Bundle Health Board - public 16 November 2017
1 OPENING BUSINESS AND EFFECTIVE GOVERNANCE 1.1 10:00 - 17.246 Chairman's Introductory Remarks - Dr Peter Higson 1.2 10:02 - 17.247 Annual Report of the Director of Public Health 2016-17 - Miss Teresa Owen Recommendation: The Board is asked to discuss the Annual Report and note the content. 17.247 Director of PH Annual report coversheet.docx 17.247 DPH Report ENGLISH.pdf 1.3 10:17 - 17.248 Special Measures Task & Finish Group Chair's Assurance Report 12.10.17 - Mr Gary Doherty Recommendation: The Board is asked to note the report. 17.248 Chair's Assurance Report SMIF TF 12.10.17 V1.0.docx 1.4 10:22 - 17.249 Apologies for Absence 1.5 10:24 - 17.250 Declarations of Interest 1.6 10:26 - 17.251 Draft Minutes of the Health Board Meeting held on 19.10.17 for accuracy and review of Summary Action Log 17.251a Minutes Health Board 19.10.17 Public V0.03.doc 17.251b Summary Action Log Public_v109 2.11.17.doc 2 ITEMS FOR CONSENT 2.1 10:36 - 17.252 Committee and Advisory Group Chair's Assurance Reports Quality, Safety & Experience Committee 10.10.17 (Ms J Dean) Finance & Performance Committee 24.10.17 (Mrs M W Jones) Financial Recovery Group 12.10.17 & 23.10.17 (Dr P Higson) Remuneration & Terms of Service Committee 16.10.17 (Dr P Higson)
Recommendation: The Board is asked to note the reports. 17.252a Chair's Assurance Report QSE 10.10.17 V1.0.docx 17.252b Chair's Assurance Report FPC 24.10.17 v1.0.doc 17.252c Chair's Assurance Report FRG 12.10.17.doc 17.252d Chair's Assurance Report FRG 23.10 17.doc 17.252e Chair's Assurance Report R&TS 16.10.17.doc 2.2 10:56 - 17.253 Mental Health Act 1983 as amended by the Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions 2008. Update of Register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales) - Mr Gary Doherty Recommendation: The Board is asked to ratify the attached list of additions and removals to the All Wales Register of Section 12(2) Approved Doctors for Wales and the All Wales Register of Approved Clinicians. 17.253 Approved Clinicians Section 12.docx 3 FOR DISCUSSION 3.1 17.254 Performance 3.1.1 10:58 - 17.254.1 Integrated Quality & Performance Report - Ms Morag Olsen Recommendation: The Board is asked to note the report. 17.254.1a IQPR Coversheet Board - September 2017.docx 17.254.1b IQPR.pdf 3.1.2 11:18 - 17.254.2 Waiting Time Reduction Plan 2017-18: Ms Morag Olsen Recommendation: The Board is asked to note the report. 17.254.2a Waiting Time Reduction Plan coversheet 31.10.17 at 1748.docx 17.254.2b Waiting time reduction plan 9.11.17 at 1410.docx 3.1.3 11:38 - 17.254.3 Unscheduled Care Update Q3/Q4 2017-18 : Ms Morag Olsen Recommendation: The Board are asked to note the content of the paper. 17.254.3 Unscheduled Care coversheet as at 6.11.17 1237.docx 17.254.3 Unscheduled Care Update 9.11.17 at 1423.docx 3.2 11:58 - 17.255 Finance Report - Mr Russ Favager Recommendation: The Board are asked to note the report.
17.255 Finance report Month 6.docx 3.3 12:18 - 17.256 Mental Health Tawel Fan Quarterly Update - Mr Martin Jones Recommendations: The Board is asked to: 1.Note the progress of both the HASCAS investigation and the Ockenden review of Governance. 2.Note the forthcoming timescales for the products of the investigation and governance review. 17.256 Tawel Fan final received 7.11.17 at 1708.docx 5 12:38 - FOR INFORMATION 5.1 17.257 Information circulated since the last Board meeting 23.10.17 Primary Care Update 5.2 17.258 Summary of In Committee Board business to be reported in public Recommendation: The Board is asked to note the report. 17.258 In committee items reported in public.docx 5.3 17.259 Vascular Update - Dr Evan Moore Recommendation: The Board is asked to note the report. 17.259 Vascular Update_amended 7.11.17.docx 5.4 17.260 Welsh Health Specialised Services Committee - Joint Committee Approved Minutes of Meeting Held 25.7.17 Recommendation: The Board is asked to note the report. 17.260 WHSSC Joint Committee Approved Minutes 25.7.17.pdf 5.5 17.261 Welsh Health Specialised Committee - Joint Committee Core Briefing Meeting Held 26.9.17 Recommendation: The Board is asked to note the report. 17.261 WHSCC Joint Committee Core Briefing 26.9.17.pdf 5.6 17.262 Mid Wales Healthcare Collaborative Progress Report October 2017 : Mr Geoff Lang Recommendation: The Board is asked to note the report. 17.262 MWHC Report Oct 2017 v2 24 10 17.pdf 6 CLOSING BUSINESS 6.1 17.263 Date of Next Meeting 14.12.17 @ 10.00am in Porth Eirias, Colwyn Bay 6.2 17.264 Committee Meetings to be held in public before the next Board Meeting Finance & Performance Committee 21.11.17; Audit Committee 23.11.17; Charitable Funds Committee 4.12.17; Quality, Safety & Experience Committee 5.12.17. 7 LUNCH BREAK - ** Information Stand and Launch for International Health Group Week **
1.2 17.247 Annual Report of the Director of Public Health 2016-17 - Miss Teresa Owen 1 17.247 Director of PH Annual report coversheet.docx
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Health Board
16.11.17
To improve health and provide excellent care
Title: Annual Report of the Director of Public Health: 2017
Author: Teresa Owen, Executive Director of Public Health John Lucy, Consultant in Public Health
Responsible Teresa Owen, Executive Director of Public Health 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 X inequalities 2. Work in partnership to design and deliver more care X 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 X 6. Use resources wisely, transforming services through x innovation and research 7. Support, train and develop our staff to excel.
Approval / Scrutiny Directors of Public Health annually present an independent report on Route the state of the population’s health, the threats to and opportunities for its improvement, and the current challenges facing organisations and communities in staying healthy, happy and well.
This is a new 2017 report, following the Board meeting and will be shared with partners.
Purpose: This year’s report (the first for Teresa Owen, in her role as Executive Director of Public Health (DPH) for Betsi Cadwaladr University Health Board) sets out the contribution of primary care to achieving public health outcomes, and highlights examples of good practice in North Wales.
Significant issues The Boards attention is drawn to the contribution of primary care in and risks improving health, and the importance of partnerships between primary care, other health care services and partners in local authority and
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third sectors. Special Measures • Leadership Improvement • Strategic & service planning Framework Theme/ Expectation • Primary care addressed by this paper Equality Impact An EqIA has not been undertaken on this report. Assessment The report highlights a range of actions to reduce inequalities.
Recommendation/ The Board is asked to discuss the Annual Report and note the content. Action required by the Board Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
Board Coversheet v9.0 June 2017
1 17.247 DPH Report ENGLISH.pdf
Improving public health through primary care Betsi Cadwaladr University Health Board Annual Report of the Director of Public Health Betsi Cadwa2017ladr University Health Board
Annual Report of the Director of Public Health
Health, wellbeing and Primary care
2017 Directors of Public Health in Wales traditionally present an annual report on the state of the population’s health. These have a long tradition going back decades, and I am delighted to add my contribution to this important practice in North Wales, with this, my first report as Executive Director of Public Health for Betsi Cadwaladr University Health Board. Preface Welcome to the 2017 Annual Public Health Report for North Wales.
This year, I have chosen to focus the ‘the place where someone is comfortable Importantly for us in North Wales, we As with all Directors Of Public Health reports, report on Primary Care and its unique role and feels right’. Professor Snowden uses also know that good primary care activity a large number of people have contributed in improving health and wellbeing, and the term in his work on complex systems helps tackle inequalities as our teams are to this publication and I am extremely addressing health inequalities. and decision making based on in contact with many vulnerable and hard grateful to all. In particular I am very grateful environmental conditions. It is interesting pressed individuals, and the teams act as to John Lucy for his work in bringing this I reflect that this year, 2017, is a time of work because we all live in different patient advocates and provide key links report to publication, and to Heather well-being planning in Wales, as new environments and groups, and the fact is, to important services, such as welfare and Thomas, Jo Charles and Rebecca Masters as legislation places duties on organisations to we need to build healthier communities, benefits advice. the editorial team; as well as the rest of the Below: work together with the public to promote to support resilience, and promote positive Public Health Team and partners for their Teresa Ann Owen, well-being, improve services and put This report looks at nine important public Executive Director health and wellbeing. contributions to the report. of Public Health individuals at the centre of their care. In health priority areas, where the primary addition, it’s an exciting year for those of us For me, primary care has a pivotal role care role is central. We’ve tried to outline interested in health and well-being as the in supporting this well-being agenda. why these topics are so important, some of Public Health (Wales) Act 2017 now makes Admittedly, this can be challenging given the work currently underway, and highlight Wales a leader in public health work. the significant issues facing our primary opportunities to do more on this important care colleagues, but they have a central role agenda alongside our patients and public. This is also the year when I’ve been fortunate as they are placed in the heart of our local to come back home to work in North Wales. communities and they work incredibly hard I hope you find the report enjoyable and Doing so, I’ve reflected lots on the work of to change people’s lives for the better. They interesting. As health is everyone’s business, I Professor Snowden who has written about treat the whole person and provide high do hope this report prompts further discussions ‘Cynefin’. This is a Welsh word which is quality care and they encourage people to and I very much welcome feedback. Please similar in meaning to habitat and refers to make healthier choices. do get in touch if you have any comments. Public Health Outcomes to frame the actions within the national strategy. Clusters have the board needs to take to improve health been encouraged to develop their own overall. The actions in this report support approaches to delivering transformation Introduction this approach. in primary care services. To date clusters Primary care clusters are an important have largely focussed around GP services, This report is designed to help with the process of improving health and element by which primary care is being and the contribution of other primary care contractors is still to be fully harnessed. transforming care by setting out clearly the contribution of primary care supported to deliver on the ambitions to improving health and reducing inequalities. In addition to informing the Betsi Cadwaladr University Health Board strategy, this report is intended to support planning within the health board primary care Public Health priorities in Primary care areas, cluster planning processes and also individual practice plans. 5. Mental Health
The report contains There is growing acceptance of the importance of Primary care in North Wales faces similar social care services too, and some primary resilience as a protective factor for mental health challenges to the rest of Wales and the UK. care teams include social care professionals. the following sections: and wellbeing. Primary care is well placed to connect The population is ageing, and in North Wales people with social support that can do this. Previous Public Health reports [English the projections are for a rise in the numbers version / Welsh version] set out the 1. Tackling health inequalities 6. Screening of older people, and at the same time a fall priorities for North Wales and rationale Poor health affects deprived areas disproportionately Primary care has a central role in promoting uptake of in the numbers of younger people. The rise for action. This report highlights the and has a significant impact on workloads for primary screening programmes. Coverage of programmes is in numbers will mean increased demand public health priorities for primary care care serving these communities. Tackling the root variable, but there are examples of good practice that for health care services. Older people are that can improve population health causes is key, and primary care is well placed for this. could help if shared across North Wales. increasingly being diagnosed with more than and also reduce demand on primary one long term condition such as diabetes 2. Smoking 7. Adverse Childhood Experiences care services. and dementia. The increasing workload in Trends in smoking are downwards, bringing with it Adverse childhood experiences (ACE’s) is an approach benefits to health in North Wales. General Practices primary care is placing strain on services, and The national strategy ‘Our Plan for a that describes the link between ACE’s and poor health and community pharmacies have played an important stimulates questions about how demand Primary Care service up to 2018’ set the and social outcomes in adult life. Awareness of the part in this, but more effort is needed particularly in can be better managed, and patients more broad aims of link is key for health and social care staff, as it can be effectively supported to stay well. deprived communities where rates remain high. the trigger for helping patients. • Developing a more ‘social’ model of 3. Obesity 8. Early Years- the best start in life Primary care is a broad concept which health, addressing root causes of ill health Obesity rates among adults are rising, accompanied includes a range of professionals who The experience of a child from conception to the • Developing a preventive model of care by rising rates of the linked chronic conditions. provide services, including age of two has a decisive impact on health in later close to home Primary care can effectively support people who are life, and giving every child the best start is a Welsh • General Practitioners • Working closely with partner agencies and overweight through simple prompting to behaviour government priority. Primary care has central role in • General Dental Practitioners voluntary bodies to coordinate care change, and signposting to local community activities. delivering the support needed to effectively support parents and children. • Nursing staff- in practices and in BCUHB is currently developing its own longer 4. Vaccination and Immunisation community nurse roles term strategy ‘Living Healthier, Staying Well’. Immunisation is a cost effective success story which 9. Social prescribing • Optometrists The contents of this report will inform the prevents many deaths and much illness. Coverage Social prescribing provides an effective way of new strategy, in particular the sections on varies across communities in North Wales. In some supporting people with a range of issues that might • Community Pharmacists Improving Health and Reducing Inequalities, areas levels are low, and ensuring all communities otherwise need a clinical service. As this area of As patients very often have social needs, and the Care Closer to Home. ‘Living have the minimum coverage for herd immunity is activity grows, primary care is well placed to connect primary care staff have to work closely with Healthier, Staying Well’ uses the Wales a priority. patients with schemes. Section 1 Title Local case study Inequalities 1 ‘Healthy Prestatyn & Rhuddlan Iach’ is an innovative NHS primary care service that is aiming to demonstrate how a different design of primary care service can better support the community it serves. It operates in an area of disadvantage, and provides an excellent example of how innovative use of primary care can enable patients to take control of their Smoking own health and also reduce demand. GPs are joined by other health professionals - Nurse 2 Practitioners, Occupational Therapists and Pharmacists, to form five multi-disciplinary ‘Key Teams’ that each take on responsibility for caring for a specific group of patients. They Inequalities offer same day services that utilises telephone assessments to ensure patients are seen as soon as possible. They also offer appointments by Skype if clinically appropriate. Their to make in this wider agenda- for instance through Why is this important? services reach far beyond those of the GP, and include a wide range of practice nurses, Obesity social prescribing schemes. There is also action health care assistants, phlebotomists alongside many other specialists. 3
primary care can take in GP practices or pharmacies The causes of health inequalities are well to target effective interventions within communities understood, and the links with income and of greatest need. Vaccination poverty are well documented. We know that What can Primary Care contribute? and those living in our poorest areas experience Primary care offers many complex public Immunisation significantly worse health throughout their lives Patient story – Beryl health interventions on a daily basis 4 than those living in the more affluent areas of – whether they are a GP supporting Recommendations: Beryl is 76 and used to attend the surgery almost North Wales. There is also a ten year gap in a patient to quit smoking, a practice Primary care teams can help every week with minor ailments. Beryl always life expectancy, which has not improved for a nurse undertaking a cervical screen or reduce health inequalities by number of years. Other factors can contribute asked Sian, the nurse practitioner, for a bandage, an ophthalmologist identifying risks for Mental to health inequalities including ethnicity even when she did not require one. Sian felt glaucoma during a routine eye exam. • Actively promoting and Health that things with Beryl didn’t seem quite right and encouraging uptake of smoking 5 and disability. Living in rural areas can drive Primary care has a role to enable patients inequalities, with the increased burden of travel thought there could be something more to this. to take responsibility for their own cessation services – research shows and living costs affecting poorer households. She decided to discuss Beryl’s care with the wider health and change lifestyle behaviours that people are four times more team, including Lesley, the team occupational that can cause them harm. Primary care likely to quit when using such The unequal burden of disease has a significant impact therapist. Lesley met with Beryl and uncovered services rather than going it alone contributes to reducing health inequalities Screening on primary care workload, as inequalities mean that the real problem. Beryl was lonely, but had noticed in a number of ways: • Routinely promoting healthy 6 people on lower incomes develop chronic diseases that if she wore a bandage then her neighbours lifestyle behaviours with patients earlier in life and in greater numbers. Those with the were more likely to stop and talk to her. Lesley • Supporting people to make improvements greatest health need are often the least able to access to their lifestyles, particularly in relation • Developing links with local third asked Beryl about her interests, and together they Adverse health care – whether it be having access to transport sector organisations that can decided that the local craft group would be a to stopping smoking and reducing their Childhood provide non-medical support such to get to a GP appointment, or having access to the good place for Beryl to get out and meet others. alcohol intake Experiences as welfare advice, walking clubs internet to check the local late night pharmacy opening With Lesley’s support, Beryl found that she loved 7 • Promoting vaccine uptake – we hours urgently during the weekend. or luncheon clubs to reduce social painting, and made new friends. Beryl and Lesley know that those living in our poorer isolation and increase resilience. Reducing health inequalities requires action on still catch up every now and again to make sure communities are less likely to be fully up the root causes- employment, education, poor that Beryl is ok, but Beryl is much happier and to date with their immunisations her visits regarding minor ailments have reduced. Early housing, effects of gambling and more. Unless we • Supporting patients to take control of Beryl’s story highlights how more effective use of Years do something to address the root causes of health their own health – for example closer 8 the wider primary care team can empower patients inequalities, we won’t reduce the health inequalities working with occupational therapy, to find their own solutions to their problems. gap that exists locally. Primary care has a contribution pharmacy, or the third sector.
Social prescribing 9 Local case study Inequalities 1 Clarence Medical Centre in Rhyl participated in a pilot study last year aimed at exploring the effectiveness of recruiting smokers into specialist smoking cessation services.
A personal invitation letter from a senior partner was sent to all smokers aged between 18 and 50 (excluding those with a chronic condition) to attend a smoking cessation Smoking appointment with a Stop Smoking Wales (SSW) advisor. At the appointment smokers 2 could self refer to SSW or attend the local Pharmacy Level 3 service. A small number of patients (5%) were prompted by the letter to engage with the specialist smoking cessation services. Although small in number, these patients were highly motivated, and their quit rate was 70%. This very high quit rate suggests the intervention helps nudge Obesity those who are ready to make this change into action. 3
What can Primary Care contribute? Vaccination Smoking and Raising awareness and promoting • Advise the smoker to quit Immunisation choice amongst their population: 4 Why is this important? Brief smoking cessation intervention in primary care • Act – refer motivated smokers to NHS is effective, with reported quit rates of between 2% • Promote Help Me Quit free phone and smoking cessation services via Help Me
and 3%. However, for maximum impact primary website by displaying posters and leaflets in Quit using existing referral routes or via Tobacco use remains one of our most care teams should offer advice, encouragement and the waiting areas and on TV monitor screens professional referral page on website significant public health challenges and is a Mental support, including referral to NHS smoking cessation major contributor to health inequalities. In • Provide ‘Making Every Contact Count’ Health services. Smokers are four times more likely to quit 5 North Wales, 19% of adults smoke and 7% training to frontline staff to equip them with specialist service support. use e-cigarettes. Smoking rates are declining with the skills to communicate the Recommendations: steadily over time, but vary considerably Community pharmacies provide a smoking cessation benefits of healthy lifestyle choices between different social groups. Adults living services which provide an alternative choice to • Community Pharmacies to effectively ToRecommendations: encourage more smokers to in the most deprived areas are three times smokers in their attempts to quit. They are accessible promote their smoking cessation services access cessation services: Screening more likely to smoke (28%) than those in the and able to meet the needs of disadvantaged and To encourage more smokers to 6 Supporting smokers to quit: • Practices to work within clusters to least deprived (9%). Smoking makes a big minority ethnic groups and those who may have accessensure thatcessation practices services: and smoking contribution to the numbers of premature difficulty accessing other community services. • Practices can set a flag on their cessation services use proactive and deaths associated with deprivation. Reducing electronic system to alert clinicians • Practices to work within clusters to Adverse intensive recruitment methods to deliver smoking prevalence among people in routine and reception staff when someone is a ensure that practices, Stop Smoking Childhood personal and tailored interventions to Experiences and manual groups, some minority ethnic groups smoker. This can provide an opportunity Wales and pharmacies use proactive smokersand intensive on a regular recruitment basis methods 7 and disadvantaged communities will help reduce for a brief intervention. health inequalities more than any other public • Clustersto deliver need personal to connect and tailored with • Proactively engage with smokers by health measure. Primary care staff, including andinterventions support digital to smokers social on a sending letter or text invitation to discuss pharmacists, GPs and practice nurses has a big marketingregular basis campaigns and other their smoking Early role to play given the contact they have. Three •platforms Clusters needto promote to connect smoking with and • Proactively talk about smoking at every Years quarters of smokers report that they want to cessationsupport digitalservices social marketing 8 contact with smoker (75% want to quit): stop smoking, and many will do so when nudged campaigns and other platforms to by primary care staff. • Ask people about their smoking status promote smoking cessation services
Social prescribing 9 Local case study: Foodwise Inequalities 1 The Clarence House GP surgery in Rhyl, as part of North Denbighshire Cluster, has been referring overweight patients to the Foodwise for Life weight management programme, a national programme delivered locally by Communities First Staff, supported by dieticians. Between January 2016 and March 2017, 6 programmes were delivered in Clarence House, Smoking and approximately 45 patients completed with an average weight loss of 2.9kg5 over the 2 8 week course. Evaluation reports also showed that 98% of participants reported making positive changes to their diet and 90% increased their activity levels. Participants reported impacts beyond their own achievements:
‘My friends have noticed my weight loss, I have explained the lifestyle changes and some are Obesity actually trying to do the things I have taken on board’ 3 In addition participants found value from the support that the group were able to give each other: ‘I think it would be useful for some of the doctors / dieticians to see how this type of course Vaccination Obesity deals with how people can lose weight by community spirit rather than a leaflet: go away and and read it and follow the instructions’ Immunisation4 Many healthcare professionals feel daunted about Why is this important? tackling the issue. Time restrictions, the lack of What can Primary Care contribute?
suitable resources, and inadequate training are Obesity is a major concern, with over half It isn’t always easy to raise the issue of • Social prescribing schemes are reasons why professionals express concerns about Mental of adults in North Wales classed as being weight, but Primary Care staff have the developing in North Wales and their role with regard to treating obesity. However Health overweight or obese1,and the numbers are opportunity to raise the subject of weight have great potential for connecting there are a number of compelling reasons why 5 steadily increasing. It is estimated that life with patients and encourage people to individuals with activities to increase obesity should be addressed in primary care3: expectancy is reduced by around 2 to 4 years make behaviour changes and can be physical activity, or improve diets 4 for those who are obese, and around 8 to • Increasing recognition that obesity is a serious effective in this role. 10 years for those who are morbidly obese. medical condition • The ‘Making Every Contact Count’ training Screening Obesity also increases the risks of developing • Primary care provides the opportunity to support programme equips frontline staff with the Recommendations: 6 individuals to lose weight rather than treat the skills to introduce weight (and other topics) chronic illness. Women who are obese are 13 times Primary care teams can help consequences into discussions and communicate the more likely to develop type 2 diabetes, and 4 times reduce health inequalities by more likely to develop hypertension, compared • Rising levels of obesity have a big impact on benefits of healthy choices. Adverse to women who are a healthy weight. Men are primary care workload, and increasingly secondary • Pre-empting the conversations by • Primary care clusters should be Childhood Experiences estimated to be 5 times more likely to develop type care as well. uploading health messages onto fully engaged with work to 7 2 diabetes and 2.5 times more likely to develop screens / posters in waiting rooms can develop weight loss services for hypertension compared to men who are a healthy help provide the cue to discuss with people who are overweight and weight2. These conditions contribute a large section patients. pathways into these. of the workload in primary care, and increasing levels • Some clusters of practices have funded • Social prescribing initiatives that Early of obesity will inevitably translate into increased additional access to leisure services, as help people to be more active Years workload in primary care. Obesity is also responsible part of the National Exercise on Referral or improve their diets should be 8 for significant economic costs to society due to time Scheme (NERS) or funded vouchers for considered for funding by primary lost from work. commercial slimming companies care clusters
Social prescribing 9 Local case study: Immunising Teams Inequalities 1 Three immunisation teams have recently been recruited to the School Nursing/Health Visiting service to work in North Wales.
The teams plan, arrange and deliver the immunisation sessions which are held in primary Smoking and secondary schools for school pupils. 2 They have a key role in the delivery of the childhood flu programme for children aged between 4 and 8 years of age. Vaccinating children against flu provides direct protection for the child but also has a big impact on reducing flu levels circulating in the community as a whole. This in turn reduces demand for primary care and social care services, as has Obesity been demonstrated in Scotland and Northern Ireland.6 3
Vaccination Vaccinations & Immunisations What can Primary Care contribute? and Immunisation • There is considerable variation in the identify individuals and families not up 4 Health inequalities are also reflected in uptake of uptake of immunisations across North to date with immunisation, taking every Why is this important? immunisations. Low uptake of immunisation results Wales at a GP practice level. Practices opportunity to immunise. The Health
in low levels of community protection and can working together in clusters have the Board’s home immunisation policy can Immunisation is one of the most successful and leave communities vulnerable to large outbreaks of opportunity to share learning from be used if necessary to support with this. Mental cost-effective public health interventions, and preventable diseases. Measles is circulating widely those practices that have higher vaccine • Community pharmacies in North Wales Health saves thousands of lives every year (WHO). The across Europe, and Wales is at high risk of measles uptake in order to reduce variation. 5 also participate in flu vaccination widespread implementation of immunisation outbreaks. Variation in uptake rates of measles, • Primary Care, with its detailed patient and have an important role to play in programmes over the last 30 years has led to a mumps and rubella (MMR) in North Wales means records systems, are well placed to provide enabling easy access to the vaccine. dramatic reduction in illness and death due to some communities are less protected, and addressing opportunistic and planned reminders to vaccine preventable diseases. low levels of uptake is a priority. parents and carers of children when a Screening The delivery of the immunisation programme is vaccine is due or has been missed. 6 Outbreaks can impact significantly on the work Recommendations: hugely complex, with hundreds of thousands of load of primary care. Staff working in primary care • Local practices could consider exploring • Review immunisation uptake data vaccines being given annually in GP practices, benefit from the protection of immunisation, and innovative approaches during flu season at both practice and cluster level schools, clinics, hospitals and in people’s homes Adverse also benefit patients by not passing on infection. such as running out-of-hours and easy on an annual basis in order to Childhood access clinics to increase reach and uptake. GP practices with their established relationships with understand variation in uptake Experiences families have a unique role to play in ensuring that • GP practices could choose to target rates and share good practice. 7 children are immunised at the right time. Primary a specific low uptake group for flu • Include actions to address variation care has a key role in ensuring vulnerable groups and vaccine and encourage the early in immunisation uptake to in their carers are protected by the flu vaccine, and a vaccination of pregnant women as soon Cluster and Practice plans. programme is being introduced in autumn of 2017 as the flu vaccine arrives. Early • Health Visitors and School Nurses for children. The children’s flu programme is highly Years • Health Visitors, with their special to work with practices to identify effective at providing herd immunity for the whole 8 relationship with families, are uniquely individuals and families not up to community and should be prioritised and promoted. placed to work closely with practices to date with immunisation.
Social prescribing 9 Five Inequalities 1 Ways to Take Keep Wellbeing Connect Be Active Notice Learning Give Smoking 2
Obesity 3
What can Primary Care contribute? Vaccination Mental Health and Wellbeing and Immunisation Demands in primary care can be reduced by 4 Why is this important? increasing the resilience of individuals and What can Primary Care contribute?
communities. One report suggested GPs spend Promoting positive mental health has the BCUHB has published its Mental Health nearly a fifth of appointment time on social issues.7 potential to improve both mental and physical Strategy which makes clear the importance The ‘Five Ways to Wellbeing’ framework provides an Mental health. Mental health problems are very of prevention work including primary care Health evidence based framework that can reduce the risk common, with one in four adults affected at 5 to promote and protect mental health. of developing mental health problems (opposite). some point during their lifetime. Of those who Primary care has a big role to play in seek medical advice, the majority will do so in a There are clear benefits for patients and for reducing supporting people to connect with support primary care setting, and mental health problems demands on primary care if people can be put outside of the NHS that can help them make up a significant part of the workload of in contact with local activities that help promote build resilience and prevent mental ill Screening practices. the five ways approach. Social prescribing is one health. Pharmacists, General Practitioners, 6 approach that can support this- connecting people Practice Nurses all have a role to: Within North Wales people report slightly better with support, often with voluntary groups, to help mental health than in Wales as a whole, the most • Develop links with local third sector build resilience. Spending time in green spaces has a Adverse common mental illnesses reported being anxiety and services such as Citizens advice, positive effect on mental wellbeing. The countryside Childhood depression. including exploring possibilities for in North Wales is an asset that can be used as part of Experiences bringing services into practices or 7 Tackling mental health problems early has big building resilience. nearby buildings. benefits in later life. Most mental illness begins before adulthood and often continues throughout • Support social prescribing initiatives as Recommendation: the opportunities arise. life. Improving mental health early in life will • Clusters develop local links with Early reduce health inequalities, improve life expectancy, • Practices to identify a champion for third sector organisations to Years economic productivity, social functioning and quality the third sector and make it their role develop alternative support for 8 of life. Mental health problems are linked to poorer to develop practical links with local people to help promote mental physical health and shorter life expectancy. voluntary organisations and groups. wellbeing.
Social prescribing 9 Local case study: Screening Champions Inequalities 1 To address inequities in screening uptake, the Screening Engagement Team are piloting a Screening Champion project in practices across North Wales with the lowest screening uptake. The approach is based on the ‘Making Every Contact Count’ methodology, whereby trained, front-line primary care staff are encouraged to have opportunistic Smoking conversations with patients about screening and to display information about screening in 2 the reception area in line with the national campaigns.
The first cohort of Screening Champions were trained in June 2017. The training was attended by Receptionists and Practice Nurses Obesity from five GP Surgeries from GP Clusters with 3 the lowest uptake. An evaluation will be conducted following the Screening for Life campaign and the outcomes will be shared Vaccination Screening with GP clusters across Wales. and Immunisation4 Primary care plays a central role in delivering the Why is this important? cervical screening programme, but has an important What can Primary Care contribute?
role in supporting and promoting other programmes, Screening is a process of identifying apparently Primary care has a central role in promoting Raising awareness and promoting such as, ensuring the right people are invited to Mental healthy people who may be at an increased the uptake of screening programmes. The informed choice amongst the the Diabetic Eye Screening programme. Evidence Health risk of a disease or condition. Early detection of Screening Division within Public Health whole practice population: shows that primary care can have a positive impact 5 illness through screening can reduce mortality Wales is available to work with clusters on improving participation in screening by the use • ‘Screening for Life’ training is available from a disease or condition and can also improve and practices to give staff the skills and of targeted letters and phone calls 9,10. Project work for your staff provided by the health outcomes for participants. There are seven confidence to make this part of their work. carried out in Wales recently showed benefit of Screening Engagement Team of Public national screening programmes in Wales (Breast a range of interventions to increase participation Primary Care interventions Health Wales. Test Wales, Bowel Screening Wales, Cervical Screening in bowel screening by targeting non-responders. targeting non-responders: • Display screening materials in waiting 6 Screening Wales, Newborn Bloodspot Pharmacies, Dentists, Community Nursing and Third area and on TV monitor screens. Screening Wales, Newborn Hearing Screening • Working with screening services to Sector Organisations also have a role in promoting Wales, Diabetic Eye Screening Wales, Wales identify those not responding to awareness, through the dissemination of accessible Adverse Abdominal Aortic Aneurysm Screening invitations to screening and: information, and having opportunistic conversations Childhood Programme) and an Antenatal Screening Wales - Sending a GP endorsed letter has with the public about screening. Optometrists play Recommendations: Experiences programme. been shown to increase uptake. 7 an important role in helping to raise awareness of • Practices to contact the Screening Uptake of screening is variable, and is generally diabetic retinopathy screening. - Phone calls can be made by trained Engagement Team to provide lower in more deprived communities. For example, practice staff to patients who are screening awareness training to uptake of bowel screening in the least deprived identified as non-responders. practice staff. Early primary care cluster in North Wales is 58.5 - Practices can set a flag on their • Practices and clusters to develop Years percent compared to 51.4 percent in the most electronic system to alert clinicians and implement strategies to follow 8 deprived cluster. 8 and reception staff to provide an up those who have not responded opportunity for a brief intervention. to their screening invitation.
