaining personal appearance in hospital is a vital element of self-esteem and we were concerned to find that patients without frequent visitors often had little choice but to wear dirty or borrowed clothes. NHS organisations should consider providing laundry facilities for such patients or work with voluntary organisations to ensure that everyone in hospital has access to their own choice of clothes.

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Many patients expressed disappointment that the “Trolley Service” bringing newspapers, sweets, toiletries and other small items was no longer available in many community hospitals. People frequently relied on visitors to bring in such items and those with few visitors often went without. NHS organisations should consider ways to ensure access for all patients; by having items on the ward, reintroducing ’Trolley Services’ or working with volunteers where available.

Above all, we found that positive staff attitudes made a significant difference to ward environments. We found some wards that encouraged collective activity including meals, watching films or craft.

CHCs believe that NHS organisations should challenge themselves and learn from each other to provide creative and innovative activities and programmes that meet individual needs.

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Introduction

This report has been produced by the Board of Community Health Councils on behalf of the seven local Community Health Councils (CHCs) in Wales.

CHCs are the independent watch-dog of NHS services within Wales and we seek to encourage and enable members of the public to be actively involved in decisions affecting the delivery of healthcare for their families and local communities.

CHCs seek to work with the NHS and inspection and regulatory bodies to provide the crucial link between those who plan and deliver the National Health Service in Wales, those who inspect and regulate it, and those who use it.

CHCs maintain a continuous dialogue with the public through a wide range of community networks, direct contact with patients, families and carers through our Enquiries Service, Complaints Advocacy Service, Inspections and Monitoring Visits and through public and Patient surveys. There are seven CHCs in Wales who represent the “Patient voice” within their respective geographical areas.

Background

Community hospitals provide vital care for local people. They are typically small, using either purpose-built premises or smaller hospitals which have been retained to provide non-emergency services after general hospital services

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OLDER PEOPLE IN COMMUNITY HOSPITALS: AVOIDING BOREDOM AND LONELINESS have been transferred to more centralised facilities. As well as a range of outpatient services and treatments, they also provide care for people who need rehabilitation and some acute medical care. There are currently 43 community hospitals in Wales2.

According to the NHS Wales Informatics Service, in October 2016 there were 1,708 people being cared for in a Community Hospital in Wales, with an average length of stay of 23 days3. Recently published information by the Welsh Government shows that as at 19th October 2016, for 252 patients who were being cared for in a community, rehabilitation or other ward, their stay in hospital was longer than it needed to be because of delays in the arrangements for the next stage of their care4.

For older people whose stay in hospital might be for long periods, boredom and loneliness are important quality of life issues. It is vital that the care provided by the NHS in Wales for older people throughout their stay in hospital not only meets their physical needs but also their social and emotional needs.

For some people, boredom and isolation can lead to a range of emotional issues, such as feelings of worthlessness, restlessness or being uncared for. Studies have found that many patients feel that time passes very slowly in hospital, especially during certain periods of the day or night. This often leads to feelings of loneliness and depression.

2 Source: NHS Wales Informatics Service, 13 December 2016 3 Source: NHS wales Informatics Service, 13 December 2016. This information is based on Welsh Providers and Welsh Residents admitted to a Community Hospital in Wales. Based on the admitting episode. Patients can be admitted more than once to a community hospital during this time period and therefore can be counted more than once. The average length of stay could increase if a patient has multiple admissions during this time period. Current date quality issues with Aneurin Bevan University Health Board have affected the length of stay figures for October 2016 and care should be taken with those figures. 4 Source: Welsh Government, Statistical First Release, 10 November 2016 http://gov.wales/docs/statistics/2016

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Older people may be safe in hospital, but if they experience feelings of isolation, lack of physical and mentally-stimulating activities and a decline in proper eating habits, they will be at a higher risk of developing more serious health issues.

What we did

In view of the importance of this aspect of care for older people, the seven CHCs carried out a series of visits to a range of community hospitals across Wales during November and December 2016. We also visited some acute hospital wards where it was likely that older patients would be experiencing long stays. A full list of the hospitals we visited is at Appendix 1.

Our visits were unannounced, and overall we visited 48 wards in 35 hospitals. We listened to the views and experiences of patients, heard from staff and volunteers about their experiences and saw for ourselves how health services are providing opportunities to alleviate boredom and support social interaction. We heard from 177 patients and over 65 nursing and other staff.

Initially we spoke to Ward Sisters/Managers and asked what was provided to alleviate boredom, increase socialisation and reduce loneliness.

CHC members then asked staff to identify long stay patients who might be willing to participate in the survey and tell us about their experiences, views and suggestions.

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Our survey looked at issues surrounding boredom and social isolation. We did not seek to comment on the standard of clinical care, although most people told us they felt that the standard of care they received was very good.

What we found

We found examples of wards where staff were enthusiastic about engaging with patients and providing them with opportunities to reduce boredom and loneliness. They were passionate about the benefits that this brought to patients and had many more developments planned.

However in many cases we found wards with few or no activities or facilities to alleviate boredom and support social interaction, and where the ward environment was described as “barren” or “depressing”. Staff on these wards often pointed to the difficulties and barriers to engaging with patients and producing an environment in which they could thrive.

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Staying in touch through technology

“Wish there was Wi-Fi”

75% of wards we visited had free Wi-Fi access for patients with 90% coverage expected in the New Year.

“The mobile signal is good here and I can keep in touch with my

neighbour who is looking after my flat”

We found that many patients in their 60’s, 70’s and 80’s used smartphones and tablets in their daily lives.

One patient in his late 60’s said that the fact he has access to the Wi-

Fi meant he could remain connected to the outside world with his iPad

and phone and this, in his words “has certainly kept me sane”.

We found that many, although not all wards required device chargers to be PAT5 tested. In some cases this was done quickly whereas in others it took a considerable time. Some patients got around this by sending their phones and

5 Portable Appliance Testing (PAT)

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OLDER PEOPLE IN COMMUNITY HOSPITALS: AVOIDING BOREDOM AND LONELINESS tablets home to be charged, whilst others just did without. The need for PAT testing could be avoided if bedside electricity outlets included a USB charging point.

A small number of wards did not allow phones, tablets or chargers at all. In one community hospital, consisting of three wards, there was a different policy on each ward.

Whilst some staff saw access to digital communication as a great benefit to patients, others appeared to under estimate its value and importance to many older people, stating that “our patients can’t use technology”. This contrasts with our discussions with many patients who were enthusiastic about their use of smartphones and tablets. Others told us they would enjoy learning how to use technology whilst in hospital.

One patient in his 50s said he spends his time doing crosswords and watching TV. He would welcome access to a tablet as long as he was instructed in how to use it.

We found some wards that did not allow personal digital devices because they were considered to be an ‘infection control’ risk. We were concerned to find this inconsistency, and from a lay perspective it is difficult to understand the need for such a rigid approach in community hospital settings.

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Television and radio is increasingly allied to digital media and several staff and patients suggested that the use of “smart TVs” could provide a large range of content, allowing individual preferences to be taken into account. The use of tablets and laptops with access to streaming services was also suggested and some patients were bringing in their own devices to use streaming services with free hospital Wi-Fi. In some areas people told us that the Wi-Fi signal was already poor. If such use became more widespread this could impact on access to internet services more widely.

Television & radio

Access to broadcast television is an expected and appreciated part of a hospital stay. It is valuable for long term patients as a means of entertainment and a way of keeping ‘in touch’ with current events.

We found that few community hospitals have ‘pay to use’ bedside TV sets. For those that did, the charges were considered to be expensive, and it was common to find that the televisions were not working due to technical faults.

The use of communal televisions was often problematic. In some cases there was lack of space for a large television within the ward itself, and dayroom facilities were limited or not available. We found that where large televisions were installed in open wards or bays, there was sometimes difficulties in reaching agreement on the preferred channel or sound levels.

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Many patients commented on the friction and difficulty that changing channels and setting volume could cause and it was not uncommon for the set to be turned off to avoid these problems.

One patient in her 80’s explained that whilst the nurses would change

channels for patients they did not always agree amongst themselves on

what to watch. She opted to spend time on her iPad, on Facebook and MS Messenger

Many patients brought in portable DVD players, laptops and tablets to watch movies as an alternative to watching the communal television. We were told that some wards had held fund raising events or had received grants from their League of Friends to buy portable DVD players.

We found that a few wards held themed “Movie Nights” or arranged communal viewing of sporting events. Often it was a much anticipated part of the ward routine with snacks provided for those attending. As well as entertainment, these sessions gave patients the opportunity to socialise with other patients and staff. This is a low cost initiative that was widely appreciated. We were told that in wards with a higher proportion of patients with dementia it was necessary to have a higher degree of staff involvement.

“The TV in this TV Room is really good and I especially like the movie channel. We all liked watching the rugby together last weekend.”

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Whilst most television programmes are now available with subtitles for those who need it, we were surprised to find that very few of the ward staff or patients identified this as a specific need. Some patients reported that poor vision and hearing loss meant that it was difficult to watch the communal television. Remote controls & headphones

“No TV again as you have to pay for it and no headphones.”

We found that in many cases where televisions were available, the remote control was missing and this was the cause of considerable frustration. Televisions were often “stuck” on a single set volume. Patients would have to call a nurse if they wished to put the television on, change the volume or the channel. This is very difficult for patients and time consuming for nurses.

“There was a TV in the room but currently one remote control is being

used between three rooms.”

Headphones were also a major issue. We found that many patients bring in radios or portable DVD players but do not bring headphones. If several patients are using different devices at the same time then the resultant noise makes an unpleasant environment for everyone.

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Patients wishing to use hospital radio also need to bring in headphones as these are no longer provided in many hospitals. Patients indicated that they were not advised that they would need to bring headphones in with them, in order to use hospital radio. Some hospitals no longer have bedside access to radio or their own radio station.

Newspapers, books, printed materials & games

Whilst we expected to find books, newspapers, printed materials and board games in good supply, this was not always the case.

The Royal Voluntary Service6 (formerly known as the WRVS) or League of Friends trolley round with newspapers, magazines and confectionary is not as common as it once was, and on the majority of wards patients relied on visitors to bring them in. Books, newspapers, magazines and crosswords remained popular amongst many people we spoke to, and those patients who did not have regular visitors often went without.

“I miss the trolley that provided newspapers and other small items that

went around the ward in the Wrexham Maelor Hospital.”

6 Royal Voluntary Service are a volunteer organisation that enrich the lives of older people and their families across Britain www.royalvoluntaryservice.org.uk

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In some cases newspapers, books and games were not permitted because they were considered to be an ‘infection control’ risk. We were again concerned to find such an approach in community hospital settings.

Many older patients have sight issues and suggested that every ward should have a supply of large print books and ‘Talking Books’ for people with impaired vision. Other patients told us their condition made it difficult to hold a book for very long, and that they would appreciate access to e-books. E-books would also address the issues of large print and access to fresh reading material.

Playing board and card games relieves boredom, can help overcome loneliness and social isolation and in some cases may have a therapeutic and rehabilitative element following illness such as stroke. There is a need for large versions of these games such as oversized dominoes, cards and Connect 4’s etc., for patients with low vision, dementia or those with hand/eye coordination problems.

Many patients suggested adult colouring books as a possible addition to the ward.

In wards that had a good supply of board and card games, space to play them often remained an issue. Many hospitals have lost their day rooms to additional beds, offices, storage rooms and other uses. It was good to see that some hospitals are now trying to reverse this trend and are converting rooms to activity areas with soft furnishings, games and reminiscence activities.

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Staff availability to support activities was an issue on many wards. Some hospitals had an Activities Nurse, a Dementia support worker or Occupational Therapy sessions to assist patients with games and other activities. This should be the norm and not the exception.

Arts, crafts & creativity

We found several good examples of wards that offered patients the opportunity to engage in some form of handicrafts or creative activity. These included;

. Knitting . Painting & drawing . Handicrafts . Gardening . Music therapy . Meditation techniques.

Some areas had introduced initiatives that involved listening to music or singing. These activities proved popular with those who spoke to us. The Alzheimer’s Society programme “Singing for the Brain7” was well received in those areas where it was available.

Wards with some form of co-ordinator were much more likely to have an activity programme. The Supported Recovery Unit at Ysbyty George Thomas had a notably wide range of activities; with a woodwork room on-site and the opportunity for patients to become involved in gardening. At the time of our

7 Singing for the Brain is a service provided by Alzheimer's Society which uses singing to bring people together in a friendly and stimulating social environment. https://www.alzheimers.org.uk/site/

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OLDER PEOPLE IN COMMUNITY HOSPITALS: AVOIDING BOREDOM AND LONELINESS visit, patients were creating Christmas cards and decorations. There was a gym on-site with a treadmill and a large screen TV. Two bicycles were available and could be taken off the premises. Patients were also supported to access facilities at the local Sports Centre including the Jacuzzi and sauna.