Social prescribing 9 Adverse Childhood Experiences, chronic disease and health service use in Wales
Adverse Childhood Experiences (ACEs) have harmful impacts on health and well-being across the life course. The Welsh ACE Study measured exposure to nine ACEs in the Welsh population and their association with chronic disease development and health service use in adulthood.
47% of adults in Wales suffered Proportion of Welsh adults suffering each ACE at least one ACE as a child Verbal abuse 23% and 14% suffered four or more Physical abuse 17% Sexual abuse 10% 53% 20% 13% 14% Parental separation 20% Household domestic violence 16% Household mental illness 14% Household alcohol abuse 14% Inequalities Household drug use 5% 0 ACEs 1 ACE 2-3 ACEs 4+ ACEs Household member incarcerated 5% 1 p to the age of 69 years, those with four or more ACEs were 2x more likely than those with no ACEs to be diagnosed with a chronic disease For specific diseases they were: 4x 3x 3x more likely to develop more likely to develop more likely to develop a Diabetes (Type 2) Heart Disease Respiratory Disease Smoking
evels of health service use were higher in adults who experienced more ACEs 2 Over a 12 month period, compared to people with no ACEs, those with four or more ACEs were: H 2x 3x A E 3x more likely to have more likely to have more likely to have stayed frequently visited a GP** attended A&E overnight in hospital
The Welsh ACE survey interviewed approximately 2000 people (aged 18-69 years) from across Wales at their homes in 2015. Of those eligible to participate, just under half agreed to take part and we are grateful to all those who freely gave their time. Obesity Information in this info-graphic is taken from the third report on the Welsh ACE survey: Adverse Childhood Experiences and their association with Chronic Disease and Health Service Use in the Welsh adult population. This report and previous reports using the Welsh ACE survey data can be accessed on the Public Health Wales website. Policy, Research and International Development Directorate, Floor 5, Public Health Wales NHS Trust, Number 2 Capital Quarter, 3 Tyndall Street, Cardiff, CF10 4BZ. www.publichealthwales.wales.nhs.uk Tel: +44(0)2920 104460 November 2016 *After taking age, sex, ethnicity and residential deprivation into account. All data was self-reported.; $Includes Type 2 Diabetes, Stroke, Cancer, Coronary Heart Disease, Liver or Digestive Disease and Respiratory Disease; #Excluding reasons relating to pregnancy; **Visited a GP six or more times over the past 12 months.
Vaccination Adverse Childhood Experiences and Immunisation4 where there was domestic violence, alcohol or drug Why is this important? abuse, are more likely to adopt health-harming and What can Primary Care contribute?
anti-social behaviours in adult life. Those who suffered There is a growing recognition in Wales Adverse Childhood experiences (ACEs) are four or more ACEs are more than twice as likely to be that early intervention and collaborative Mental traumatic experiences that occur before the age diagnosed with a chronic disease in later life compared working are essential to reducing the Health of 18. These experiences range from experiencing to adults that have experienced none. They were also Recommendations: 5 impact of ACEs. It is useful for all relevant verbal, mental, sexual and physical abuse, to three times more likely to have attended Accident and professionals, and Primary Care staff have being raised in a household where domestic • Consider how your service Emergency units, three times more likely to have stayed particular role to play. Further work is violence, alcohol abuse, parental separation or could contribute to preventing overnight in hospital, and twice as likely to have visited needed to be clear how primary care staff drug abuse is present. ACEs have been researched or mitigating any of the ACEs. their GP, compared to individuals with no ACEs. can contribute, but the starting point is to in Wales and recent reports have shown a clear Some GPs have found it helpful Screening be ACEs aware. Health Visitors and GPs 6 link between ACEs and poor health and social This powerful evidence brings extra impetus to to sensitively ask questions about have a key role to play here. outcomes in later life. preventing ACEs from happening in childhood, and childhood experiences to patients learning the best ways to acknowledge and mitigate For the future, a simple and brief process who attend frequently with non- Evidence shows children who experience stressful Adverse the effects in childhood and in later life. Impacts are called Routine Enquiry, carried out with specific ailments. The evidence and poor quality childhoods are more likely: Childhood substantively mitigated by always having support in adults in primary care and in other suggests just acknowledging that Experiences • to develop health-harming and anti-social childhood from a trusted adult, a key ingredient for settings, has shown promising results, this can have long term positive 7 behaviours, building resilience. and major trials are ongoing. effects • Raise awareness of • to perform poorly in school, A short (five minute) animated film has ACEs with all primary • to be involved in crime been developed to raise awareness of ACEs, care staff using this Early their potential to damage health across • and less likely to be a productive member of society. short (five minute) Years the life course, and the roles that different 8 animated film. Adults in Wales who were physically or sexually agencies can play in preventing ACEs and abused as children or brought up in households supporting those affected by them.
Social prescribing 9 Local case study: Resources for breastfeeding and weaning Inequalities 1 Parents want to do the right thing for their babies but can be bombarded with conflicting advice from families, friends and social media. Primary care is a place that many will turn to for help in deciding what they should do. Betsi Cadwaladr University Health Board has made it easy Smoking for professionals to give advice about breastfeeding 2 and weaning by compiling comprehensive web pages for the public. There is more detailed clinical information and relevant policies on the health board’s intranet site, accessible from the home page. Obesity Here is an example from the 3 weaning pages:
Early Years Breastfeeding advice pages for the public in English Weaning advice pages in English Vaccination Breastfeeding advice pages for the public in Welsh Weaning advice pages in Welsh and A range of primary care services support women Immunisation Why is this important? through pregnancy and both parents and children 4 in the early years of parenthood. Effective care relies Fully immunised There is strong evidence that the things that on good communication between disciplines and child according to happen to a person in the first 1000 days of services to ensure problems are picked up early, and the schedule life have a decisive impact on health through appropriate help offered. Systems ensure Mental childhood and later life. The time period from maximum take-up Health conception to age 2 years offers a unique window Essential building blocks for health are laid down of immunisations 5 in which to deliver the most effective and best in the first 1000 days. Primary care makes a major Healthy weaning at value health interventions. Improving outcomes in contribution across the whole pathway (highlighted Good mental the right time, when Recommendations: the first 1000 days of life is a high profile national in red in the shaded blocks): wellbeing in parents, the child is ready, • Support implementation of the priority for Wales. Primary care is a natural setting around 6 months and rapid help with Healthy Child Wales programme for much contact with services during this period. any mental ill-health, Advice to parents Screening to prioritise evidence based supports good 6 interventions in the first 1000 days attachment and Active play (including playing outside every of life. High impact population A breast fed baby positive parenting day), social interaction health interventions include; folic gives life-long benefits Mental health Adverse A planned and spoken acid, booking by 10 weeks of for mother and child. screening and Childhood pregnancy gives communication Good nutrition and referral in pregnancy pregnancy, smoking in pregnancy, Experiences a woman the Advice during Prompt referral regular physical and for new parents breastfeeding, immunisation and 7 chance to make pregnancy and for speech and activity in pregnancy, perinatal mental health support. sure she is a postnatal support Plenty of sleep and language difficulties alcohol-free, with folic healthy weight A safe and supportive regular bedtime • Maximise opportunistic contacts Actions which acid and vitamin D Limit screen time, and not a smoker home and loving routines for babies with women of child-bearing age may be in supplements promote books and before conception and children Early from the start parents/family who may be planning a pregnancy primary care encourage curiosity Years Advice from to offer advice and support. Actions for other Advice about School education 8 Advice at the start of community Advice from preparing for about healthy The Every Child Wales website professionals pregnancy, including nursing and other community nursing pregnancy relationships is a helpful resource. at pregnancy testing parenting support and education Social prescribing 9 The evidence base Inequalities 1 There is a growing evidence base to suggest that empowering patients to manage their own conditions, and engaging with communities to develop a social model of health, brings tangible benefits to patients and to the traditional health and social care services that support them.11,12 Smoking Some successful social prescribing programmes have demonstrated that the cost of managing 2 patients with long-term conditions could be reduced by up to 20%, and that there could be a three-fold return on the initial financial investment in services that are delivering positive outcomes.13 The recent evaluation of a North Wales social prescribing programme demonstrated that there was a positive social value return of £3.42 for every £1 invested.14 Obesity 3 Social prescribing in North Wales
Within North Wales, there are a number social care, education and third sector Vaccination Social prescribing of social prescribing schemes operating, together to develop best practice and a and ranging from signposting schemes to consistent approach. There is a vibrant Immunisation4 in-depth one-to-one work with a social arts and health network in North Wales sectors such as housing also having a significant role prescriber. Work is beginning to bring which has a track record of imaginative What is social prescribing? to play. This is an area for collaboration between different organisations across the health, support to individuals and communities. Social prescribing is a term used to describe ways of primary care and other partners to develop networks connecting people with support in their community that can provide support to people before they even Mental as an alternative to a healthcare intervention. approach primary care for help. Social Prescribing initiatives in North Wales Health Social prescribing promotes self-help and enables 5 Social prescribing programmes are a different Social Prescribing in South Flintshire Cluster; 2 GP Practices Click here for Details a person take more control of their own health. approach to supporting people, and can and can in South Flintshire agreed to trial an approach whereby patients or see further In the primary care setting, this can improve the be a catalyst for the wider change needed to build were identified through risk stratification where there was a information links at patient experience and outcomes through offering a community-focused approach to supporting high risk of them attending surgery on a regular basis, where the end of this report opportunities such as volunteering, arts activities, individuals and communities. clinical management was not their primary need and/or a more Screening group learning, and a range of sports and social holistic approach could be beneficial 6 activities. There is promising evidence that the What do social prescribing Arfon Cluster, Gwynedd (Area West); Mantell Gwynedd: Click here for Details approach can make a positive contribution to A community link officer is the first point of contact for patients or see further managing demand in primary care at the same schemes aim to address? referred from GP surgeries / Primary care / community nurses information links at Adverse Childhood time as more effectively helping people . Many of Typical outcome: etc with social, emotional or practical needs to range of local, the end of this report the long-term conditions that are associated with Experiences • Strengthening an individual’s social networks. non-clinical services 7 primary care appointments stem from increased • Reduction in the use of health care. Anglesey; Service established during 2016-17 to provide Click here for Details social isolation and poor physical and mental • An improvement in psychosocial problems. support and signposting to various community based support or see further health. Social interventions which link patients to • A positive impact on healthy behaviours and use groups and activities for individuals to improve health and information links at community based sources of support enables them of preventative services. wellbeing as well as information on practical support the end of this report Early to take ownership of their own conditions and to • Improvement in mental well-being. Social Prescribing in North West Wales; 3 Individual Projects Click here Short Breaks Years benefit from a community support structure. • Improvements in clinical outcomes and quality 1 Anglesey short breaks for disabled children with learning Click here Men’s Sheds 8 of life measures. disability Click here LD Hub The referral routes into social prescribing schemes do • Improvements in the self-management of 2 Anglesey Men’s Sheds or see further not have to be exclusively from primary care, with long-term conditions. 3 Arfon leisure centre activities for adults with learning disability information links at the end of this report Social prescribing 9 References Further Information 1. National Survey for Wales (2016/17) available at: http://gov.wales/docs/statis- ACEs web pages in English available at: http://www.wales.nhs.uk/sitesplus/888/page/88504 tics/2017/170629-national-survey-2016-17-population-health-lifestyle-en.pdf ACEs web pages in Welsh available at: http://www.wales.nhs.uk/sitesplus/888/tu- 2. NICE Guidance NG7: Maintaining a Healthy Weight available at: dalen/88518 https://www.nice.org.uk/guidance/ng7 Anglesey LD Hub available at: Anglesey LD Hub 3. National Obesity Forum: The Role of Primary Care available at: http://www.nationalobesi- tyforum.org.uk/images/stories/PDF_training_resource/in-depth-the-role-of-primary-care.pdf Anglesey Men’s Sheds available at: Anglesey Men’s Sheds
4. NICE Guidance NG7: Maintaining a Healthy Weight available at: Anglesey Short Breaks available at: Anglesey Short Breaks https://www.nice.org.uk/guidance/ng7 Conwy West Community Navigator available at: Conwy West Community Navigator; 5. National Average figures, RBA Report Card Foodwise Communities First 2016-17 available Health Education England, Social Prescribing at a glance: A scoping report of activity for the at: http://senedd.assembly.wales/documents/s61664/PC%2034%20Welsh%20Dietetic%20 North West, (March 2016) available at: https://www.hee.nhs.uk/sites/default/files/docu- Leadership%20Advisory%20Group%20Annex%20156%20and%207.docx.pdf ments/Social%20Prescribing%20at%20a%20glance.pdf 6. Peabody et al. 2014 Surveillance and Outbreak Report available at: Health Inequalities and Population Health available at: https://www.nice.org.uk/advice/lgb4/ http://www.eurosurveillance.org/images/dynamic/EE/V19N22/art20823.pdf chapter/introduction 7. How much time does a GP spend on issues other than health available at: Help me Quit website available at: http://www.helpmequit.wales/ https://www.citizensadvice.org.uk/about-us/policy/policy-research-topics/health-and-carepol- icy-research/public-services-policy-research/a-very-general-practice-how-much-time-dogps- Intervention and prevention services for Children (LD & CCN) Anglesey available at: spend-on-issues-other-than-health/ Anglesey Social Prescribing
8. Screening for Life web pages available at: http://www.screeningforlife.wales.nhs.uk/statis- Link Officer; Arfon Cluster, Gwynedd available at: Arfon Community Facilitator tical-reports-1 Screening Engagement Team Web pages available at: Screening Engagement Team 9. Hewitson P, Ward A, Heneghan C, et al. (2011) Primary care endorsement letter and a patient leaflet to improve participation in colorectal cancer screening: results of a factorial Social prescribing a pathway to work? (Work Foundation 2017) available at: randomised trial. British Journal of Cancer 2011;9;105(4):475-80 http://www.theworkfoundation.com/wp-content/uploads/2017/02/412_Social_prescribing.pdf
10. Shankleman J, Massat N, Khagram L et al (2014) Evaluation of a service intervention Social Prescribing in South Flintshire Cluster available at: South Flintshire Social Prescribing to improve awareness and uptake of bowel cancer screening in ethnically-diverse areas. Available at: https://www.towerhamlets.gov.uk/Documents/Public-Health/Bowel%20screen- Social Prescribing Projects by Area available at: ing%20study%202012%20BJC%20online.pdf http://www.primarycareone.wales.nhs.uk/social-prescribing-projects-by-area
11. University of York Centre for Reviews and Dissemination, Evidence to Inform the World Health organisation: Immunisation available at: commissioning of social prescribing, (February 2015) available at: http://www.who.int/topics/immunization/en/ https://www.york.ac.uk/media/crd/Ev%20briefing_social_prescribing.pdf
12. Public Health Wales Observatory, Social prescribing evidence map: summary report, (June 2017) available at: http://www2.nphs.wales.nhs.uk:8080/PubHObservatoryProjDocs. nsf/0/d8aba77d02cf471c80258148002ad093/$FILE/Social%20prescribing%20summa- ry%20report%20v1%20GROUPWARE.pdf
13. Sheffield Hallam University, The Rotherham Social Prescribing Service for People with Long-Term Health Conditions, (January 2016) available at: http://www4.shu.ac.uk/research/ cresr/sites/shu.ac.uk/files/rotherham-social-prescribing-annual-eval-report-2016_7.pdf
14. Mantell Gwynedd, The social impact of the Arfon social prescription model Social Return on Investment evaluation and forecast report, (June 2017) available at: http://eprints.uwe. ac.uk/28452/7/Value%20of%20social%20prescribing2.pdf Contributors
Siobhan Adams
Sarah Andrews
Sian Ap Dewi
Dr Robert Atenstaedt
Delyth Jones
Siwan Jones
Rachel Lewis
Hannah Lloyd
John Lucy
Rebecca Masters
Dr. Glynne Roberts
Production- Heather Thomas; Kelvin Jones; Jo Charles; Karen Vickers
Cover Photo Acknowledgement: Thanks to staff and patients at Ardudwy Health Centre, Harlech & Alltwen Hospital, Tremadog
1.3 17.248 Special Measures Task & Finish Group Chair's Assurance Report 12.10.17 - Mr Gary Doherty 1 17.248 Chair's Assurance Report SMIF TF 12.10.17 V1.0.docx
1
Health Board
16.11.17
To improve health and provide excellent care
Committee Chair’s Report
Name of Special Measures Improvement Framework Task & Finish (SMIF Committee: T&F) Group
Meeting date: 12.10.17
Name of Chair: Mrs Margaret Hanson, Health Board Vice-Chair
Responsible Mrs Grace Lewis-Parry, Board Secretary Director:
Summary of key • The meeting focused on developments in primary care. risks and other Evidence was received of work carried out to gain a better items discussed: understanding of the overall stability and sustainability of GP practices across North Wales. New primary care dashboards are in place to monitor key indicators of quality and safety. Primary care clusters have established a range of schemes that will contribute to system change. Visits have taken place to primary care providers both in Wales and in England, with a view to learning lessons from good practice in order to inform service transformation. Other transformational work undertaken includes the ongoing development of new models of primary care and of new roles that will mitigate risks within the current system. There remain some key risks relating to instability caused by GP availability and recruitment challenges, most notably in respect of the Wrexham area currently. • The Group received a schedule setting out the timeline for production and submission of the End of Phase 3 Report (Phase 3 ends on 30th November). • The Group reviewed the updated action & progress monitoring log and was pleased to note that harms dashboards are now live and being actively used to support quality & safety, organisational development work in maternity services is due to commence on 1.12.17, Board members have development programmes in place, the new Financial Recovery Group is up and running and stakeholder engagement surveys to provide benchmark data against which to measure improvement are now almost complete.
Key assurances • The T & F Group considers that the risks and timescales provided at this associated with the Special Measures Improvement Framework meeting: are being managed appropriately. Overall, satisfactory progress is being made, however there is more to be done to maintain 2
stability and sustain improvements in some key areas as outlined above. It is clear to the group that several of the themes within the framework might be deemed to have either satisfied, or be close to satisfying, the SMIF expectations as set out by WG.
Key risks and Some concerns were expressed regarding the need for further concerns: work on clinical and staff engagement. There were also concerns regarding sickness absences and the need to maintain leadership, operational and financial stability in the Mental Health and Learning Disabilities Division. It was noted that action was being taken to address this.
Issues to be - referred to another Committee Matters requiring The Board is asked to note this report. escalation to the Board: Planned business Review of the draft End of Phase 3 Report. for the next meeting: Date of next 13.11.17 meeting:
Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
1.6 17.251 Draft Minutes of the Health Board Meeting held on 19.10.17 for accuracy and review of Summary Action Log 1 17.251a Minutes Health Board 19.10.17 Public V0.03.doc
Minutes Health Board Public 19.10.17 v0.03 draft 1
Betsi Cadwaladr University Health Board (BCUHB)
Minutes of the Health Board Meeting held in public on 19.10.17 in Venue Cymru, Llandudno Present: Dr P Higson Chairman Cllr C Carlisle (part meeting) Independent Member Mr J Cunliffe Independent Member Ms J Dean Independent Member Mr G Doherty Chief Executive Mr R Favager Executive Director of Finance Cllr B Feeley Independent Member Mrs M Hanson Vice Chair Mrs G Harris Executive Director of Nursing & Midwifery Mr JM Jones Executive Director of Workforce and Organisational Development Mrs MW Jones Independent Member Mr G Lang Executive Director of Strategy Mrs G Lewis-Parry Board Secretary Mrs L Meadows Independent Member Dr E Moore Executive Medical Director Ms M Olsen Chief Operating Officer Miss T Owen Executive Director of Public Health Prof M Rees (part meeting) Associate Board Member, Chair of Healthcare Professionals Forum Mrs B Russell-Williams Independent Member Mr C Stradling Independent Member Mrs N Stubbins (part meeting) Associate Board Member, Director of Social Services Mr F Williams Associate Board Member, Chair of Stakeholder Reference Group
In Attendance: Mrs J Baxter (part meeting) Consultant Ophthalmologist Mrs S Baxter (part meeting) Assistant Director Health Strategy Ms A Birch (part meeting) Retinal Lead Nurse Mr T Berry Observer (Deloitte) Mrs K Dunn Head of Corporate Affairs Ms E Foreman Observer (Deloitte) Mr J Mathews (part meeting) Consultant Ophthalmologist Ms G Pryce (part meeting) Admin Manager Mr R Taylor (part meeting) Director of Estates & Facilities
Translator, staff, Community Health Council, observers and members of the public
Agenda Item Action
17/222 Chairman’s Introductory Remarks
The Chairman welcomed those present to the meeting. Minutes Health Board Public 19.10.17 v0.03 draft 2 17/223 Special Measures Themed Report : Living Healthier Staying Well : Strategic Direction
17/223.1 Mrs Sally Baxter was welcomed to the meeting. The Chief Executive reminded members of the role of the Special Measures Improvement Framework (SMIF) Task & Finish Group which was chaired by the Health Board Vice Chair. The Executive Director of Strategy presented the agenda item, indicating there was a detailed set of papers before the Board for consideration and that he would focus on Appendix 1 which set out the strategic direction and emerging priorities. He indicated that the suite of documents provided were not a finished product and were continually being developed. The Executive Director of Strategy referred to the Well-Being of Future Generations Act, which, sets out a clear duty on Boards to ensure that strategic plans demonstrated improvements in health and well-being and did not compromise the future. He suggested that the document clearly set out key priorities and outcomes to move the Health Board towards its long term goals, and identified other areas of work that would contribute to delivery of the strategy. The Executive Director of Strategy indicated that in terms of improving health and reducing inequalities, there were statements about what the Board could achieve on its own, what it could achieve with partners, and where it could only influence. It was noted that with regards to the theme of care closer to home, people had generally responded positively to the model although hospital services remained an essential part of the Board’s services, and there were clear statements within the documentation regarding the future of hospitals. The Executive Director of Strategy drew members’ attention specifically to the recommendation to proceed to a period of broader engagement, primarily using Appendix 1 as the basis for a conversation and then to reflect on the feedback to ensure this was reflected within the actual strategy document when it was presented to the Board in January.
17/223.2 A discussion ensued. In response to a question regarding the integration of finance and workforce plans, it was confirmed that the implications were already being considered and would be worked up in more detail once the broad principles and direction of travel had been tested. The point was raised regarding disinvestment and that the timing of any such plans was crucial. It was suggested there was huge potential associated with the Well-Being of Future Generations Act to implement and evaluate social investment, and it was confirmed there were a range of projects but these would require embedding with partners. Members were of the view that engagement by the Health Board had improved and this needed to be sustained and developed even further with hard to reach groups.
17/223.3 With regards to transformation, members were keen to see this clearly described. The Executive Director of Strategy indicated that the direction of travel and broad ambitions were set out and the next step would be to clarify what services the Board intended to deliver. There was a concern raised that transformation work should not be delayed whilst the wider strategy was developed, and the Chief Operating Officer assured the Board that a great deal of transformation work had been undertaken already, which would need to be shared and publicised at the forthcoming engagement events as the details were not perhaps captured fully within the documentation. The point was also made that the Board would need to deliver a great deal within the first year to support its finance and performance challenges. The Executive Director of Finance concurred that establishing new ways of working was critical to releasing resources and focus needed to be on the use of the whole budget not just the margins. The principles within the IMTP included Prudent Healthcare, the Value work should address this around reducing inappropriate variation and only doing what needs to be done. Minutes Health Board Public 19.10.17 v0.03 draft 3
17/223.4 The point was raised that as around 90% of care is delivered within a primary care setting, was enough being done to engage effectively with multi disciplinary teams. It was accepted there was always more that could be done and that engagement was a continuous journey. The Chair of the Healthcare Professionals Forum (HPF) also highlighted that the workforce were the Board’s ambassadors for its strategic plans and any service change, and therefore staff engagement needed to be thorough and meaningful. He was grateful for the level of engagement undertaken with the HPF to date. A comment was also made that the document would benefit from a strengthened focus in terms of helping patients and families navigate what was often a complex healthcare system, and secondly on the impact upon carers and ensuring they themselves remained healthy. It was added that communities needed to be more resilient and connected with an understanding that the population needed to work with the Health Board on identifying solutions for the future. The Vice Chair referred to the importance of the Board’s strategy impacting positively on the poverty agenda.
17/223.5 The Chairman suggested that a joint letter be sent by himself and the Chief Executive to accompany the document when it was widely circulated, setting out the Board’s commitment to partnership working. GD
17/223.6 It was resolved that the Board • receive the report • support the strategic direction described in Appendix 1 • approve the commencement of a period of broader engagement on the strategic direction described and detailed in Appendix 3
[Mrs S Baxter left the meeting]
17/224 Apologies for Absence
Apologies were received from Mr A Roach, Prof J Rycroft-Malone and Mr A Thomas.
17/225 Declarations of Interest
None declared. 17/226 Draft Minutes of the Health Board Meeting Held In Public on 21.9.17 for Accuracy, Matters Arising and Review of Summary Action Log
The minutes were approved as an accurate record and the summary action log was reviewed and noted.
17/227 Committee and Advisory Group Chairs’ Assurance Reports
17/227.1 Quality, Safety & Experience Committee 12.9.17 The Committee Chair presented the report, highlighting the key assurances that the Committee had received and also the areas of risk or concern – as detailed within the written report. A discussion ensued and further assurances were provided regarding trajectories for improvements to clinical coding performance. In addition, it was agreed that the paper due at Committee on pooled budgets should also be discussed by the full MO Board. The report was noted.
17/227.2 Finance & Performance Committee 26.9.17 Minutes Health Board Public 19.10.17 v0.03 draft 4 The Committee Vice Chair presented the report, highlighting the key assurances that the Committee had received and also the areas of risk or concern – as detailed within the written report. A discussion ensued and assurance given that dates had been reviewed with regards to postponed accountability meetings. With regards to future-proofing of the North Denbighshire Community Hospital scheme in terms of population need, it was confirmed that the Gateway review had reported and further initial work to respond to the issues raised was expected to report by the end of the month. At this point a timescale for a business case would be set out. The report was noted.
17/227.3 Charitable Funds Committee 18.9.17 The Committee Chair presented the report, highlighting the key assurances that the Committee had received and also the areas of risk or concern – as detailed within the GLP written report. A discussion ensued and with regards to the paper regarding compliance with the new General Data Processing Regulations, it was suggested this be an agenda item for the Trustees Board meeting on 30.1.18. The report was noted.
17/227.4 Strategy, Partnerships & Population Health Committee 5.9.17 The Committee Chair presented the report, highlighting the key assurances that the Committee had received and also the areas of risk or concern – as detailed within the written report. The report was noted.
17/227.5 Audit Committee 14.9.17 The Committee Chair presented the report, highlighting the key assurances that the Committee had received and also the areas of risk or concern – as detailed within the written report. A discussion ensued. It was noted there was a good level of representation by Executives and senior managers at Audit Committee meetings to respond to the various audit reports. The Board Secretary reminded members that there had been an electronic system established for gifts and hospitality and declarations of interest, and this was working well with other Boards looking to utilise the same system. The first audit had now been undertaken and the data highlighted there was more work to do in terms of ensuring that those individuals who were required to make declarations did GLP so, and to encourage appropriate declarations by all staff. The Chairman requested an update paper to the Health Board in December. The report was noted.
17/227.6 Stakeholder Reference Group (SRG) 25.9.17 The Advisory Group Chair presented the report, describing a range of presentations and papers that the Group had received and the areas where the SRG would wish to highlight an issue to the Board - as detailed within the written report. A discussion ensued. With GD regards to identifying and quality assuring savings plans, the Chief Executive agreed to think this through and define further to provide assurance to the SRG. The report was noted.
17/227.7 Healthcare Professionals Forum (HPF) 1.9.17 The Advisory Group Chair presented the report, describing a range of presentations and papers that the Group had received and the areas where the HPF would wish to highlight an issue to the Board - as detailed within the written report. A discussion ensued. With regards to research and development it was noted that a paper was scheduled for the next Board meeting. The paper was noted.
17/228 North Wales Laundry & Linen Service Option Appraisal
17/228.1 The Chief Operating Officer welcomed the Director of Estates & Facilities to the Minutes Health Board Public 19.10.17 v0.03 draft 5 meeting and thanked him and the wider team for their hard work in preparing the paper and also acknowledged the contribution of staff and trade unions. The Director of Estates & Facilities presented the paper which identified key challenges including changes in national guidance for decontamination and recognising the age and suitability of the current facility which was a North Wales service based at Ysbyty Glan Clwyd covering all clinical services within North Wales and for the Ambulance Services Trust. He indicated that the organisation had sought external support through Capita to work through the options available which had also been shared with staff side representatives. The initial high level options had been developed into three main options as set out within the paper, with financial and efficiency implications incorporated. The Director of Estates & Facilities indicated that the Finance & Performance Committee at its meeting on the 25.7.17 concluded that Option 2 (New off-site fit for purpose facilities) best met the requirements as set out in the scoping brief.
17/228.2 A discussion ensued. In response to a question regarding best fit with the intended all Wales model, it was confirmed that Capita had also been commissioned with this regard, and the Board were assured that the preferred option was in line with this model. The Chair of the Finance & Performance Committee confirmed that the Committee had considered the financial and service implications in some detail and had been unanimous in their view that Option 2 should be developed further. Whilst there had been an element of regret expressed at the Committee that there was not a private sector option, the Committee had been informed that Welsh Government advice was to keep the facility within the public sector. The Chair of the Stakeholder Reference Group (SRG) queried whether this could be challenged as he had concerns that Option 2 would commit the Health Board to the long-term delivery of a service that may in future become a constraint. The Chief Executive felt that this was relatively low risk and whilst there may be better value within a private option, the Health Board had to work within Welsh Government policy.
17/228.3 The point was also made regarding opportunities for a social solution in partnership with other public sector organisations and it was confirmed this had been given considerable thought. The potential for the escalation of costs in a capital project of this nature and associated costs in clearing the existing site was raised, and it was confirmed that issues of this nature would be picked up within a full business case if it was decided to proceed to that stage. The Chairman emphasised that the current facilities were adequate and would continue to be maintained to ensure they remained fit for purpose as part of an essential service whilst any new facility was being developed. The point was raised that there could be considerable time delays with funding of major capital schemes and it was suggested that there should be a contingency plan should funding not materialise. The Director of Estates & Facilities responded to a question regarding purchase of land and confirmed that this was included within Option 2.
17/228.4 The Chairman reminded members that many of the issues raised in the discussion would be addressed as part of the development of a full business case, and he also asked that environmental aspects of service provision on a single site be looked at as part of the next phase. The Chair of the SRG added a caveat that he was happy to agree the recommendations within the context of the constraints and environment that the organisation was currently working within.
17/228.5 It was resolved that the Board: • Having considered the short list of options detailed within the report, accepted the recommendations made by the Finance and Performance Committee on the 25th of Minutes Health Board Public 19.10.17 v0.03 draft 6 July 2017 which supported Option 2 (New off-site fit for purpose facilities). • Approved the development of a full business case (FBC) based on Option 2 for submission to Welsh Government for capital funding consideration.
[Mr R Taylor left the meeting] 17/229 Winter Resilience Planning Process 2017-18
17/229.1 The Chief Operating Officer presented the report which identified priority actions for delivery over the winter period and gave an analysis of when it was believed that significant pressures would hit district general and acute hospitals. The paper attempted to focus on areas that would achieve the most difference – for example the ‘Choose Well’ and ‘Choose Pharmacy’ initiatives to promote self care and keeping people out of hospital, and also a reduction in infection and promotion of the flu vaccination. It was reported that the week between Christmas and New Year was a predicted peak period which would then likely impact during the first week in January with a significant rise in admissions. The importance of keeping the workforce healthy was also highlighted and that work was underway with staff side and trade union representatives.
[Cllr C Carlisle joined the meeting]
17/229.2 A discussion ensued. The Chair of the Healthcare Professionals Forum (HPF) was keen to see the use of technology maximised to assist with capacity on hospital sites and to reduce unnecessary admissions. With regards to staff health and well-being the point was made that high bed occupancy rates also impacted on staff, and the Health Board had a responsibility to ensure that staff were able to work within their contracted hours and to take their annual leave. This was acknowledged. The important role of third sector organisations was also noted in that they were key partners in helping people avoid unnecessary hospital care and it was suggested this could have been reflected more strongly within the plan. The Chief Operating Officer responded that the associated winter resilience planning ‘checklist’ document did contain more detail in this regard but it had been challenging to ensure the core document did not become too cumbersome by inclusion of too much detail but was able to articulate outcomes. Members were broadly supportive of the format and structure of the plan, and acknowledged that a greater level of detail had been scrutinized by the Strategy, Partnerships & Population Health Committee. It was acknowledged that the plan could only be successfully delivered in partnership and members were assured that the overarching unscheduled care transformation group did truly operate in partnership, although there were long-standing concerns regarding capacity in health and social care. The Director of Social Services noted that whilst there were known challenges, all agencies were wholly committed to communicating and working together. With regards to the timeframe for the production of the plan, it was suggested that the Board should be seeing it earlier in the year. The Chief Operating Officer indicated that the aim was to move towards an unscheduled care plan which would be operational throughout the year as pressures were not limited just to the winter season. The Executive Director of Workforce & Organisational Development alluded to the importance of workforce plans and differences in remuneration and career options across health and social care, with the need to ensure all parts of the system remained attractive for staff to work within.
17/229.3 It was resolved that the Board endorse the seasonal plan.
17/232 Macular Service : HM Stanley Eye Unit [Agenda item taken out of order at Chair’s discretion] Minutes Health Board Public 19.10.17 v0.03 draft 7
17/232.1 Members of the Abergele eye care team were in attendance and Mrs J Baxter (Consultant Ophthalmologist) delivered a presentation which incorporated:- • Background to the development of the macular IVT service and the treatment of age related macular degeneration (AMD) • Capacity and activity. • Waiting times and patient flow. • Evidence of the need for expansion at the unit. • Receipt of award from the Macular Society for clinical service of the year
17/232.2 A discussion ensued. Barriers to expansion of the service were discussed and it was noted these were both financial and physical in terms of the building environment. It was suggested that there could be potential for a bid through Charitable Funds and the team would look into this further. The question was asked around future technology and it was reported that whilst alternative medications were being considered by NICE, the use of injections was deemed the way forward currently.
17/232.3 The Chairman thanked the team for their attendance and congratulated them on behalf of the Board for achieving the award. He then called a lunch break with public session to be reconvened at 1.20pm
[Members of the Abergele eye care team, Mrs N Stubbins and Prof M Rees left the meeting]
17/230 Integrated Quality Performance Report (IQPR)
17/230.1 The Chairman requested a focused discussion on the IQPR due to time pressures and he reminded members that the detail within the domains had been scrutinized by the respective Committees. He also highlighted that BCU was the only Health Board in Wales to meet monthly and therefore was able to demonstrate regular scrutiny of performance at Board level.
17/230.2 The Chief Operating Officer referred to unscheduled care performance in that there had been a slight deterioration in September although the overall position remained improved upon 2016. There were four main areas of work (escalation, community, ringfenced capacity and discharge processes) all of which had action plans led by executives to ensure delivery by the end of November. The Executive Director of Nursing & Midwifery referred to a range of workshops that had been held with Ambulance Trust colleagues on pathways including falls, cardiac care and respiratory care. The Chief Operating Officer also stressed the importance a resilient workforce through working smarter and ensuring the health and well-being of staff.
17/230.3 With regards to referral to treatment it was confirmed that a plan had been put forward to improve the Board’s +36 week position by the end of the year, with the current profile being 4,237 patients waiting. Additional theatre capacity had also been sourced at Gobowen Hospital for the next six months and a bid was being put into Welsh Government around the funding of this. The Executive Director of Strategy outlined ongoing discussions regarding a range of short term solutions including the hire of mobile theatres and installation of modular theatres. The Chief Operating Officer went on to confirm that weekly performance discussions had been reinstated with regards to stroke performance, and that the 31 day target for cancer was currently being met, however, there were 16 breaches around the 62 day target. The Chairman asked that context Minutes Health Board Public 19.10.17 v0.03 draft 8 against this figure be provided, ie 16 breaches out of how many and for what reasons.
17/230.4 It was resolved that the Board note the report. 17/231 Finance Report
17/231.1 The Executive Director of Finance reminded the Board that the Month 5 report had been through the Finance & Performance (F&P) Committee on the 26.8.17 where it was discussed in some detail. He also confirmed that given the failure to realise the required improvements in the Board’s financial position, a Financial Recovery Group (FRG) had been established which had now met twice under the Chairmanship of the Health Board Chairman.
17/231.2 The Executive Director of Finance drew members’ attention to the headlines for month 5 in that the Health Board had overspent by £21.6m, £11 of this relating to the planned budget deficit of £26m approved by the Board meaning the variance against plan was a £10.6m overspend after 5 months. It was noted that unfortunately despite all the additional work and controls put in place the underlying run rate experienced in the first 5 months of the year had continued into month 6 with a deficit of £25.2m which is £12m variance from plan. The run rate reduced from around £4.5m overspend per month to £3.5m in month 6 but this was due to one offs and reprofiling issues rather than a genuine reduction in the underlying run rate. The Executive Director of Finance confirmed that the month 6 position would be discussed at the F&P Committee on the 24.10.17 but the Board should be very familiar by now with the main cost drivers for the overspend which related to • Mental Health £5.5m mainly due to Out of Area Placements (£2m), Individual Care Packages including Continuing Health Care (£2.5m) mainly around learning disabilities, nurse agency costs and undelivered savings. • Secondary Care £8.1m pay related cost pressures due mainly to unscheduled care, undelivered savings and cancer and AMD Drugs. The Executive Director of Finance reported that from a subjective basis the £10.6m was split into £4m of pay overspends (half of which was within medical staffing due to vacancies in secondary care and locums in managed practices) and £5.3m from out of Health Board care packages and placement.
17/231.3 It was suggested that board members would be familiar with the analysis of the challenges and the need to focus on holding to account the divisional actions agreed within the Financial Recovery Plan and ensuring that the series of controls and processes that flow through the organisation are complied with. The Executive Director of Finance confirmed that there was a clear scheme of delegation through the Standing Financial Instructions (SFIs) that needed to be robustly adhered to, and that the management focus needed to be on continued implementation of and compliance with control actions. He confirmed that all accountability agreements had been signed and that operational managers must concentrate on their entire budget and not just the current overspending areas as a lack of focus could lead to the emergence of unsighted issues. He gave an example of this in that a clear management focus on Mental Health Out of Area placements had seen a steady reduction in the number of out of area patients however at the same time there had been a 3% increase in individual care packages and cost of packages have increased by 8%. Low secure packages had also increased in number by 12% (7) and costs by 17% (£1.3m). It was reported that individual care packages including Continued Healthcare represented the biggest forecast financial overspend for the Mental Health division at £5m. The division were due to attend the F&P Committee to discuss individual care packages and their forecast which had increased from £5m to Minutes Health Board Public 19.10.17 v0.03 draft 9 £7.6m. The importance of adhering to the appropriate due diligence and procurement framework controls that are in place was highlighted.
17/231.4 It was confirmed that the FRG had met on the 12.10.17 and discussed the weekly cost drivers activity report, emerging issues around individual care packages and primary care prescribing. Representatives of the secondary care division had attended to discuss their financial recovery plan with members, and at the next meeting planned for the 23.10.17 an update on progress against the National Improvement Programme, prescribing pressures and recovery plans would be discussed.
17/231.5 The Executive Director of Finance reminded the Board that the Financial Recovery Plan if fully delivered would only close the gap down to around £33m,further work had been undertaken which identified a potential further £4m of savings in procurement, drugs and savings from the national pay cap. However, the forecast position for Mental Health had deteriorated by over £2m. The Board were also reminded that the current financial projections did not include the outcome of the Supreme Court Judgement in relation to Continuing Healthcare fees, and that work was ongoing to estimate the potential impact with colleagues across Wales to ensure a consistent approach. Similarly Healthcare Resource Group (HRG4+) was also excluded from the current projections as discussions continued with NHS Improvement and Welsh Government.
17/231.6 The Executive Director of Finance summarised that the underlying run rate for the Health Board had not reduced during the first six months of the financial year, although month 6 had seen some reduction due to one-off benefits. Without the divisions delivering a stepped change in terms of both the delivery of the identified savings and continuous strict budget management, the deficit for the Health Board was likely to be significantly in excess of the financial plan set. It was also noted that the current assessment assumed that any costs associated with managing winter pressures highlighted earlier on in the agenda are constrained within the £3m commitment within the financial plan and RTT performance costs incurred are funded from additional funding from Welsh Government. An early assessment of the underlying deficit position in readiness for budget setting 2018/19 would be presented to the F&P Committee but this would be in excess of the current forecast deficit. In conclusion, the Board’s financial position and performance against the financial targets had improved slightly at month 6 but was still disappointing and the underlying financial position remained extremely challenging. The Executive Director of Finance offered his professional advice that the Board would need to consider if and when it would officially revise its forecast deficit with Welsh Government. This would need to be agreed by the FRG and F&P Committee.
17/231.7 A discussion ensued. The Chair of the F&P Committee was pleased to note the savings gap was reducing but expressed concern at the significant challenges that remained and sought assurance that adherence to the application of controls was being addressed. It was confirmed that continuous messages in this regard were given but there remained some issues of accountability to work through. The Chief Executive stated that expert assistance was being sought to help the organisation meet the challenging budget for continuing health care. The Chairman indicated that the FRG would be considering further savings over and above what had already been identified and that there had been a positive and useful conversation with secondary care colleagues at the previous meeting of the FRG. The seriousness of the present financial situation was acknowledged and it was suggested that every opportunity be taken to increase staff awareness and ownership of the financial situation. Minutes Health Board Public 19.10.17 v0.03 draft 10
17/231.8 It was resolved that the Board note the report.
17/233 Information Circulated Since Last Board Meeting
It was resolved to note that a copy of the Board’s response to the White Paper consultation had been circulated.
17/234 Summary of In Committee Board Business to be Reported in Public
It was resolved to note this summary for information.
17/235 Emergency Ambulance Services Committee Confirmed Minutes 28.3.17 and Summary of Key Matters 27.6.17
It was resolved to note the information provided.
17/236 Date of Next Meeting
Thursday 16.11.17 at 10.00am in Neuadd Reichel, Bangor University.
17/237 Committee Meetings to be Held in Public Before the Next Board Meeting
The scheduled meetings were noted.
1 17.251b Summary Action Log Public_v109 2.11.17.doc
HEALTH BOARD SUMMARY ACTION LOG – ARISING FROM MEETINGS HELD IN PUBLIC
Lead Minute Reference and Action Agreed Original Update Action to Executive / Timescale be closed Member Set 21.9.17 M Olsen 17/205 Circulate timetable for key November 4.10.17 Current year plan is in place in line with the milestones in respect of elective milestones set out in the paper presented to Board in orthopaedic surgery service strategic September. Work ongoing with Welsh Government in development plan. respect of the longer term arrangements and further update will be provided via summary action log in November.
1.11.17 The Chief Operating Officer has indicated that December discussions remain ongoing with Welsh Government. 19.10.17 M Olsen 17/227.1 Provide paper on pooled November Paper provided for initial consideration as part of the in- Closed budgets committee session on 16.11.17 G Lewis-Parry 17/227.3 Ensure compliance with GDPR 30 January Added to Cycle of Business Closed be an agenda item for Trustees Board 2018 meeting G Lewis-Parry 17/227.5 Provide update to Board on December Added to Cycle of Business Closed compliance with declarations of interests and gifts & hospitality declarations G Doherty 17/227.6 Consider further how best to December 1.11.17 The Executive Director of Finance will provide a ensure the Stakeholder Reference briefing note setting out the arrangements for the R Favager Group can be assured that savings information of SRG members plans are quality assured. 19.10.17
V109 2.11.17 1 Summary Action Plan – Health Board – arising from meetings held in public 2.1 17.252 Committee and Advisory Group Chair's Assurance Reports 1 17.252a Chair's Assurance Report QSE 10.10.17 V1.0.docx
Health Board
16.11.17
To improve health and provide excellent care
Committee Chair’s Report
Name of Quality, Safety & Experience Committee Committee:
Meeting date: 10.10.17
Name of Chair: Mrs Margaret Hanson
Responsible Mrs Gill Harris, Executive Director of Nursing & Midwifery Director:
Summary of key 1. Revised terms of reference were noted with further risks and other amendments suggested for inclusion at next review. items discussed: 2. Recent PSOW Section 16 reports were noted. 3. Prison Healthcare report received with agreement that the Quality & Safety Group would monitor quality and safety within healthcare delivery at the prison, with twice yearly updates to the Committee and the ability for the Committee to receive exception reports on appropriate risks. 4. PSOW Annual Letter for 2016-17 was received. Copy is available on BCU website at http://www.wales.nhs.uk/sitesplus/861/page/85396 5. Health Protection Team (North Wales) Annual Report 2016-17 was received 6. The Committee received the report (in-committee) of the recent external review of infection prevention and control. A 90 day action plan and key performance indicators would be developed against the report for consideration by the Committee in November. Key assurances The Committee were assured that the risks relating to the Patient provided at this Administration System were mitigated and monitored through the meeting: Quality Safety Group. The Public Service Ombudsman had indicated he was comfortable with the Board’s direction of travel in terms of managing concerns and complaints in line with the NHS Duty of Candour. 1. Key risks and 1. Delays with Patient Administration System – data cleansing concerns: ongoing. 2. Further deterioration in ward staffing levels performance. A paper will be prepared early in 2018 on staffing and skill mix challenges.
3. Ongoing concerns over microbiology support to the Health Board. Special Measures Leadership and governance Improvement Framework Theme/Expectation addressed Issues to be None referred to another Committee Matters requiring None escalation to the Board: Planned business Range of standard reports plus: for the next meeting: Corporate risks Child health Listening and learning Wales Ambulance Trust patient experience Managing reduction in patient and visitor violence Mortality Tissue and organ donation annual report Date of next 7.11.17 meeting: Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board V1.0
1 17.252b Chair's Assurance Report FPC 24.10.17 v1.0.doc
1
Health Board
16.11.17
To improve health and provide excellent care
Committee Chair’s Report
Name of Finance & Performance Committee Committee:
Meeting date: 24 October 2017
Name of Chair: Mrs Marian Wyn Jones
Responsible Mr Russell Favager, Executive Director of Finance Director:
Summary of key • Performance against the Informatics Operational Plan risks and other objectives quarter 2 was reported. Concerns were noted on items discussed: delay in the work required to plan for the implementation of the Welsh Patient Administration System programme; delays due to specification issues with the Welsh Community Care Information System project and suspension of the Welsh Emergency Department system project pending conclusion of discussions with the National team and other Health Boards. • The Committee congratulated the Information Department on their highly commended recognition at the Association of Professional Healthcare Analysts annual conference in respect of their development of the Harm and Primary Care Dashboards. • The Committee received a presentation on Packages of Care in Continuing Health Care and Mental Health and Learning Disabilities. As this area was considered a primary risk to achieving financial balance, the Committee scrutinised how current process and review management was being developed and improved to address the increasing overspend. Concern was noted on the limited confidence that was provided. • The Committee received an update on the financial position for the year to date. After 6 months, the Health Board is £12.0m overspent against its planned position, bringing the cumulative deficit to £25.2m. The two main divisions of concern are MHLD (£5.5m deficit to date) and Secondary Care (£8.2m deficit to date). • Following the development of the Day 6 Finance Flash report, which was provided to Committee members, the finance report focused on two key emerging issues. The first of which related to packages of care, mainly around Learning Disability packages. The second related to primary care prescribing, and 2
in particular dressings used in the community. The risks to the year end were highlighted, along with mitigating actions. • The Committee were advised that the Health Board’s forecast will need to be reconsidered given the pressures arising within packages of care in particular, along with risks of delivery within the savings and recovery plan. At this stage, the Committee were advised that the likely outturn position was a £36m deficit, but that this position itself would be a challenge. • The Committee received an update on the financial planning for the IMTP and for the coming financial year. The broad challenges to the NHS were outlined in terms of demographics, service developments, and cost pressures. Alongside this, an initial view of the Health Board’s underlying deficit calculation was provided. While the financial challenges were assessed as signficiant, there are also significant opportunities identified through the Value work which has been undertaken to date. The Committee were advised of the challenges in developing pooled budgets with Local Authorities, given the legal challenges for Local Authorities in particular, which meant that implementing these arrangements in full by 1 April will be particularly difficult. • The Capital Programme Report was received for Month 6, outlining the current position on capital; and an update on the available capital funding for all-Wales schemes. Specifically, it was noted that Welsh Government had confirmed £500k to support the Interventional Radiology suite at Ysbyty Glan Clwyd and indicated support for additional funds to address issues of the Day Case Theatres and Endoscopy suite at Wrexham Maelor hospital. The Capital resource Limit had increased in month due to reductions for Patient Administration system and ED system following ongoing reviews in relation to system functionality and standardisation. £3.947m funding for Mental Health Anti-Ligature and Environmental Works had been received. • The Committee received the Integrated Quality and Performance Report. The committee focussed on the presentation of the Key Performance Indicators for unscheduled care, referral to treatment (RTT), diagnostics, cancer and stroke. The performance was recognised as not being at an acceptable level and it was disappointing to see deterioration in performance especially in areas that had previously improved such as stroke. The Committee scrutinised the plans for Unscheduled Care which were presented in terms of the important and sustainable work needed on the whole system under the previously prioritised themes and the urgent immediate actions needed to recover the 4 hour ED and MIU target to the 80% milestone. It was noted that many of the immediate actions will focus on the minor flows to ensure that capacity and skills can be used to avoid 4 hour breaches for patients. The 4 prioritised areas are expected to be 3 implemented by the end of November, with the exception of the BCU/WAST chest pain pathway which will be implemented in December once the telemetry is established. It was noted that the ring-fenced capacity has been implemented in the form of the Comprehensive Older Persons Assessment Unit in Ysbyty Gwynedd (YG) which will now increase in capacity from 12 to 24 beds, the Clinical Assessment Unit in Wrexham which opened on schedule and will now move to take direct HPC calls from the Ambulance stack and the Rapid Assessment plus unit in Ysbyty Glan Clwyd (YGC). The safety huddles will commence by 1st November on each site and the SAFER bundles have commenced in YGC and Wrexham and will be rolled out to YG to ensure early and senior review of patients takes place, estimated date of discharge is both implemented and senior reviews take place to support compliance with delivery of effective discharge in accordance with clinical plans. The committee noted the formal confirmation of the allocation of £13.29m had been received on the previous Friday. This is allocated specifically for RTT £11.09m, Diagnostics £1.7m and Urological Cancer £0.5m. The requirement is clear that this resource must secure the delivery of 0 over 8 week waits in diagnostics, 0 over 14 weeks in therapies and no more than 4237 patients waiting over 36 weeks from Referral to Treatment under RTT pathways and a reducing in the volume waiting over 52 weeks. Failure to deliver these outputs could result in financial claw back. The committee scrutinised the present plans and were made aware of the following risks: a) 250 orthopaedic cases within the profile not included in the resource b) Risk to delivery of core activity in Wrexham following the loss of the day case facility. This affects both the RTT and diagnostic elements of the delivery. Mitigating actions were outlined including the re-location of ophthalmology elective day case surgery to Robert Jones Agnes Hunt (RJAH) new theatre with effect from 25.10.17. for 6 months, 3 session days and weekend working in the main theatres, pan BCU working and the procurement of 2 modular theatres. The costs associated with these, plus the need to recover existing lost capacity since the closure are in the order of £2.1m and subject of further discussion with Welsh Government. c) Risk to delivery of core activity. The Committee were reminded that moving from the original profile of 11,770 at the end of March to 9,300 is dependent on a clinically- engaged improvement in cohort management so as to improve proportion of present activity undertaken on longest waiting patients. This work has been slow to show impact, however the new clinical directors on each site have been appointed within the last two weeks and therefore early discussion with these key individuals is expected to provide 4
greater clinical leadership • The Committee approved the reviewed Performance Appraisal and Development Review (PADR) Policy for Agenda for Change Staff. A range of workforce guidelines and procedures were noted, of which the importance of the new Exit Interview procedure and questionnaire was particularly welcomed for the potential of organisational learning. • The Information Governance Annual report 2016/17 and updated Committee Terms of Reference were received. Key assurances • Progress against the IM&T operational plan provided at this • Progress to address the challenges within packages of care, in meeting: particular around Learning Disabilities • Actions taken to address the financial position • Progress against Capital schemes • Actions taken to address improvements required in unscheduled care and RTT performance Key risks and • Financial position and forecast outturn, in particular surrounding concerns: packages of care and the delivery of savings and recovery actions • Performance on unscheduled care and RTT trajectory • Capital availability remains a concern • Ysbyty Glan Clwyd capital scheme. Special Measures • Governance and Leadership themes Improvement Framework Theme/Expectation addressed Issues to be None referred to another Committee Matters requiring • Financial position escalation to the • Unscheduled care and RTT Board: Planned business Range of regular reports plus for the next • Workforce Intelligence report meeting: • External Contracts update • Nurse staffing report • Recruitment update report • Performance Assurance and Management Framework • National delivery plan and future plans Date of next 21 November 2017 meeting:
Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
V1.0 1 17.252c Chair's Assurance Report FRG 12.10.17.doc
1
Health Board
16.11.17
To improve health and provide excellent care
Committee Chair’s Report
Name of Finance Recovery Group Committee: Meeting date: 12.10.17
Name of Chair: Dr Peter Higson
Responsible Mr Russell Favager, Executive Director of Finance Director:
Summary of key • The weekly cost drivers activity report was scrutinised – significant risks and other efforts to reduce agency spend were noted items discussed: • The Month 6 flash report was scrutinised – it was noted that the agency cap, if applied across the board, would save £2.5. million. • The Secondary Care team attended to present further detail on the work being undertaken to reduce the deficit and further plans to make savings – medicines management was highlighted as a key area where savings could be made eg; using bio-similars to reduced prescribing costs.
Key assurances Via the FRG’s fortnightly meetings, a process is now up and running to provided at this seek assurance and more closely monitor progress against financial meeting: recovery plans.
Key risks and Medicines management - the team has been invited to the next concerns: meeting for further scrutiny.
Issues to be None. referred to another Committee Matters requiring None. escalation to the Board: Planned business Medicines management. for the next meeting:
Date of next 14.11.17. meeting:
Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board 1 17.252d Chair's Assurance Report FRG 23.10 17.doc
1
Health Board
16.11.17
To improve health and provide excellent care
Committee Chair’s Report
Name of Finance Recovery Group Committee:
Meeting date: 23.10.17
Name of Chair: Dr Peter Higson
Responsible Mr Russell Favager, Executive Director of Finance Director:
Summary of key The Pharmacy team/ Medicines Management attended to present risks and other further detail on the work being undertaken to reduce the deficit and items discussed: further plans to make savings –e.g. using bio-similars to reduce prescribing costs.
Key assurances The Pharmacy team/ Medicines Management are on track to deliver provided at this the Month 6 Savings PRG of £7.596m meeting: Key risks and To work more collectively together as an Executive Team. concerns: (Morag Olsen, Martin Jones, Adrian Thomas and Evan Moore invited to next meeting).
Issues to be None. referred to another Committee Matters requiring None. escalation to the Board: Planned business To invite members of the Executive Team (as set out in key risks and for the next meeting: concerns above)
Date of next Tuesday 14.11.17. meeting:
Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
1 17.252e Chair's Assurance Report R&TS 16.10.17.doc
1
Health Board
To improve health and provide excellent care
Committee Chair’s Report
Name of Remuneration & Terms of Service (R&TS) Committee Committee:
Meeting date: 16.10.17
Name of Chair: Dr P Higson, Chairman
Responsible Mr J M Jones, Executive Director of Workforce & Organisational Director: Development
Summary of key • The Committee noted its revised terms of reference, risks and other including standard wording relating to the Well-being of items discussed: Future Generations Act and a paragraph on ensuring that the Chair of the Finance & Performance Committee Chair is sighted on relevant delegated matters, which had already been approved by the Board. • The Committee received a Welsh Government July 2017 report on Senior Manager pay across the Welsh public sector • An Internal Audit report was discussed in committee and further work was allocated to the Audit Committee in respect of this item • A list of individuals in displaced positions was reviewed. • A report on individuals receiving pay protection was reviewed. • A Voluntary Early Release Scheme application was considered and approved.
Key assurances • BCUHB is not an outlier in respect of senior manager pay, provided at this and compares well compared to other organisations on meeting: aspects such as gender. • The small number of displaced staff (9) was noted and the Committee was assured that all were actively engaged in various roles within the Health Board. • It was noted that efforts were ongoing to secure posts at an appropriate level for members of staff receiving pay protection. The majority of staff receiving protection were in the lowest payment bracket. A new Organisational Change Policy is now in place.
2
Key risks and Further work and assurance will be required in respect of the concerns: Internal Audit report.
Special Measures • Leadership Improvement • Governance Framework Theme/Expectation addressed Issues to be referred to another The Internal Audit report has been referred to Audit Committee. Committee Matters requiring None. escalation to the Board: Planned business for the next Scrutiny of job planning. meeting: Date of next 23.1.18 meeting:
Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
V0.01
2.2 17.253 Mental Health Act 1983 as amended by the Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions 2008. Update of Register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales) - Mr Gary Doherty 1 17.253 Approved Clinicians Section 12.docx
Health Board
16.11.17
To improve health and provide excellent care
Title: Mental Health Act 1983 as amended by the Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions 2008. Update of Register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales)
Author: Mrs Heulwen Hughes All Wales Project Support Manager for Approved Clinicians and section 12(2) Doctors
Responsible Dr Evan Moore, Executive Medical Director 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’ 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 information is collated by the All Wales Project Support Team and Scrutiny Route register updates are submitted directly to the Board.
Purpose: Betsi Cadwaladr University Health Board is the Approval Board for Approved Clinicians and Section 12(2) Doctors in Wales and as such, receives regular register updates.
Significant issues Register updates are presented for Section 12(2) Doctors and and risks Approved Clinicians for 31.12.15-26.1.16 and for 27.1.16-25.2.16
Special Measures Leadership and Governance Framework Strategic and Service Planning addressed Equality Impact No equality impact assessment is considered necessary for this update Assessment paper. Approval Process is part of Legislative process.
Recommendation/ The Board is asked to ratify the attached list of additions and removals Action required by to the All Wales Register of Section 12(2) Approved Doctors for Wales the Board and the All Wales Register of Approved Clinicians.
Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
Update of Register of Approved Clinicians and Section 12 (2) Approved Doctors for Wales 19th August 2017 – 15th October 2017 AC S12 (2) Approvals and Re- 9 7 approvals Removed – Expired 1 2 Approvals suspended – *8 NA yearly evidence not submitted as no longer working in Wales Approvals re-instated – 1 NA yearly evidence submitted late Approval Ended 2 1 Removed – AC approved NA 10 No longer registered 0 Transferred from AC NA 0 register No longer working in See above * 3 Wales Mental Health Act 1983 as amended by the Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions Update of Register of Approved Clinicians for Wales
19th August 2017 – 15th October 2017
Approvals and re-approvals – 9
Surname First Name Workplace Expiry Date Nash Jon Delfryn House Independent Hospital, Argoed Hall Lane, Mold, 04 September 2022 Flintshire CH7 6FQ Rao Ranjini Gwent Specialist Substance Misuse Service, Maindiff Court Hospital, 06 September 2022 Abergavenny, Gwent NP7 8NF Ingley Sanjay Older Person's Mental Health Team, Wepre House, Civic Way, Wepre 10 September 2022 Drive, Connah's Quay, Deeside, Flintshire CH5 2HA Feeney John Thomas (aka North West Wales Forensic Service, Ty Llywelyn MSU, Llanfairfechan 14 September 2022 Sean) LL33 0HH Ramachandran Jayalakshi Ty Garngoch Hospital, Hospital Road, Gorseinion, Swansea, SA4 4LH 17 September 2022 Chugh Sanjay Kumar Trehafod Child and Family Clinic, Trehafod, Waunarlwydd Road, 18 September 2022 Swansea SA2 0GB Hunter Stephen Llanarth Court Hospital, Raglan, Abergavenny, Monmouthshire, NP15 19 September 2022 2AU Biswas Mridul Mental Health Unit, First Floor, Keir Hardie Health Park, Aberdare 26 September 2022 Road, Merthyr Tydfil. CF48 1BZ Shooter Ben Bronllys Hospital, Brecon Road, Bronllys, LD3 0LS 11 October 2022
Approvals expired – 1
Surname First Name Workplace Expiry Date Nair Akshey Caebryn, Prince Philip Hospital, Llanelli, SA14 8QF 17 September 2017
Approvals suspended – yearly evidence not submitted as no longer working in Wales – 8
Surname First Name Workplace Expiry Date Khan Muhammad Priory Hospital, Church Village, Church Road, Tonteg CF38 1HE 23 August 2020 Shameel Faluyi Yetunde Opeyemi Wepre House, Wepre Drive, Civic Way, Connahs Quay, Flintshire CH5 5 October 2020 4HA Badr Kamal Hamadryad Centre, Hamadryad Road, Butetown, Cardiff, CF10 5UY 14 May 2020 Holub David North CMHT, Unit 22, The Laxin Industrial Estate, Rhymney NP22 12 September 2020 5PW Govindaswamy Kayalvizhi Kannan Ty Catrin, Dyfrig Road, Cardiff CF5 5AD 29 September 2020 Sen Gupta Arup Kumar Ystradgynlais Hospital, Glanrhyd Road, Ystradgynlais, Swansea SA9 3 October 2021 1UA Adusumilli Yugandha Hergest Unit, Ysbyty Gwynedd, Bangor 3 October 2021 Windgassen Everard Jacob New Hall Independent Hospital, New Hall Road, Ruabon, Wrexham 10 October 2021 LL14 6HB
Approval re-instated – yearly evidence submitted late 1
Surname First Name Workplace Expiry Date Obeid Tarig Bronllys Hospital, Bronllys, Brecon LD3 0LU 22 April 2020
Approvals Ended – 2
Surname First Name Workplace Expiry Date Badr Kamal Hamadryad Centre, Hamadryad Road, Butetown, Cardiff 14 May 2020 CF10 5UY Kerr Mike Learning Disabilities Directorate, Treseder Way, Caerau, Ely, CF5 17 September 2017 5WF
Mental Health Act 1983 Update of Register of Section 12(2) Approved Doctors for Wales 19th August 2017 – 15th October 2017
Approvals and Re-approvals – 7
Date Approval Surname First Name Workplace Expires Withecomb Julie Louise Ty Llidiard, Princess of Wales Hospital, Coity Road, Bridgend CF31 1RQ 04 October 2022 Howe Gareth David Hafod y Wennol Assessment and Treatment Unit, Hensol, Pontyclun 03 September 2022 CF72 8JY Barrattshaw Stephen Marc Hafan y Coed, Llandough University Hospital, CARDIFF CF64 2XX 31 August 2022 Pearson Laura Jayne Cefn Coed Hospital, Cockett, Sketty, Swansea SA2 0GH 30 August 2022 Rhydderch Danielle Claire Gwelfor, Cefn Coed Hospital, Waunarlwydd road, Cockett, Swansea SA2 29 August 2022 0GH Krishnaraaj Rameshraj Hafan Wen Ward, Wrexham Maelor Hospital, Wrexham LL13 7TD 02 October 2022 Mostafaie- Majid Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 2PW 20 September 2022 Mehr
Removed – Expired – 2
Date Approval Surname First Name Workplace Expires Bright James Ablett Unit, Glan Clwyd Hospital, Rhyl, Denbighshire LL18 5UJ 28 August 2017 Howe Gareth David Hafod y Wennol Assessment and Treatment Unit, Hensol, Pontyclun 18 September 2017 CF72 8JY
Removed – Ended – 1
Date Approval Surname First Name Workplace Expires Samin Kashif Blaenau Ffestiniog Health Service Centre, Wynne Road, Blaenau 15 November 2020 Ffestiniog LL41 3DW
Removed – AC approved – 10
Date Approval Surname First Name Workplace Expires Chugh Sanjay Ty Bryn, St Cadoc Hospital, Lodge Road, Caerleon NP18 3XQ 29 March 2022 Badr Kamal Whitchurch Hospital, Park Road, Whitchurch, Cardiff, CF14 7XB 12 August 2019 Briggs Patrick Mental Health Wellbeing Unit, Princess of Wales Hospital, Coity Road, 07 January 2020 Bridgend CF31 1RQ. Locum Millington Malcolm Ty Helyg, Bronglais Hospital, Caradog Road, Aberystwyth, SY23 1ER 27 July 2021 Griffiths Mark Andrew Ty Bryn, St Cadocs Hospital, Lodge Road, Caerleon, Newport NP18 3XQ 06 April 2021 Watkins Lance Vincent Royal Glamorgan Hospital, Ynysmaerdy, Pontyclun, CF72 8XR 12 August 2019 Sinivasalu Padmavathy Y Delyn, West Wales General Hospital, Dolgwilli Road, Carmarthen, SA31 01 September 2018 Gopinath 2AF Peter Lionel Cajetan Savio St Cadocs Hospital, Lodge Road, Newport, NP18 3XQ 19 October 2019 Adrover Maria del Mar Hafod y Wennol Unit, Hensol, Pontyclun CF72 8YS 05 May 2019 Amengual Duffin-Jones Benjamin Andrew Caswell Clinic, Glanrhyd Hospital, Tondu Road, Bridgend CF31 4LN 31 October 2017
No longer registered – 0
Date Approval Surname First Name Workplace Expires
Transferred from AC Register – 0
Date Approval Surname First Name Workplace Expires
No longer working in Wales – 3
Date Approval Surname First Name Workplace Expires Shamim Aamer Glan Clwyd Hospital, Bodelwyddan 18 November 2017 Binnamangala Somashekar Taliesin Ward, Hergest Unit, Ysbyty Gwynedd, Penrhosgarnedd, Bangor 23 June 2021 Siddappa LL57 2PW. Locum Menzies Pia Jane Ty Bryn Unit, St Cadoc's Hospital, Caerleon, Gwent, NP18 3XQ. 12 November 2017
3.1.1 17.254.1 Integrated Quality & Performance Report - Ms Morag Olsen 1 17.254.1a IQPR Coversheet Board - September 2017.docx
1
Health Board 16.11.17
To improve health and provide excellent care
Title: Integrated Quality & Performance Report
Author: Dr Jill Newman, Director of Performance
Responsible Ms Morag Olsen, Chief Operating Officer 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 / Scrutiny Four sections of the report have had prior scrutiny with the Finance & Route Performance committee and three sections have had prior scrutiny by the Quality Safety and Experience committee.