In Barry Hospital there has been a joint arts and crafts project with the Barry Comprehensive School and patients and pupils have made items which are displayed in the gardens.

Bronllys Hospital had colouring books and other activities available within certain wards. There were seated exercise classes, art & craft club, music therapy and dance and movement sessions, supported by Powys Befrienders. The day hospital area had activity and craft rooms with facilities for arts and crafts, including knitting, interactive games (including a Wii Fit), quizzes (word searches and anagrams) and music therapy.

Fidget blankets and mitts were widely available for patients with dementia across Wales.

In those wards where such activities were limited “infection control” concerns were again frequently cited as the reason. In one hospital we were advised that knitting, crochet and needlework were not allowed because the wool might harbour infection.

“I would like to paint but is not allowed – no provision.”

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Visiting

People told us that they value frequent visits from friends and family. Approaches to visiting varied across Wales with some hospitals adopting a flexible approach to visiting although most maintained fixed visiting times once or twice a day. Staff in many hospitals told us they were reviewing their ‘fixed visiting time’ policy and, most hospitals took a more flexible approach to visitors who have travelled a long way, for people receiving palliative care or people nearing the end of life.

People told us that they looked forward to visiting times.

“One woman we spoke to deliberately left her phone at home when

staying in hospital. She told us that “if I bring the phone, my daughters won’t come, they’ll just phone”.

In some wards, when people were well enough they were encouraged to go out with visitors and this is something which patients told us they enjoyed doing.

We were surprised to find that some community hospitals did not allow children under sixteen to visit – preventing patients receiving visits from younger grandchildren.

People in hospital may not always have friends and family who can visit them regularly. In these circumstances, many staff felt that patients could benefit from

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OLDER PEOPLE IN COMMUNITY HOSPITALS: AVOIDING BOREDOM AND LONELINESS access to volunteer visitors and befriending services, although these services were not always widely available. Patients told us that they would appreciate somebody to speak to and to help in other ways like doing a little personal shopping or helping them to leave the ward for a bit when they are well enough to do so.

In rural and valley areas, we found that visitors tended to circulate and talk to a range of people that they knew from their community, reducing the sometimes difficult task of finding more “official” volunteers.

“Volunteers to talk to please.”

Many nursing staff told us they believed “John’s Campaign”8 to be valuable to people living with dementia and their carers. John’s Campaign is asking for the families and carers of people with dementia to have the same rights as the parents of sick children, and be allowed to remain with them in hospital for as many hours as they are needed. Some wards had made progress in implementing John’s Campaign and a few provided overnight accommodation for carers. Staff told us that the presence of a family member often reduced anxiety and distress in patients exhibiting challenging behaviour.

8 http://johnscampaign.org.uk/#/

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Encouraging & maximising socialisation

“Not talking to anyone is the most depressing part of being in

hospital.”

During our visits we looked for examples of how wards encouraged and supported people to socialise.

We asked nurses whether they introduced patients to each other and to the staff on the ward. Whilst most staff told us they did, this was not universal and on one ward we were told “introducing patients to each other is not a standard procedure”. In another hospital we were told “We don’t do any of that – we don’t want them getting too comfortable here. Patients need to understand that they will be moving on”.

Some patients described their stay in hospital as enjoyable.

One patient told us he had particularly enjoyed opportunities to

engage in singing during his stay.

Unfortunately many other patients told us that they felt bored, lonely or isolated and had very little opportunity for conversation.

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One patient told us he was very bored. He said that he had only made one friend although he had been on the ward for around three weeks.

He had no interest in the TV as he did not like the programmes that the other patients liked.

In wards that had successfully encouraged social interaction, feedback from patients was very positive, one person told us that he had thoroughly enjoyed his stay in hospital and had spent his time socialising. Others talked about getting on with fellow patients, supporting each other and developing a sense of camaraderie.

“We all chat in this room. The other three ladies in here like talking

and we talk a lot about TV. I was introduced to this lady next to me and she’ll know exactly how long I’ve been here. We do eat together in the dining room and I like that.”

We found in rural and valley hospitals it was commonplace for patients to know one another and for staff to arrange for patients to be close to someone they know if this is what they wanted. In one such hospital, a patient described the ward as a small community of people who know each other and are good company.

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Some ward environments provided little opportunity for socialisation because of their design and layout. Several patients told us that they rarely left their room or bed area. In some bays without clocks or calendars people told us that they had lost track of time and were unsure what day it was or how long they had been in hospital.

In other areas the environment had been designed to encourage interaction between patients. In Cambrian Ward at Ysbyty George Thomas patients were encouraged to sit and talk together in a room that has been decorated with large murals, a seaside picture amongst others. Staff noted that patients found this relaxing and that it allowed for some reminiscing conversations and activities to take place.

Some wards encouraged people to “Buddy Up” with others at mealtimes rather than eating alone. Many wards used mealtimes as an opportunity for people to socialise but this was sometimes difficult where there was limited space available to support shared dining.

Where dining rooms were available, some wards ran lunch clubs every day where patients were encouraged to eat together. Relatives were also able to attend to provide support where needed. In the Supported Recovery Unit at Ysbyty George Thomas the full-time Activities Co-ordinator supported excursions off site which concluded with a meal together in a local restaurant.

Some patients however told us they preferred to eat alone within their own space.

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Personal appearance & self esteem

We found that in many hospitals a hairdresser would visit the ward either weekly or fortnightly and people could have their hair done by appointment. In some cases the cost was subsidised by the League of Friends.

Patients told us that nursing staff sometimes helped them to do their hair, apply makeup or to shave. Nurses on some wards told us that they would also support people with foot and nail care.

We found many wards had arrangements with third sector organisations like the Red Cross, for patient “pampering” and massage. These additional services were much appreciated where they were available. There were however a few wards where we found that people had little or no access to services to support them to maintain their appearance.

Access to clean clothes or laundry facilities was a common issue. We heard that in many areas people relied on visitors to wash clothes. People who did not have regular visitors often found that they had to rely on hospital gowns or re- wear dirty clothing as no laundry facilities were available to them. Patients and staff raised concerns about the affect that wearing dirty or borrowed clothing may have on people’s well-being.

In some cases we found positive examples where support was available. This included the supply of nighties and pyjamas by the League of Friends, and the installation of washing machines and tumble dryers for patients use.

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Our conclusions

Overall, we found that the picture across Wales was varied. On the one hand we saw some positive examples of ward environments that were specifically designed to enable a range of activities and support interaction. On the other we saw ward environments that provided little opportunity for collective activity, were crowded and were described to us as barren and depressing.

CHC members undertaking our survey reported concerns about wards with few activities or facilities to alleviate boredom and reduce social isolation. Staff on these wards were often quick to point out the difficulties and barriers to engaging with patients and producing an environment in which they could thrive.

Conversely, we found that where patients were positive about their experience, the staff were often enthusiastic about engaging with patients and providing them with opportunities to reduce boredom and loneliness. They were passionate about the benefits that this brought to patients and had many more developments planned.

As far as we could see, these wards did not always have better staffing, additional resources or better facilities than others. The difference seemed to be in the motivation of the staff and, in particular, the leadership.

Our visiting teams found that people in community hospitals often had a range of individual needs. This included patients with sensory loss, restricted mobility and dementia. In some cases, these individual needs were seen by staff as

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OLDER PEOPLE IN COMMUNITY HOSPITALS: AVOIDING BOREDOM AND LONELINESS barriers to providing activities. This is not acceptable, and health services need to develop a wide range of activities and opportunities that meet people’s individual needs for communication and fulfilment.

What health services can do to improve patients’ experience

We identified a range of areas where the NHS in Wales should do more to improve older people’s overall experience of care in hospital. In particular:

. Patients value access to books etc., and yet these things are frequently denied across Wales on the basis of infection control. There is a clear need for some guidance for NHS staff to avoid the inconsistency we found across Wales

. improve the physical environment to avoid overcrowding and maximise the opportunity for social interaction

. ensure everyone is able to maintain their personal appearance, including their choice of clean clothes and regular access to hairdressing and other personal grooming

. NHS staff should challenge themselves and learn from each other to provide creative and innovative activities and programmes that meet individual needs

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. ensure appropriate staffing to enable and facilitate those activities that support people’s well-being and help them to regain and/or maintain their independence

. build upon the important relationships between health services and those volunteers and third sector organisations who can play a vital role in improving the experience of people in community hospitals

. develop a coherent strategy and clear guidance to support the use of technology by people in hospitals.

More specifically, there are opportunities to:

. Reinstate dayrooms . Reinstate ward trolleys with newspapers, magazines and other small items. . Provide a good supply of free reading material including large print books, e-Books and audio books. . Provide more access to Pets As Therapy dogs . Provide magazines, quiz books, word searches etc. . Provide adult colouring books and pencils . Avoid PAT testing issues by providing USB charging points at the bedside . Provide headphones, small radios, DVD & CD players, tablets and e- readers on loan – working with charities to raise funds where appropriate

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. Provide support for individuals who wish to learn to use digital devices– possibly working with high school and six form college volunteers as has been done in South Wales . Increase the speed, bandwidth and coverage of free hospital Wi-Fi . Remove all ‘paid for’ bedside TV and telephone services (as soon as contracts permit) and develop the use of “smart TV” and digital streaming services which will provide a large range of content, allowing individual patient preferences to be taken into account . Provide access to gardens and open spaces when the weather is good. . Create Dementia-friendly areas . Provide access to Art and Music Therapy for people who are in hospital for long periods . Look at new patient-centred roles for Health Care Assistants in co- ordinating patient activities to reduce loneliness and boredom . Increase availability of Volunteer Visitors – especially for patients that have no visitors . Ensure visiting times and ward policies enable carers and families to continue to be involved in care . Provide laundry services for patients without visitors.

Next steps

CHCs will discuss this report and the detailed findings from local visits with the NHS organisations in their area so that improvements can be made where needed.

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Appendix 1 The hospitals we visited Name Health Board Area

Alltwen Hospital Betsi Cadwaladr

Amman Valley Hospital Hywel Dda

Barry Hospital Cardiff & Vale

Bronllys Hospital Powys

Bryn Beryl Hospital Betsi Cadwaladr

Chepstow Hospital Aneurin Bevan

Chirk Hospital Betsi Cadwaladr

Colwyn Bay Hospital Betsi Cadwaladr

County Hospital Aneurin Bevan

Deeside Hospital Betsi Cadwaladr

Denbigh Community Hospital Betsi Cadwaladr

Dolgellau & Barmouth Hospital Betsi Cadwaladr

Eryri Hospital Betsi Cadwaladr

Gorseinon Hospital Abertawe Bro Morgannwg

Holywell Community Hospital Betsi Cadwaladr

LLandovery Hospital Hywel Dda

Llandrindod Wells County War Memorial Powys Hospital

Llandudno General Hospital Betsi Cadwaladr

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Name Health Board Area

Maesteg Community Hospital Abertawe Bro Morgannwg

Mold Hospital Betsi Cadwaladr

Montgomery County Infirmary Powys

Neath Port Talbot Hospital Abertawe Bro Morgannwg

Penrhos Stanley Hospital Betsi Cadwaladr

Rookwood Hospital Cardiff & Vale

Royal Glamorgan Hospital Cwm Taf

Ruthin Community Hospital Betsi Cadwaladr

St Davids Hospital Cardiff & Vale

Tregaron Community Hospital Hywel Dda

Tywyn & District War Memorial Hospital Betsi Cadwaladr

University Hospital of Llandough Cardiff & Vale

University Hospital of Wales Cardiff & Vale

Ysbyty Cwm Cynon Cwm Taf

Ysbyty Cwm Rhondda Cwm Taf

Ysbyty George Thomas Cwm Taf

Ysbyty Ystrad Fawr Aneurin Bevan

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Contact us Abertawe Bro Morgannwg CHC Aneurin Bevan CHC 1st Floor, Cimla Hospital Raglan House, Llantarnam Business Park Cimla, Neath Cwmbran SA11 3SU NP23 5LW 01639 683490 01633 838516

Cardiff and Vale of Glamorgan CHC Cwm Taf CHC Park House Unit 10 Maritime Offices Greyfriars Road Woodland Terrace Cardiff Maes-y-Coed, Pontypridd CF10 3AF CF37 1DZ 02920 377407 01443 405830

Hywel Dda CHC North Wales CHC Suite 1, Cedar Court Unit 11 Chestnut Court Havens Head Business Park Ffordd y Parc, Parc Menai Milford Haven Bangor Pembrokeshire LL57 4FH SA73 3LS 01248 679284 01646 697610

Powys CHC Board of Community Health Councils in Neuadd Brycheiniog Wales Cambrian Way 3rd Floor, 33-35 Cathedral Road Brecon Cardiff LD3 7HR CF11 9HB 01874 624206 02920 235558 www.communityhealthcouncils.org.uk Accessible formats If you would like this publication in an alternative format and/or language, please contact us. Our publications are also available to download and order from our website.