Purpose: This report provides the Board with a summary of key quality, performance, financial and workforce indicators.
Significant issues The integrated quality and performance report for June 2016 includes: and risks • National Indicators aligned to the seven national performance domains • Locally agreed indicators aligned to the performance domains
Many of our information sources are reliant upon good, accurate and reliable information systems. In the month of November, our acute site at Ysbyty Glan Clwyd t(YGC) ransferred to a new computerised Patient Administration System. We have highlighted this within the report and in some cases we advise caution whilst work continues to validate the information. Refreshed and updated information will be published in future reports. A weekly issues group, chaired by the Director of Performance has been established with a view to addressing the data
2 quality issues by the end of 2017.
National Targets
Improved Sustained Decline in Domain Performance Performance Performance
Staying Healthy 0 3 3
Safe Care 1 1 3
Effective Care 0 2 6
Dignified Care 0 0 1
Individual Care 0 1 3
Timely Care 4 2 12
Staffing and 4 0 2 Resources
Total 9 9 30
Local Targets
Improved Sustained Decline in Domain Performance Performance Performance Staying Healthy 1 0 0
Safe Care 10 2 5
Effective Care 1 0 4
Dignified Care 1 1 1
Individual Care 3 0 5
Timely Care 5 1 1 Staffing and 3 0 1 Resources Total 24 4 17
Staying Healthy
Financial Balance, Unscheduled Care (USC) and Referral to Treatment (RTT) performance was moved to Welsh Government
3 targeted intervention in August 2017.
The USC performance fell to 78.4% in September 2017, and it is unfortunate that we weren’t able to sustain the 80% rate achieved in August 2017. Work continues on the four key unscheduled care system-wide work-streams with Executive leadership implemented during August 2017 to drive forward prioritised improvement work. Given the continuing concerns during October additional immediate actions were taken to improve performance, focussing on ensuring patients with minor conditions can be treated and leave ED within 4 hours. The 30th and 31st October are being used to “jolt” the whole system, aiming to address flow across the whole system so as to enable improvement to be delivered as we move into November.
The RTT end of year internal profile has been revised to improve the year end over 36 week position to 4237 following confirmation of £13.29m from WG.Work has been undertaken in-month to prepare additional delivery plans in the expectation of capacity being created for circa 19,000 additional patient contacts resulting in circa 5000 additional long-waiting patients receiving treatment during this year. Recovery work has commenced following the closure of the day case unit in Wrexham. The dedicated work of staff has enabled the ophthalmology elective day case service to be temporarily re-located to a new theatre commissioned at RJAH. Theatre lists commenced at this location on 26.10.17..
Diagnostic services have been challenged to sustain the 8 week access time during September 2017. A number of operational issues have resulted in an increased number of breaches seen in endoscopy, and radiology. Neurological breaches reduced due to the recovery of 8 weeks for nerve conduction studies, however breaches still exist for EMGs. Endoscopy breaches are attributable to: contractual delay to activation of the insourcing for endoscopy following the recent procurement, estate issues resulting in the closure of an endoscopy suite and WPAS set up codes for diagnostic waiting list management. Radiology breaches arise from late cancellation of insourced ultrasound provision at the end of the month and demand increases for additional cardiac MRI tests. Actions are being taken forward to address these and a recovery plan is being put in place. The consultant neurophysiologist took up post in September and will focus on recovery to 8 weeks by December 2017 for these procedures.
Cancer performance showed continued improvement in September, delivering the 31 day NUSC target. However, performance against the 62 day target fell to 89.2%. Challenges remain in providing sustainable service capacity in colorectal clinics and for urological cancer surgery. The straight-to-test work to support colorectal was implemented in September 2017 at Ysbyty Glan Clwyd (YGC) which enables all 3 sites to offer this service. Additional Urological Cancer surgery is being offered via capacity commissioned at both Wirral and Liverpool robotic
4 services.
Staying Healthy
Although performance against both Admission and Readmission of patients within the basket of 8 chronic conditions, has dropped slightly in June 2017, performance is still well within the target thresholds. There has been a consistent fall in the number of both admissions and readmissions month on month. The data published via the Chief Executive Officers (CEO) Papers demonstrates that the Health Board continues to be the best performer in Wales with regards both of these measures. Exception Reporting against these two measures has been stepped down until such a time as performance deteriorates beyond the target thresholds.
The Annual Flu vaccination programmes were launched in September 2017. Covering the ‘at risk’ groups, and the Health Board’s Staff Flu campaign, sessions are now underway to ensure the uptake targets set are reached, and performance is higher than last year so as to protect our population and our staff. There is a strong communication strategy which aims to increase take-up and the campaign increases accessibility through the use of local vaccinators. The first set of data from this year’s campaign will be made available in the October report.
Safe Care
A Never Event was reported in September 2017. This event occurred when a foreign object was left within a wound during an operative procedure. The event is being thoroughly investigated by the Health Board and in partnership with Welsh Government’s Delivery Unit. Further details regarding this event can be found on page 24.
The focus, effort and actions put in place to reduce the number of Healthcare Acquired Pressure Ulcers (HAPU) continues to deliver reductions in the number of HAPUs recorded, with 22 reported in September 2017, compared to 33 in August 2017. The details of what is being done to achieve the planned number by the end of Quarter 2 2017/18, and strive to achieve the national target of 20 or less by the end of March 2018 can be seen on page 20.
Unfortunately, the number of C.Difficile cases reported across the Health Board rose from 16 cases in August to 29 cases in September. However, there were 2 cases of MRSA reported in September 2017, compared to 4 in August 2017.There was also a slight rise in the number of MSSA, reporting 14 in September 2017 compared to 13 in August 2017. Further details of what the Health Board is doing to tackle infections can be seen on pages 21 to 23.
Risk Adjusted Mortality (RAMI) – a newly revised indicator is being provided by CHKS from December 2017. The present indicator will
5 cease to be available from November. The new indicator reflects that age and length of stay are key factors in predicting outcomes for patients and uses these more strongly in calculating the index. The early intelligence suggests that the revised RAMI figure will be significantly lower than the present index figure reported.
Effective Care
In July 2017, 38.7% of episodes were clinically coded within 1 month of the episode end date. A slight dip of 1.5% from June 2017, at 40.2%. Although performance has dipped slightly, the additional resources and actions put in place in the last few months are beginning to bear fruit and month on month improvement should be consistent from now on. The backlog continues to affect accurate and timely reporting of other measures such as admissions for chronic disease, mortality and day-case rates. Despite additional resources being put in place, due to the oldest episodes being cleared first, we do not expect to achieve the target rate until Quarter 2 or 3, 2018/19. Further details can be found on page 39.
Individual Care
In September 2017, the number of patients experiencing delays in their Transfers of Care (DToC) rose to 107 compared to 87 in August 2017. This has reduced in the October Census figures which will be reported next month. Although the actions and processes being put in place over the last few months are working, difficulties in securing places with 3rd party provides continues to compound patient flow. As stated with last month’s improved position, improvements should be noted with caution, as sustainability is proving challenging, given the increasing difficulty being reporting in recruiting staff to provide care packages. In Mental Health, the reporting methods of DToC are being investigated and corrected. This work enabled complete reporting to be in place for the October census date and as expected resulted in an increase in the reported patient numbers and occupied bed days. An update will be provided to the committee of the outcomes in next month’s paper. Details of what the services are doing to reduce DToCs can be found on page 44.
In September 2017, the number of patients leaving our Emergency departments without being seen increased slightly to 8.6% compared to 8.2% in August 2017 (still just above the target threshold of 8%). Wrexham Maelor Hospital (WMH) continues to be the outlier with regards this measure and details of what is being done to reduce the number of patients leaving ED without being seen can be found on page 48.
The un-validated position across the Mental Health measures demonstrate a drop in performance against all but one measure in September 2017. In future months it is intended to report this data only
6
when validated as frequently the validations demonstrate improved performance at or close to the target level. Further details can be seen on pages 45 to 47.
Dignified Care The number of Inpatient Cancellations rebooked within 14 days has deteriorated further in September 2017 with only 7% of patients undergoing their procedure within 14 days of being cancelled more than once. It is unclear if this is a data quality issue or the true position, and this is being investigated. Further information can be found on page 51.
Timely Care The Health Board has submitted the Referral to Treatment trajectories for 2017/18 post confirmation of the additional £13.29m allocation from Welsh Government. Internal and external additional capacity is being implemented in line with this trajectory so as to deliver the improved year end position. The volume of patients waiting over 36 weeks slightly better than the expected profile position based on the revised end of year position. More detail is on page 57.
Our Emergency Departments saw performance deteriorate through September 2017 for both the 4 and 12 hour measures at 78.4% and 1,170 respectively. Performance on the unscheduled care system overall remains a major concern for the Health Board, requiring rapid improvement. Work continues on the four prioritised work streams with Executive Director leadership to ensure focus on those areas likely to have greatest impact for our patients. The Delivery Unit are providing interventional support to the Health Board and a national summit with Welsh Government was held in June 2017. Further information around our Emergency Department waiting times can be found on pages 59 & 60.
Our Staff & Resources
Staff sickness fell slightly by 0.1% in August 2017 to 4.73% (the second best performing Health Board in Wales against this measure). For more information, turn to page 71.
The financial position of the Health Board has required the development of a detailed recovery plan with targeted support being provided from Welsh Government. Full details are provided in the Director of Finance reports.
Special Measures This paper supports the revised governance arrangements at the Improvement Health Board and supports the Board Assurance Framework by Framework Theme/ presenting clear information on the quality and performance of the care Expectation the Health Board provides. It also addresses key indicators for mental addressed by this health and primary care.
7 paper Equality Impact The Health Board’s Performance Team are establishing a rolling Assessment programme to evaluate the impact of targets across the Equality & Diversity agenda.
Recommendation/ The Board is 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
Board Coversheet v8.0 June 2016
1 17.254.1b IQPR.pdf 1
Integrated Quality & Performance Report 2017/18
Performance to the end of September 2017 Health Board
To improve health and provide excellent care Table of Contents 2 Mental Health Assessment and Title 1 New Never Events 23 45 Achievements Staff Resources 67 Therapy – Child & Adolescent Welsh Government Reportable Table of Contents 2 24 MHM Care & Treatment Plans (Part 2) 46 Staff & Resources National Summary 68 Incidents Foreword 3 Incidents 25 Left ED Without Being Seen 47 Staff & Resources Local Summary 69
Status Guide 4 Patient Safety Alerts 26 Achievements Dignified Care 48 Sickness 70
Monthly Comparison Table (Board) 5 Patient Safety Notices 27 Dignified Care Summary 49 Financial Balance 71
Summary: Unscheduled Care: ED KPI 6 Complaint Acknowledgement 28 Inpatient Cancellations 50 Outpatient DNA 72
Summary: Unscheduled Care: DToC 7 Complaint Response 29 Outpatient Cancellations 51 Appraisals (Non Medical) PADR 73
Summary: Referral to Treatment (RTT) 8 ITU Delayed Transfers 30 Achievements Timely Care 52 Mandatory Training 74 Summary: 8W Diagnostic and Therapy 9 Caesarean Section 31 Timely Care National Summary 53 Agency and Locum Spend 75 Waits Summary: Cancer Care 10 Ward Quality Audit 32 Timely Care Local Summary 54 Operating Theatres 76
Summary: Stroke Services 11 Safe Staffing 33 GP Opening Times 55 Hospital Activity - Year to Date 77
Achievements Staying Healthy 12 Achievements Effective Care 34 Referral To Treatment 56 Hospital Activity - Year to Date 78
Staying Healthy National Summary 13 Effective Care National Summary 35 Diagnostic Waiting Times 57 Appendix A – Further Information 79
Staying Healthy Local Summary 14 Effective Care Local Summary 36 Emergency Department Waits 58
My Health Online 15 Mortality Measures 37 ED Waits over 12 Hours 59
Achievements Safe Care 16 Data Quality 38 Ambulance Handover Times 60
Safe Care National Summary 17 Community Average Length of Stay 39 Non Urgent Suspected Cancer 61
Safe Care Local Summary 18 Achievements Individual Care 40 Urgent Suspected Cancer 62
Healthcare Acquired Pressure Ulcers 19 Individual Care National Summary 41 NHS Dental Access 63
C.difficile infections 20 Individual Care National Summary 42 Stroke Pathway 64 Delayed Transfers of Care Non-Mental Staph Aureus infections 21 43 Follow Up Waiting List 65 Health Mental Health Assessment & Therapy MRSA and MSSA infections 22 44 Out Of Hours 66 Adult
Performance Report September 2017
Page 2 3 Foreword
Seven Domains We present performance to the Board using the frameworks against which NHS Wales is measured. This report includes the indicators from the seven domains of; Staying Healthy, Safe Care, Effective Care, Dignified Care, Individual Care, Timely Care and Our Staff and Resources.
The first three domains of Staying Healthy, Safe Care, Effective Care are scrutinised at the Quality, Safety & Experience committee. The Individual Care domain has shared scrutiny, with some indicators being scrutinised by the Quality, Safety & Experience committee and the remaining indicators being scrutinised by the Finance & Performance committee. The final three domains of Dignified Care, Timely Care and Staffing & Resources are scrutinised by the Finance and Performance Committee.
Computerised Patient Administration System at Glan Clwyd Hospital A significant number of data related issues have been identified with the Central Area patient Administration System (WPAS). These can be categorised as user error or system configuration issues. They are now being addressed as a matter of urgency via the Programme Board. Any significant trends in activity or waiting lists since November 2016 should be scrutinized.
Introductory Reports & Exception reports Each new local indicator has an introductory report that gives the context of the indicator. We include exception reports where performance is either worse than the required standard or the Board require sight of the actions we are taking to maintain or improve performance. After we have achieved an indicator for three consecutive months, it will be stood down from exception reporting.
We have moved to the use of bar charts in the exception slides to show month-on-month performance. Performance Report September 2017
Page 3 4 Status Guide Performance Against Plan & Escalation Status Update
The Health Board received the National Delivery Framework for 2017/18 during April 2017. This framework will be used by Welsh Government as part of its performance framework and aligned to the escalation framework of Welsh Government. The indicators within this framework take precedent over previous indicators and those submitted to WG as part of the 2017/18 Operational plan. A separate paper is included in this month’s report that addresses the mechanism being used to incorporate new or revised indicators in future IQPR reporting. The current measures, used in this report for assessing performance are shown below. Green Performance is better than the target level
Red Performance is worse than the target level
Cross- Cross-hatch background. Where the background is cross-hatched this figure is the provisional, 90% hatch unvalidated position. No target level or the trajectory has not been set. This is used for new indicators which we are - No Target introducing into the report. The relevant executive director has been asked to set the target level.
Arrow and Performance against Plan
This report uses arrows to show if the position has become better or worse than the previous month. Where the arrow is coloured, green signifies that performance is better than where we planned to be this month, whereas red signals that we are worse than where we planned to be this month. Black indicates no profile plan has been set. The way we measure performance against plan is also being revised by the group noted above. ↑ The value is better than the previous month → The value is the same as the previous month ↓ The value is worse than the previous month
Performance Report September 2017
Page 4 (Board)
5 Comparison with Last Report Comparison
The two tables below show the levels of performance compared to the last reported period in the report, usually this is last month’s position, but in some cases it is the previous quarter or year. Within this summary table, only the indicators for the Board are shown.
National Indicator Summary Local Indicator Summary
Improved Sustained Decline in Improved Sustained Decline in Domain Domain Performance Performance Performance Performance Performance Performance
Staying Healthy 0 3 3 Staying Healthy 1 0 0
Safe Care 1 1 3 Safe Care 10 2 5
Effective Care 0 2 6 Effective Care 1 0 4
Dignified Care 0 0 1 Dignified Care 1 1 1
Individual Care 0 1 3 Individual Care 3 0 5
Timely Care 4 2 12 Timely Care 5 1 1
Staffing and Staffing and 4 0 2 3 0 1 Resources Resources
Total 9 9 30 Total 24 4 17
Performance Report September 2017
Page 5 Summary Report: Emergency Departments 6
Following discussions with Welsh Government (WG) during Additional Immediate Actions from mid-October: October 2017 actions have been prioritised, reduced and themed into 4 key work streams with Executive and operational leads identified:
1. Escalation – Led by the Executive Medical Director and includes Safety Huddle supported by the Delivery Unit (DU) ENP – 8am to 2am ( 7 days/week) 2. Community – Led by the Executive Director of Nursing Protecting minors space and capacity (and if necessary and includes 4 main conveyance pathways, MIU and identify another area) interface with clinical desk, 111, GP OOH Extending scope of practice where it is safe to do so 3. Discharge Processes – Led by the Executive Director of Therapies and Health Sciences and includes SAFER Clinical validation (look forward and look back for bundle, discharge planning October) 4. Ring-fenced capacity – Led by the Chief Operating Wider circulation of robust weekday and weekend site Officer and includes assessment unit functions and specific plans. Introduce loop learning to reflect back impact, redesign of assessment unit functions moving on plans and their success forward with primary care. Shift of medical and nursing workforce to match demand profile DU continue to work closely with execs and operational teams on the development of the safety huddles Progress chaser between 8am and midnight, 7 Additional immediate actions needed with the objective of days/week achieving 80% compliance against ED target combined with Hold clinical and management teams for every respective MIU. To support this achieve 100% minors avoidable ED patient breach performance (all greens) on all sites.
Performance Report September 2017
Page 6 Summary Report: Delayed Transfers of Care (DToC) 7
Delayed Transfers of Care (DToC) showed an improvement at the census date in October 2017 with 6 fewer patients and 62 fewer bed days delayed. The improvement in non-mental health delays was significant with a reduction of 16 patients and 821 bed days delayed. Improvement is particularly noted this month in the delays due to healthcare assessment which reduced from 29 last month to 10.This is set in the context of local authority partners reporting increasing difficulty in providers staffing care packages, especially where double-handed packages of care are required.
The increase in MH delayed transfers of care is largely accounted for by the correction of historical under-reporting in the West. From this month, submissions are complete across all sites. Retrospective look back indicates a deficiency of 9 patients per month in previous reports.
Performance Report September 2017
Page 7 Summary Report: Referral to Treatment (RTT) 8
Current position Against Trajectory Actions
September position > 36 wks.: 9280 – performance • Delivery of Core activity including efficiencies 9066 (All Residents) better than trajectory • Management of Treat out of Turn 8982 (Welsh residents) • Clinical leadership of variation in clinical variation • Recovery plan for Wxm DCU includes use of RJAH for ophthalmology, 3 session days and plan for 2 modular >52 wks.: 2391 – theatres. 2504 (All residents) of which 71.6% Performance worse • Improved validation and resolution of WPAS issues at YGC orthopaedics than trajectory • Confirmation of £13.29m resource for RTT, Diagnostic and 2491 (Welsh residents) Urological Cancer additional activity • Additional actions scheduled and being performance managed 79.9% under 26 weeks Target 95%
Performance Report September 2017
Page 8 Summary Report: 8W Diagnostic and Therapy Waits 9
Target September 2017 Position Issues Actions 8 444 Increase noted due to: • Modular theatre Wxm weeks Deterioration of 100 since end of August a) Endoscopy – • Outsourcing sessions and 2017 Wrexham DCU contract review loss of service • YG endoscopy recovery Profile 0 capacity expected by end Nov b) Endoscopy – • NCS back on schedule insourcing contract • EMG recovery by end of delay Dec c) EMG recovery plan • Cardiology/Radiology till Dec 2017 discussions we additional d) Radiology – activity and resource shift cancellation of US underway lists in last week of • Radiology using month framework agreement for e) Radiology – additional US capacity cardiology service demand increased
Performance Report September 2017
Page 9 Summary Report: Cancer Care 10
Target Delivered Issues
31 Days 98.8% Challenges: 98% • Colo-rectal YGC consultant sickness – seeking to recruit 62 Days 89.2% locum, continuing to transfer patients East and West, 95% Straight to Test to reduce OPD clinic requirements. 15 breaches. • Colo-rectal and Upper GI – Endoscopy reduction due to Day case closure in Wrexham, re-provision in main 4 patients were on complex theatre, addition to lists, insource tender for weekend diagnostic pathways; working. Remaining 11 breached due to delays to: • Urology surgery – additional capacity started to be used in Liverpool. 9 patients referred to date. • urology surgery (4) • first appointment (5) • oncology appointment (2) • endoscopy (1)
Performance Report September 2017
Page 10 Summary Report: Stroke Services 11
Performance has deteriorated on the quality improvement measures during September 2017 and variation between the three sites is noted with YGC delivering the highest performance on access to the stroke bed within 4 hours and Wrexham the highest thrombolysis rates across the health board. The SSNAP report for April to July 2017 shows YGC and Wrexham retaining their C level of performance, while YG deteriorated to a D.
• Re-escalated QIM performance – weekly performance reviews commenced 6.10.17. • Peer Review Action Plan being managed via the North Wales Stroke Clinical Collaborative established July 2017 and chaired by Area Director East to ensure whole system approach. • Weekly site specific clinical governance meetings set up. • Living Well Staying Healthy – Service Model review to be included in October Board report with full reporting in Jan 2018. • Comprehensive Stroke Care model of Prevention, FAST, HASU, ASU, Rehabilitation, ESD, Life after stroke.
<= 4 Hours Care Performance Indicator 100.0% 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0%
10.0%
Jul-16 Jul-17
Jan-17
Jun-16 Jun-17
Oct-16
Apr-16 Apr-17
Sep-16 Feb-17 Sep-17
Dec-16
Aug-16 Aug-17
Nov-16
Mar-17
May-16 May-17
West Central East BCUHB Total
Performance Report September 2017
Page 11 12 Our Achievements - Staying Healthy I am well informed & supported to manage my own physical and mental health
Praise for support service helping people live with dementia and their carers
People living with dementia and their carers are receiving better support following diagnosis, thanks to a partnership between Betsi Cadwaladr University Health Board and North Wales charity The Carers Trust North Wales Crossroads. The camaraderie in these groups is Since being established in October 2016, the Dementia Support Service partnership has anniversary of the service at the Oriel House remarkable and helped over 600 people who have received a Hotel, St Asaph, Mr Hughes said: “It can be patients and diagnosis of dementia. quite bewildering when a loved one is diagnosed with dementia and there is lots of information to carers get an The collaboration ensures that every person take in and different organisations who offer awful lot out of diagnosed with dementia and their carer has a different support. named Dementia Coordinator who can provide sharing their advice, support and signposting to other support “Having a named person who you can contact is experiences services. really reassuring. I’ve been kept informed about lots of different events that are happening.” Victor Hughes is among those to have praised the service, having benefitted from it ever since In addition to the Dementia Support Service, his wife Pauline was diagnosed with dementia in Betsi Cadwaladr University Health Board’s free February 2017. and confidential dementia helpline offers emotional support, advice, and signposting to Gwenno Davies Speaking at a celebration event to mark the first statutory and voluntary support services. Dementia Co-ordinator
Performance Report September 2017
Page 12 Staying Healthy Overview – National Standards 13
Executive Exception National March 18 Current Welsh Staying Healthy Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Number of emergency admissions for 8 chronic Morag No - 970 990 857 913 Jun-17 1st conditions per 100,000 population (rolling 12 months) Olsen Number of emergency readmissions for 8 chronic Morag No - 225 225 191 205 Jun-17 2nd conditions per 100,000 population (rolling 12 months) Olsen Teresa % uptake of the influenza Over 65s No 75.0% 70.0% 70.0% 68.70% 68.70% Mar-17 2nd Owen vaccine in the following Under 65s in at risk Teresa groups: No 75.0% 55.0% 55.0% 49.10% 49.30% Mar-17 2nd groups Owen Teresa Pending % uptake of the influenza Pregnant women No 75.0% 75.0% 75.0% 40.70% Sep-17 - Owen vaccine in the following Link Teresa groups: Healthcare workers No 62.5% 62.5% 62.5% 49.40% 49.40% Mar-17 5th Owen Percentage of children who received 3 doses of the ‘5 in Teresa No 95.0% 95% - 96.00% 96.00% Q1 - 17/18 o - 1’ vaccine by age 1 Owen Percentage of children who received 2 doses of the MMR Teresa No 95.0% 95% - - 91.60% Q1 - 17/18 o - vaccine by age 5 Owen % estimated smoking population treated by smoking Teresa No 5.0% 4.7% 3.5% 3.8% 1.0% Q4-16/17 2nd cessation services; year to date Owen % smokers treated by NHS smoking cessation CO- Teresa No 5.0% 40.0% 30.0% 31.1% 34.4% Q4-16/17 7th validated as successful; year to date Owen % of reception class children (aged 4/5) classified as Teresa No - 27.0% 25.4% 27.4% 28.6% 2015/16 - overweight or obese Owen Of those practices set up to use MHOL, % who are Morag Pending Yes - 50.0% 46.0% 40.2% Aug-17 o 4th offering appointment bookings Olsen Data Of those practices set up to use MHOL, % who are Morag Pending No - 90.0% 86.0% 100.0% Aug-17 o 1st offering repeat prescriptions Olsen Data
Performance Report September 2017
Page 13 14 Staying Healthy Overview – Local Standards
Executive Exception National March 18 Current Welsh Staying Healthy Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of children in the Flying Start Programme who have Morag No - 82.0% - 81.1% 80.5% Aug-16 - - met or exceeded their developmental milestones at age Olsen Percentage of live singleton births with a birth weight of Morag No - 7.0% 7.0% 6.3% 4.7% Sep-17 - less than 2500 grams Olsen
Performance Report September 2017
Page 14 Exception Report: My Health Online 15 Executive Exception National March 18 Current Welsh Staying Healthy Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Of those practices set up to use MHOL, % who are Morag Pending Yes - 50.0% 46.0% 40.2% Aug-17 o 4th offering appointment bookings Olsen Data Of those practices set up to use MHOL, % who are Morag Pending No - 90.0% 86.0% 100.0% Aug-17 o 1st offering repeat prescriptions Olsen Data
Where we are Of those practices set up to use MHOL, % who are offering appointment bookings Please note this data is based on the July report as August data was not available. 60% 50% All 107 GP Practices across North Wales have access to My Health On-Line MHOL. The monthly data collected reflects actual usage of online appointments by practices 40% and fluctuates month on month. Some inaccuracies have been discovered within the 30% data reports provided. This has been highlighted to NWIS and a resolution is being 20% worked on. 10% The percentage of GP Practices offering appointments via MHOL increased July to 0%
40.2% (43 practices), last month 38% (41 practices).
Jul-17
Oct-16 Oct-17
Apr-17
Jan-17 Jun-17 Jan-18
Mar-17 Mar-18
Feb-17 Feb-18
Sep-16 Nov-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 100% of GP Practices offer repeat prescriptions via MHOL. May-17 Actual Plan Target What are we doing about it Of those practices set up to use MHOL, % who The NWSSP Primary Care IM&T Team are actively encouraging and supporting the are offering repeat prescriptions use of MHOL with GP Practices, using the regularly scheduled site visits as the 100% opportunity to promote. They also continue to direct targeted support to Practices that are not actively using the online service. 75%
When we expect to be back on track 50% Following the resolution of access to EMIS practice data in May 2017 there are 25% questions on the accuracy of some of the data coming through. We are working with
NWIS in seeking a resolution to these issues. 0%
Jul-17
Oct-16 Apr-17 Oct-17
Jan-17 Jun-17 Jan-18
Feb-17 Mar-17 Feb-18 Mar-18
Nov-16 Dec-16 Nov-17 Dec-17
Aug-16 Sep-16 Aug-17 Sep-17 May-17 Actual Plan Target
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 15 Triangulated Understood Underway Complete 16 Our Achievements - Safe Care I am protected from harm & protect myself from known harm
Vaccination is the best way to protect against influenza
The annual campaign to encourage people in eligible groups across Wales to have a vaccination to protect themselves from influenza (flu) is being launched today (Monday, 2 October).
The Beat Flu Campaign encourages those who need it most to get protection each year against The best people can influenza, a potentially dangerous disease. do to protect The eligible groups include pregnant women, “Flu can cause serious complications and even themselves is to people with certain chronic long term health lead to death. The flu vaccine can significantly have the vaccine. conditions, people with a BMI over 40 and reduce the chances of people getting flu so it is everyone aged over 65. very important that those who are eligible for the vaccine by their GP, local community pharmacist Children aged between two and eight years are or employer take up the offer to ensure they are also eligible as the vaccine programme for protected. children is being extended again this year. The vaccine for adults is a small injection, but for “GPs across North Wales have been preparing children it is a simple nasal spray. for this winter’s battle against the flu bug and are already contacting eligible patients inviting Teresa Owen, Director of Public Health for Betsi them for the vaccine. Our own Occupational Teresa Owen, Cadwaladr University Health Board, is urging all Health Department and local vaccinators have Director of Public Health those who are eligible to have the flu jab: also started vaccinating our staff.
Performance Report September 2017
Page 16 17 Safe Care Overview – National Standards
Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Number of healthcare acquired pressure ulcers in a Gill Harris Yes 20 32 32 33 22 Sep-17 - hospital setting The rate of laboratory confirmed C.difficile cases per Gill Harris Yes - 25.0 26.5 27.1 35.7 Sep-17 3rd 100,000 of the population The rate of laboratory confirmed S. Aureus Bacteraemia Gill Harris Yes - 18.0 19.0 28.8 28.5 Sep-17 1st (MRSA and MSSA) cases per 100,000 of the population Combined (co-amoxiclav, Cephalosporin & Quinolone Evan Pending No 5% 5.00% Q1-17/18 - items as percentage of total antibacterial items Moore Data % compliance with Welsh Patient Safety - Safety Evan Yes 100.0% 100% 100% 71.0% 71.0% Sep-17 - Solutions Wales Alerts (post Apr-14) Moore % compliance with Welsh Patient Safety - Safer Patients Evan Yes 100.0% 100% 100% 94.0% 91.0% Sep-17 - Notices (post Apr-14) Moore Number of new never events Gill Harris Yes 0 0 0 0 1 Sep-17 6th
The Quality, Safety & Experience committee scrutinises the performance for the indicators above.
Where performance has not reached the required standard, we have included an exception report.
Performance Report September 2017
Page 17 18 Safe Care Overview – Local Standards Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of complaints acknowledged within 2 working days Gill Harris Yes - 98% 98% 91% 97% Sep-17 -
% of complaints closed within 30 working days Gill Harris Yes - 50.0% 50.0% 30.4% 37.2% Aug-17 -
% of complaints closed within 6 months Gill Harris No - 80.0% 80.0% 91.9% 94.0% Apr-17 -
Ward Quality Audit Gill Harris Yes - 95% 95% 90% 90% Sep-17 -
The number of C.difficile reported cases in month Gill Harris Yes - 15 15 16 29 Sep-17 -
The number of MRSA reported cases in month Gill Harris Yes - 2 2 4 2 Sep-17 -
The number of MSSA reported cases in month Gill Harris Yes - 11 11 13 14 Sep-17 -
Hand Hygiene Rates Gill Harris No 95.0% 95.0% 95.0% 98.6% 97.3% Sep-17 -
Ward Staffing Levels Fill Rate (Medical & Surgical Acute) Gill Harris Yes 100% 95% 95% 82% 83% Sep-17 - Ward Staffing Skill Mix Ratio Gill Harris Yes 60% 60% 60% 55% 56% Sep-17 - Registered : Unregistered (Medical & Surgical Acute) Maternity : Caesarean Section Rate Gill Harris Yes - 24.9% 24.9% 29.5% 26.80% Sep-17 -
% of incidents closed within 30 days Gill Harris Yes - 65.0% 65.0% 60.0% 58.0% Aug-17 -
% of incidents closed within 6 months Gill Harris No - 80.0% 80.0% 83.0% 67.0% Mar-17 - Number of Regulation 28 responses overdue more than Gill Harris No 0 0 0 0 0 Sep-17 - 56 days Of the serious incidents due for assurance within the Gill Harris Yes 100% 50% 50% 19% 29% Sep-17 - month, % which are assured in the agreed timescale. % of hours lost due to Intensive Care Unit delayed Morag Not Not Yes 5.0% 13.7% 9.8% Aug-17 - transfers Olsen submitted submitted % of Intensive Care discharges within 4 hours of patient Morag Not Not Yes 95.0% 43.4% 48.0% Aug-17 - being ready Olsen submitted submitted
Performance Report September 2017
Page 18 Exception Report: Pressure Ulcers 19 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Number of healthcare acquired pressure ulcers in a Gill Harris Yes 20 32 32 33 22 Sep-17 - hospital setting Where we are Number of healthcare acquired pressure In September 2017, a total of 22 Hospital Acquired Pressure Ulcers (HAPU) were 60 ulcers in a hospital setting reported in the Health Board. Of these, 2 were unstageable, 1 a suspected deep 50 tissue injury , 2 were grade 3, and the remaining 17 were grade 1 & 2. 40 What we are doing about it? 30 Access to the HAPU specific Harms Dashboard has started to provide feedback in 20 response to pressure ulcer reporting, reinforcing local successes, highlighting areas 10 of non-reporting and defining those areas requiring further support in order to achieve 0
full implementation of improvement strategies.
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Feb-17 Feb-18
Aug-17 Sep-17 Sep-16 Nov-16 Dec-16 Nov-17 Dec-17 May-17 Under the supervision of Safeguarding Service, the Tissue Viability Service continue Actual Plan Target to develop and implement a ‘pressure ulcer prevention’ education programme; ensuring patients at risk are correctly recognised and prevention strategies are incorporated into the culture of all clinical areas.
Collaboration between clinical areas, Tissue Viability Service, Clinical Governance and Safeguarding continues, resulting in a seamless process for reporting HAPU to Welsh Government as well as providing evidence that action plans have been implemented and having an impact.
When we expect to be back on track In recognising the exceptional improvements and downward trend it is further anticipated HAPU cases will meet set targets during the next quarter 3 & 4 of 2017/18.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 19 Triangulated Understood Underway Complete Exception Report: C. difficile infections 20 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark The rate of laboratory confirmed C.difficile cases per Gill Harris Yes - 25.0 26.5 27.1 35.7 Sep-17 3rd 100,000 of the population The number of C.difficile reported cases in month Gill Harris Yes - 15 15 16 29 Sep-17 -
Where we are : Clostridium difficile infection (CDI) The rate of laboratory confirmed C.difficile The number of people developing Clostridium difficile across North Wales saw a cases per 100,000 of the population sharp increase in September 2017, to 29. This takes the Health Board to 43 infections above trajectory. 40
3 cases were recorded in Ysbyty Gwynedd (YG), 6 cases reported in Ysbyty Glan 20 Clwyd (YGC) and 9 cases were reported in Wrexham Maelor Hospital (WMH): of these 13 were in-patient infections.
0
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Jan-17 Jun-17 Jan-18
Feb-17 Mar-17 Feb-18 Mar-18
Sep-16 Nov-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 Where we are: Staphylococcus aureus bacteraemia (St au BSI) May-17 Actual Plan In September 2017, there were 16 recorded cases of Staphylococcus aureus Target England Benchmark bacteraemia (St au BSI) across the Health Board. This takes the Health Board to 30 infections above trajectory. Benchmark Chart (Delayed Information) Number of cases A total of 2 cases of MRSA were recorded, both in-patients. A total of 14 cases of of C.difficile per 100,000 of the MSSA, were recorded, of which 2 were inpatients. population April 2017 - Sep 2017 (Rolling) It appears that 5-6 of these were contaminated blood cultures. CWM TAF 54.6 60 CARDIFF 42.6 44.4 38.1 BCUHB 40 30.9 20.1 HYWEL DDA 20 ANEURIN BEVAN 0 ABMU
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 20 Triangulated Understood Underway Complete Exception Report: S. aureus infections 21 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark The rate of laboratory confirmed S. Aureus Bacteraemia Gill Harris Yes - 18.0 19.0 28.8 28.5 Sep-17 1st (MRSA and MSSA) cases per 100,000 of the population
What we are doing about it The rate of laboratory confirmed S. Aureus An external review took place on 16-17th August 2017. Feedback makes a number of Bacteraemia (MRSA and MSSA) cases per 100,000 of the population recommendations in order to tackle and change organisational culture, and increase 50 the pace of improvement. The report will be presented to QSE and to the Board, and 40 an initial 90-day plan is being developed to take the work forwards at pace. 30 Additional focus remains in place regarding MRSA bacteraemia 20 The actions at Wrexham Maelor Hospital (WMH) continue, with focus on improving 10 the following: 0 • Care bundle compliance for invasive devices, via the weekly point of focus review
meeting.
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Jan-17 Jun-17 Jan-18
Mar-17 Mar-18
Feb-17 Feb-18
Sep-16 Nov-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 • Aseptic Non Touch Technique (ANTT) training and competence assessment for May-17 medical staff. Actual Plan Target • MRSA screening compliance, and use of decolonisation for positive patients. Benchmark Chart (Delayed The Informatics Team have now provided initial monthly data on screening Information) Number of cases of compliance for one of the universal screening groups, and are working on the data for s.Aureus bacteremias per 100,000 of the other groups and for patients admitted from care homes or other hospitals. This the population April 2017 - Sep is enabling targeted work with areas where compliance is below standard. 2017 (Rolling) BCUHB Microbiology have been asked to provide information on costs and timescales for 50 ANEURIN implementing universal screening for all patients admitted to medical wards. We have 40 38.8 BEVAN 33.8 34.7 35.8 HYWEL DDA chased this information. 29.0 30 28.4 ABMU An executive-led table top review of C.difficile deaths in the past 6 months took place 20 CARDIFF in September 2017, with a detailed review provided by the clinical team at YG. This 10 found no obvious cause for the increase in 30-day all-cause mortality that had been CWM TAF 0 seen on the site earlier in 2017. Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 21 Triangulated Understood Underway Complete Exception Report: MRSA & MSSA infections 22 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark The number of MRSA reported cases in month Gill Harris Yes - 2 2 4 2 Sep-17 -
The number of MSSA reported cases in month Gill Harris Yes - 11 11 13 14 Sep-17 -
When we expect to be back on track The number of MSSA reported cases in month The Health Board is aiming to achieve an on-target position against the national 24 targets by year-end for both Clostridium difficile infection and Staphylococcus aureus 20 bacteraemia. 16 This will be challenging, but it can be achieved provided there is sufficient focus from 12 leaders across all disciplines of BCUHB. 8 4
0
Jul-17
Apr-17 Oct-17 Oct-16
Jan-17 Jun-17 Jan-18
Feb-17 Feb-18 Mar-18 Mar-17
Sep-16 Nov-16 Dec-16 Sep-17 Nov-17 Dec-17 Aug-17 May-17 Actual Plan Target England Benchmark
The number of MRSA reported cases in month 10
8
6
4
2
0
Jul-17
Oct-16 Apr-17 Oct-17
Jan-17 Jun-17 Jan-18
Feb-17 Mar-17 Feb-18 Mar-18
Sep-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 Nov-16 May-17
Actual Plan Target England Benchmark
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 22 Triangulated Understood Underway Complete Exception Report: Never Events 23 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Number of new never events Gill Harris Yes 0 0 0 0 1 Sep-17 6th
Where we are: Number of new never events
A Never Event relating to a retained foreign object post-operation was reported in 2 September 2017.
What we are doing about it: 1
The initial review has been completed and immediate actions taken to make safe. 0
The patient has been kept fully informed throughout. Remedial action has been
Jul-17
Oct-16 Apr-17 Oct-17
Jan-17 Jun-17 Jan-18
Feb-17 Mar-17 Feb-18 Mar-18
Aug-16 Sep-16 Nov-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 taken to remove the guide wire and the patient is unharmed. The full investigation is May-17 continuing and the Hospital Medial Director is supporting the staff involved. Actual Plan Target
Never Events are fully investigated by the Health Board, with support from the Delivery Unit (DU) at Welsh Government (WG) to ensure that robust investigations are undertaken, actions are completed and lessons are learned and shared across the Health Board.
All Never Events are reported directly to Clinical Executives as soon as possible following the incident. The investigation is chaired by a Director and supported by the Senior Investigation Managers.
When we expect to be back on track: Discussions are ongoing between the DU and the Chairs and Investigation Officers of the panels regarding final assurance by the DU.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 23 Triangulated Understood Underway Complete Exception Report: Reportable Incidents 24 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Of the serious incidents due for assurance within the Gill Harris Yes 100% 50% 50% 19% 29% Sep-17 - month, % which are assured in the agreed timescale.
Where we are Of the serious incidents due for assurance within 68 incidents reportable to Welsh Government (WG) were due for assurance in the month, % which are assured in the agreed September 2017 and of these 29% (20) were submitted within the agreed timeframe. timescale. This is a 10% improvement on August 2017. 100% 80% There were 94 reportable incidents September 2017. The top 3 incident types were; 60% Unexpected death whilst under the direct care of a health professional; Grade 3 or 40% above healthcare associated pressure ulcer; Patient fall resulting in harm/death to 20% patient. 0%
What we are doing about it Jul-17
Oct-16 Apr-17 Oct-17
Jan-17 Jun-17 Jan-18
Feb-17 Mar-17 Feb-18 Mar-18
Nov-16 Dec-16 Nov-17 Dec-17
Sep-16 Aug-17 Sep-17 A process of an initial 72 hour review has been implemented led by the senior May-17 operational nurse managers for all WG reportable incidents. A comprehensive Actual Plan Target investigation will be undertaken for each and plans to deliver improvement are developed. Performance against the closure within 60 working days is being monitored by the local site/area weekly concerns meetings in each geographic area and weekly information is provided by the Corporate Team to support this. A senior manager is reviewing all open incidents to identify lessons to be learnt and progress them through to closure. All serious incidents graded as major/catastrophic are reported to clinical executives and the relevant Lead Nurse on a weekly basis. Harms dashboard has been launched within clinical areas and trajectories set. The Tissue Viability Team are strengthening early intervention and education.
When we expect to be back on track The performance is above trajectory to address historic cases.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 24 Triangulated Understood Underway Complete Exception Report: Incidents Closed 25 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of incidents closed within 30 days Gill Harris Yes - 65.0% 65.0% 60.0% 58.0% Aug-17 -
% of incidents closed within 6 months Gill Harris No - 80.0% 80.0% 83.0% 67.0% Mar-17 -
Where we are % of incidents closed within 30 days Of the 2638 incidents reported in August 2017, 58% (1,529) were closed within 30 days. The top 3 incidents reported are: Slips, trips, falls and collisions; Pressure sore 80% / decubitus ulcer; Abuse etc. of staff by patients. These themes are a consistent 60% trend. 40% Of the 15,969 incidents reported between April 2017 and September 2017, 67% (10,795) were finally approved within the 6 month timeframe. 20% 0%
What we are doing about it
Jul-17
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Jun-17 Jan-18
• Incident data is included as part of the dashboard developments lead by the Jan-17
Mar-17 Mar-18
Feb-17 Feb-18
Sep-16 Nov-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 May-17 Informatics Teams. Actual Plan Target • A process of an initial 72 hour review has been implemented led by the senior operational nurse managers. % of incidents closed within 6 months
• Performance against both 30 day and 6 month response trajectories are being 100% monitored by local daily and weekly meetings. The learning from incidents is reported to the divisional Quality & Safety Committees which are responsible for 80% the delivery of improvement and sharing of lessons learnt. 60% • Reports are submitted to both the Quality and Safety Group and the Quality Safety 40% and Experience meetings which detail themes and trends emerging. A revised reporting schedule is being implemented which requires the divisions to report on 20%
actions taken to learn from Concerns 0%
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Oct-16 Apr-17 Oct-17
Jan-17 Jun-17 Jan-18
Mar-17 Feb-18 Mar-18
When we expect to be back on track Feb-17
Nov-16 Dec-16 Nov-17 Dec-17
Sep-16 Aug-17 Sep-17 May-17 Trajectories have been agreed for 2017/18 as part of the operational plan Actual Plan Target
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 25 Triangulated Understood Underway Complete Exception Report: Patient Safety Alerts 26 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % compliance with Welsh Patient Safety - Safety Evan Yes 100.0% 100% 100% 71.0% 71.0% Sep-17 - Solutions Wales Alerts (post Apr-14) Moore
Where we are % compliance with Welsh Patient Safety - Of the 7 Welsh Government (WG) Patient Safety Alerts where compliance was due in Safety Solutions Wales Alerts (post Apr-14) September 2017, 2 remain open: 100% PSA003 The update to National Patient Safety Agency (NPSA) alert for safer spinal (intrathecal), epidural and regional devices was due for completion 01/07/2016. Aims 75% to reduce the risk of intravenous medicines being administered by the intrathecal 50% route, and epidural medicines being administered by the intravenous route. Action is also required to reduce the potential for medicines intended for regional anaesthesia 25% to be administered by the intravenous route. PSA007 Restricted use of open systems for injectable medication due for completion 0%
01/08/17. Alert issued to prevent use of “open systems” to draw up medication and
Jul-17
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Apr-17
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Feb-17 Feb-18
Sep-16 Nov-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 restrict the same to procedures involving embolic agents and then only when May-17 supported by specific protocols/procedures. Actual Plan Target
What we are doing about it PSA003 – Women’s and Children’s Services have confirmed compliance. Assurance statements received with respect to the expected use in BCUHB of dedicated infusion devices. Response from Secondary Care to include Theatres, Anaesthesia, Critical Care and Cancer overdue. Manufacturer produced packaging for Chirocaine infusions not compliant with the alert. Applying across the UK, this is being raised nationally as an issue to be addressed - Compliance issues escalated to the Medical Director PSA007 – Trials of safer alternatives to open systems have identified a number of risk and safety issues that need to be resolved and work is underway to resolve these issues and risk assess revised processes. Update to follow in October 2017 report
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 26 Triangulated Understood Underway Complete Exception Report: Patient Safety Notices 27 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % compliance with Welsh Patient Safety - Safer Patients Evan Yes 100.0% 100% 100% 94.0% 91.0% Sep-17 - Notices (post Apr-14) Moore
Where we are % compliance with Welsh Patient Safety - Safer Patients Welsh Government (WG) issued 35 Patient Safety Notices (PSN) where the Notices (post Apr-14) compliance due by date is within the period of this report. The Health Board are 100% compliant with 32 Notices and 3 remain open: PSN030 The safe storage of medicines: Cupboards due 26/08/2016. All Wales Chief Pharmacists meeting with WG. Outlined that the expectations and timescales are 95% unrealistic within the Notice. Further national discussion being undertaken. The Assistant Director of Pharmacy and Medicines Management commissioned a BCUHB
wide audit in respect of the requirements of the notice 90% PSN034 Supporting the introduction of the National Safety Standards for Invasive
Procedures Jul-17
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Mar-17 Mar-18
Feb-17 Feb-18
Nov-16 Dec-16 Nov-17 Dec-17
Sep-16 Aug-17 Sep-17 May-17 PSN036 Reducing risk of oxygen tubing being connected to air flowmeters. Actual Plan Target What we are doing about it PSN030 The Assistant Director of Pharmacy and Medicines Management has sent the results of a BCUHB wide audit to Site Directors of Nursing. Guided by this information they are requested to log to risk registers and develop action plans addressing any shortfalls, feeding back to the Quality & Safety Group. PSN036 Operational Estates have identified locations of air outlets and provided blanking caps on request. Number of issues still to be resolved - blanking caps to be confirmed fitted to redundant air outlets, sign off by Secondary Care required When we expect to be back on track PSN030 – On the agenda for the September QSG, further information will be available after this, and agreement on next steps anticipated PSN034 – Task and Finish Group led by Medical Director Quality & Transformation To date several elements have been achieved, further action being taken to address outstanding issues PSN036 – October 2017
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 27 Triangulated Understood Underway Complete Exception Report: Complaint Acknowledgement 28 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of complaints acknowledged within 2 working days Gill Harris Yes - 98% 98% 91% 97% Sep-17 -
Where we are % of complaints acknowledged within 2 working days In September 2017 the Concerns Team received 110 new complaints, 97% (107) of which were acknowledged within 2 working days. This is a 6% improvement on the 100% August 2017 position. 90% There were a number of administration staff vacancies within the Concerns Team, which have now been filled. 80% 70% What are we doing about it The Corporate Team monitor performance as a local KPI and this is reported to the 60%
Corporate Concerns Management Team meeting. Discussions are ongoing and
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awareness raising so other areas are aware of the need to promptly forward Jan-17
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Aug-17 Sep-17 Sep-16 May-17 complaints. Actual Plan Target Measures are being put in place for the divisions to make direct contact with % of Complaints Acknowledged within 2 complainants and resolve complaints immediately where appropriate and possible. working days 100% Where a complaint is dealt with formally, the contact will be to agree the issues to be 99% 97% 97% investigated and responded to and including these in the acknowledgment letter. 95% 94% 94%94%94% 93% 93% 92% 90% 91% 91%91% It is expected that the acknowledgement compliance rate may decline in future 88% 87% 87% months as processes are put in place and embed to increase the number of 85% complaints managed successfully on an ‘On the Spot’ basis. This position will be closely monitored by the Corporate Management team. 80% 75% When we expect to be back on track We expect to be back on track by October 2017, by when we will have a full establishment of administration staff in post. Performance Profile
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 28 Triangulated Understood Underway Complete Exception Report: Complaint Response 29 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of complaints closed within 30 working days Gill Harris Yes - 50.0% 50.0% 30.4% 37.2% Aug-17 -
% of complaints closed within 6 months Gill Harris No - 80.0% 80.0% 91.9% 94.0% Apr-17 -
Where we are: % of complaints closed within 30 working days Of the 164 concerns opened in August 37% (61) were closed within the 30 working day target. This remains below target, however performance continues to improve 60% over recent months. There were 387 formal Concerns open at the end of September 2017. 40%
20% What we are doing about it: Plans are in place for the Divisions to work collaboratively to address all complaints 0% overdue and to amend working practices to increase compliance with the 30 day target moving forward. This being lead by lead by the Nurse Director and supported by the Corporate teams Actual Plan Target
The development of the Patient Advice and Support Service (PASS) in YGC will % of complaints closed within 6 months increase opportunities to deal with complaints early and resolve issues for 120% complainants quickly without the need to make a formal complaint. 100%
When we expect to be back on track: 80% With a full establishment of administrative support in place from October 2017, the embedding of collaborative working between Concerns Teams and the Divisions and 60% the roll out of PASS, it is expected that we will be back on track in December 2017.
40%
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Sep-16 Aug-17 Sep-17 May-17 Actual Plan Target
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 29 Triangulated Understood Underway Complete Exception Report: Delays in Transfer from ITU 30 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of hours lost due to Intensive Care Unit delayed Morag Not Not Yes 5.0% 13.7% 9.8% Aug-17 - transfers Olsen submitted submitted % of Intensive Care discharges within 4 hours of patient Morag Not Not Yes 95.0% 43.4% 48.0% Aug-17 - being ready Olsen submitted submitted
Where we are. % of hours lost due to Intensive Care Unit In August 2017, there were 9.8% of hours lost in our Intensive Care Units due to delayed transfers Delayed Transfers, whilst 48% of Intensive Care dischargers were within 4 hours of 18% the patient being ready. Please note, data should be treated with caution for the 15% previous reporting period . 12% 9% What we are doing about 6% • Intensive Treatment Unit (ITU) discharges are highlighted at daily bed meetings 3% • Discharges are highlighted at daily bed meetings. 0%
• We are facilitating ITU transfers to ensure elective and emergency capacity is
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prioritised and risk assessed. Feb-17
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Sep-16 Aug-17 Sep-17 May-17 • Lost ITU hours are escalated to the Hospital Management Team. Actual Plan Target • Twice daily ward rounds are completed by ITU Consultant to identify discharges. • Discharges are identified to the Clinical Site Manager in real time. % of Intensive Care discharges within 4 hours of • There is Senior Sister/Matron attendance at every bed meeting. patient being ready • As many Delayed Transfer of Care (DToC) patients as possible are discharged 100% home to reduce the DToC load. 80% • Buddy wards and swaps identified to expedite discharges. 60% • Root causes for the delays is due to the unscheduled care pressures on site. • Length of DTOC identified at bed meeting. 40% 20% When we expect to be back on track 0%
We expect to be back on track by the end of Quarter 1 2017/18.
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Sep-16 Aug-17 Sep-17 May-17 Actual Plan Target
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 30 Triangulated Understood Underway Complete Exception Report: Caesarean Section 31 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Maternity : Caesarean Section Rate Gill Harris Yes - 24.9% 24.9% 29.5% 26.80% Sep-17 -
Where We are: Maternity : Caesarean Section Rate The overall Caesarean Section rate for September shows an improved position at 26.8% compared to 29% in August. Despite a 1.2% increase in the number of 40% deliveries (586 compared to 579 in August) it was pleasing to note a 6.5% decrease 30% in the overall number of CS performed (157 compared to 168 in August). This month both the emergency and elective CS rates have improved with the emergency rate at 20% 16.9% and the elective at 9.9%, now within target. 10% In West, the overall CS rate increased by 10 cases from 47 in August to 57 in September 2017. Month to month variation is to be expected, and the rolling average 0%
over the previous 12 month period is 26.4%. In Central, the overall CS rate
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Jan-17 Jan-18 Jun-17
Mar-17 Mar-18
Feb-17 Feb-18
Sep-16 Nov-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 decreased by 17 from 64 in August to 47 in September 2017. The emergency CS May-17 reduced from 20% in August to 12% in September 2017. There was also an increase Actual Plan Target in Midwifery-led deliveries. In East, at 24.2% the reduction in overall CS rates continues and is now within the national target rate.
What we are doing about it: We continue to focus upon Cardiotocography (CTG) training and second stage operative vaginal deliveries as obstetricians. We continue to monitor and promote Vaginal Delivery After Caesarean (VBAC) clinics and more hands-on involvement of consultant obstetricians on the labour ward. The CS rate is discussed at the Labour Ward Forum and each CS is audited and reviewed to identify trends. Junior Doctors trained to perform rotational deliveries. An audit of emergency caesarean is being undertaken by the Clinical Lead Consultant and SHO. When we expect to be back on track: We expect to be back on track within Quarter 2, 2017/18.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 31 Triangulated Understood Underway Complete Exception Report: Ward Quality Audits 32 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Ward Quality Audit Gill Harris Yes - 95% 95% 90% 90% Sep-17 -
Where we are Ward Quality Audit
The current aggregated score for the General Wards is 90% (Mental Health data is 100% not included in this overall percentage). Staying Healthy remains the lowest scoring theme. This theme is with regard to documenting the What Matters conversation, and 95%
providing it with transfers and referrals. 90%
What are we doing about it 85%
For General wards to move to a better position, the following three measures have 80%
been identified as RED status for August in the Safe Care Theme;
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• documenting the frailty score on admission Actual Plan Target • completing the Clostridium Difficile pathway • implementing care plans for patients with a medium or high nutritional assessment score.
The lowest scoring theme in Mental Health is Timely Care, which is a measure of evidence of multidisciplinary estimated date of discharge planning. In order to move to a better position Mental Health wards should focus on improving processes to ensure that estimated dates of discharge are implemented and documented.
When we expect to be back on track We are expecting to have an incremental improvement of a minimum of 1% for next reporting period.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 32 Triangulated Understood Underway Complete Exception Report: Ward Staffing 33 Executive Exception National March 18 Current Welsh Safe Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Ward Staffing Levels Fill Rate (Medical & Surgical Acute) Gill Harris Yes 100% 95% 95% 82% 83% Sep-17 - Ward Staffing Skill Mix Ratio Gill Harris Yes 60% 60% 60% 55% 56% Sep-17 - Registered : Unregistered (Medical & Surgical Acute)
Where We are: Ward Staffing Levels Fill Rate (Medical & Within Secondary Care, there has been a ward staffing fill rate of 83% which is a 1% Surgical Acute) increase compared to 82% for the previous month. Site variability is detailed in table 100% below. There are 249.63 Whole Time Equivalent (WTE) Registered Nurse (RN) and 80% 66.74 WTE Health Care Assistant vacancies, of whom 60.12 WTE RN are currently in 60% the recruitment phase, 61 WTE RN from the overseas recruitment drive. Of the 40% overseas recruits 5 have passed their IELTS exam however they will now need to complete the Nursing and Midwifery Council (NMC) requirement. NMC changes 20% regarding the English language testing will be implemented in November. This will 0%
mean overseas recruits taught their nursing degrees in English do not need to
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complete the IELETS test which will support recruitment. There are also 52.45 WTE Feb-17
Nov-16 Dec-16 Nov-17 Dec-17
Aug-16 Sep-16 Aug-17 Sep-17 May-17 Registered nurses and 11.40 WTE Health Care Assistants on maternity leave. Actual Plan Target What we are doing about it: Recruitment event in Dublin and further overseas recruitment drive is being Ward Staffing Skill Mix Ratio Registered : Unregistered (Medical & Surgical considered. The Train Work Live recruitment drive for the BCUHB launched. The Acute) establishment confirmation exercise commenced in Secondary Care in April is 65% undertaking a line by line alignment of staffing templates to budget and will refer to 60% acuity information collected daily across secondary care in June. All wards at Ysbyty Glan Clwyd are using the SafeCare tool which gives an overview of the match of 55% staff-to-patient nursing need three times a day and also simplifies other tasks such as 50% timesheet approval. Roster scrutiny is now occurring weekly at Secondary Care and Executive level to improve consistency. 45%
When we expect to be back on track:
Jul-17
Oct-16 Oct-17
Apr-17
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Mar-17 Mar-18
Feb-17 Feb-18
Sep-16 Nov-16 Dec-16 Aug-17 Nov-17 Dec-17 Sep-17 The position is expected to remain static during the remainder of 2017. May-17 Actual Plan Target
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 33 Triangulated Understood Underway Complete 34 Our Achievements - Effective Care I receive the right care & support as locally as possible & I contribute to making that care successful
Cancer survivor Jules Peters praises Ysbyty Gwynedd surgeon who “saved her life”
Jules Peters has opened up about her life changing battle with cancer to mark Breast Cancer Awareness month
The wife of Alarm frontman, Mike Peters, was The breast cancer diagnosed with breast cancer on 4 July 2016. nurses are
The mum-of-two underwent two operations at absolutely Ysbyty Gwynedd with our Consultant Breast amazing, they Surgeon, Mr Ilyas Khattak which was followed by 18 weeks of chemotherapy, followed by a “As Mr Khattak was operating on me his finger immediately put four-week period of radiation treatment at Glan touched something that didn’t feel quite right to you at ease – I will Clwyd Hospital. him and he decided to take it out, biopsied it, and found it was more cancer. never forget what Jules, who has been by the side of her husband they have done for throughout his lengthy journey battling cancer, “The third tumour had showed I had five or six said she was devastated when she was told she very small areas of cancer, two of which were in me had the disease. my lymph nodes.
She said: “It was a very upsetting time and I “If it had not been for Mr Khattak spotting that thought the first operation would just remove the there wasn’t something right during the surgery I lump but we were left devastated following the may not have been as lucky as I have been, he surgery when we were told a second lump was is an amazing surgeon and I really believe he Jules Peters found. has saved my life.” Cancer campaigner
Performance Report September 2017
Page 34 35 Effective Care Overview – National Standards Executive Exception National March 18 Current Welsh Effective Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Evan Crude Mortality - rolling 12 months Yes - 1.6% 1.5% 1.8% 1.8% Aug-17 - Moore Risk Adjusted Mortality Index rolling 12 months (2016 Evan Yes - 108 108 164 176 Apr-17 - RAMI) Moore Percentage episodes clinically coded within 1 month of Evan Not Not Yes 95.0% 40.2% 38.7% Jul-17 7th the episode end date Moore submitted submitted Number of Health & Care Research Wales clinical Evan Pending Pending No - 117 117 Q1-17/18 - research portfolio studies (quarterly Year-To-Date figure) Moore Data Data Number of patients recruited into Health & Care Evan Pending Pending No - 1,844 1,844 Q1-17/18 - Research Wales clinical research portfolio studies Moore Data Data Number of commercially sponsored studies (rolling 4 Evan Pending Pending No - 11 11 Q1-17/18 - quarter sum) Moore Data Data Number of patients recruited into commercially Evan Pending Pending No - 145 145 Q1-17/18 - sponsored studies (rolling 4 quarter sum) Moore Data Data Morag % of GP locality cluster plans that have been agreed No - 100.0% 100.0% 100.0% 100.0% Q4-17/18 - Olsen
The indicators above are monitored at the Quality, Safety & Experience committee.