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Quality Safety & Experience Committee

6.6.17 To improve health and provide excellent care

Title: Avoiding boredom and loneliness: Older People in Community Hospitals

Author: Reena Cartmell, Interim Deputy Director of Nursing Diane Read, Head of Transforming Care Alison White, Transforming Care Team

Responsible Director: Gill Harris, Executive Director of Nursing & Midwifery

Public or In Committee Strategic Goals (Indicate how the subject matter of this paper supports the achievement of BCUHB’s strategic goals – tick all that apply)

1. Improve health and wellbeing for all and reduce health X inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the X NHS’ best 4. Respect individuals and maintain dignity in care X 5. Listen to and learn from the experiences of individuals X

6. Use resources wisely, transforming services through X innovation and research 7. Support, train and develop our staff to excel.

Approval / Scrutiny Route Purpose: This report provides a summary of the BCUHB findings and recommendations in response to the Older People in Community Hospitals: Avoiding Boredom and Loneliness report published by the Community Health Council (CHC) in December 2016.

Significant issues and risks This document highlights good practice that has taken place across the organisation and identifies areas where further work is required.

Special Measures Engagement Improvement Framework Theme/Expectation addressed by this paper Equality Impact No EQiA is required for this document. Assessment Recommendation/ Action This document is presented to the Committee for consultation and required by the Board comments / feedback in relation to the content.

Response to CHC Report: Older People in Community Hospitals: Avoiding Boredom and Loneliness

Opportunities to learn and drive improvement

1.0 Purpose:

This report provides a summary of the BCUHB findings and recommendations in response to Older People in Community Hospitals: Avoiding Boredom and Loneliness report published by the Community Health Council (CHC) in December 2016.

“Older people in hospital need opportunities for social interaction, they need meaningful activities that stimulate their minds and alleviate boredom”

Holloway, I.M. et al. (1998). Patients experienced a lack of control over their time in hospital. Journal of Clinical Nursing, Vol. 7, p460.

2.0 Background:

The Community Health Council is an independent watchdog of the National Health Services within Wales and represents the interests of the public. It works collaboratively with the NHS, regulatory bodies and Inspection to ensure the patient and user voices are heard.

As part of their role, the CHC undertakes both general inspection and monitoring visits as well as thematic investigations. These inspection and monitoring visits are a method of evaluating the quality of services from a public and patient perspective as well as supporting the spread of good practice via publication.

3.0 Assessment:

During November and December 2016, the CHC undertook a series of themed visits to 35 hospitals in Wales which incorporated 48 different wards to understand how NHS organisations were utilising strategies to alleviate boredom, support social interaction and reduce loneliness.

The review was informed by observation and by speaking to staff, patients and visitors. The completed report has been published by the CHC, and includes the overall findings, themes, and potential opportunities for learning and improvement for the Health Board.

As part of these visits the CHC visited the following BCUHB Community Hospitals:

 Ruthin;  Tywyn;  Denbigh;  Llandudno;  Ysbyty Penrhos Stanley;  Colwyn Bay;  Deeside;  Eryri;  Mold;  Bryn Beryl;  Holywell;  Alltwen;  Dolgellau;  Chirk.

The CHC issued a report in December 2016 which found a high level of variation across organisations and in some instances in adjoining wards. There were many examples of excellent practice, but no consistent evidence of how this was being shared across Health Boards.

The CHC report was presented under eight thematic headings (All Wales findings) as follows:

1. Staying in touch through Technology 2. Television and Radio 3. Remote controls and headphones 4. Newspaper, books, printed materials and games 5. Arts, Crafts and Creativity 6. Visiting 7. Encouraging and Maximising Socialisation 8. Personal Appearance and Self Esteem

4.0 Opportunities for improvement:

As a Health Board we recognise that improvement work is continuous and we must never lose sight of the needs, expectations and vision for the services we provide for our patients. There are areas / pockets of excellence across BCUHB which we need to share and embed in all of our Community Hospitals.

“Too much sleep because I’m bored nothing to do”

HCS monthly Quality & Safety Audit, Patient response / comment.

4.1 Staying in touch through Technology

We know that it is important for our patients to be able to stay in touch with relatives and friends whilst in hospital. This has a direct impact on their health and wellbeing.

During the visits, the CHC found that not all Community Hospitals had access to WiFi. However since the publication of the CHC report it is positive to note BCUHB Informatics have now introduced WiFi in all of our Hospitals across the Health Board.

Where there is no mobile signal available either a cordless hand phone or a BCUHB desktop phone can be used by patients should the need arise.

Patients are encouraged to bring in their own mobile phones into hospital and this includes IT tablets to access social media.

4.2 Television and Radio

Access to television and / or radio is an expected and appreciated part of a hospital stay. It is a valuable means of entertainment for patients and a way of “keeping in touch” with current events.

Not all wards, side rooms and / or day rooms at present across the Health Board have access to television and / or radio. However since the recent CHC visit our Matrons have been tasked to review all opportunities to purchase and increase patient access to both television and radios within their clinical service. Patients are encouraged to bring their own radios and headphones into hospital with them to also reduce risk of boredom.

4.3 Remote controls and headphones

Control of the TV, agreeing a channel and the volume of a TV can cause frustration to patients and staff in some instances. Therefore, providing bedside TVs with headphones would allow patients to independently watch / listen as they wish.

The provision of headphones and access to remote controls in our Community Hospitals is inconsistent. We recognise this needs to be considered as part of refurbishment projects however there are local solutions to ensuring we promote the use of headphones with the use of local tablet devices which our matrons and ward managers are taking forward.

4.4 Newspaper, books, printed materials and games

Newspapers and books are a valuable means of entertainment for patients and a way of “keeping in touch” with current events.

There is an inconsistency across our Community Hospitals in the provision of trolleys visiting wards to provide patients with the opportunity to purchase newspapers and magazines. In addition there is presently an inconsistency in access to books, printed materials and games across BCUHB. Our Matrons are taking forward a review to ensure equitable access to all our patients and encouraged to come forward with solutions to address this issue.

In some Community Hospitals the Health Board have a Dementia Activity Coordinator who works with patients to encourage them to participate in activities. It should be noted that their role ensures they work with all patients on the ward and not only those patients with a diagnosis of dementia.

All Community Hospitals have (or are in the process of accessing funding to introduce) an activities room from which the Dementia Activity Coordinator will work. These rooms will provide patients with an area to engage and undertake activity away from the bedside.

4.5 Arts, Crafts and Creativity

All Community Hospitals have, or are in the process of accessing funding, to introduce an activities room from which the Dementia Activity Coordinator will work. These rooms will provide patients with an arts and crafts area to engage and undertake activity away from the bedside.

The “Creative Well” Arts in Health and Wellbeing team provide support in some community hospitals for patients to engage in art activities; however this is not presently consistent across BCUHB however where it is working well the intention is to spread the learning and initiative.

4.6 Visiting

We know that some of our Community Hospitals engage with the local community to encourage visiting. For example, some Community Hospitals work with local schools who visit patients to talk about their life and skills and share this as part of their education.

BCUHB were the first in Wales to adopt and introduce the UK wide initiative “Johns Campaign” which was established by carers of people with dementia. This campaign allows unrestricted visiting for relatives’ friends and carers and stresses the importance of the carer having the right to stay and maintains a continuity of care.

Recognising the benefits for open visiting this will be taken forward in June 2017 for all of our inpatient wards across BCUHB.

4.7 Encouraging and Maximising Socialisation

We know that not all Community Hospitals utilise their day rooms which reduces the opportunity for patients to socialise and interact. This will be an important aspect of the Matron and Ward Managers review to regain / promote the use of these important patient areas especially at mealtimes or to hold patient activities.

As noted above in some Community Hospitals we have a Dementia Activity Coordinator who works with all patients to encourage socialisation and interaction.

We work with volunteers and 3rd sector to encourage social interaction such as the Chaplains volunteers visiting programme, however this is not at present consistent across our Health Board.

We work with PAT dogs who socialise with patients via the national PAT programme.

We encourage pastoral care support which offers friendship and support beyond specific religious care. These volunteers spend time on the wards engaging with patients to maximise socialisation.

Where available, patients are encouraged to access outside areas to improve wellbeing. Some community hospitals have worked with their local community / businesses to improve outside hospital areas to encourage a change of environment and opportunity to socialise.

4.8 Personal Appearance and Self Esteem

In some Community Hospitals patients have access to a hairdressing service; however this is not standardised across our services. Following the CHC review this will be considered locally to enhance this opportunity for our patients in our care.

Laundering of patients clothes is encouraged with the support of patients’ family and carers. Maintaining these standards are important to avoid the use of clothing such as hospital nightwear and to conserve dignity.

5.0 Conclusion We must consider the impact our support services, local community, volunteers and Third Sector have upon the older person’s experience.

Following review of the CHC report, it is clear that there are pockets of good practice across our Health Board; however we have also identified opportunities for improvement in terms of addressing loneliness and boredom.

We will continue to work closely with the CHC and welcome their support in providing assurance and monitoring of our services to help us to continually improve.

6.0 Recommendations

 Review and purchase of suitable radios and televisions where there is a shortage;  Revisit the opportunities for the daily newspaper trolley and promote and encourage access to these services including mobile hairdressing services;  A clear and consistent message regarding the encouragement of patient electronic communication aids such as electronic tables;  Consideration made regarding TVs, radios, headphones for patients as part of refurbishment programmes;  In future planning / refurbishment programmes, Older Peoples Commissioners recommendations and patients loneliness and isolation to be fully considered;  Review of all Community Hospitals to ensure they have a dementia friendly environment (including outside areas);  Strengthen partnership working with volunteers and the 3rd sector to enhance support for patients whilst in our Community Hospitals (e.g. volunteer visitors, patient activities etc);  Linking in with local authority for patients to access library services;  Adopting an open visiting across BCUHB and ensure this is communicated widely and clearly to both staff and the public;  Ensure all Day Rooms are dementia and older person friendly and utilised / patients encouraged to use them;  Ensure consistency of the Dementia Coordinator role and sharing of good practice;  Where laundry facilities are not available, alternative service to be explored / provided;  Consider options to utilise Viewpoint feedback system in Community Hospitals;  Include key questions within leadership walkaround framework

All the above recommendations will be considered and integrated into the existing older people workstreams in the organisation and progress monitored.

“One Simple Thing” Improving NHS services for people living with Dementia

April 2017

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A Carer’s Experience “There are two stages - looking after your loved one whilst fearing what will happen next. You want to preserve their dignity and for them to experience the familiarity of the home they have loved and the love of their family. It seems a terrible thing to hand them into the care of strangers but the day comes when their complete physical collapse makes it inevitable. It is not just the brain that is wearing out but the body too. From this point you want to support the hospital staff and carers.

You meet such contrasts - wonderful kindness but also its opposite, staff who are under stress themselves or undertrained. Monitoring would appear to be the key but all of the documentation necessary takes time which should be spent with the patient. A real problem we experienced was the use of male staff to give personal care to our mother - particularly in hospital. As an ex- nurse herself she found this completely unacceptable and was very difficult and aggressive towards them. The EMI home where she received palliative care until her death was excellent with staff who were more understanding of behaviour that others treated simply as bad behaviour.

There has been far more publicity about dementia since she died in 2013 but I wonder how much awareness there is of the different kinds of dementia, particularly when it results from an illness such as MS. I've sat on hospital wards and A&E, nursing and care homes so often observing other patients as well as family members. The problems are so complex in so many cases that you can only admire the dedication of so many medical and support staff. Quite frankly so many of them look worn out. They know how crucial their role is but also that they don't have enough time.”

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Contents

Introduction ...... 4

Background ...... 5

What we asked ...... 7

What we heard ...... 7

Assessment and diagnosis ...... 8

Information and support after diagnosis ...... 9

Respect & Dignity ...... 15

Providing the right environment...... 17

Funding ...... 18

Looking forward ...... 20

Appendix ...... 21

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Introduction

This report has been produced by the Board of Community Health Councils on behalf of the 7 Community Health Councils (CHCs) in Wales.