An exception report is included for indicators which are not achieving the standard.
Performance Report September 2017
Page 35 36 Effective Care Overview – Local Standards Executive Exception National March 18 Current Welsh Effective Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Morag % of procedures undertaken as a daycase No - 80.0% 80.0% 82.8% 77.9% May-17 - Olsen British Association of Day Surgery (BADS) basket of Morag No - 85.0% 85.0% 94.4% 95.7% Jun-17 - procedures score Olsen Morag Not Not Average Length of Stay (Elective Admissions) No - 3.2 3.7 Aug-17 - Olsen submitte submitte Morag Average Length of Stay (Emergency Admissions) Yes - 10.6 10.6 10.3 10.9 Aug-17 - Olsen Morag Average Length of Stay - Community Hospitals Yes - 24.3 24.3 30.0 32.0 Sep-17 - Olsen
The Quality, Safety & Experience committee monitors the indicators above.
We have included an exception report for any area not achieving the standard.
Performance Report September 2017
Page 36 Exception Report: Risk Adjusted Mortality 37 Executive Exception National March 18 Current Welsh Effective Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Evan Crude Mortality - rolling 12 months Yes - 1.6% 1.5% 1.8% 1.8% Aug-17 - Moore Risk Adjusted Mortality Index rolling 12 months (2016 Evan Yes - 108 108 164 176 Apr-17 - RAMI) Moore
Where we are Risk Adjusted Mortality Index rolling 12 months (2016 RAMI) RAMI continues to be adversely affected by coding completeness and issues regarding refreshing data have now been resolved. With crude mortality reported as a 180 rolling 12 months the mean rate maintains at 1.8%. 170 160 150 What we are doing about it 140 Work is progressing to address the findings from the Wrexham Mortality review. 130 120 The Installation of the Mortality tracking system (MTS) is currently on hold due to no 110 further work being undertaken by the system developer, communications are on-going 100
to negotiate terms for completion of the installation. The Health board commenced
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Sep-16 Nov-16 Sep-17 Nov-17 Sep-16 Nov-16 May-16 the 6 month pilot on 1st September 2017 to trial a new stage 1 form which will be May-17 completed at the point of death certification to identify deaths linked to mental health Actual Plan Target and learning disability conditions, this is being monitored on a regular basis to identify Crude Mortality - rolling 12 months any developing issues and information is being passed to mental health teams as soon as identified for stage 2 review. 2.0%
1.8% When we expect to be back on track Further changes will come at a slower pace as they require progressive work in key 1.6% programme areas. Due to the arrears in coding and the work required to implement 1.4% these changes improvements in the RAMI will not be seen for at least 18 months. 1.2%
1.0%
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Feb-17 Mar-17 Feb-18 Mar-18
Sep-16 Nov-16 Aug-17 Sep-17 Nov-17 Dec-17 Dec-16 May-17 Actual Plan Target Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 37 Triangulated Understood Underway Complete Exception Report: Clinical Coding 38 Executive Exception National March 18 Current Welsh Effective Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Percentage episodes clinically coded within 1 month of Evan Not Not Yes 95.0% 40.2% 38.7% Jul-17 7th the episode end date Moore submitted submitted Where we are At the end of September 2017, the coding backlog was at 33,030 Clinical Coding: Episodes Created and episodes. Episodes Coded What are we doing about it 6000 The 5 new members of staff continue to bed-in and are increasing 4000 their coding capacity month on month as their training continues. 2000 Agency coders are still working weekdays and weekends across all 0 sites to clear the backlog. It is anticipated that reliance on agency staff will decrease as the new substantive staff develop their coding abilities over the next few months. Episodes Coded Episodes Created When we expect to be back on track As the coding backlog is being cleared with oldest episodes to newest it will be some months until we see an improvement in the Coding Backlog Improvement Trajectory National 1 month completion target. 80000 80000 70000 70000 60000 60000 Some areas of service are now being coded in real time to improve 50000 50000 40000 40000 data availability. As the coding backlog clears, more areas will follow 30000 30000 20000 20000 this model. 10000 10000 0 0 It is anticipated that the coding completeness will be reaching Welsh
Government target of 95% coded within 1 month of episode end date
01/06/2017 01/07/2017 01/08/2017 01/09/2017 01/10/2017 01/11/2017 01/12/2017 01/01/2018 01/02/2018 01/03/2018 01/04/2018 01/05/2018 01/06/2018 01/07/2018 01/08/2018 by Q2 of 2018/19. 01/05/2017 West Central East Trajectory
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Triangulated Understood Underway Complete Page 38 Exception Report: Community Length of Stay 39 Executive Exception National March 18 Current Welsh Effective Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Morag Average Length of Stay - Community Hospitals Yes - 24.3 24.3 30.0 32.0 Sep-17 - Olsen
Where we are: In September 2017, the Average Length of Stay (ALoS) in our Average Length of Stay - Community Hospitals community hospitals was 32 days. Reducing the ALoS remains challenging as this is 40 impacted by the scarcity of Care Home placements available locally, with some areas 32 in the having no beds available in care homes. Access to carers remains an issue in some patches and work is underway with the local authority to develop alternative 24 schemes. Singlehanded care is also being developed in conjunction with both local 16 authority partners to facilitate discharge with the use of alternative equipment which 8 reduces the need for 2 carers 0
What we are doing about it: MFD meetings on Monday and Wednesday co-
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Feb-17 Feb-18 Mar-18 Mar-17
Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 Sep-16 Nov-16 ordinated by Area May-17 Weekly Tuesday morning DTOC meeting with Area and Maelor Actual Plan Target Weekly DTOC meeting for Community Hospitals. Fridays Central Area - We are interviewing HSCSW for Conwy to support Health DTOCs which will be mirrored in West and East ANP’s going into care homes daily to support. We are working jointly across areas on care pathways for COPD, MIU and district nursing to enhance communication and referrals direct to prevent admissions.. Local Authority communicate directly on a daily basis for difficult cases that teams are struggling with that they escalate, so we can give advice and support and authorise additional resources where necessary. District Nursing service is now 24/7 Daily Board round in ED (consultant and Therapies) identifying patients for the CAU Norovirus plan developed for Area shared across North Wales
When we will be back on track: Difficult to quantify as capacity within Social/EMI care is an issue Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 39 Triangulated Understood Underway Complete 40 Our Achievements - Individual Care I am treated as an individual, with my own needs and responsibilities
BCUHB recognised for improving the use of the Welsh language in healthcare
Our dedicated Welsh Language team have been awarded for their efforts in improving the lives of people living with dementia.
Betsi Cadwaladr Health Board was the only The active offer organisation in Wales to be nominated in three provides services categories at this year’s More than just words confirmed that patients living with dementia Celebration Event in Cardiff. revert to their mother tongue as their condition in Welsh for deteriorates, leaving some patients unable to Our Welsh Language team scooped the recall the language they have learnt most individuals by ‘Active Offer’ award with their Language recently. Choice Scheme and were highly commended asking if they need in the ‘innovation’ category and the To benefit those living with the disease, the their hospital ‘Developing a Bilingual Workforce’ strategy, team piloted a ‘Preferred Language Scheme’ following the appointment of a new Welsh with dementia patients on Glaslyn Ward at services through Language tutor. Ysbyty Gwynedd. The aim of the scheme is for the medium of our patients to receive Welsh language They were also highly commended for their services without having to request them. Welsh. leadership approach in establishing a pan North Wales Forum for health and social care Our Dementia Nurse Specialist, Delyth organisations to address the Welsh Thomas, said the new scheme provides a Government’s ‘More than just words’ proactive approach to ensure that the Welsh framework and to share good practice. Delyth Thomas , language needs are identified as an integral Dementia Nurse part of safe, high quality person centred care. Specialist Over the years, various research efforts have Performance Report September 2017
Page 40 41 Individual Care Overview – National Standards Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of assessment by the LPMHSS undertaken within 28 Andy No 80.0% 80.0% 80.0% 79.6% 77.0% Sep-17 4th days of the date of referral Roach % of therapeutic interventions started within 28 days Andy No 80.0% 80.0% 80.0% 81.0% 77.3% Sep-17 4th following an assessment by LPMHSS Roach % of LHB residents (all ages) to have a valid CTP Andy Yes 90.0% 90.0% 90.0% 90.2% 89.9% Sep-17 4th completed at the end of each month Roach % of hospitals with arrangements to ensure advocacy Andy No 100% 100% 100% 100% 100% Q2-17/18 1st available to qualifying patients Roach Service users assessed under part 3 to be sent a copy of Andy No 100.0% 100.0% 100.0% 100.0% 100% Aug-17 1st the assessment in 10 working days Roach
Individual Care Overview - Local Standards Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Andy Delayed transfers of Care per Mental Health No 2.70 2.30 2.40 1.96 1.84 Sep-17 1st Roach 10,000 population, Rolling 12 Non Mental Health aged Morag months Yes 129.5 176.0 178.0 186.9 182.5 Sep-17 7th over 65 Olsen The number of non-mental health bed days lost due to Morag No - 2,089 2,089 1,396 2,105 Sep-17 - delayed transfers of care in the month Olsen Morag Patients who leave ED without being seen Yes - 8.0% 8.0% 8.2% 8.6% Sep-17 - Olsen
Where we have not achieved a target, we have included an exception report.
Performance Report September 2017
Page 41 42 Individual Care Overview – National Standards Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of assessment by the LPMHSS undertaken within 28 Andy No 80.0% 80.0% 80.0% 79.6% 77.0% Sep-17 4th days of the date of referral Roach % of therapeutic interventions started within 28 days Andy No 80.0% 80.0% 80.0% 81.0% 77.3% Sep-17 4th following an assessment by LPMHSS Roach % of LHB residents (all ages) to have a valid CTP Andy Yes 90.0% 90.0% 90.0% 90.2% 89.9% Sep-17 4th completed at the end of each month Roach % of hospitals with arrangements to ensure advocacy Andy No 100% 100% 100% 100% 100% Q2-17/18 1st available to qualifying patients Roach Service users assessed under part 3 to be sent a copy of Andy No 100.0% 100.0% 100.0% 100.0% 100% Aug-17 1st the assessment in 10 working days Roach
Individual Care Overview – Local Standards Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Morag Patients who leave ED without being seen Yes - 8.0% 8.0% 8.2% 8.6% Sep-17 - Olsen % of assessment by the LPMHSS undertaken within 28 Andy Yes 80.0% 80.0% 80.0% 79.9% 77.4% Sep-17 - days of referral - Adult Services Roach % of therapeutic interventions started within 28 days Andy No 80.0% 80.0% 80.0% 82.7% 78.7% Sep-17 - following an assessment - Adult Mental Health Services Roach % of assessment by the LPMHSS undertaken within 28 Morag Yes 80.0% 100.0% 100.0% 71.2% 74.7% Sep-17 - days of referral - Child Adolescent Mental Health Services Olsen % of therapeutic interventions started within 28 days Morag Yes 80.0% 100.0% 100.0% 82.8% 72.9% Sep-17 - following an assessment - Child and Adolescent Mental Olsen
The Individual Care domain has shared scrutiny between our Finance & Performance committee and our Quality, Safety & Experience committee. Only the Finance & Performance committee indicators are shown above.
Performance Report September 2017
Page 42 Exception Report: Delayed Transfers of Care 43 Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Delayed transfers of Care per 10,000 population, rolling Morag Yes 129.5 176.0 178.0 186.9 182.5 Sep-17 7th 12 monthsNon Mental Health aged over 65 Olsen The number of non-mental health bed days lost due to Morag No - 2,089 2,089 1,396 2,105 Sep-17 - delayed transfers of care in the month Olsen
Where we are In September 2017 there was an increase in the number of non Mental Delayed transfers of Care per 10,000 population, Health delayed patients from 87 to 107, the second highest month this year. Although rolling 12 months Non Mental Health aged over 65 Denbighshire, Wrexham and Anglesey saw small reductions there were big increases 250 in Gwynedd (10), Conwy (8) and Flintshire (4). There is also a corresponding increase 200 in the days lost due to DToC, up over 700 from 2092 in August to 2800 in September 150 2017. Conwy and Denbighshire show the biggest increase in lost days with 445, however, Flintshire and Wrexham lost the largest total with 1936 bed days. 100 What we are doing about it There is more variation in the DToC rates this year and 50 this is as a result of the fragility of external providers. Multiagency work and scrutiny, 0 both internal and external is continuing in all 3 Areas with particular emphasis on day to
patient pathway reviews. Escalation is carried out as required. It should be noted that Jul-17
Oct-16 Apr-17 Oct-17
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Feb-17 Mar-17 Mar-18 Feb-18
Nov-16 Nov-17 Dec-17 Dec-16
Sep-16 Aug-17 Sep-17 May-17 the categories around the provision of home care and placement in Institutional Care Actual Plan Target continue to provide the largest delays. Councils do have some variation but Mon, Gwynedd , Wrexham and Flintshire are reporting real challenges in Agencies being The number of non-mental health bed days lost due to able to provide adequate home care and in some cases, large Packages of Care have delayed transfers of care in the month 3,000 been handed back. Wrexham and Flintshire reported 36 clients being returned. There was also an increase in the number of homes requiring escalation. 2,500 Work is continuing with Local Authorities to bolster the independent sector and ICF 2,000 funding is being deployed to assist sustainability by supporting pay rates, training and 1,500 support. In some Areas it is being utilised to support the development of Generic 1,000 Workers who bridge shortfalls in staffing. Working groups are looking into options for 500 developing home in the future in partnership with Local Authorities. 0
When we expect to be back on track
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Sep-16 Aug-17 Sep-17 May-17
Actual Plan Target
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 43 Triangulated Understood Underway Complete Exception Report: Mental Health Measure - Adult 44 Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of assessment by the LPMHSS undertaken within 28 Andy Yes 80.0% 80.0% 80.0% 79.9% 77.4% Sep-17 - days of referral - Adult Services Roach % of therapeutic interventions started within 28 days Andy No 80.0% 80.0% 80.0% 82.7% 78.7% Sep-17 - following an assessment - Adult Mental Health Services Roach
Where we are % of assessment by the LPMHSS Performance for September 2017, at 77.4% (441 from 570) is below target for the undertaken within 28 days of referral - percentage of assessments carried out within 28 days of referral. The percentage on 100% Adult Services target for therapeutic interventions started within 28 days of assessment is at 78.7% 90% (144 out of a total of 183 interventions). This is position is un-validated and validation 80% is ongoing and figures will change. 70% What are we doing about it 60% • The Mental Health Measure Team are providing additional support, training and 50% advice to the Clinical Network Managers, Lead Nurses, Locality and County 40% Managers as well as staff. • New monthly waiting list positions with patient level information sent out to team managers. Actual Plan Target • The 3 tiered reporting structure continues with Weekly compliance and performance % of therapeutic interventions started indicators; Operational service delivery information for service improvement and within 28 days following an administration; Individual compliance and caseload information for action. assessment - Adult Mental Health Services • Service managers are accountable for following local action plans which improve 100% targets and are monitored through local Operational meetings. 90% • Waiting list reports to be developed by the information department and published to 80% the new Mental Health and Learning Disability dashboard on the intranet. 70% 60% When we expect to be back on track 50% The Division is not meeting either target and will aim to be on track by October 2017. 40%
. Actual Plan Target Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 44 Triangulated Understood Underway Complete Exception Report: Mental Health Measure - CAMHS 45 Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of assessment by the LPMHSS undertaken within 28 Morag Yes 80.0% 100.0% 100.0% 71.2% 74.7% Sep-17 - days of referral - Child Adolescent Mental Health Services Olsen % of therapeutic interventions started within 28 days Morag Yes 80.0% 100.0% 100.0% 82.8% 72.9% Sep-17 - following an assessment - Child and Adolescent Mental Olsen
Where we are % of assessment by the LPMHSS In September 2017, 75% (62) of children were assessed within 28 days of being undertaken within 28 days of referral - Child Adolescent Mental Health referred and 73% (43) of children started therapeutic interventions within 28 days of Services being assessed. 100% 80% Children experienced delays in being assessed in the West and East areas, whilst the 60% children experiencing delays in starting therapeutic interventions were in West and 40% Central areas. 20% What we are doing about it 0% Actions we are doing to address this in the areas include: • Securing of funding from WG allocation to Mental Health services, discussions remain ongoing Actual Plan Target
• Review of capacity in line with to ensure substantive capacity is sufficient including % of therapeutic interventions started robust demand and capacity modelling within 28 days following an assessment - Child and Adolescent • Review of Crisis Services being undertaken including pathway and capacity Mental Health Services • Regular caseload reviews and DNA/CNA reviews with necessary action 100% • Regular reviews of closures to ensure cases are closed in a timely manner 80% • Implementation of CAPA (Choice and Partnership Approach) service model which 60% will support structured approach to waiting list management. Implementation has 40% taken place in Central and East teams with West to be implemented. 20% When we expect to be back on track: 0% Resolution is yet to be received on the additional Mental Health funding from WG, CAMHs services will require additional investment to meet and sustain both targets Actual Plan Target
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Triangulated Understood Underway Complete Page 45 Exception Report: Care & Treatment Plans 46 Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of LHB residents (all ages) to have a valid CTP Andy Yes 90.0% 90.0% 90.0% 90.2% 89.9% Sep-17 4th completed at the end of each month Roach
Where we are % of LHB residents (all ages) to have The Mental Health & Learning Disability (MH & LD) Division are currently a valid CTP completed at the end of each month performing at 89.9% (5101 from 5687). This is broken down across the 100% division as follows: 90% Adult Community Mental Health – 88.2% (3797 from 4303) OPMH Community Mental Health – 94.0% (1179 from 1253) 80% Learning Disability Services – 95.4% (125 from131) What we are doing about it 70% • The 3 tiered reporting structure continues with Weekly compliance and performance indicators; Operational service delivery information for 60% service improvement; administration and Individual compliance and caseload information for action. Actual Plan Target • Service Managers are accountable for following local action plans which improve targets. Benchmark Chart (Delayed • The Mental Health Measure Team and Information Analysts will support Information) % of LHB residents (all 100% ages) to have a valid CTP completed at agreed change to reporting processes directly to individual teams. the end of each month Aug-17 • The caseload audit is continuing. 95% 93% • Mental Health Measure Champions have been identified within the teams 91% 91% HYWEL DDA 90% 89% 88% CWM TAF
When we expect to be back on track ANEURIN BEVAN We are currently performing on target in Older Peoples and Learning Disability BCUHB Services for the percentage of residents with a valid CTP completed. Work in 80% POWYS Adult services is on-going. ABMU
70%
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 46 Triangulated Understood Underway Complete Exception Report: ED Left Without Being Seen 47 Executive Exception National March 18 Current Welsh Individual Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Morag Patients who leave ED without being seen Yes - 8.0% 8.0% 8.2% 8.6% Sep-17 - Olsen
Where we are Patients who leave ED without being seen At 8.6% overall in September 2017, performance across North Wales remained almost 15% consistent with August 2017 (8.2%). Ysbyty Gwynedd (YG) at 5.1%, Ysbyty Glan Clwyd (YGC) at 6.8% and Wrexham Maelor Hospital (WMH) remains an outlier at 12% 12.8% (670 patients). A data entry issue has been identified with up to 1% of 9% Wrexham patients being wrongly categorised as LWBS. These are patients who were seen by a Clinician but self discharged against medical advice. Clarity is being sought 6% on whether these patients should be excluded. The split of Wrexham patients by 3% Triage category is on the table to the right. The majority of those in the Not Triaged category (123 patients) left within 30 mins of arrival, those with longer waits in this 0%
category arrived when the ED was in extremis with long triage waits. There is a
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correlation between performance of 4Hr waits and when the overall performance May-17 improves, the percentage of patients who LWBS reduces. Actual Plan Target
What we are doing about it We are continuously working to improve the overall performance against the 4hr Triage No of target. However there are significant challenges to all three sites due to delays in ward Category Patients discharges impacting upon the flow from ED to ward beds. Overall performance Red 0 improvement will see a reduction in the number of patients who LWBS and therefore Orange 21 reduce the potential clinical risk to these patients. The ED Team discuss the Yellow 222 management of clinical risks at monthly Clinical Governance meetings. Green 289 Blue 15 When we expect to be back on track *Not Triaged 123 Work is ongoing to improve the overall performance of the 4 hour target which in turn Total 670 reduces the number of patients who leave without being seen. Further LWBS WMH - September 2017 transformational work with Area colleagues due to commence in the coming months is *Left before being Triaged expected to support overall improvements
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Triangulated Understood Underway Complete Page 47 48 Our Achievements - Dignified Care I am treated with dignity & respect and treat others the same
Health Board “Ste into Work” programme helps North Wales residents gain new work opportunities
A Holyhead mum has been given a chance to get back into work thanks to a new project run by Betsi Cadwaladr University Health Board. The participants Joanne Hogarth said she struggled to even get an interview for jobs after spending 18 years as we’ve had on the a full time carer for her son. programme since
But thanks to the Health Board’s Step into Work it launched almost programme, which supports people at a the last ten months, she has high hopes for the 12 months ago disadvantage in the job market in returning to future after getting back into work. work, Joanne has returned to the workplace as have all really a Training Clerk at the Health Board’s Workforce She said: “I think people don’t realise that I’ve benefited from the and Organisational Development offices in not been unemployed for 18 years, I’ve been Llanfairfechan. caring for my son. But nobody wanted to know. I opportunities it’s spent my days firing off applications, filling in provided. Joanne, who was given a chance to shine CVs, and just wasn’t getting anywhere. It got to through Step into Work’s adult volunteer work a point where I thought I just wasn’t employable, placement programme, is now gaining new but have 20 years left until I retire. qualifications alongside her work, helping rebuild her CV. “It’s now 10 months since joining as part of the Mandy Hughes, Step into Work programme, and I’m now in a Workforce Modernisation And having now worked for the Health Board for full-time post and loving every minute of it. Manager
Performance Report September 2017
Page 48 Dignified Care Overview – National Standards 49
Executive Exception National March 18 Current Welsh Dignified Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % procedures postponed more than once, patient had Morag Yes 100.0% 95.0% 75.0% 9.1% 7.0% Aug-17 3rd procedure under 14 days or at their earliest convenience Olsen
Dignified Care Overview – Local Standards
Executive Exception National March 18 Current Welsh Dignified Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Efficiencies: Patient admitted but procedure not carried Morag Yes - - - 2.7% 2.7% Jun-17 - out Olsen Morag Total Cancellations Inpatient (Clinical and Non-Clinical) Yes - 5.0% 5.0% 11.5% 12.0% Aug-17 - Olsen Total Cancellations for Consultant and Nurse Led Morag Yes - 5.0% 5.0% 11.9% 11.1% Sep-17 - Outpatient appointments Olsen
The Finance and Performance committee scrutinises performance within this domain.
Where we have not achieved the target, we have included an exception report.
Performance Report September 2017
Page 49 Exception Report: Inpatient Cancellations 50 Executive Exception National March 18 Current Welsh Dignified Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % procedures postponed more than once, patient had Morag Yes 100.0% 95.0% 75.0% 9.1% 7.0% Aug-17 3rd procedure under 14 days or at their earliest convenience Olsen Efficiencies: Patient admitted but procedure not carried Morag Yes - - - 2.7% 2.7% Jun-17 - out Olsen Morag Total Cancellations Inpatient (Clinical and Non-Clinical) Yes - 5.0% 5.0% 11.5% 12.0% Aug-17 - Olsen
Where we are Efficiencies: Patient admitted but For July 2017, 7% of patients experienced having their operation cancelled more procedure not carried out than once and received their operation within 14 days of the second cancellation. 7% 6% What we are doing about it 5% Actions that were Cancellation Reviews and Theatre Accountability Meetings 4% continue. Unused elective slots are now being filled with Trauma patients; Patients 3% are admitted earlier for anaesthetic screening. Scheduling is being reviewed to 2% ensure patients are booked in turn of clinical priority and length of wait. Across the 1% Health Board the process for bringing in short notice, standby patients has been 0%
streamlined with particular success in Ophthalmology in East, ENT in West and HDU
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in Central. However, use of ‘standby’ patients may have a negative impact on the Jun-16
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Aug-16 Sep-16 Nov-16 Dec-16 Actual Plan TargetMay-17 Treat out of Turn (TooT) numbers as they are called in based on their availability, not necessarily their clinical or wait priorities. The Theatre Transformation Group Total Cancellations Inpatient (Clinical continues to monitor performance against these measures, with the Transformation and Non-Clinical) 15% Board escalating issues as required. 12% 9% When we expect to be back on track 6% With continuation of the actions outlined above, it is expected that we will achieve the 3%
5% target rate within Quarter 4 of 2017/18. 0%
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Sep-16 Aug-16 Nov-16 Dec-16 Aug-17 May-17 Actual Plan Target Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 50 Triangulated Understood Underway Complete Exception Report: Outpatient Cancellations 51 Executive Exception National March 18 Current Welsh Dignified Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Total Cancellations for Consultant and Nurse Led Morag Yes - 5.0% 5.0% 11.9% 11.1% Sep-17 - Outpatient appointments Olsen
Where we are It should be noted that the reported position excludes all data from Central Total Cancellations for Consultant due to issues with processes and data quality in WPAS. The reduction of Hospital Initiated and Nurse Led Outpatient appointments Cancellations (HIC) by 50% is one of the key performance indicators for the Outpatients 15% Improvement Programme for 2017/18. Short notice HICs can result in lost capacity and 12% under-utilisation of staff. Inaccuracy of data has required urgent resolution as it has not been possible to extract accurate information on HICs across the sites to inform 9% improvement and realise benefits; the current data does not reflect true position. 6% What are we doing about it • Identified and agreed Health Board Outpatient Department (OPD) specific HIC drop down 3% codes are now in WPAS in Central. 0% • The second Plan Do Study Act (PDSA) cycle commenced with some slight adjustments
to the reason codes and generated reports. The full report expected towards the end of
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Sep-16 Sep-17 Nov-16 Dec-16 Aug-17 September 2017. Actual Plan May-17 Target • The HIC data report will direct future Rapid Improvement Events and focus on the top 3 reasons for under 1 week cancellations and work to agree solutions. • Meetings have been arranged to roll out the new HIC codes to PiMS (West) and Myrddin (East) to standardise data and processes across all three sites. This will require support from Informatics to drive through the changes across the sites. • The work has been shared with the ‘All Wales OPD Transformation Steering Group’ with potential for the HIC codes used by the Health Board to be adopted across Wales and is one of the key Health Board actions for the All Wales 1000 Lives Outpatient Collaborative. • Continual reassessment of HIC data and compliance is monitored as part of the monthly Strategic Mission and weekly site planning cells. When we expect to be back on track Continued support from all stakeholders for the Outpatients Improvement Programme is crucial for the success of reducing HIC’s and our ability to achieve the 5% target rate by March 2018 is wholly dependent upon this support Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 51 Triangulated Understood Underway Complete 52 Our Achievements - Timely Care I have access to services based on clinical need & am actively involved in decisions about my care
Health Board issues Norovirus advice ahead of busy winter illness season The rules
Betsi Cadwaladr University Health Board is 1. Everyone entering and leaving a ward must use the reminding North Wales residents of its advice on hand rub or wash their hands. what to do if someone has diarrhoea and 2. Visitors must not come into any of our hospitals if vomiting over the winter months. they have suffered from diarrhoea and/or vomiting in Norovirus is the main cause of winter diarrhoea the previous 48 hours. 3. Patients who are due to come in but have had either and vomiting, and tends to circulate more diarrhoea or vomiting in the previous 48 hours are prominently in communities across the UK asked to contact us first for advice, and so we can throughout the winter, with October usually make appropriate arrangements. We want seeing the start of an increase in the number of 4. All visitors to our hospitals must follow the advice on people reporting diarrhoea and vomiting. the signs and notices at ward entrances and any members of the guidance from nursing or other staff. Please only visit wards affected by Norovirus if it is essential. public to help us Anybody experiencing symptoms of Norovirus, 5. Children should not come visiting to affected wards which includes sickness and diarrhoea, are prevent the risk advised to stay at home and rest, and to stay well hydrated. Following this advice will help stop of infection. the spread of the highly contagious virus within Tracey Cooper, Assistant Director of Nursing - communities, helping protect vulnerable people Infection Prevention, said: “Every year Norovirus who are at greater risk. circulates in communities throughout North Wales, in particular during the winter months. The Health Board also requests that people who have experienced symptoms of Norovirus in the “Norovirus is unpleasant, but usually clears up previous two days stay away from hospital, to after a few days, and it’s important members of Tracey Cooper help prevent it from spreading to hospital the public follow our advice on how to recover Assistant Director of Nursing patients. and prevent others from picking up the bug.” – Infection Prevention
Performance Report September 2017
Page 52 53 Timely Care Overview – National Standards Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark offering appts between 17:00 and 18:30 Morag Yes - 99.0% 99.0% 96.3% 95.4% Q2-17/18 - at least two days a week Olsen offering appts between 17:00 and 18:30 Morag Not % GP practices Yes - - 70.20% 70.4% Q2-17/18 - 5 days a week Olsen submitte open during daily core hours or within1 Morag Yes - 91.0% 91.0% 88.9% 87.9% Q2-17/18 6th hour of daily core hours Olsen Morag % of patients waiting less than 26 weeks for treatment Yes 95.0% 90.0% - 83.1% 81.6% Sep-17 7th Olsen Morag Number of 36 week breaches- all specialties Yes 0 9,300 8,800 8,781 9,066 Sep-17 7th Olsen Morag % of patient waiting less than 8 weeks for diagnostics Yes 100.0% 100.0% 100.0% 96.6% 95.9% Sep-17 - Olsen % of new patients spend no longer than 4 hours in A&E Morag Yes 95.0% 86.0% 86.0% 80.2% 78.4% Sep-17 7th (inc Minor Injury Units) Olsen Morag Number of patients spending 12 hours or more in A&E Yes 0 0 350 859 1,170 Sep-17 7th Olsen Morag % of red 1 call responses within 8 minutes No 65.0% 65.0% 65.0% 80.3% 80.3% Sep-17 6th Olsen Morag Number of ambulance handovers over one hour Yes 0 0 350 584 838 Sep-17 6th Olsen % of patients newly diagnosed with cancer not via the Morag Yes 98.0% 98.0% 98.0% 98.2% 98.8% Aug-17 3rd USC pathway, treated within 31 days of diagnosis Olsen % of patients referred via the USC pathway definitively Morag Yes 95.0% 95.0% 93.0% 92.0% 89.2% Aug-17 3rd treated within 62 days of referral Olsen Percentage of the health board population regularly Morag Yes 54.7% 52.0% 51.0% 49.5% 49.6% Aug-17 6th accessing NHS primary dental care Olsen % of stroke patients who have a direct admission to an Morag Yes - 65.0% 65.0% 40.4% 35.0% Sep-17 6th acute stroke unit within 4 hours Olsen % of stroke patients who receive a CT scan within 12 Morag Yes - 100.0% 100.0% 92.3% 95.1% Sep-17 4th hours Olsen % of stroke patients who have been assessed by a Morag No 82% #N/A - 90.80% 84.40% Sep-17 5th stroke Consultant within 24 hours Olsen % of stroke patients who have received a formal swallow Morag No - 100.0% 100.0% 100.0% 100.0% Sep-17 2nd assessment in 72 hours Olsen All patients overdue their target date on the Follow Up Morag Yes - 49,750 54,250 53,383 70,383 Sep-17 6th Waiting List Olsen
Performance Report September 2017
Page 53 54 Timely Care Overview – Local Standards Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark The number of patients waiting more than 52 weeks for Morag Not Not Yes 0 2,286 2,504 Sep-17 - treatment Olsen submitte submitte Morag Therapies Waits Over 14 weeks No 0 0 0 3 2 Sep-17 - Olsen Out of Hours : Urgents triaged/assessed within 20 Morag Yes 98.0% 98.0% 98.0% 76.0% 77.0% Sep-17 - minutes Olsen Out of Hours : Non-urgents triaged/assessed within 60 Morag Yes 98.0% 98.0% 98.0% 83.0% 85.0% Sep-17 - minutes Olsen Morag Admission on day of surgery No 75.0% 95.0% 95.0% 88.1% 95.8% Aug-17 - Olsen Morag % of all strokes thrombolysed Yes - 12.0% 12.0% 9.6% 9.7% Sep-17 - Olsen Morag % of all eligible patients thrombolysed No - 100.0% 100.0% 100.0% 100.0% Sep-17 - Olsen
Where we have not achieved a target, we have included and exception report
Please note, the Follow-Up Waiting List figure is inflated due to a data quality issue, following the implementation of WPAS. This requires validation and the correct figure will be published when this is completed.