CHCs are the independent watch-dog of NHS services within Wales and we seek to encourage and enable members of the public to be actively involved in decisions affecting the design, development and delivery of healthcare for their families and local communities.

CHCs maintain a continuous dialogue with the public through a wide range of community networks, direct contact with patients, families and carers through our Enquiries Service, Complaints Advocacy Service, visiting activities and through public and Patient surveys. Each of the 7 CHCs in Wales represents the “Patient voice” within their respective geographical areas.

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Background

In January 2017 the Welsh Government launched its consultation “Together for a Dementia Friendly Wales”. The consultation sought views on developing and implementing a national dementia strategy for Wales.

This consultation follows on from the publication of a number of reports focusing on dementia care in Wales. In March 2016, the Older People’s Commissioner for Wales published her report “Dementia: more than just memory loss1”. Her report reflected on the experiences of people with dementia and those who care for and about them. The Commissioner challenged everyone to build upon the work that had already been done to deliver a better quality of life for people living with dementia.

In July 2016, the Alzheimers Society published its report “Dementia in Rural Wales: the three challenges2”. The report found additional challenges for people affected by dementia in rural areas.

In January 2017, taking into account the work already undertaken in this area, CHCs decided to undertake a wide engagement exercise to gather views and ideas from people across Wales on improving NHS services for people with dementia and their carers.

We heard from many people whose lives had been touched by dementia in all its forms. We used what people told us to inform our response to the

1 Dementia: More than just memory loss (March 2016). Find out more at http://www.olderpeoplewales.com/en/news/news/16-03- 14/Dementia_More_Than_Just_Memory_Loss.aspx#.WRAKyXmGOUk 2 Dementia in Rural Wales (July 2016). Find out more at https://www.alzheimers.org.uk/info/20089/wales/240/dementia_in_rural_wales_our_new_report 5 | P a g e

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Welsh Government’s consultation, which is included as an Appendix to this report.

People shared a wide range of ideas for improving services for people living with dementia. Some of these suggestions could be taken forward by the NHS independently, while others would need to be taken forward in partnership with others.

This report sets out in more detail what people told us. We hope that all bodies involved in the development and delivery of services for people living with dementia will use it to consider where and how they might improve.

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What we asked

CHCs across Wales asked people whose lives have been touched by dementia one question:

“What one simple thing could the NHS do better to support people with dementia?”

We used a variety of ways to reach people. This included Twitter, a smartphone app, SMS text, Freepost and a dedicated answerphone. CHC members and staff also met with people all over Wales during February and March 2017.

We received over 500 suggestions (mainly from carers) and our reach through social media was over 70,000 impressions.

What we heard

People shared a wide range of ideas with us. Some of these suggested small but important practical changes, and others proposed larger, system wide improvements.

There are some common themes in the ideas people shared, and we have used these to structure our report.

Importantly, almost all the responses we received recognised the vital role played by carers – and highlighted the need to plan and provide care and

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“ONE SIMPLE THING” IMPROVING NHS SERVICES FOR PEOPLE LIVING WITH DEMENTIA support not only for those people with dementia but also those who care for them.

Assessment and diagnosis

Lots of people told us there is a need for earlier diagnosis.

“An early and direct route to diagnosis followed by early treatment, medication and service provision to secure best outcome. Early diagnosis is key”.

Some people talked about the environment in which assessments take place. For example, people highlighted the importance of a stress-free environment, and some people suggested that community settings might be more appropriate than busy District General Hospitals.

Some people shared a positive experience of assessment. Examples included use of the “Montreal Cognitive Assessment tool” and “computer based assessments”. Some people particularly in rural areas referred to the effective use of ‘telehealth’.

“We want consistency across the board, swift accurate diagnosis for people living with dementia, more help to keeping us at home,

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scrap the PIP3 system for people with dementia as of today there is no cure, we can't do it alone we need your help and support”

Information and support after diagnosis

People frequently told us they needed better information when diagnosed. They want to know what to expect, what they can do to help delay and manage their symptoms and where to get support.

Some people told us they had a positive experience which should be available to all.

“The NHS was pretty good! Mum went on courses to learn about it – this was offered to her – this should be done for everyone”.

Others provide a range of suggestions for improving support and information for people with dementia and carers.

3 Personal Independence Payment aims to provide help with some of the extra costs caused by long term ill- health or disability. You can find out more at https://www.gov.uk/pip/overview 9 | P a g e

“ONE SIMPLE THING” IMPROVING NHS SERVICES FOR PEOPLE LIVING WITH DEMENTIA

“It would be really helpful if all carers and patients could be given one key worker who could help them stay informed about all the services available to them and help them to contact these.

This wouldn't necessarily need to be a health professional but more a sort of facilitator who could keep in touch and have ready access to service points and good information on what's available.

Most ordinary people have no idea what exists or how to access it and when a relative has dementia it's difficult to find out what you need, especially if you are already experiencing health problems yourself.”

Some people told us they struggled to cope with the practical and emotional implications of being diagnosed with dementia.

“Provide families with greater support to understand how to cope”

Many of the carers who responded told us they too would welcome more information and support to help them come to terms with the diagnosis and to help them support the person they cared for.

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“Not all dementia is just forgetfulness. Inappropriate behaviour is a very hard thing to live with and people are unaware of why the person is behaving in this way. We weren’t prepared for that”.

People also told us that dementia touches every part of their life. The information and support they need may be varied and wide ranging – extending beyond healthcare and covering life changing matters, including finances, housing, work, benefits, etc.

“Dad’s main concern was how mum would cope, and whether they would have to sell the house they had lived in since they were married 40 years ago”.

People want a joined up, multi-agency approach that helps them to access the information and support they need in one place.

People also told us about their need for support from their employers. We received a response from a nurse who felt unsupported by her NHS employer:

“The NHS can support carers by treating them with equality and dignity....equality meaning treating the carer fairly according to individual needs and perhaps they can start this in-house first”.

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People also told us they were looking for a flexible and responsive service to meet their particular needs.

“Far more responsive and flexible carers, and better training for [paid] carers”

Many people called for improvements in respite and crisis care.

“Patients should be able to go to groups, etc., to keep their minds active and give respite to carers and family”

Some people told us crisis care often came too late, or that the threshold for accessing crisis care was too high.

“My mother in law had dementia, and we found that there was a minimum of support offered until things got to crisis point, and she tried to take her own life, more than once.”

Some people suggested an on-call system for advice and guidance, available on a 24 hour basis (rather than just office hours).

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“I think a “dementia crisis team” would be a good idea. I've seen many families who are happy to care for their relative at home but reach a point of crisis because of short term pressures.

The care of the relative then suddenly becomes a burden. The family would have access to support that could provide a carer to sit with the relative to enable the family to deal with the other pressures.

This would be a short term provision until the family were fully able to provide care again.”

People emphasised the importance of meeting individual needs and providing different levels and types of support.

“Simple things matter! More support in the community with resources such as - Community Agents - Memory Cafes - Befriending - Good Neighbours - Carers Clubs”

“Pet therapy for people with dementia – it’s a great stress reliever”.

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For many people this involved support for people to live well in their community for longer. For some, this meant providing greater support at home, as well as access to groups and memory clinics. Others pointed out that travel to such groups could be difficult for some people, and additional support is not always seen as being easily available, particularly for people in rural communities.

“Enable the family to use disability parking! My dad had dementia and taking him out was a nightmare”

Some people who are receiving care from more than one agency spoke of the need to improve communication.

“Much better communication between social services, families and the NHS.”

Where people have clearly expressed their preferences and wishes for their care, it is important that these are respected and responded to. We were told by some people that they welcomed the use of a “This is me4” book which recorded people’s likes and dislikes. However, several people commented that some staff had not read it or did not provide care in line with its contents.

4 This is me is a tool for anyone receiving professional care who is living with dementia or is experiencing delirium or other communication difficulties. It is suitable for use in any setting – at home, in hospital, in respite care or a care home and provides a valuable way of integrating person-centred care. Find out more at http://www.alzheimers.org.uk/info/20033/publications_and_factsheets/680/this_is_me_tool_for_people_with _dementia 14 | P a g e

“ONE SIMPLE THING” IMPROVING NHS SERVICES FOR PEOPLE LIVING WITH DEMENTIA

Carers reported that visits from family and friends often became less frequent when those they cared for were no longer able to communicate as they once did. This often led to carers themselves feeling lonely and isolated. Some people suggested a need for stronger networks for carers with similar experiences, as well as additional support when the time came to move on. Respect & Dignity

“Show respect. Respect the fact that these are people who have had lives and are now ill. Do not write them off. My mother has dementia and I am shocked at her treatment by the NHS and social services.”

Many people told us NHS staff treated those they cared about with dignity and respect.

“My father was diagnosed with Alzheimer’s several years ago and has been treated (at Llandough) with dignity and respect in all interactions, even though it has not been easy to communicate with him. In particular, when my mother died, the staff spoke to him directly, made sure he was looked after and understood what was happening.”

However, others highlighted a need to improve respect and dignity for people with dementia.

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“NHS staff can treat them with dignity. If they have lost their way around the hospital, staff can help them without making them feel stupid”

Some suggested this was due to time pressures, and called for staff to have more time with patients. Many people linked this with inadequate staffing levels and NHS funding.

Some people called for better training for all NHS staff.

“My suggestion is that ALL staff working for the NHS gain a clear understanding of what dementia is. By learning about dementia, they will be better equipped to deal with patients who have dementia when they are hospitalised”.

The need for better and more effective communication was consistently identified.

“Answer my question as though it is the first time I’ve asked it”

“Active listening and positive calmness is a must!!”

“These individuals are human beings ….please be patient with them at all times.”

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“The one thing I can suggest is to continue to highlight the importance of communication when working with dementia patients. I find in practice and through personal experience that communication is key – short sentences, no more than one person talking”.

Communicating in Welsh was identified as a key component of respect and dignity for some.

“My husband’s last months were transformed by the involvement of a Welsh speaking nurse because Welsh was the language through which we have lived our lives”.

Providing the right environment

Many people told us how the NHS can provide the right environment for people with dementia.

Staying in hospital People suggested some improvements for people with dementia staying in hospital: • Safe and easy access to outdoors, including a garden area • Suitable activities • Suitable and sufficient access to TV and radio when it is needed • Quiet, calm space when needed • Homely environment and familiar belongings • Domestic toilet rolls and domestic toilet roll holders in hospital wards

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Accessing NHS services People told us how important it is to provide the right environment for people with dementia who may need to access any NHS service in the community or in a hospital setting.

In particular, people told us someone with dementia may need:

. A calm, quiet environment in waiting rooms and clinical areas . Clear signage . Assistance (as required) to navigate appointment arrangements . Support and understanding from NHS staff.

Funding

Many people told us they were concerned about funding for dementia care, which was seen by some as being very limited.

“In 1944 the NHS said that people’s illness should be paid for from the cradle to the grave by the NHS – the NHS won’t pay for Dementia although it is an illness. There is a tax on Dementia but not on cancer or heart disease”.

Some people pointed to the Scottish system as being a way forward for Wales, with funding being provided for people’s personal as well as nursing care.

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“My One Simple Thing is this: imagine Jean was your mother, unable to afford the best in private care, then treat her as you would your own Mr Politician - and I will judge you on that basis”

People consistently told us that they had been unable to access services that were listed as locally available. They called for appropriate funding for groups and services to ensure they were sustainable in the longer term.

“Stop cutting funds to local community groups that help and support individuals with Dementia, and that includes carers and their support groups. I wonder when the government will actually take the cotton wool out of their ears and actually take notice as, by supporting the local groups in the long-term, it is far cheaper than paying for hospitalisation”.

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Looking forward

Over 500 people took the time to tell us “one simple thing” that could improve NHS services for people living with dementia. Their voices deserve to be heard.

We welcome and await the outcome of the Welsh Government’s consultation on developing and implementing a national dementia strategy “Together for a Dementia Friendly Wales”.

CHCs in Wales will continue to work with the NHS, the Welsh Government and others to ensure that the needs of people living with dementia are at the heart of service design and delivery.

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Appendix Consultation response form: Together for a Dementia Friendly Wales (2017-22)

Overview Proposed Together for a Dementia Friendly Wales (2017-22)

How to Responses should be submitted by 3 April 2017 to: respond [email protected]

Or post the completed form to:

Mental Health and Vulnerable Groups Health and Social Services 4th Floor, North Core Welsh Government Cathays Park Cardiff CF10 3NQ

Further Large print, Braille and alternative language versions of information this document are available on request. and related documents

Contact Queries on the consultation should be sent to: details [email protected]

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Data Responses will be seen in full by Welsh Government staff protection dealing with the issues included in this consultation. It may also be seen by other Welsh Government staff to help them plan future consultations.

The Welsh Government intends to publish a summary of the responses to this document. We may also publish responses in full. Normally, the name and address (or part of the address) of the person or organisation who sent the response are published with

the response. This helps to show that the consultation was carried out properly. If you do not want your name or address published, please tick the box further down this page.

Names or addresses we blank out might still get published later, though this does not happen often. The Freedom of Information Act 2000 and the Environmental Information Regulations 2004 allow the public to ask to see information held by many public bodies, including the Welsh Government. This includes information which has not been published. However, the law also allows us to withhold information in some circumstances. If anyone asks to see information we have withheld, we will have to decide whether to release it or not. If someone has asked for their name and address not to be published, that is an important fact we would take into account. However, there might sometimes be important reasons why we would have to reveal someone’s name and address, even though they have asked for them not to be published. We would get in touch with the person and ask their views before we finally decided to reveal the information.

Responses to consultations may be made public – on the internet or in a report. If you would prefer your response to be kept confidential, please tick here:

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1. Contact Details

Your name: Clare Jenkins / Alyson Thomas Joint Acting Chief Executives

Organisation (if Board of Community Health applicable): Councils in Wales (BCHCW) on behalf of CHCs in Wales

Email address: [email protected]

Contact telephone 02920 235 558 number:

Your address: 33/35 Cathedral Road Cardiff

CF11 9HB

2. Are you responding as an individual or on behalf of an organisation?

Please tick box.

Individual On behalf of an organisation (please tell us which organisation)

√ Board of Community Health Council in Wales (BCHCW) on behalf of CHCs in Wales

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3. Structure of the document

In the Welsh Government’s Programme for Government ‘Taking Wales Forward 2016-2021’ we confirmed we would take further action to make Wales a dementia friendly country through developing and implementing a national dementia plan. This commitment was also highlighted in the 2016-19 delivery plan supporting the Welsh Government’s 10 year ‘Together for Mental Health’ strategy aimed at improving mental health and well-being for the whole population.

This is the first dementia strategy for Wales but builds on previous work. Engagement with people with dementia, their families and carers has been central to drafting this strategy. Feedback from stakeholders has informed the layout of the strategy, including organising actions as part of a pathway and embedding a ‘rights based approach’ within the document.

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Question 1

The strategy follows the following themes:

 Risk reduction and health promotion.  Recognition and identification.  Assessment and diagnosis.  Living as well as possible for as long as possible with dementia.  The need for increased support in the community.  More specialist care and support  Supporting the plan: o Training o Research. Do you feel there should be any additional themes included? Please tick the appropriate box below.

Yes √ No Partly

Where you have ticked ‘Yes’ or ‘Partly’, please explain what the additional themes should be.

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The Strategy Themes are well thought out and welcomed.

There is a need to make support for carers (particularly crisis support), and recognition of their vital role an explicit theme in itself.

The Board of Community Health Councils in Wales recently undertook an engagement exercise titled “One Simple Thing” that asked what one simple change could improve the quality of NHS dementia care. We received over 500 responses, mainly from carers.

The responses highlighted the need to support Carers in their role of maintaining dementia patients in the community for as long as possible. Lack of access to timely crisis care was seen as the breaking point for many.

Our engagement also revealed a need for more information and support at diagnosis, with both the patient and the carer struggling to cope with the practical and emotional implications of being diagnosed with dementia. This formed such a large element of the response that the CHC movement believes that information should be a distinct theme of the Strategy.

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Question 2

Within each theme we have identified a number of proposed key actions. Do you feel these are the right ones? Please tick the appropriate box below.

Yes √ No Partly Where you have ticked ‘No’ or ‘Partly’, please provide an explanation and any alternative suggested wording below. Please state which theme you are commenting on.

The CHC movement believes that the key actions are good starting points. No Strategy document can set down all the complex and detailed actions needed to implement these proposals and it is right that individual LHB’s should take responsibility for engaging with local populations, Local Government and the Third Sector to map the way forward.

The proposal to publish information on services would meet the needs of carers who tell us that they struggle to find what is available to them following diagnosis.

The “This is Me” book is also welcomed but some carers tell us that where this initiative is already implemented, some staff clearly have not read it and provide care that does not accord with the patient’s expressed wishes and preferences. This is an issue for training and development.

We strongly commend the proposal that Local Health Boards should ensure that every newly diagnosed person with dementia receives an information pack in an accessible format and is offered access to a dementia support worker or equivalent. The CHC movement recommends that this be extended explicitly to carers. We believe that this initiative is so important that LHB’s should be required to publish their performance on this requirement.

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Question 3

The strategy describes what services should be available for people and their families and carers to live well in the community for as long as possible.

What do you think are the key features of this type of service?

Availability – at levels sufficient for local needs Accessibility Timeliness Flexibility – to meet diverse individual needs Genuinely valuing the role of carers and making real efforts to support them Joined up – a multi-agency team approach to providing care Recognising the problems of rurality Respect Responsiveness to crisis – these events seem to be a key factor in carers losing the ability to cope any longer. A crisis team that can respond to events when they happen was regarded as vital by our respondents Wider approach to the difficulties of living with dementia – many of our respondents reported that managing every aspect of their lives, domestic, social, financial, became more difficult and their ability to cope reduced as the illness advanced

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Question 4

Within the final Together for a Dementia Friendly Wales we would like to include examples of notable practice. If you have any which you would like to highlight, please do so here.

Please explain why you think it is an area of notable practice e.g. an evidence base, an achieved accreditation award.

The examples shown are excellent and it is the experience of the CHC movement through our engagements, visits and monitoring of local services that there are many other examples available. The issue, as in so many services, is one of consistency. We also see many examples of poor practice; this was highlighted in our recent “Lonely in Hospital” report.

We suggest that NHS Wales actively collects and disseminates a guide to best practice.

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Question 5

Within the document we have highlighted the advantages of using telehealth, telecare and assistive technologies to help people live more independently and safely within their own home.

What do you think the challenges and barriers are in making this happen and how could you overcome these?

The CHC movement’s “Lonely in Hospital” report looked at the use of digital communication in relation to older people. We found that many NHS staff believed that older people do not use and are not comfortable with digital communication. Older people told us a very different story. Many older people use smartphones and tablets extensively and would welcome increased use of technology in their care and to communicate with care- givers.

The Mid-Wales Healthcare Collaborative has led the way on telehealth and shown how well received it can be – particularly in rural areas.

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Question 6

Do you think the key actions will provide a positive impact for people based on the following protected characteristics:-  Disability  Race  Gender and gender reassignment  Age  Religion and belief and non-belief  Sexual orientation  Human Rights  Children and young people Yes  √ No Partly

Where you have ticked ‘No’ or ‘Partly’, please explain why.

The Board of CHCs welcome these actions unreservedly.

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Question 7

Do you think the key actions will provide a positive impact on the opportunities for use of the Welsh language? Yes √ No Partly

Where you have ticked ‘No’ or ‘Partly’, please explain how you feel the opportunities for using Welsh could be strengthened to ensure it is treated no less favourably than English.

This is a vital element of the Strategy. One of our respondents reported that the last months of her husband’s life was transformed by the involvement of a Welsh speaking nurse as Welsh was the language through which this couple had lived their lives.

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Additional Comments

We have asked a number of specific questions. If you have any related issues which we have not addressed, please use the space below to comment.

Our recent engagement exercise revealed a great sense of injustice that the burden of the cost of dementia care was treated differently from other diseases. Set out below is a comment typical of the many we received:

“In 1944, the NHS said that people’s illness should be paid for from the cradle to the grave by the NHS – the NHS won’t pay for Dementia, although it is an illness. There is a tax on Dementia, but not on cancer or heart disease.”

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Many people looked to the Scottish system as being the way forward for Wales.

There was also a perception that funding for dementia care was very limited and consistent reports of people being unable to access services that were listed as locally available.

Support for carers and respite care was an often expressed need from our respondents and they wanted a 24 hour crisis response team – they told us that the small hours of the morning were often a very difficult time and that it was often impossible to get advice, reassurance or help at this time.

Respondents spoke of a lack of respect and dignity for dementia patients;

“Show respect. Respect the fact that these are people who have had lives and are now ill. Do not put men and women in the same areas. Do not expect them to eat or drink without encouragement. Do not write them off. My mother has dementia and I am shocked at her treatment by the NHS and social services.”

It was recognised that on most occasions this was caused by time pressures or lack of awareness but many carers found it difficult to cope with on a continuing basis and called for staff to be given more time with patients and more training.

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8. Sources of information

The final document will include a list of useful sources of information. If there is anything you feel should be included, please state in the space below:

Older People in Community Hospitals: Avoiding Boredom and Loneliness (December 2016) (Community Health Councils in Wales)

One Simple Thing: Ideas to improve the NHS for people living with Dementia (April 2017) (Community Health Councils in Wales)

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Abertawe Bro Morgannwg CHC Aneurin Bevan CHC 1st Floor, Cimla Hospital Raglan House, Llantarnam Business Cimla, Neath Park SA11 3SU Cwmbran 01639 683490 NP44 3AB 01633 838516

Cardiff and Vale of Glamorgan CHC Cwm Taf CHC Unit 3, Pro-Copy Business Centre Unit 10 Maritime Offices Parc Ty Glas Woodland Terrace Llanishen Maes-y-Coed, Pontypridd Cardiff CF37 1DZ CF14 5DU 01443 405830 02920 750112

Hywel Dda CHC North Wales CHC5 Suite 5, First Floor Unit 11 Chestnut Court Ty Myrddin Ffordd y Parc, Parc Menai Old Station Road Bangor Carmarthen LL57 4FH SA31 1BT 01248 679284 01646 697610

5 North Wales CHC is the operational name of ‘Betsi Cadwaladr Community Health Council’

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Powys CHC Board of Community Health Councils Neuadd Brycheiniog in Wales Cambrian Way 3rd Floor, 33-35 Cathedral Road Brecon Cardiff LD3 7HR CF11 9HB 01874 624206 02920 235558 www.communityhealthcouncils.org.uk

Accessible formats If you would like this publication in an alternative format and/or language, please contact us. Our publications are also available to download and order from our website.

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Appendix 5

BCUHB response to ‘One Simple Thing’ – Improving NHS Services for people living with dementia (The Board of Community Health Councils, April 2017)

‘One Simple Thing’ is a report aimed at capturing and projecting the ‘patient voice’ in the context of our fellow citizens who are living with or affected in some way by a dementia of any type. It is a report that is welcomed by BCUHB as we endeavour to listen to those voices and work in partnership to develop our local dementia strategy that aims to see the health board become a more dementia friendly organisation.

The report is well written with a clarity of style and presentation that makes it accessible. Its findings are based upon a straightforward approach of asking those people most affected by dementia to answer one question; ‘What one simple thing could the NHS do better to support people with dementia?’

There were 500 responses which is a respectable number and in the region that one would expect from a survey of this kind.

The responses are themed, which adds to the clarity of presentation, and each theme is directly linked to the voices of those involved which serves to legitimise the need that is being referred to. It would seem appropriate to address each theme from the perspective of BCUHB to explore our current practice and the aspirations we will set out in our dementia strategy.

Assessment and Diagnosis

We agree there is a need for earlier diagnosis. Recognising any dementia at as early a stage as possible is important for those affected to begin coming to some adjustment and preparing for the future. It is equally important from a clinical perspective to start offering treatment, care and support to try and achieve a degree of stability over an otherwise inherently unstable set of illnesses. Specialist memory assessment services are the principal diagnosis making service within the health board and we aim to see them becoming increasingly located outside of our hospital

Appendix 5 sites, preferably in primary care practices. We believe this will support GP’s to consider early referral whilst offering the person referred a more familiar and convenient place to be seen than a large hospital site.

In addition to this we are challenging memory services to commence assessment within 28 days which is earlier than the national quality standard1 of up to 42 days. We also want to see time to diagnosis being quicker but acknowledge that there can often be clinical uncertainties and complexities that mean good practice is to take time to get it right. If this is the case we expect the person concerned and those close to them to be fully informed about this.