Performance Report September 2017
Page 54 Exception Report: GP Opening Times 55 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark offering appts between 17:00 and 18:30 Morag Yes - 99.0% 99.0% 96.3% 95.4% Q2-17/18 - at least two days a week Olsen offering appts between 17:00 and 18:30 Morag Not % GP practices Yes - - 70.20% 70.4% Q2-17/18 - 5 days a week Olsen submitte open during daily core hours or within1 Morag Yes - 91.0% 91.0% 88.9% 87.9% Q2-17/18 6th hour of daily core hours Olsen
Where we are % GP practices open during daily core September figures are identical to August as they are based on the Quarter 2 data hours or within1 hour of daily core hours collection exercise. This data has been collated from 107 GP practices across North 100% Wales. 90% • The percentage of GP Practices ‘offering appointments between 17.00 and 18.30 at 80% least two days per week’ has come down to 95.37%, (102 practices). This change is 70% due to Panton Managed Practice in Holywell, Flintshire no longer offering this. • The percentage of GP Practices ‘offering appointments between 17.00 and 18.30 for 60% 5 days a week’ has reduced to 70.4% (76 practices). Park house in Denbighshire, 50% Panton & Roseneath in Flintshire and Plas y Bryn and Borras in Wrexham are no longer offering this. • The percentage of GP Practices ‘Open during core hours or within 1 hour of daily core hours’ has reduced to 87.9% (94 practices). This is due to a change in opening Actual Plan Target hours for Borras in Wrexham. What we are doing about it The Area Teams and PCSU continue to encourage practices to ensure that patients have good access hours for appointments. However, following further Practice resignations and retirements due to come into effect over the coming months, the main focus and priority for the Area Teams and PCSU has been the support to these Practices to ensure patients continue to receive access to GMS Services. When we expect to be back on track GMS Access standards are key components of the Cluster Plans and PCSU will be supporting the Area Teams and the Clusters to develop them during the year. Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 55 Triangulated Understood Underway Complete Exception Report: Referral To Treatment 56 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark The number of patients waiting more than 52 weeks for Morag Not Not Yes 0 2,286 2,504 Sep-17 - treatment Olsen submitte submitte Morag Number of 36 week breaches- all specialties Yes 0 9,300 8,800 8,781 9,066 Sep-17 7th Olsen Morag % of patients waiting less than 26 weeks for treatment Yes 95.0% 90.0% - 83.1% 81.6% Sep-17 7th Olsen
Where we are % of patients waiting less than 26 At the end of September 2017, the number of patients experiencing waits beyond 36 weeks for treatment weeks on an Referral to Treatment (RTT) pathway increased to 9,066 (All patients, 100% 9,061 Welsh patients). 80% 60% What we are doing about it 40% • Ensure the activity plan for the remainder of the year is fully delivered. 20% • Theatre productivity gains are fully implemented (already counted in the activity 0%
plan) – this is still work in progress and is not yet being delivered.
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Sep-16 Nov-16 Aug-17 Sep-17 Nov-17 Dec-17 Dec-16 • Booking is tightened to optimise routine capacity. May-17 • RTT rule compliance in relation to DNA. Actual Plan Target • Validation continues to remove 6% Medical specialties are continuing to reduce access times below 36 weeks”. Number of 36 week breaches- all specialties 10,000 8,000 When we expect to be back on track 6,000 With additional funding granted by Welsh Government we expect to get to 4237 (Plan 4,000 2 in the graph opposite) at the end of March 2018. 2,000
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Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 56 Triangulated Understood Underway Complete Exception Report: Diagnostic Waiting Times 57 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Morag % of patient waiting less than 8 weeks for diagnostics Yes 100.0% 100.0% 100.0% 96.6% 95.9% Sep-17 - Olsen
Where we are % of patient waiting less than 8 In September 2017, 444 patients experienced waits of over 8 weeks for a diagnostic weeks for diagnostics test. Of these 249 were in Endoscopy, 110 in Neurophysiology, 74 in Radiology, 4 in 100% Urology and 7 in Cardiology. 90% What we are doing about it 80% Endoscopy insourcing has recommenced in West, with further work underway to 70% review vetting process for USC referrals. In East, the endoscopy unit has only 1 room operating due to underlying estate issues. Some sessions have been provided in 60% Main Theatres out of hours and weekend capacity has been secured with an external 50% provider for October 2017. Business continuity plans are in development – options include either a mobile unit or modular suite. Actual Plan Target A new Neurophysiology Consultant with an EMG remit started in post on 20th September 2017. A 12 week plan has been agreed to recover through additional clinics, although accommodation is yet to be agreed. Additional Cardiac CT sessions have been scheduled to address some of the backlog in East. In Central, discussions are ongoing with regards additional cardiac CT sessions. Additional US capacity is being secured through framework approved locum agencies.
When we expect to be back on track Endoscopy in West expected to be back on track by end of November 2017. Further detail is required regarding contingency options in East. Neurophysiology expect to be back on track by end of December 2017. Radiology – Nuclear medicine should be back on track by end of October with Ultrasound by end of November 2017. Cardiac CT capacity is dependent on the outcomes of discussions with Cardiology.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 57 Triangulated Understood Underway Complete Exception Report: Four Hour Target 58 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of new patients spend no longer than 4 hours in A&E Morag Yes 95.0% 86.0% 86.0% 80.2% 78.4% Sep-17 7th (inc Minor Injury Units) Olsen
Where we are % of new patients spend no longer At 78.4% in September 2017, the Health Board was not able to sustain the delivery of than 4 hours in A&E (inc Minor the expected 80% milestone, as achieved in August 2017. The variation in Injury Units) 100% performance between site shows that Ysbyty Gwynedd (YG) delivered 80.97%, Ysbyty Glan Clwyd (YGC) 79.01% and Wrexham Maelor Hospital (WMH) 75.23%. 90%
What we are doing about it 80% The Health Board has prioritised its key actions under 4 themes being lead by an 70% executive director. 60% • Escalation – Led by the Executive Medical Director and includes Safety Huddle 50% supported by the Delivery Unit (DU) • Community – Led by the Executive Director of Nursing and includes 4 main conveyance pathways, MIU and interface with clinical desk, 111, GP OOH • Discharge Processes – Led by the Executive Director of Therapies and Health Actual Plan Target Sciences and includes SAFER bundle, discharge planning • Ring-fenced capacity – Led by the Chief Operating Officer and includes assessment units functions and impact, redesign of assessment units function moving forward with primary care.
In addition following a summit with Welsh Government individual site actions for immediate improvement are being strengthened to deliver an improved 4 hour performance. Theses include: closer alignment between rostering and demand in ED, extended ENP hours to 2am, increased patient trackers in ED.
When we expect to be back on track We expect to turn around performance to be above 80% by November 2017. Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 58 Triangulated Understood Underway Complete Exception Report: Twelve Hour Target 59 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Morag Number of patients spending 12 hours or more in A&E Yes 0 0 350 859 1,170 Sep-17 7th Olsen
Where we are Number of patients spending 12 During September 2017 the number of patients experiencing waiting times of over 12 hours or more in A&E hours in our Emergency Departments (ED) increased to 1,170, a rise of over 300 1,500 compared to August 2017. 1,200
What we are doing about it 900 The programme of work related to the safety huddle commences on the 1st November 2017 and is intended to ensure daily whole system actions are agreed each morning. 600 The SAFER bundle has been introduced in YGC and is being rolled out across the 300 Health Board during November to ensure senior assessment on admission, improved flow using estimated date of discharge and daily review of compliance against 0 expected discharge to review any actions needed to escalate discharge processes. This is intended to enable patients to be safely discharged with shorter length of stay and earlier in the day so as to improve access to ward beds for patients waiting Actual Plan Target admission from ED. The comprehensive assessment unit in Wrexham opened during September and is pulling suitable patients from ED to enable them to be assessed, treated and returned to normal place of residence in the day. The RAU plus in YG is developing a similar approach and the Comprehensive Older Persons Assessment Unit in YG will be expanded from 12 to 24 beds to enable a higher volume of patients to receive the services of the team, shortening the time older people spend in hospital and improving access for other patients. This expanded unit will link directly to the short stay assessment area in the hospital
When we expect to be back on track We are expecting the work streams to be commenced by the end of November 2017 and expecting performance to improve aligned to this.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 59 Triangulated Understood Underway Complete Exception Report: Ambulance Handover Times 60 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Morag Number of ambulance handovers over one hour Yes 0 0 350 584 838 Sep-17 6th Olsen
Where we are Number of ambulance handovers The number of ambulances waiting over one hour at a hospital increased to 838 in over one hour September 2017, compared to 584 in August 2017. 1,000 800 What we are doing about it 600 The community work stream lead by the Executive Director for Nursing aims to reduce the volume of ambulance conveyances by implementing the new pathways of care 400 and fully utilising the facilities available at the Minor Injuries Units. These aim to 200 provide patients with timely, effective care while taking the pressure off the front doors 0 of ED, so enabling those in need of ambulance transfer to ED the opportunity to have shorter waits for access to the ED. This work is combined with the immediate work being undertaken to improve the service within ED. This includes extending the hours Actual Plan Target of the ENP service to from 8am-2am 7 days per week, protecting minors space and capacity, more effective matching of staff rostering to the demand profile of attendances at ED, and the work of the Safety Huddle and the SAFER bundle. In addition it is intended to improve the use of ring-fenced capacity to support direct access routes and so further improve ability to hand over patients between the ambulance and the hospital.
When we expect to be back on track We expect the new work streams to be in place by the end of Nov.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 60 Triangulated Understood Underway Complete Exception Report: Cancer Treatment (31) 61 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of patients newly diagnosed with cancer not via the Morag Yes 98.0% 98.0% 98.0% 98.2% 98.8% Aug-17 3rd USC pathway, treated within 31 days of diagnosis Olsen
Where we are % of patients newly diagnosed with In August 2017, 98.8% (167 out of 169) Non Urgent Suspected Cancer (NUSC) cancer not via the USC pathway, treated within 31 days of diagnosis patients (i.e. those not referred urgently with symptoms suggestive of cancer) were 100% treated within 31 days of decision to treat. This is above the target of 98% for the second consecutive month. 99% 98% What we are doing about it 97% All breaches have been reviewed. Both were due to a delay to laparoscopic urology 96% surgery. Additional capacity has been identified in North West England and funding 95% was approved for this capacity at the end of September. Waits for surgery will therefore now decrease. Actual Plan Target Weekly and bi-weekly escalation meetings continue to be held on each site with each specialty team in order to ensure delays are minimised. Benchmark Chart (Delayed Information) % of patients When we expect to be back on track referred as non-urgent suspected cancer seen within 31 We expect to continue to achieve this target. days Aug-17 100% 99% 100% 99% 98% 98% CARDIFF 98% ANEURIN BEVAN 96% 96% BCUHB 94% HYWEL DDA CWM TAF 92% ABMU 90%
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 61 Triangulated Understood Underway Complete Exception Report: Cancer Treatment (62) 62 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of patients referred via the USC pathway definitively Morag Yes 95.0% 95.0% 93.0% 92.0% 89.2% Aug-17 3rd treated within 62 days of referral Olsen
Where we are % of patients referred via the USC 89.2% (124 out of 139) Urgent Suspected Cancer (USC) patients (i.e. those pathway definitively treated within 62 referred urgently with symptoms suggestive of cancer) were treated within 62 days days of referral of referral in August 2017. 4 of the 15 breach patients were on complex diagnostic 100% pathways. 90%
What we are doing about it 80% The remaining breaches have been reviewed and the following themes identified and actions taken: 70% Delays to urology surgery – Additional capacity has been secured and funded in North West England for additional cases; this will lead to a reduction in waiting 60% times from October onwards Delay to first appointment – The main area of concern remains colorectal waits in Central; Central are currently diverting referrals to East and West due to a lack of Actual Plan Target capacity and holding additional clinics where possible in order to reduce waiting Benchmark Chart (Delayed times. The first ‘straight to test’ telephone assessment clinic will be held in Information) % of patients referred October in order to improve patient pathways and reduce waits as urgent suspected cancer seen Delay to endoscopy – USC waiting times remain a challenge across the Health within 62 days Aug-17 Board, in particular due to the loss of physical capacity in Wrexham. Out of hours working is in place but a broader solution is required. 100%
95% ANEURIN BEVAN 91% Weekly and bi-weekly escalation meetings continue to be held on each site with 91% HYWEL DDA 90% 89% 88% each specialty team in order to ensure delays are minimised. BCUHB CARDIFF 85% 83% CWM TAF When we expect to be back on track 80% There remains a significant risk to achievement in 2017/18 as a significant amount 80% ABMU of capacity was funded via non-recurrent funding in 2016/17 75% Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 62 Triangulated Understood Underway Complete Exception Report: Primary Care Dental Access 63 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Percentage of the health board population regularly Morag Yes 54.7% 52.0% 51.0% 49.5% 49.6% Aug-17 6th accessing NHS primary dental care Olsen
Where we are Percentage of the health board Performance during the 3 months, June to August 2017 has remained the same at population regularly accessing NHS 49.6%* or approximately between 344,036 and 344,695 patients. (*49.5% in July primary dental care 2017): 55% 53% What we are doing about it • Commissioned additional activity with those contractors with capacity to deliver 50% increased access during 2017/18 48% • Propose to commission further additional activity as part of the mid year review process with those contractors identified with capacity to increase 2017/18 access 45% • A tender exercise underway to re-commission services in Dolgellau and commission further additional capacity prioritising areas identified with low dental access and/or high oral health needs Actual Plan Target • Encouraging contractors to implement NICE patient recall guidelines thus potentially freeing up capacity for additional patients. • Working with all contractors to ensure they have adequate plans in place for the full delivery of existing contracted activity levels
When we expect to be back on track Any significant recovery in access levels is not expected before April 2018 when services commissioned as part of the current tender process begin to come on stream.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 63 Triangulated Understood Underway Complete Exception Report: Rapid Stroke Care 64 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark % of stroke patients who have a direct admission to an Morag Yes - 65.0% 65.0% 40.4% 35.0% Sep-17 6th acute stroke unit within 4 hours Olsen % of stroke patients who receive a CT scan within 12 Morag Yes - 100.0% 100.0% 92.3% 95.1% Sep-17 4th hours Olsen % of stroke patients who have received a formal swallow Morag No - 100.0% 100.0% 100.0% 100.0% Sep-17 2nd assessment in 72 hours Olsen
Morag % of all strokes thrombolysed Yes - 12.0% 12.0% 9.6% 9.7% Sep-17 - Olsen Morag % of all eligible patients thrombolysed No - 100.0% 100.0% 100.0% 100.0% Sep-17 - Olsen Where we are: Performance has deteriorated on the quality improvement measures during September and variation between the three sites is noted with YGC delivering the highest performance on access to the stroke bed within 4 hours and Wrexham the highest thrombolysis rates across the health board. The SSNAP report for April to July 2017 shows YGC and Wrexham retaining their C level of performance, while YG deteriorated to a D. What we are doing about it: The performance level has triggered escalation and therefore weekly patient level pathway reviews and performance action meetings recommenced on 6th October. The escalation policy for ring-fencing of the stroke bed has been reviewed, updated and signed by the Medical Director and COO. This has been recirculated to the on call and site managers as well as the stroke teams. The additional commitment from Therapies in increase input into the stroke wards with immediate effect has been secured and vacancies within therapies will be filled to increase therapeutic daily impact for the patients on the acute stroke unit. The Peer review action plan has been collated into a Pan BCU plan. This is being managed via the BCU Stroke Governance Collaborative. The work on the strategic stroke model is continuing with a further stakeholder event undertaking an option appraisal in October and a MDT working group set up to review the rehabilitation model in November. It is expected the outcome from this work will report to Board early in the new year. When we will be back on track: It is too early in the escalation to give a clear indication of how long the actions will take to impact , however review of performance after the first week of escalations shows an early and significant improvement on the QIMS compared to the previous recent performance. Performance Report September 2017
Page 64 Exception Report: Follow Up Appointments 65 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark All patients overdue their target date on the Follow Up Morag Yes - 49,750 54,250 53,383 70,383 Sep-17 6th Waiting List Olsen
Where we are Reported figures for this measure should be read with caution until the All patients overdue their target date on process and data quality issues with WPAS in Central Area have been resolved. In the Follow Up Waiting List September 2017, there were 70,383 reported as waiting beyond their due date for a 75,000 follow up appointment. 60,000 45,000
What we are doing about it 30,000 In West, increased capacity in the Ophthalmology Diagnostic Treatment Centre 15,000 (ODTC) is expected to positively impact the number of patients waiting beyond their target follow up appointments as ophthalmology has the biggest number of such 0 patients.
Actual Plan Target In Central, it is not clear what the actual backlog number is due to the ongoing process and data quality issues with WPAS and until the issues with WPAS have been fully resolved and the quality of data is assured, it isn’t possible to accurately articulate the full extent of the follow up backlog issue in Central.
In East, as at the end of September 2017, performance continues to be on profile to achieve the 10% reduction in the number of patients overdue their follow up appointments.
When we will be back on track In West, the impact of the work in ophthalmology along with other initiatives and actions to achieving a 10% reduction by the end of the financial year. In Central, due to the WPAS issues alluded to above, it isn’t possible to provide an assured statement as to when we will be back on track. In East, we are on trajectory to achieve the agreed 10% reduction by the end of March 2018.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 65 Triangulated Understood Underway Complete Exception Report: Out of Hours GP Service 66 Executive Exception National March 18 Current Welsh Timely Care Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Out of Hours : Urgents triaged/assessed within 20 Morag Yes 98.0% 98.0% 98.0% 76.0% 77.0% Sep-17 - minutes Olsen Out of Hours : Non-urgents triaged/assessed within 60 Morag Yes 98.0% 98.0% 98.0% 83.0% 85.0% Sep-17 - minutes Olsen
Where we are Out of Hours : Urgents In September 2017, 77% of URGENT calls were triaged within 20 minutes and 85% triaged/assessed within 20 minutes of ROUTINE calls were triaged within 60 minutes (76% and 83% respectively for 100% August 2017), demonstrating continued improvement in performance overall. 80%
The GPOOH service received 10,323 calls in September 2017 compared to 9,412 60% calls in September 2016 (an increase of 911 calls or 9.7%). 95.7% of triage nurse 40% shifts were filled in September 2017 compared to 92.5% in August 2017. 20% What we are doing about it 0% Month on month increase in activity continues to impact on our ability to achieve and maintain the Welsh Government Standards. We are nearing completion of training for 3 recently appointed Triage Nurses and have now appointed a further 3 Triage Actual Plan Target Nurses. However, there is still a deficit of 2.76 WTE Triage Nurses, approximately Out of Hours : Non-urgents 20% of our establishment. The continued increase in activity and the increase in triaged/assessed within 60 minutes patients with more complex medical needs continues to prove challenging. 100% Operational Managers, Senior Nurses and Medical Advisers regularly review the rotas against this increased level of activity and where necessary, will propose 80% changes to divisional staffing rotas to the respective Quality, Safety and Patient 60% Experience groups.. 40% When we expect to be back on track 20% With this in mind we continue to work on improving current performance levels month 0% on month with a view to achieving the 98% requirement for both standards as soon as possible.
Actual Plan Target Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 66 Triangulated Understood Underway Complete Our Achievements - Our Staff and Resources 67
I can find information about how the NHS is open & transparent on its use of resources & I can make careful use of them
Health Board steps up efforts to champion staff mental wellbeing
North Wales’ biggest employer is marking World Mental Health Day (October 10th) by stepping up efforts to improve the mental wellbeing of its staff.
Betsi Cadwaladr University Health Board hope to establish ‘mental wellbeing champions’ On World Mental throughout its hospitals and health centres, as Health Day, and part of a range of initiatives to improve the wellbeing of its 16,500+ staff. The Health Board’s Occupational Health Team every other day, will also be running wellbeing workshops for staff we’re determined Earlier this year, the Health Board lent its support to promote how the ‘5 Ways To Wellbeing’ can to the national ‘Time to Change Wales’ campaign help staff to stay mentally well, and support staff to support our staff to improve awareness, reduce stigma and to manage stress and anxiety. to look after their support staff who are experiencing mental health problems Meanwhile, the Clinical Psychology Service at mental wellbeing Ysbyty Glan Clwyd’s Ablett Psychiatric Unit have It now plans to further develop the range of begun delivering a 6 month wellbeing support it can offer its staff by establishing a programme. It is hoped that the weekly wellbeing network of ‘mental wellbeing champions’ who will sessions will equip staff and patients with the help to challenge the stigma associated with skills to look after their wellbeing by utilising mental health in the workplace and encourage mindfulness and compassion focused open discussion about the topic with colleagues. acceptance and commitment therapy principles Gary Doherty Chief Executive
Performance Report September 2017
Page 67 68 Staff & Resources Overview – National Standards Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Martin % staff absence due to sickness (rolling 12mths) No 4.55% 4.55% 4.55% 4.83% 4.73% Aug-17 2nd Jones % of total medical staff undertaking appraisals Evan Moore No - 98.0% 98.0% 98.5% 98.4% Sep-17 - Russ Finance - % variance against budget Yes 0.0% 2.2% 2.2% 3.9% 3.0% Sep-17 - Favager Morag New Outpatient DNA rates for selected specialties Yes - 4.7% 4.9% 6.1% 6.2% Aug-17 3rd Olsen Morag Follow up Outpatient DNA rates for selected specialties Yes - 6.6% 6.8% 7.3% 7.2% Aug-17 3rd Olsen Martin % of staff (non-medical) undertaking an appraisal - PADR Yes - 90% 85% 54% 56% Aug-17 - Jones
The Finance & Performance committee scrutinises the indicators in the Staff & Resources domain.
Where we are not achieving the required standard, we have included an exception report.
The statutory duty to financially break even has been included to the national template.
Performance Report September 2017
Page 68 69 Staff & Resources Overview – Local Standards Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Martin Mandatory Training overall percentage trained Yes - 90% 85% 80% 81% Aug-17 - Jones Russ Not Not Agency & Locum Spend in £000's Yes - 3,400 3,100 Sep-17 - Favager submitte submitte Theatre lists finishing 30 or more minutes before the Morag Yes - 20.6% 20.6% 34.2% 32.7% Sep-17 - scheduled end time Olsen Theatre lists starting 15 or more minutes after Morag Yes - 13.5% 13.5% 45.3% 57.8% Sep-17 - scheduled start time Olsen
Performance Report September 2017
Page 69 Exception Report: Staff Sickness Rate 70 Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Martin % staff absence due to sickness (rolling 12mths) No 4.55% 4.55% 4.55% 4.83% 4.73% Aug-17 2nd Jones Where we are Absence levels showed a slight improvement in August with absence levels falling to % staff absence due to sickness (rolling 12mths) 4.73%. This corresponds with an increase in care referrals to 49.28%. . The equivalent 5.5% of 708 staff were absent every day of the month with HCSWs, Qualified Nurses, 5.2% Midwives, Estates and Facilities staff experiencing the highest levels of absence. 4.9%
4.6% What we are doing about it Workforce will continue to promote early intervention in the management of sickness 4.3% absence. Research has demonstrated that the use of adjusted duties to allow an 4.0% earlier return prevents the onset of depression and other mental health issues. Working in partnership with trade unions and managers, workforce will continue to Actual Plan Target support staff to stay in work while managing their ongoing health conditions. The link between older workers and increased levels of absence is demonstrated in the graph to the right. Currently only staff aged below 40 or over 71 meet the Welsh Government target. A training package is being developed to provide support and guidance for staff who may be required to work longer due to increasing pension ages. The emphasis is on maintaining health and wellbeing, financial planning and employment policies that allow staff to adjust to the changes.
When we expect to be back on track Absence levels are traditionally cyclical with a rise during winter months. The Flu campaign has commenced and staff are encouraged to protect patients, family, colleagues and themselves. As we approach the autumn it is important that WOD continues to support departments to proactively manage sickness absence and to promote employee health and wellbeing.
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 70 Triangulated Understood Underway Complete 71 Exception Report: Financial Balance Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Russ Finance - % variance against budget Yes 0.0% 2.2% 2.2% 3.9% 3.0% Sep-17 - Favager
Where we are The Health Board 2017-18 Financial Plan includes a planned deficit of £26m for the Finance - % variance financial year (£2.2m per month). The financial position for September is a deficit of against budget £3.5 million, which is £1.3 million over the planned monthly amount. This is an 8.0% improvement on the previous month run rate which was a deficit of £4.5 million. The year to date deficit is £25.2 million. 6.0% What we are doing about it The Health Board's financial plan for 2017/18 includes a savings target of £35.4m. To 4.0% date, £39.8m of savings plans have been identified but £12.2m have a high risk rating. A cumulative savings requirement of £17.7m has been profiled into September's 2.0% financial reports. The reported savings to date are £11.6m resulting in an under achievement of £6.1m. A number of saving schemes are profiled to deliver savings
0.0%
Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 later in the year and this should result in a reduction of monthly overspend in future Sep-16 months. Achievement of the 2017/18 Financial Plan is dependent on the full delivery of saving schemes. -2.0% 2016/17 funding for RTT (£7.7m) & 9/12ths of When we will be back on track -4.0% Work is ongoing to ensure that saving plans deliver the level of savings required by Treatment Fund (£2.52m) released into the financial the Financial Plan and further details on the financial position are contained in the position. Director of Finance reports. -6.0%
Actual Variance %
Planned Variance %
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 71 Triangulated Understood Underway Complete Exception Report: Outpatient DNA 72 Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Morag New Outpatient DNA rates for selected specialties Yes - 4.7% 4.9% 6.1% 6.2% Aug-17 3rd Olsen Morag Follow up Outpatient DNA rates for selected specialties Yes - 6.6% 6.8% 7.3% 7.2% Aug-17 3rd Olsen
Where we are In August 2017, 6.2% of New Outpatient appointments resulted in a New Outpatient DNA rates for selected Did Not Attend (DNA), whilst 7.2% of Follow-up appointments were recorded as DNA. specialties 8% What we are doing about it In West, all teams are focussed on the action plans implemented in July and August and updates are being provided on a weekly basis. 7% In Central we are continuing with the Plan Do Study Act (PDSA) cycle methodology to 6% identify how we can reduce DNA rates. In Urology we have identified that clinics are 5% being cancelled so clinical staff can support inpatient cancer services. This has led to patients then not attending the re-arranged appointments. This is part of a wider piece 4%
of work looking at urology services as whole and is due for completion in November
Jul-17
Oct-16 Apr-17 Oct-17
Jan-17 Jun-17 Jan-18
Feb-17 Mar-17 Feb-18 Mar-18
Nov-16 Dec-16 Nov-17 Dec-17
Sep-16 Aug-17 Sep-17 2017. However, it should be noted that issues with processes and data quality within May-17 WPAS is negatively impacting upon our ability to obtain accurate figures and is Actual Plan Target hindering the work being undertaken to improve performance against these measures. Follow up Outpatient DNA rates for selected In East, Ophthalmology is the specialty where DNAs are most prevalent. To reduce the specialties number of DNAs, the teams have tried several different methods of booking patients, 8% without success. The Management Team are analysing the data in order to ascertain whether the DNAs are due to patient or hospital cancellations. As part of this work we 7% are reviewing the Eye Casualty Clinics to understand what the DNA patterns and reasons are. 6% When we expect to be back on track With continued focus on the specialties where DNAs are most prevalent, we expect to be back on track before the end of Quarter 4, 5%
2017/18.
Jul-17
Oct-16 Apr-17 Oct-17
Jan-17 Jun-17 Jan-18
Feb-17 Mar-17 Feb-18 Mar-18
Sep-16 Nov-16 Dec-16 Aug-17 Sep-17 Nov-17 Dec-17 May-17 Actual Plan Target
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 72 Triangulated Understood Underway Complete Exception Report: Staff Appraisal 73 Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Martin % of staff (non-medical) undertaking an appraisal - PADR Yes - 90% 85% 54% 56% Aug-17 - Jones Where we are PADR % Compliance 1st August In August 2017, 56% due a PADR received one, this equates to 9,121 PADRs completed between 01/08/16 – 31/08/17. 2016 to 31st August 2017 What we are doing about it • PADR information, the benefits of appraisal and pay progression are included in Project Monitoring… 3 Orientation training every month (All staff /managers attend Orientation on their first Therapies Executive 9 day working with us in BCUHB). We have revised the PADR content, explain how Nursing Executive 215 PADR is linked to organisational objectives and what the benefits are to the COO Management 34 individual, team and the organisation. Estates & Facilities 1,536 • Bespoke session requests continue to come in and were held in Informatics and Area Teams -… 136 Estates Department during August. Medical Education and… 103 • PADR training continues to be covered on all our Leadership development Office of the Board… 57 programmes with sessions carried out on A Step Into Management during August. Area Teams - Central 1,668 • Feedback continues to be consistently positive that the new paperwork and Secondary Care 6,594 handbook are user friendly and encourage PADRs being carried out positively. Area Teams - East 1,996 • Following the recent PADR audit an action plan is being developed to implement Medical Executive 449 recommendations Area Teams Total 5,210 When we expect to be back on track WF & OD Executive 138 Each Director is responsible to discuss PADR within Accountability meetings and to Mental Health & LDS 1,741 take action with their local teams. Chief Executive 32 Finance and Performance Committee will require a report from all poorly performing Area Teams - West 1,410 areas to provide assurance on an improvement plan and trajectory. Finance Executive 148 A minimum of 85% compliance is expected with effect from Quarter 4. Strategy Executive 28
0% 20% 40% 60% 80% 100%
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 73 Triangulated Understood Underway Complete Exception Report: Staff Training 74 Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Martin Mandatory Training overall percentage trained Yes - 90% 85% 80% 81% Aug-17 - Jones Where we are For August 2017, Mandatory Training compliance was as follows: Overall Compliance by Division • Level 1 compliance at 81% Secondary Care • Level 2 compliance at 67% Area Teams - Central Nursing Executive These figures now reflect the All-Wales position of reporting compliance without Bank Area Teams - Pan/Other… Staff figures. Mental Health & LDS Area Teams - West Mandatory Training department reported a decrease from 28% to 20% with Strategy Executive Resuscitation department [East] also reporting a decrease to 18% for September Project Monitoring Office 2017. Finance Executive 0% 20% 40% 60% 80% 100% What we are doing about it • Promotion of the ESR app for mobile devices continues to be launched around the Core Mandatory Training Compliance Infection Prevention L2 - 1… 12,536 sites on a monthly rolling programme supported by the communication and Patient Handling - 2 Years 8.903 informatics team. Violence & Aggression - 2… 12,064 • The revised Mandatory Training Policy has was fully implemented on the 1st Safeguarding Adults L2 - 3… 12,572 October 2017. Safeguarding Adults L1 - 3… 17,794 Information Governance… 17,794 • Planning of 3D workshops for a managers are in place to engage mangers and Moving and Handling - L1 - 2… 17,794 line managers with their responsibilities of the revised policy. Safeguarding Children L2 - 3… 12, 642 Safeguarding Children L1 - 3… 17,794 When we expect to be back on track Equality, Diversity and… 17,794 Health, Safety and Welfare -… 17,794 Following implementation of the policy we expect to reach a target compliance of 75- Fire Safety - 2 Years 17,794 85% before the end of Quarter 4, 2017/18. Each Director remains responsible for Infection Prevention and… 17,794 progressing this action within their teams. Violence & Aggression… 17,794 Resusitation - L1 Once… 17,794 0% 50% 100%
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 74 Triangulated Understood Underway Complete Exception Report: Agency and Locum Spend 75 Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Russ Not Not Agency & Locum Spend in £000's Yes - 3,400 3,100 Sep-17 - Favager submitte submitte
Agency Spend Where we are £5.0 M The total agency costs for September was £3.1m which is £0.6m lower than the £4.5 M average monthly expenditure of £3.7m in the last financial year. The September £4.0 M agency expenditure for the 3 hospital sites was £1.6m and mental health was £0.4m. £3.5 M Medical agency costs are £1.9m in September £0.1m lower than last month. Agency £3.0 M Nursing spend is £0.8m which is £0.1m lower than in August. £2.5 M Locums are paid via the Health Board’s payroll and the total costs for September are £2.0 M £638k or 1.1% of total pay, a reduction of £265k from August. £1.5 M
£1.0 M What we are doing about it £.5 M The operational teams are working with the financial leads to reduce agency and £.0 M locum costs, recruit to funded posts and fully utilise bank staff at reduced costs where
available. This action is being progressed by the Nursing and Medical Director. West Area Central Area East Area Ysbyty Gwynedd Ysbyty Glan Clwyd Ysbyty Maelor Wrexham Mental Health & LDS Other Medical Agency Nursing Agency Nurse - Qualified Agency Nurse - Unqualified When we expect to be back on track The return to lower rates of expenditure is dependent on the success of actions outlined above.