Information and Support after diagnosis

We agree that the right kind of information and support is crucial for those affected as they adjust to living with dementia. We see no distinction here between the needs of the person diagnosed and the needs of the carer they are one and the same and we aim to support both. Currently we make a standard offer of post diagnostic support across North Wales to ensure that regardless of age, locality and language preference2 the same information and support is available. Fundamental to this is the offer of a dementia support worker to guide each person or family individually through the available options.

We aim to go further. People we talked to told us that they wanted to hear from those who were already diagnosed and so we will commission a third sector organisation to provide peer support after diagnosis. For families and carers struggling to come to terms with this new and unwelcome life we will be offering many more opportunities to undertake a gold standard ‘Coping with Caring and Loss’ psychological intervention. For those diagnosed as part of an acute hospital admission we will make available on every acute adult ward the range of information that the Alzheimer’s society recommend as valuable.

1 From Memory Services National Accreditation Programme for England and Wales. 2 Welsh or English

Appendix 5

Crisis Support and Respite

We agree that crisis is always undesirable for those affected by dementia and acknowledge that it often is another life changing event particularly as it represents the breaking point for many carers. The crises brought about by behaviour changes are often the most difficult for carers to cope with and we agree that there is a need to consider a community based crisis intervention or home treatment service specifically for older people.

Respite services are more difficult. Generally, across the NHS as a whole, such services are not provided by the health service but more usually fall to social care and increasingly to the third sector. The Alzheimer’s society provides an excellent range of opportunities for people with dementia to be active and engaged within their local communities and we see our dementia support workers as helping to sign post families to those opportunities. We as a health board aim to fully support the emergence of dementia supportive communities within which we see ourselves wherever possible partnering with social care and the third sector.

Better Communication

We agree that effective communication with carers and between agencies involved in delivering care is fundamental to easing the strain felt by many. In our older persons mental health wards we have piloted ‘Care to Talk’ a conversational model that encourages open, honest, frequent interaction between in-patient staff and carers of people with dementia. We aim to review this with the aspiration of rolling it out to community hospitals and care of the elderly wards. We fully endorse the use of the ‘This is me’ approach and expect every person with dementia to have the opportunity to develop their own.

Respect and Dignity

We agree that showing others respect and promoting their dignity is so basic that it is disheartening to see it included as an unmet need for some. We acknowledge that further culture change is required and that whilst we support our staff to work through

Appendix 5 that process (with increased amounts of training, education, reflection and supervision) we will always hold to account those whose practice falls below the expected standard. In respect of training we endorse the point made that all staff need to understand what dementia is (in the past two years we have exceeded Welsh Government targets and delivered awareness training to around 10,500 staff) and we aim to bring the voices of those affected by dementia directly into our training modules.

Providing the Right Environment

We would agree that clinical environments as healing spaces need to be more supportive and enabling for people with dementia, as such that represents one of the four key priorities for our dementia strategy. In respect of the social environment we feel the emphasis lies on staff training. In respect of the physical or built environment we follow Welsh Government guidance that all new build and refurbishment work must conform to the national standards for dementia supportive environments. We have recently audited all our acute adult wards using the gold standard Kings Fund assessment tool and will be using the results to identify areas for priority action.

Funding

To some extent it seems your audience here is Welsh Government.

To summarise it is important to say again that BCUHB welcomes this report. We feel it reflects those things we have heard as part of the consultation we undertook to begin drafting our dementia strategy. We look forward to working with the Community Health Council as we both strive to see improved NHS services for people with dementia across North Wales.

Appendix 6

North Wales CHC Urology & Catheterisation Review

“Urinary catheterisation is not a treatment. Catheterisation can only be a temporary measure for male patients suffering urinary obstruction”

Introduction

This review was undertaken by Jackie Allen (CHC Chair) and Christine Evans (retired Urological Surgeon) following concerns expressed by male urology patients and their families.

A male urinary catheter is painful and has a profound effect on quality of life. Catheters are prone to blockage, inevitably cause infections and urethral strictures and preclude sexual activity.

Most male catheters are unnecessary and can be avoided by prompt prostatic surgery to remove the obstruction. Patients with chronic retention can be helped to self-care by teaching Clean Intermittent Self-Catheterisation (CISC) to patients and carers.

The practice of maintaining patients on catheters rather than undertaking prompt TURP/Prostatic Ablation is returning to the situation that applied in North Wales prior to 1987. Urological surgeons at that time made a concerted effort to end the practice and benefits were felt across the health care system in terms of reducing infection and blocked catheters. The benefits for patients in terms of reduction in pain and discomfort were immeasurable. The Community Health Council strongly believes that we should not return to this situation.

A summary of the key action points is set out below. The detailed visit reports are on the following pages.

Summary of Key Action Points

We have found that all Acute Hospital Urology departments and Emergency departments are aware of the problem of patients being inappropriately and unnecessarily maintained on catheters for extended periods of time. All departments are making some efforts to correct this problem. We were both very pleased with the enthusiasm of the staff and their commitment to improve the care of patients. The equipment in all the departments is excellent.

 Patients with an indwelling catheter should be rapidly identified, treated as priority and admitted within 3 months. Routine TURP wait is currently1 year because cancer cases take priority  Too many catheterised patients are lost to the system and simply attend when they have an emergency, the emergency is treated and they are lost again

Appendix 6

 It is unacceptable that so little is known about the patients awaiting effective treatment. It has not been possible to determine how long patients have been catheterised, why they are catheterised, whether they are known to the Urology Department or the District Nursing Service, which waiting list (if any) they are on or even their gender.  More work should be done to identify the reasons for long term male catheterisation  A digital Catheter Register is long overdue and urgently required  The biggest request from Urology staff was for more operating lists and more ring-fenced beds. Four urologists, in each centre, cannot manage with 6 beds especially when major cancer work is being performed as well.  The lack of beds leads to many last minute cancellations – this is demoralising and distressing for patients  We commend the Waiting List initiatives but more are needed to ensure that all patients currently being inappropriately managed on catheters are treated rapidly  Further development of Rapid Access Clinics  More day case lists with General Anaesthetic  It is disappointing that catheterisation has become the standard mode of care when TURP and Laser Ablation are so rapid, effective and have dramatically reduced In Patient stays.  It may be beneficial to allocate work differently; for example, Wrexham Maelor has the shortest waiting list and does not undertake urgent cancer surgery so perhaps they should take over more of the benign surgery from the centre.  There is a needed for more Urology Nurse Specialists especially in the centre where they have disappeared. These are very valuable workers who can replace the middle grade doctors in many areas  There is much good practice and this should be standardised across the three areas; for example, the East Nurses are more organised with their catheter register.  Training and Confidence is a major issue for both nursing and WAST staff – all staff should be able to undertake catheter re-insertion and bladder washouts. WAST staff are being re-trained in the West.  Increase the use of self-care by training patients in CISC (Clean intermittent catheterisation) whenever appropriate.  End the practice of requiring patients to endure two Trials Without Catheter (TWOC). It unnecessarily delays timely treatment for patients and prolongs pain and infection risk.  Improve compliance with the Catheter Insertion Bundle. Forms should be completed for every patient.

Appendix 6

Unannounced Visit – 11th May 2016 Urology Department, Ysbyty Glan Clwyd

The CHC team initially visited the Diagnostic Department and discussed the management of catheters with the Sister and the Urodynamic Nurse Specialist. They were informed that if a male patient is catheterised anywhere in the hospital, including the Emergency Department (ED) and all other wards, they are admitted for trial without catheter (TWOC) within two weeks after having been prescribed Tamsulosin (an alpha blocker) to relax the prostate urethral muscles and Finasteride (a prostate shrinker) for two weeks.

The outliers i.e. those not from the urology department, tend to become lost to the system and linger at home unrecorded. The Trial Without Catheter (TWOC) patients are admitted to the diagnostic unit. If this fails they are re-catheterised and re- booked for another TWOC. Christine Evans believes that this is second TWOC unnecessarily delays appropriate treatment and recommends that the practice should cease. If the first TWOC is unsuccessful then the patient should be immediately listed for Trans-Urethral Prostatectomy (TURP) or Prostatic Ablation.

If the patient’s second TWOC fails, only then is a referral made. This means that the patient will have been catheterised for a minimum of four weeks. Often it is a great deal longer than this.

The catheters are looked after in the community by the district nurses. Blocked catheters are generally dealt with in ED, Diagnostics or even by surgical admission.

The CHC Team asked why community nurses and paramedics did not deal with blocked catheters. They were informed that, despite having received appropriate training, community based staff appeared to lack the confidence to deal with these emergencies. This means that a patient with a blocked catheter and a painfully distended bladder is assessed by district nurse or paramedic and then sent for treatment at YGC, enduring painful and unnecessary travel and waiting.

The CHC Team also spoke with the Urology Consultant, Ross Knight, and asked; “Who sends for the patients and deals with the waiting lists? How are the catheterised patients identified?” They were informed that Mr Knight and Mr Toussi manage their lists personally and Mr Srinivasan’s is managed by his secretary. Mr Knight identifies his catheterised patients by computer but this does not seem to be a pan-North Wales system. We understand that there is a catheter audit being undertaken at the moment but the information will not be generally available.

We have been informed that the waiting list for benign disease is currently over twelve months. This is not good news for patients with a catheter. Conversely, the delays come at a time when the operative procedure for prostate resection is infinitely safer, with very little blood loss and far fewer complications. Normally, there is only a 24 to 48 hour stay for most patients.

A key factor behind the increasing wait for surgery is that the Urology Department have lost lists. They now have only two half days per week run as a full day. This is a marked reduction from 10 years ago. There is no GA day case list, these patients

Appendix 6 fill the main theatre lists. There is no dedicated Urology ward - just beds on Ward 5 and these are no longer ring-fenced.

The Urology Department in YGC is overstretched as they are doing most of the radical prostatectomies and radical cystectomies in North Wales. Mr Srinivasan has a 6 month waiting list for radical prostatectomy (for operable prostatic cancer); this is unacceptable as the cancer may spread in that time.

Having regard to the long waiting times and the complex cancer related case mix at YGC, we strongly suggest that BCUHB provide increased capacity in the form of increased lists, dedicated beds and additional facilities.

An alternative would be to refer routine prostate and other surgery to Wrexham or Bangor. There are now three separate waiting list managers, one for each hospita, so is there communication and a willingness to help each other out?

Other suggestions is the need for

YGC – Action Points

1. The YGC Urology service cannot cope with volume of cancers currently presented to them; they need two sites. 2. Develop a Catheter book - like there is a stent book 3. More main theatre lists 4. Develop use of Cystodiathermy for bladder tumours under local anaesthetic (we are informed that a bid for equipment has been made). 5. Limited GA in Diagnostic Unit setting up discussions with anaesthetists 6. Get the GA list back from Llandudno, it is not in use at the moment. These sessions could be used for the fourth Urologist who is now in post. 7. Protected Urology beds 8. Laparoscopic assistant for Mr Toussi 9. Replace Urology Nurse Practitioners lost through vacancy control - using nurse practitioners means there is less need for the middle grade registrars.

Appendix 6

Catheter Presentations to Emergency Department Group CHC Attendance at the meeting on 20th May 2016 at YGC

Chaired by Nia Baldwin other attendees included ; Adam Griffith (Head of Nursing ED), Liz Greaves and a WAST representative.

Key discussion points

 Over the past 2 years 187 patients came in to ED with catheters in, and they were unknown to their GP or the district nursing service

 Most catheters in ED are inserted without rectal examination and patients are sent home without Urology department knowledge.

 This group have put together a catheter pathway. On this pathway, if a patient has a blocked catheter a District Nurse is sent within 2 hours.

 A digital catheter register is being developed for all catheters as well as certain patients who must be seen by the Urology department...

 We then discussed CISC (Clean intermittent catheterisation) in certain cases

 Currently being considered is Trial Without Catheter (TWOC) at home with the District Nurse rather than have to go to Urology diagnostics. The CHC strongly commends this initiative.

 There needs to be a method of identifying patients with catheters on the WL

 Many nurses don’t like to do the first catheterisation and have never done it. This seems to be a confidence/training issue . Some nurses don’t like to do the first catheter change. This needs to be addressed urgently

 It would be very helpful to know what number/proportion of patients manage to pass urine after their first TWOC

 It would be helpful to know how many calls to WAST are for blocked catheters.

 There is poor compliance with the Catheter Insertion Bundle. Forms should be completed for every case presenting at ED. This is not done consistently and the form should be sent to the GP and District Nursing Service

 We need to know the causes of catheter insertion i.e. retention of urine/ incontinence

 It should be made clear to all staff that the catheter IS NOT the treatment. The treatment is dealing with the obstruction by TURP or other appropriate procedures.

Appendix 6

District Nursing Services - Central 25th May 2016

Jackie and Christine met with Nia Boughton, (Head of Nursing - Central) to find out whether district nurses were replacing catheters and doing bladder washouts, thus avoiding the need for male patients having to go to ED at YGC. It was found that nurses in the community can only do repeat catheterisations and some are more prepared to insert catheters and undertake bladder washouts than others - depending on their training and confidence. This situation must be addressed and all staff should be undertaking the full range of catheter care.

Catheter care accounts for one in every five 5 district nursing visits. There were 43 blocked catheter callouts in January 2016 in Central area alone.

Nia informed the CHC team that a digital/electronic catheter register for the whole of North Wales was essential for effective management but that this was at least six months away.

Nia highlighted the difficulties in relation to Welsh Ambulance Service Trust teams being called out to blocked catheter emergencies. WAST staff capability to undertake catheter care has been limited by training and confidence. There is currently a pilot in the west, where an advanced nurse practitioner goes out with ambulance crew to attend blocked catheter call-outs. An extension of hours for District Nurses is being considered. This would provide for overnight presence. At the moment District Nurses are on duty 8am -10pm, 7 days a week.

Appendix 6

Unannounced Visit - 24 May 2016 Urology Department - Ysbyty Wrexham Maelor

Christine Evans and Jackie Allen met with Christian Siepp, Consultant Urologist, Kelly Price, Urology Nurse Specialist (UNS) and Hazel Allen, Sister in Charge, to discuss the management of catheters and the Urology Waiting List.

There are plans to set up an emergency access service for urology in normal working hours so that patients with catheter problems will not need to go to ED or SAU (Surgical Admissions Unit) except when Out Patients is closed.

We were informed that Out Patients Sister changes catheters up to three times and then refers the patient to the District Nurse. Trial without catheter (TWOC) is unsuccessful in approximately 50% of cases. The Department teaches patients CISC - especially for chronic retention

Findings

 Diagnostics are done in Out-Patients; they have Ultrasound, Flexible Cystoscopy and Trans Rectal Ultra Sound.  Urodynamics and ESWL are done in X-ray department.  Prostates are dealt with by TURP, bipolar and laser.  Radical and pelvic surgery are not done at the Maelor  Each consultant has 2 lists a week plus some day case lists where general anaesthetic can be given

The main reported problem is the lack of Urology beds (on Lister and Glyndwr). These beds are not ring-fenced; so patients are often cancelled at the last minute for lack of a bed. In the week previous to this visit, the Consultant could not find a bed after a penile prosthesis operation because the bed, he had booked before the operation, had been filled.

Currently the waiting time for benign disease is one year, for Urgent treatment it is eight months. The day case lists are currently filled with botox treatment (for hyperactive bladder). There is a 7 month wait for cystoscopies for bladder tumours. Patients with recurrent bladder tumours requiring treatment with Mitomycin and Bacillus Calmette-Guerin (BCG) do get in BUT with difficulty.

YWM - Action Points

1. The Diagnostic Unit should be all inclusive. It should not be based Out Patients. This was determined over five years ago and plans were started but no action furtherhas been taken. 2. There are too many unnecessary admissions which should go to the Surgical Admissions Unit and not Urology beds e.g. scrotal pain and loin pain yet to be investigated 3. Further development of Rapid Access Clinics – currently one day per week 4. More day case lists with General Anaesthetic – currently only three per month

Appendix 6

Unannounced Visit – 25th May 2016 Urology Department, Ysbyty Gwynedd

This was the third and last visit to Urology departments in BCUHB to discuss the increasing number of male catheterised patients and to talk about remedying this unacceptable situation. Jackie and Christine met with Sue Harrison (Urology Nurse Practitioner) and Alexandru Kyriakos (Consultant Urologist). We were well received by the staff who are anxious to improve the service

The situation is similar to the other two DGHs, there are currently 4 consultants, doing both cancer and benign work. The new consultant Mr Kotb has taken over the cancer work from Ernst Ahiaku who has reduced his sessions, and also taken back the operating list used by Mr Srinivasan from YGC. The other consultant Mr Thankavelu does renal work.

Most of the prostates are done by TURP with a typical post-operative stay of 2 days because there is no laser available at YG. There is a diagnostics unit where flexible cystoscopies and urodynamics are done, Trans-Rectal Ultra Sound (TRUS )is done in Endoscopics and Extracorporeal shock wave lithotripsy (ESWL) has gone but is planned to return.

There is no urology ward now, the Department has access to up to 6 beds on Tegid ward but these beds are not ring fenced. Day surgery is also done from Tudno ward. The lack of a urology ward has meant the nurses are now more generalised and are not necessarily good at post op bladder washouts. The specialist trained nurses were excellent at this but all of these well trained nurses have left to go into the community. It is interesting that we expect our surgeons to become more specialised but our nurses more generalised.

As far as catheters are concerned, insertion can be undertaken anywhere in the hospital(although patients are not always examined rectally) or recorded on the catheter insertion bundle.

YG – Action Points

1. Ring fenced beds 2. More operating sessions although waiting initiatives on a Saturday are starting 3. More specialist nurses to do the cancer work and replace Registrars 4. Additional District Nursing training in catheter care. Currently catheters are inappropriately managed in the district. Nurses won’t change catheters if they don’t know the patient. This may be a confidence issue. In the daytime catheter problems go to Urology department and at night they go to ED 5. There is a new template guided biopsy facility at Llandudno Hospital (bought by charitable donation for £60,000). It needs to be shared with YG as there are up to 49 patients waiting up to 7 months for template biopsy of prostate 6. Patients with an indwelling catheter should be rapidly identified, treated as priority and admitted within 3 months. Routine TURP wait is currently1 year because cancer cases take priority

Appendix 6

Meeting with Jayne Sankey - East Community Services 22nd June 2016

The purpose of this visit by Jackie Allen and Christine Evans was to ascertain what the District Nursing Services were in the east for the patients with indwelling catheters - especially male patients.

Jayne Sankey is the Lead Nurse in the East. This area has had a catheter pathway with a catheter register for many years. The register states clearly the reason for fitting the catheter. East Community Services have 598 patients with indwelling catheters both male and female.

District Nurses provide a full service for catheter patients in this area (if they are informed about the patient) and will change and washout blocked catheters. The Out of Hours Service will also provide this care to patients known to the District Nursing Service.

With the help of the Wrexham Maelor ED consultant, Dr Hywel Hughes, the number of patients going ED with a blocked catheter has been reduced from three to one per week. The situation in West and Central is very different and we strongly suggest that all areas adopt this best practice.

Action Points

 The doctors in ED and the wards need re-education and supervision to make sure the Catheter Insertion bundle sheet is filled in and sent to the DN /GP.  There is some IT support needed to improve the usability of the Register  The District Nurse Liaison Team should continue to go on daily ward rounds to pick up catheterised patients.  Patients are going to ED and not the Surgical Admissions Unit because there are rarely beds available in SAU  More work should be done to identify the reasons for long term male catheterisation  Discharge letter summary for the GP needs to go home with the patient  Patients awaiting surgery need identified and “known” to the Urology Department and others providing care. Admission for surgery for patients with catheters should be expedited. An increase in the numbers of Consultant Urologist, combined with waiting list initiatives should make this possible.

1 B17.20b White Paper Board Response BCUHB V1.0 Final Submitted 29 September 2017.docx

The BCUHB response to the White Paper Consultation Document: Services Fit for the Future - Quality and Governance in Health and Care in Wales.

Effective Governance 1.1 Board Membership and Composition

The Welsh Government believes that the Boards of both Health Boards and NHS Trusts should share some core key principles which are outlined including delivering in partnership to deliver person centred care and a strong governance framework to enable the Board to work effectively and meet its responsibilities.

All Boards should have Vice Chairs in order to support focussed and skilled leadership.

The Welsh Government also believes that Ministers should have the authority to appoint additional Board members on time limited appointments if an NHS Health Board/Trust is under performing or under escalation procedures in accordance with the NHS Wales Escalation and Intervention arrangements.

The Welsh Government believes that Board Executive Officer membership for local health boards should probably include some key positions which are consistent across local health boards but also allow some flexibility to appoint based on remit and priorities.

Do you agree with these proposals?

What further issues would you want us to take into account in firming up these proposals?

Health Board Response

The Board agrees that there should be shared key principles for Health Boards and Trusts, as outlined in the White Paper. This would provide greater coherence between NHS bodies in the pursuit of improving health and health services across Wales.

The Board supports the formal appointment of Vice-Chairs to Trusts. This model has underpinned good governance arrangements in Local Health Boards to date.

The Board supports the proposal that the Cabinet Secretary for Health, Well-being and Sport should have the authority to appoint additional Board members under the circumstances described. The Board must have the means and skills to lead the organisation so that decision making is effective and the right outcomes are delivered for patients. Building upon the positive impact made by specialist advisers appointed by Welsh Government when the Health Board was placed in special measures, additional skills and capacity focussed on key areas is seen as a positive intervention.

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In respect of the composition of boards, BCUHB believes that generally, there should be consistency in some key positions for Executive Officers but also allowing some local flexibility to appoint based on local priorities. Regulations should permit the Board to determine the final Executive structure that best meets its own requirements. The principle of having a greater number of Independent Members (IMs) compared to Executives should be maintained, as the challenge and holding to account role of Independent Members is a cornerstone of good governance. Boards should have greater flexibility than currently prescribed to determine the best fit / skills sets when appointing IMs. In respect of succession planning and board stability, IM appointments should be staggered to avoid significant numbers of tenures ending at once.

The Health Board believes that it is important to preserve the staff voice at Board level as a non-officer member with the same legal duties and responsibilities as other board members. Having the employee voice within the formal governance structure brings a different perspective and information set that is shown to improve the quality of Board decisions.

1.2 Board Secretary

In order to deliver on the key principles outlined the Welsh Government believes that the role of Board Secretary should be placed on a statutory basis and have statutory protection to allow the role to be independent with safeguards in place to challenge the Chief Executive of an NHS organisation or the Board more widely.

Do you agree with these proposals?

What further issues would you want us to take into account in firming up these proposals?

Health Board Response

There is increasing recognition that robust and effective Corporate Governance is integral to high-performing organisations. Since the inception of Health Boards in 2009, the role of the Board Secretary as Corporate Governance Adviser has evolved and matured.

The proposal to provide greater profile and clarity is welcomed, to assist in ensuring the role is perceived at an appropriately senior level and be seen as a trusted position providing independent advice to the Chair, Chief Executive and Board. This will also enable the role to be in a position to effectively challenge and advise Boards (Executive and Independent), as necessary.

While the role of Board Secretaries is stipulated in Standing Orders, and a model Job Description has been produced by the Welsh Government, we would recommend that there is no deviation from the model to ensure the protection of the independence of the Board Secretary role and eliminate opportunity for conflicts of interest. It is essential that operational management is not allowed to encroach on the stipulated accountabilities of the Board Secretary to ensure potential conflicts are avoided.

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2. Duties to Promote Cultural Change

2.1 Duty of Quality for the Population of Wales

The Welsh Government believes that the duty of quality should be updated and enhanced to better reflect our integrated system. This duty should be sufficiently wide in scope to facilitate the needs of the population of Wales to facilitate and enable collaborative, regional and all-Wales solutions to service design and delivery NHS bodies should also be placed under a reciprocal duty with local authorities to co-operate and work in partnership to improve the quality of services provided.

Welsh Government also believes that strengthening the existing planning duty will make sure health boards work together on the needs of the population of Wales in the planning and delivery of quality healthcare services.

Do you agree with these proposals?

What further issues would you want us to take into account in firming up these proposals?

Health Board Response

If we are to ensure that we put the needs of people at the centre of our plans and services, then a duty of quality is fundamental and integral to the ways in which we work with organisations delivering health and care services. However, BCUHB does not believe that there is a need for further legislation as regards a duty of quality for the integrated system, because it is considered that this is already dealt with adequately by the requirements for closer collaborative working between health and other public services set out in the Social Services and Well-being (Wales) Act 2014 and the Well-being of Future Generations (Wales) Act 2015. Additional legal duties could create unintended governance challenges to system wide working, inhibiting partnerships from working effectively at scale and pace.

The Health Board is supportive of the emerging ways of working between NHS bodies as part of Regional Planning Boards. However, particular consideration needs to be given to the work undertaken by the Mid Wales Health Collaborative. We recognise the benefits of this wider partnership but seek to develop mechanisms that are more streamlined and focused on improving NHS delivery.

2.2 Duty of Candour

The Welsh Government believes that the development of a statutory duty of candour across health and social services in Wales would consolidate existing duties and be in the interests of a person centred system.

Do you support this proposal?

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What further issues would you want us to take into account in firming up this proposal?

Health Board Response

BCUHB is committed to ensuring that honesty and transparency are the norm. We support the introduction of a statutory duty of candour to strengthen the expectation for openness that currently exists. The principles of openness and candour must extend beyond the current requirements set out in Putting Things Right regulations, to include the design of care plans as well as the delivery of health care, building upon the duty of candour already held by registered health professions. Introducing a legal requirement would enable inspection to take place and this commitment to be tested. However, this would be reliant upon clarification as to what would count as evidence of being open and transparent. Any such duty introduced within Wales will need to be aligned to the regulations introduced within NHS England in 2014, in regard to the thresholds in place to measure the consistency of standards. This will be important to ensure there is a common basis for proportionate regulatory action if required.

3. Person-Centred Health and Care

3.1 Setting and Meeting Common Standards

The Welsh Government believes there should be a common set of high level standards applied to health and social care and that the standards should apply regardless of the location of care.

Do you support this proposal?

What further issues would you want us to take into account in firming up this proposal?

Health Board Response

BCUHB supports the concept of having in place consistent standards, which should be integrated with social care, the third sector and the independent sector. This common set of requirements should not only set out a clear description of safe and acceptable quality but should also be used as the framework for continuous improvement so that a measureable rise in achievement can be tracked. Associated monitoring arrangements would need to be similarly joined up.

3.2 Joint Investigation of Health and Social Care Complaints

The Welsh Government believes that requiring different organisations to work together to investigate complaints will make it easier for people to complain when their complaint is about both health and social services. We also believe it will encourage organisations to learn lessons to improve their services. Do you support this proposal?

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What further issues would you want us to take into account in firming up this proposal?

Health Board Response The Health Board believes that the complaints process should be integrated. Statutory guidance should set out a transparent joint complaints process for service users who wish to complain about health and social care, where their package of care includes both. Cross border cases would also benefit from better transparency and communication systems. All opportunities to support and encourage organisations to learn lessons to improve their services would be embraced.

4. Effective Citizen Voice, Co-production and Clear Inspection

4.1 Representing the Citizen in Health and Social Care

The Welsh Government believes that local health and social care organisations should be working with the public to co-design and co-create services and that the way they do this needs to be independently monitored.

We propose replacing the current statutory CHCs and their functions with a new national arrangement to represent the citizen voice in health and social care, to advise and provide independent assurance. The new body will work alongside Healthcare Inspectorate Wales and Care and Social Services Inspectorate Wales and have autonomy to decide how it will operate at local level.

Do you support this proposal?

Health Board Response Efforts to achieve effective and meaningful patient and public involvement in healthcare care have been evolving and maturing. Locally, the Health Board has developed mechanisms for robust and systematic engagement and has begun, involving local people in co-designing and co-creating services so that the care is more patient centred.

Scrutiny of these arrangements is already in place via a number of existing mechanisms including Local Authorities, Voluntary Groups and Welsh Government as well as the CHC. The CHC’s function in providing an advocacy service for patients across North Wales, its input into shaping and improving services and its constructive challenge has been very effective in representing the population served by the Health Board. The Health Board will of course support any arrangement that can be more effective than our current arrangements in representing the patient’s voice.

4.2 Co-producing Plans and Services with Citizens.

The Welsh Government believes that introducing an independent mechanism to provide clinical advice on substantial service change decisions, with advice from the proposed new citizen voice body, will encourage continuous engagement and increase the pace of strategic change through enabling a

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more evidence-based, transparent process and a more directive and guiding role on the part of Welsh Government.

Do you agree with this proposal?

What further issues would you want us to take into account in firming up this proposal?

Health Board Response BCUHB is supportive of the proposals to make it possible for health boards to make more decisions locally with access to and support from, “an independent mechanism” providing clinical advice on substantial service change decisions.

4.3 Inspection and Regulation and Single Body

The Welsh Government believes that ensuring a clearer underpinning legislative framework for HIW will help to foster closer integration and joint working with CSSIW and at the very least this should be taken forward.

What do you think of this proposal?

Are there specific issues you would want us to take into account in developing these proposals further?

However we also believe there could be merit in considering a new body – for example, a Welsh Government Sponsored Body – to provide more independence in regulation and inspection and citizen voice.

Would you support such an idea?

What issues should we take into account if this idea were to be developed further?

Health Board Response

The Health Board agrees that there should be underpinning legislation for integrated inspection and regulation, leading to the development of a single regulator for health and social care, which should be independent of Welsh Government. Regulators need to be robust and have appropriate resourcing so that they can maintain their independence and have clear boundaries so that the public can have confidence in the Regulator. However, caution may need to be exercised with regard to connecting within a single organisation those responsible for regulation with those responsible for citizen engagement and thereby elements of co-production. This could potentially create conflict in situations where regulators were commenting on a process that its own organisation had already had a part in.

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10 B17/21 Complaints Management : Update on Performance - Mrs Gill Harris 1 B17.21a Complaints Management coversheet.docx

Board to Board

16.11.17

To improve health and provide excellent care

Title: Complaints Management : Update on Performance

Author: Mrs Barbara Jackson, Deputy Director Corporate Services

Responsible Mrs Gill Harris, Executive Director Corporate Services Director: Public or In Public Committee Strategic Goals 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the √ NHS’ best 4. Respect individuals and maintain dignity in care √ 5. Listen to and learn from the experiences of individuals √ 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel.

Approval / Monitoring of Concerns performance is via the Quality and Safety Scrutiny Route Group and the Quality, Safety and Experience Committee

Purpose: To provide an update regarding the performance in the management of complaints

Significant issues To truly eradicate the ‘backlog’ and to maximise the opportunity of and risks avoidable overdue complaints not reoccurring, the Health Board need to consider the management of all open complaints, whether overdue or not; resolve historic cases and manage newly received complaints within the national timescales.

In May 2017 Executive responsibility for the management of Concerns (Complaints, Claims and Incidents) under the ‘Putting Things Right’ guidance, changed to the Executive Director of Nursing and Midwifery. Concerted efforts have continued to be made to improve complaints management and from September 11th 2017 a managed plan was put in place to significantly reduce the number overdue and at the same time improve the delivery of the 30 day target.

Special Measures The management of Concerns forms part of Special Measures Improvement monitoring

Framework Theme/ Expectation addressed by this paper Equality Impact Update report Assessment Recommendation/ The Health Board and Community Health Council Board are asked to Action required note the progress reported

Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

1 B17.21b Complaints Management amended 7.11.17.docx

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Betsi Cadwaladr University Health Board Betsi Cadwaladr Community Health Council Board to Board 16.11.17

Complaints Management; update on performance Introduction To eradicate the ‘backlog’ and to maximise the opportunity of avoidable overdue complaints not reoccurring, the Health Board need to consider the management of all open complaints, whether overdue or not; resolve historic cases and manage newly received complaints within the national timescales. In May 2017 Executive responsibility for the management of Concerns (Complaints, Claims and Incidents) under the ‘Putting Things Right’ guidance, changed to the Executive Director of Nursing and Midwifery. Concerted efforts have continued to be made to improve complaints management and from September 11th 2017 a managed plan was put in place to significantly reduce the number overdue and at the same time improve the delivery of the 30 day target. Planned approach ‘Backlog’ Each geographical area (acute and community) are working together as a team, supported by the Corporate Concerns Team to resolve all complaints within the defined backlog. In addition each team are managing their own ‘new’ complaints within the 30 working day target to prevent the recurrence of a backlog. Each geographical area has submitted local plans on how they will manage their complaints backlog. These plans will be managed by the Division/Areas to deliver the required trajectories. Separate plans have been agreed with Mental Health and Women’s divisions as these divisions have specific plans under the Special Measures monitoring. Management of new complaints To prevent a future ‘backlog’ developing whist the focus is on the clearance of the existing ‘backlog’, all complaints received moving forward will be managed within the national target. Where a complaint graded at a level 4/5 the acknowledgement letter reflects that the 30 day target is unlikely to be delivered but should identify an end point the complainant can expect and should then be managed to deliver that end date. The letter currently includes the statement: ‘We will aim to let you have a response as soon as possible. However, our initial assessment of the serious issues raised within your concern indicate that it requires an indepth investigation which may take up to six months to complete. Once the investigation has commenced, we will keep you informed of progress.’

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All grade 5 complaints continue at present to be managed by the relevant corporate team and Executive oversight. All other complaints are coordinated by the relevant division allocating the complaints to the relevant senior manager for the location the complaint relates to e.g. sister of ward 1 or DN for Conwy team. Each division is determining who is best placed to manage each complaint. The Executive Nurse Director is continuing to take forward the implementation of the Being Open policy. The policy requires a Being Open lead be identified for each serious incident or complaint, who will maintain an ongoing relationship with the patient and/or their carers/family. In addition to, and building on this there is an intention to develop this further to ensure there is a clear process in place to identify a ‘buddy’ for the complainant in a serious or complex complaint to provide them with a single point of contact who will proactively communicate with them to keep them fully informed and supported. For complaints with no allegation of harm – these are from September 11th 2017 logged on receipt by the corporate teams as an On the Spot (OTS) and passed to the relevant division for action. The divisional staff contact the complainant within 2 days of receiving the complaint and attempt to resolve the issues to the complainant’s satisfaction. Should this be successful the complaint will be closed as an OTS. Should a written response be required the staff member can write a letter confirming the actions taken as OTS are not considered under PTR. Should the complainant remain dissatisfied or request the complaint be managed formally, the complaint should be managed under PTR and appropriately investigated – concise or comprehensive in line with PTR1a. The Corporate Concerns Team must be notified immediately to ensure a prompt acknowledgement letter is sent. Where a returned OTS is graded as a grade 1 these will be responded to be the Corporate Concerns Team. Staff must be aware of patient confidentiality and data protection issues when the complainant is a third party speaking for the patient. Consent from the patient should be sought if necessary. For complaints with an allegation of harm; these are investigated as a formal complaint – concise or comprehensive investigation in line with PTR1a. The complainant should still be contacted by the divisional staff within 2 working days to clarify the issues identified from the letter and offer a meeting to resolve the issues wherever possible. This may be done by the Corporate Concerns Team (for local determination). A meeting was held on October 25th 2017 with the CHC Complaints Advocates across North Wales to describe and discuss the revised approach. It was a useful discussion and the approach was well received.

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Trajectory for delivery The division have each agreed trajectories that deliver the resolution of the overdue complaints with 8 weeks. This work commenced on September 15th 2017. In addition the Health Board has secured an additional resource that may allow the management of complaints to be accelerated by up to 2 weeks. Progress to date Backlog The three areas are dedicated to delivering both their action plans and their agreed set trajectories. Additional monitoring mechanisms are in place to monitor all overdue complaints. There is a downward trend since the beginning of September for the total number of complaints open and the total complaints overdue (see table 1 below). All trajectories aim to clear overdue complaints by the beginning of November 2017. Alternative arrangements for new complaints are aimed at managing new complaints within the 30 day target, however some complex complaints by nature will take more than 30 days to respond to. The Putting Things Right regulations allows for this but requires the complainant is kept informed and ideally provided with an alternative end date. Table 1

The divisions recognise the need to increase the numbers being resolved to be in a position to deliver no avoidable overdue concerns by the end of November. NB: an unavoidable overdue complaint would be defined as a complex complaint (normally graded as a 4/5) whereby the complainant has been informed resolution would not be within the 30 days – in these cases the regulation allow up to a maximum of 6 months.

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New Complaints In terms of the revised arrangements for managing new complaints; the initial focus has been on resolving all complaints were there is no allegation of harm as On the Spots (OTS). This is rolling out steadily and a significant number of complaints being managed this way have been resolved on this basis and are not converting to formal. There is a cultural and practice change required to make this routine and embed this into normal practice – this has begun well and is being supported by the senior nursing teams. The Corporate Concerns team is offering support which includes ensuring all complaints are logged and closed once resolved. It should be noted this approach may affect the performance against the 2 day acknowledgement of formal complaints as this approach beds in. Monitoring Performance is monitored via the local management structures. Weekly performance is reported to the Executive Director of Nursing and Midwifery, and monthly to the QSG. Weekly data continues to be provided, by the Corporate Team, to all division and to the divisional quality and safety groups. The quality of the responses and implementation of lessons learnt will be the responsibility of the local management/governance structures. Action plans for all grade 5 complaints will be provided to the QSG with updates as appropriate.