Medical & Nurse Total Pay Chart Locum Spend £21 M North Wales Wide £1,000 Hospital Services £20 M £900 Women's
£19 M £800 Mental Health & LDS
£18 M £700 Ysbyty Maelor Wrexham £17 M £600
Ysbyty Glan Clwyd
£16 M £500 £'000 Ysbyty Gwynedd £15 M £400
East Area £300 £14 M
£200 Central Area £13 M
£100 West Area £12 M
£0
Total Nursing Pay Total Med Pay Projected Med Pay after Savings Projected Nurse Pay after Savings
Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 75 Triangulated Understood Underway Complete Exception Report: Theatres 76 Executive Exception National March 18 Current Welsh Staff and Resources Previous Current Month Arrow Lead Report? Target Plan Plan Benchmark Theatre lists finishing 30 or more minutes before the Morag Yes - 20.6% 20.6% 34.2% 32.7% Sep-17 - scheduled end time Olsen Theatre lists starting 15 or more minutes after Morag Yes - 13.5% 13.5% 45.3% 57.8% Sep-17 - scheduled start time Olsen Where we are Theatre lists finishing 30 or more minutes before In September 2017, 32.7% of lists started 15 minutes or more after the scheduled the scheduled end time start time and 57.8% of theatre lists finished 30 minutes or more before the scheduled 40% end time. 30%
What we are doing about it 20% All three sites have been conducting a number of Plan Do Study Act (PDSA) cycles 10% looking at ward-to-theatre patient handovers and bed management processes so that decisions can be made earlier in the day. Further PDSA cycles are being undertaken 0% within ITU, Recovery and in Theatres to support improvement in flow and capacity to
allow for early starts. In East, ward and theatre staff have committed to call for the Jul-17
Oct-16 Oct-17
Apr-17
Jan-17 Jun-17 Jan-18
Mar-18 Mar-17
Feb-17 Feb-18
Sep-16 Nov-16 Dec-16 Sep-17 Nov-17 Dec-17 Aug-17 first patient for arrival in theatre at 08:50am. Furthermore, two surgical beds have May-17 Actual Plan Target been ring-fenced so that cancer patients can be operated on regardless of the remaining bed capacity. August figures showed that this approach has been working Theatre lists starting 15 or more minutes after as very few cancellations were due to bed or capacity reasons. This will now be rolled scheduled start time out across all specialties and all sites. 60% 50% When we expect to be back on track 40% We are continuing to look at all processes and using the PDSA methodology to 30% identify further areas for improvement. As we share best practice of what works 20% across all sites, we expect to be back on track by the end Quarter 4, 2017/18. 10%
0%
Jul-17
Oct-16 Apr-17 Oct-17
Jan-17 Jun-17 Jan-18
Mar-17 Mar-18
Feb-17 Feb-18
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Actual Plan Target Performance Report September 2017 Intelligence Root Cause Actions Actions Action Plan Set Page 76 Triangulated Understood Underway Complete 77 Activity vs Plan: April to September 2017/18
2016/17 2017/18
Health Board Total Health Board Total Patient Type Plan Actual Diff % Diff Plan Actual Diff % Diff Emergency Inpatients 90,313 90,828 515 1% 45,067 47,005 1,938 4% Elective Daycases 33,287 32,914 -373 -1% 15,343 15,765 422 3% Elective Inpatients 18,048 18,524 476 3% 7,522 8,368 846 11% Endoscopies 21,495 19,774 -1,721 -8% 10,125 8,271 -1,854 -18% MOPS (Cleansed DC) 2,009 1,939 -70 -3% 1,220 733 -487 -40% Regular Day Attenders 47,890 46,050 -1,840 -4% 24,208 20,574 -3,634 -15% Well Baby 2,575 2,862 287 11% New Outpatients 200,894 185,595 -15,299 -8% 127,095 131,651 4,556 4% Review Outpatients 380,743 397,897 17,154 5% 260,356 264,022 3,666 1% Pre-Op Assessment 15,580 14,641 -939 -6% New ED Attendances 213,999 215,985 1,986 1% 114,519 118,243 3,724 3% Review ED Attendances 12,254 8,287 -3,967 -32% 5,202 3,561 -1,641 -32% Grand Total 1,020,932 1,017,793 -3,139 0% 628,811 635,696 6,885 1%
Please note : East's Nephrology, Regular Day Attenders figures are obtained from a manual source and are one month in arrears - July 2017 activity is missing from the above figures. Please: note that due to issues resulting from the implementation of WPAS it is recommended that Central's New Outpatients, Review Outpatients and Pre-Op Assessments are analysed as a total figure rather than independently. Work is ongoing to correct Activity Type for Central Outpatients
Performance Report September 2017
Page 77 78
NHS England Contracted Activity – July 2017
Elective Total Emergency Inpatient & Provider Contract Data Inpatient New Follow Up Provider Daycase Code Value Month (inc. Outpatient Outpatient (inc. (£'000) Maternity) Endoscopy) Countess of Chester NHS Foundation Trust RJR 26,432 June 707 610 1,725 3,908
Robert Jones & Agnes Hunt NHS Foundation Trust RL1 13,295 June 202 3 581 1,373
Hywel Dda LHB 7A2 4,078 June 92 120 89 205
Royal Liverpool and Broadgreen University Hospitals NHS Trust RQ6 5,016 May 90 18 149 513
Wirral University Teaching Hospital NHS Trust RBL 2,591 May 58 20 36 129
Shrewsbury & Telford Hospitals NHS Trust RXW 1,455 June 11 13 182 341
Aintree University Hospital NHS Foundation Trust REM 3,150 May 44 5 57 181
The Clatterbridge Cancer Centre NHS Foundation Trust REN 2,187 May 13 3 25 685
University Hospital of North Midlands NHS Trust RJE 3,096 June 7 17 21 32
University Hospital of South Manchester NHS Trust RM2 752 May 10 6 24 115
Liverpool Women's NHS Foundation Trust REP 891 May 7 7 44 139
Shropshire Community Health NHS Trust RID 255 June 0 0 13 2
Performance Report September 2017
Page 78 79 Appendix A – Further Information
Further detailed information is available
• Further information is available from the office of the Chief Operating Officer which includes; • performance reference tables • tolerances for red, amber and green • the Welsh benchmark information which we have presented
• Further information on our performance can be found online at: • Our website www.pbc.cymru.nhs.uk www.bcu.wales.nhs.uk • Stats Wales www.statswales.wales.gov.uk
• We also post regular updates on what we are doing to improve healthcare services for patients on social media: follow @bcuhb http://www.facebook.com/bcuhealthboard
Performance Report September 2017 Page 79 3.1.2 17.254.2 Waiting Time Reduction Plan 2017-18: Ms Morag Olsen 1 17.254.2a Waiting Time Reduction Plan coversheet 31.10.17 at 1748.docx
1
Health Board
16.11.17
To improve health and provide excellent care
Title: Waiting Times Reduction Plan 2017-18
Author: Dr Jill Newman, Director of Performance
Responsible Ms Morag Olsen, Chief Operating Officer 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 / Scrutiny This report has been reviewed by the Chief Executive and Chief Route Operating Officer prior to submission.
Purpose: This report provides the board with a high level overview on the 2017/18 waiting time reduction and the alignment to the development of the Integrated Medium Term Plan (IMTP).
Significant issues This paper outlines the substantial improvement expected in the and risks volume of patients waiting over 36 and 52 weeks by the end of March following revision of the Referral to Treatment (RTT) plan. This revision has been facilitated following the allocation of an additional £13.29m. The paper describes the internal and external levels of additional activity planned to deliver this level of improvement. The paper outlines the approach being adopted to develop solutions to provide sustainable waiting time reductions as part of the IMTP, building on the support given to the orthopaedic plan.
Special Measures RTT is subject to targeted intervention. Improvement Framework Theme/ Expectation
2 addressed by this paper Equality Impact The RTT plan is addressing our longest waiting patients equally, some Assessment of whom will have protected characteristics. Their needs are being taken into account when considering transfer arrangements between sites, with additional transport support being provided as appropriate. A formal Equality Impact Assessment has not been completed at this point in time.
Recommendation/ The Board is 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
Board Coversheet v8.0 June 2016
1 17.254.2b Waiting time reduction plan 9.11.17 at 1410.docx
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2017/18 Waiting Time Reduction Plan
1. Introduction This paper aims to provide the Board with a high level overview on the implementation of the Referral to Treatment (RTT) action plan for 2017/18 and confirming the actions being taken to ensure the 2018/19 requirements are built into the Integrated Medium Term Plan (IMTP). Betsi Cadwaladr Health Board is one of the best performing organisations in Wales in areas such as Cancer waiting times and diagnostic waiting times. However, we have a number of specialties where demand has outstripped capacity with resulting long waiting times. 2. 2017/18 Funding and Plan Following submission of plans to Welsh Government we have been allocated £13.29m which will enable us to deliver (in comparison to the position as at September): • A 53% reduction in the number of patients waiting over 36 weeks • A 50% reduction in the number of patients waiting over 52 weeks • No patient to wait over 8 weeks for diagnostics and no patient to wait over 14 weeks for therapy waits. The graph below shows progress against our profile for > 36 weeks for September, as well as our target profile for the rest of the year. As can be seen we have made good progress and are ahead of where we planned to be.
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Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 36 week Profile with WG RTT resource 9280 9224 8418 7502 6406 5308 4237
Actual over 36 weeks 9066 We expect that medical specialties such as dermatology, rheumatology, nephrology, care of the elderly and endocrinology will all achieve waiting times within 26 weeks, and that our longest waits will be in orthopaedic surgical pathways. The key components of the plan to deliver our profiled improvement are: • Delivering Core Activity • Delivering efficiency gains i.e. more productive use of existing clinics and lists • Additional internally funded activity • Additional NHS provider externally contracted activity • Additional procured activity insourced or via external private providers. The biggest single challenge is within orthopaedics and ophthalmology. Internally we are aiming to treat over 3,300 extra patients. In terms of other NHS providers, to date capacity has been agreed for 880 additional cases and transfers started at the end of September and have continued into October for the first groups of patients to both the Countess of Chester NHS Foundation Trust and The Robert Jones & Agnes Hunt Orthopaedic Hospital NHS Foundation Trust. A third NHS provider is confirmed via a signed contract, with the first patients being offered transfer before the end of 1st week in November. In order to secure a further circa 800 cases we will be going out to tender and an evaluation panel will review the proposals submitted during the 1st week of December to enable tenders to be awarded in time for the delivery of treatments.
At this point in time the greatest risks arise from the internal delivery plans such as the reduction in day case/endoscopy capacity at Wrexham. We have developed a plan to respond to this loss of capacity which includes our staff utilising theatres at the Robert Jones & Agnes Hunt Orthopaedic Hospital, hiring mobile theatres in the short term and seeking to purchase modular theatres by April of next year. 3. Planning for 2018/19 In terms of moving into 2018/19 the Board has previously agreed our Orthopaedic Plan which has now been submitted to Welsh Government and will be taken forward as part of our Integrated Medium Term Plan. Our capacity planning work over the next few months will identify other services that have underlying capacity imbalances. The approach being adopted is as follows: • Capacity of each acute service being revisited for in-year changes in job plans, retirements, appointments etc. • Demand change assessment applied • Efficiency and productivity plans applied to output • Service redesign and skill mix changes proposed being applied • Core service gap split into recurrent (sustainable gap) and backlog • Solution development and costing of solutions to close service gap over one, two or three years of the IMTP.
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• Output from the service gaps and solutions proposed fed into the bed and theatre capacity requirements • Costed plans fed into IMTP, workforce and financial planning scenarios prior to end of December for budget setting.
4. Recommendation
The Board are asked to note the contents of this paper.
3.1.3 17.254.3 Unscheduled Care Update Q3/Q4 2017-18 : Ms Morag Olsen 1 17.254.3 Unscheduled Care coversheet as at 6.11.17 1237.docx
1
Health Board
16.11.17
To improve health and provide excellent care
Title: Unscheduled Care Update – Q3/Q4 2017/18
Author: Mr Nigel Lee, Secondary Care Director
Responsible Ms Morag Olsen, Chief Operating Officer 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 x inequalities 2. Work in partnership to design and deliver more care x 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 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through x innovation and research 7. Support, train and develop our staff to excel.
Approval / Scrutiny This paper has been reviewed by the Executive Management Group. Route Given the current level of unscheduled care performance by the Health Board, and the importance to support quality of care, updating the Board on the actions is timely and appropriate.
Purpose: The purpose is to update the Board on the actions being taken to improve unscheduled care performance across North Wales, and the mechanism of monitoring the impact of the actions. Significant issues Under the leadership of the Chief Operating Officer, the unscheduled and risks care transformation group revised the list of projects in the unscheduled care operational plan for 17/18 into 4 key workstreams: • Community (including key pathways) • Escalation • Ring fenced capacity • Discharge
Performance across North Wales has continued to be below target, and the paper identifies the main actions and proposed methods of
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monitoring the impact and benefit of actions.
Special Measures Strategic and service planning Improvement Framework Theme/ Expectation addressed by this paper Equality Impact Not required Assessment Recommendation/ The Board are asked to note the content of this paper Action required by the Board Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
Board Coversheet v9.0 June 2017
1 17.254.3 Unscheduled Care Update 9.11.17 at 1423.docx
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Unscheduled Care Update – Q3/Q4 2017/18
Purpose
This paper provides an update on actions in each of the main Unscheduled Care operational plan workstreams, focusing on those actions which are expected to provide benefit swiftly, and support system resilience now and into the winter period. The objective is that the sum of these actions will improve performance and maintain >80% for the 4 hour waiting time as our initial improvement target and as a foundation for further improvement.
Background
The demand for urgent care remains high, with over 480 patients per day attending our Emergency Departments, and a further 150-200 per day accessing our Minor Injuries units (giving a total of over 15,000 per month to the Emergency Departments, and a total of over 20,000 patients to both the acute sites and Minor Injuries Units per month).
As part of developing the 2017/18 plan, the Chief Operating Officer and members of the wider unscheduled care transformation group revised the list of projects into 4 key workstreams:
• Community (including key pathways) • Escalation • Ring fenced capacity • Discharge
It is also essential that the Health Board is able to monitor and quantify the impact of actions; whilst the major national indicators remain paramount, other metrics are needed to provide greater confidence of actions. Some improvements may well support unmet need, or combine with other actions, so not all changes are easily tracked. However, key measures are described below.
The performance expectation for the Health Board is to be at or above 80% for November 2017 and to maintain that for December 2017 and Quarter 4.
Community
Within the Community workstream, a number of improvements have been developed, with details below. Joint work with Welsh Ambulance Service Trust (WAST) features heavily given the demand in North Wales. In October 2017, there 2 were 4882 ambulance conveyances to the 3 acute sites, a rise of 5% year on year (comparing October 2016 with October 2017).
- Pathways – building on the work done by the Executive Director of Nursing with her counterpart in WAST, the majority of the pathways development (falls, breathing problems, chest pains, mental illness) will be complete by the end of November, with information packs being made available on all WAST vehicles. Baseline data has been collected with plans to monitor the changes. The objective is to not only reduce conveyances, but also to reduce admissions.
- Advanced Paramedic Practitioners – working in parallel with the pathways workstream, WAST have identified 9 Advanced Paramedic Practitioners to be based in N Wales, working from 0900-2200 daily; the staff will be tasked through the Clinical desk in the ambulance Control Centre.
- Clinical Desk development – further work as per discussed at the recent Community Transformation Group meeting, a sub-group is required to understand further and take forward including developing a business case.
- Minor Injuries Units – WAST recognise that the number of conveyances to MIUs is lower than expected. Building on the Standard Operating Procedure re-issued in 2016, a further review of pathways and guidance has been completed, with the final version of documentation reissued on 31st October. Linking with the District Nursing teams, the revised information allows WAST staff to have contact details for District Nursing and guidance on patients to refer. They can also contact the Minor Injuries Units or District Nursing with any questions. Recording of the numbers of patients treated and ambulance conveyances to Minor Injuries Units will be completed.
- Community Resource Teams – this will form part of the Community Transformation Group plan for the Health Board 3 year plan; initially an understanding is required with each Area on the current services within a Community Resource Team. A number of developments are already in progress, such as community Advanced Nurse Practitioners, supporting patients at home; data collection surrounding the key performance indicators specifically averting hospital admissions, reducing GP contacts and WAST callouts has been devised and will be reported on a monthly basis.
Escalation
The primary objective of this workstream has been to develop and introduce a daily ‘safety huddle’ for each region (site/Area). Work through September and October has been focused on liaising with Fife health economy (where the concept 3 originated), confirming data sources and flows, and training senior leaders, site management teams and wider departmental leaders. The first run-through took place at Ybsyty Glan Clywd (YGC) on 30th October, with Ysbyty Gwynedd (YG) planning to begin on 31st October, and Wrexham on 1st November, and the meetings have continued to be developed during November.
Whilst the model will not achieve performance improvement alone, the objective is to develop greater clinical leadership of the challenges, and emphasise patient safety concerns. It will also help to draw out wider delays and blockages, increase awareness of infrastructure challenges and risks, and enable whole-health region and pan-North Wales learning. The Safety Huddles have become established during early November, with cross-region learning; the initial feedback is positive from senior clinicians
Alongside this, all sites are reviewing the ‘internal professional standards’, defining the expected response by specialties to the Emergency Department. This has been reviewed during October by the Secondary Care Medical Director and 3 site medical directors, but requires further discussion during November to ensure consistency across the 3 sites and to confirm the methods of recording activity and monitoring compliance; the standards will then be finalised and communicated to the wider teams.
Ring Fenced Capacity
Development of assessment areas, primarily focused on Older People’s assessment units has been making progress on all 3 acute sites during September and October. The unit at Wrexham combines the Clinical Hub; the Older People’s Assessment Unit and the Rapid Assessment Unit. The Older People’s assessment unit at YG has been running for some time, and the development at YGC has made progress, with a first phase review at the end of October. Each unit has key aims:
• Early specialist Multi-Disciplinary Team assessment and intervention with a “do once and share” way of working; • To provide a rapid, responsive service for patients and act as a safe alternative to an acute admission; • To ensure timely transfer of care back out into the community for those patients whose needs can be met more effectively within that setting; • To support patients in the transition between acute and community services including intermediate care; • To ensure that if admission to an inpatient ward is required, this is part of a defined treatment process; • To improve links with external agencies such as Mental Health and Advocacy Services to facilitate improved patient experience.
There has been positive feedback during the initial period on demonstrating admission avoidances; for example, an elderly (99 year old) patient with known 4 dementia, who was able to stay at home and receive IV antibiotics and IV fluids in their own home via visits from the IV suite team. As well as recording overall activity in these assessment units, key measures include admission avoidance and reduced Length of Stay for certain specialties such as Care of the Elderly. In addition, work is underway in all areas to review the process of a Healthcare Professional (HCP) referral, to not only consider alternate urgent pathways, but also to understand how many can be managed as a planned event. This will involve close liaison between primary care, WAST, acute hospitals and the wider community teams. The focus on Ambulatory Emergency Care (non-admitted) pathways is well proven, both in England and in parts of Wales (such as the changes in Nevill Hall Hospital in Aneurin Bevan Health Board which have reduced admissions by over 20%).
Specific actions related to improvements in the management of Emergency Department patients (in minors as well as majors) have been described by the acute site teams; the objective is to eliminate ‘minors’ breaches, with daily review of any issues and breaches with the clinical teams. BCU currently has over 700 minors breaches per month; a reduction of 200 breaches equates to a 1% improvement in the 4 hour performance. Actions include adding and maintaining Nurse Practitioner capacity, and aligning staff to the peaks in demand. The pressures on the Emergency Department team will be supported by the parallel work on clinical standards for response to the Department.
Discharge
The implementation of the ‘SAFER’ (including Red to Green methodology) is well underway, with YGC further ahead at present. SAFER is an acronym that covers:
• S - Senior Review. All patients will have a Consultant Review before midday. • A - All patients will have an Expected Discharge Date (that patients are made aware of) based on the medically suitable for discharge status agreed by clinical teams. • F - Flow of patients will commence at the earlier opportunity (by 10am) from assessment units to inpatient wards. Wards (that routinely have patients transferred from assessment units) are expected to ‘pull’ the first (and correct) patient to their ward before 10am. • E – Early discharge, 33% of our patients will be discharged from base inpatient wards before midday. TTO’s (medication to take home) for planned discharges should be prescribed and with pharmacy by 3pm the day prior to discharge wherever possible to do so. • R – Review, a weekly systematic review of patients with extended lengths of stay (> 14 days) to identify the issues and actions required to facilitate discharge.
The implementation has involved significant education with wards and other teams, and the lead for NHS England, Pete Gordon, has visited and presented to the Health 5
Board. A consistent ‘SAFER’ dashboard of measures has also been developed, to enable monitoring of actions and progress, and a consistent data set across the 3 sites. Key measures include Expected date of discharge (EDD), patients discharged before 1200, total numbers discharged and Length of Stay. Other measures are in development.
Aligning with the ‘SAFER’ rollout, improvements have been made (and continue) with the joint ‘progress’ meetings in all 3 sites reviewing medically-fit for discharge patients; there is improved focus on numbers of delayed patients (linking to health- related Delayed Transfers of care), and escalation to senior managers in the Health Board and partners such as Local Authorities.
In addition, following the Welsh Audit Office report on BCUHB Discharge Planning, the discharge workstream has initiated a benchmarking and self-assessment process for the 3 Areas and 3 Secondary Care Hospitals to review current processes. Whilst there are identified areas of good practice, there is scope for improvement across North Wales, and opportunity for greater consistency and sharing.
Adding capacity to deliver change
As part of developing the operational plan, it is recognised that senior operational capacity to manage and deliver the improvements is under pressure. WAST have made a positive change by introducing new additional senior management posts (2 x 8b) supporting the senior Area manager for North Wales. One has started already, with the second due to start on 27th November. In addition, the Health Board will be providing additional leadership resources within the Health Board to improve our capacity to project manage and deliver changes. The additional resource should be in place by the end of November/start of December.
Performance Monitoring
As described above, the workstreams have identified a range of measures to monitor effectiveness and impact. The main measures will remain as:
- 4 hour waits - 12 hour wait - 15 minute ambulance handover - 1 hour ambulance handover - Category A ambulance performance
In addition, a number of other measures can be readily captured and used:
Pre-Hospital
- Conveyances avoided
Emergency Department 6
- > 3 hour ambulance handover (linking to patient safety) - Patients waiting > 4 hours but < 4.5 hours - Minors (green) performance (%, numbers) - Yellow, Amber and Red category performance (%, numbers)
Assessment Units
- Admissions avoided
SAFER/Discharge
- % of patients with an Expected Date of Discharge - Patients discharged before 1200 - Non-elective Length of Stay (by ward, by specialty) - Number of patients Medically-fit for Discharge - Non-Mental Health Delayed Transfers of Care
Whilst a number of the measures are recorded electronically, some remain manual. The Director of Performance, together with operational teams in BCU and WAST, as well as information leads, has set up an unscheduled care measures group with the intention of defining the KPI for each of the 4 thematic areas and providing a baseline to track performance against. From this we will propose the potential impact of each work stream and devise profiles accordingly. The meeting will report into the USC Transformation group
Recommendation
The Board are asked to note the content of this paper
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WORKSTREAM HIGHLIGHTS
Community inc Pathways
4 pathways: Falls, Chest Pain,
Breathlessness and Mental Health
Advanced Paramedic Practitioners
Minor Injuries Units
Community Resource Teams
Escalation Ring-Fenced Capacity
Safety Huddle Older people’s assessment
Clinical Standards for Emergency Emergency Department Department improvements
Ambulatory emergency care
Clinical Hub/HCP calls
Discharge
SAFER
Discharge audit
DTOC
Management and Programme Capacity – Health Board and Partners
Performance and Improvement measures
3.2 17.255 Finance Report - Mr Russ Favager 1 17.255 Finance report Month 6.docx
Health 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 Board 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
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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.
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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.
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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
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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.
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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.
9
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.
11
• 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.
13
• 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
15
• 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
0
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.
17
Trade Aged Receivables
12,000
10,000
8,000
6,000 £'000
4,000
2,000
0
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
21
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 3.3 17.256 Mental Health Tawel Fan Quarterly Update - Mr Martin Jones 1 17.256 Tawel Fan final received 7.11.17 at 1708.docx
1
Health Board
16.11.17
To improve health and provide excellent care
Title: Update report to the Board on progress with:
a) Ockenden ‘Review of Governance arrangements in older person’s mental health services prior to the closure of Tawel Fan ward and currently. b) HASCAS ‘Independent investigation into concerns raised about the care and treatment of patients on Tawel Fan ward’. Author: Mr Martin Jones, Executive Director of Workforce and Organisational Development
Responsible Mr Gary Doherty, Chief Executive 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’ 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 / Scrutiny Route Purpose: The purpose of the report is to update the Board on the progress with the HASCAS independent investigation and the Ockenden Governance review, together with the timetable and approach going forward.
Significant issues The investigation and governance review seek to provide insight that and risks will influence a number of key issues and risks including: • Resolution of complaints and Putting Things Right (PTR) redress processes that are still outstanding. 2
• Resolution of altered employment situations for staff who previously worked on Tawel Fan ward. • Learning from past experience and improving service to the future. • Securing further improvement to partnership working with statutory agencies. • Providing assurance to the Board, the public and staff across the organisation on adequacy of governance arrangements. Special Measures The ongoing work contributed to three of the improvement themes of: Improvement • Leadership Framework Theme/ • Governance Expectation • Mental Health addressed by this • Partnership working paper
Equality Impact An Equality Impact Assessment has not been carried out as this report Assessment does not propose a change of policy, direction or budgetary provision. The report seeks to update members of the Board.
Recommendation/ The Board is asked to: Action required by the Board 1. Note the progress of both the HASCAS investigation and the Ockenden review of Governance. 2. Note the forthcoming timescales for the products of the investigation and governance review.
Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
Board Coversheet v9.0 June 2017
3
Betsi Cadwaladr University Health Board
Update report to the Board on progress with:
a) Ockenden Review of Governance arrangements in older person’s mental health services prior to the closure of Tawel Fan ward and currently. b) HASCAS ‘Independent investigation into concerns raised about the care and treatment of patients on Tawel Fan ward’.
1. Summary:
1.1 This report has been prepared to update the Board with progress on the Ockenden review of governance and the HASCAS independent investigation. It sets out the background to the governance review and investigations, progress to date and the planned activities and timescales going forward.
1.2 The Board will publish both the Ockenden review of governance and the HASCAS independent investigation on the 8th of March 2018. The period between November and Christmas will be used to discuss with families their preferences about how they would like to receive the overall reports and their individual report and how they would wish to engage with HASCAS & the Health Board and the support they will require. A paper will come to the Health Board meeting in January 2018 summarising these detailed discussions.
1.3 Prior to the release of the reports arrangements will be made to brief: 1.3.1 The Tawel Fan Families 1.3.2 Trade Unions and Professional Organisations representing staff 1.3.3 Key public sectors partners e.g. Local Authorities and North Wales Police 1.3.4 Assembly Members/MPs
1.4 A special meeting of the Health Board will be held on the 15th March 2018 to formally receive the Ockenden review of Governance and the HASCAS thematic reports and consider the actions arising. Following the special meeting of the Health Board, individual patient reports will be shared/considered with each family as per the agreement reached, and formal Putting Things Right processes will progress including an assessment of any requirements for redress.
1.5 Following the 15th March the individual staff reports produced by HASCAS will, as appropriate, be used as investigative reports for the purpose of employment and professional regulation purposes.
4
2. Background: 2.1 Donna Ockenden was first commissioned in January 2014 to undertake an external investigation into concerns raised regarding the care and treatment of patients on Tawel Fan ward. This was commissioned in line with the Health Board’s Concerns Policy and procedures and with reference to the Wales Interim Policy & Procedures for the Protection of Vulnerable Adults from Abuse (2002). 2.2 Whilst her report was completed in September 2014 and received by the Health Board, consideration of matters by North Wales Police resulted in the report not being presented to the Health Board until the 9th June 2015. 2.3 At the meeting held on the 9th June 2015 (minute 15/36), the Chairman advised that ‘Mrs Ockenden would be commencing a Board to Ward review with immediate effect’. 2.4 Progress on setting the scope of the review of Governance was subsequently reported to meetings of the Board held on the 14th July 2015 (minute 15/165.2) and 8th September 2015 (minute 15/225.4). The Terms of reference were approved at a meeting of the Health Board held on the 10th November 2015 (minute 15/285.2). 2.5 Progress on the commissioning of HASCAS was reported at the meetings of the Health Board held on the 14th July 2015 (minute 15/165.2) and the 11th August 2015 (minute 15/194.1). 2.6 At the meeting of the Health Board held on the 8th September 2015 (minute 15/225.5), it was confirmed that ‘the Health Board had commissioned HASCAS to provide the lead independent investigator role in relation to the complaints, concerns and professional regulation & employment issues arising from the significant failings in care on Tawel Fan ward …’. The HASCAS terms of reference were attached to the paper presented to the Board. 2.7 HASCAS were commissioned to provide three products: 2.7.1 A thematic report that would aid learning by the organisation. This will be a public document. 2.7.2 Individual patient specific reports to support the Health Board’s complaints and Putting Things Right process. 2.7.3 Individual staff reports that would, as appropriate, be used as investigative reports for the purpose of employment and professional regulation purposes. 2.8 Progress with the review of governance and the independent investigation was initially overseen by Health Board oversight panels as set out in papers to the Health Board on the 8th September 2015 (minute 15/225.2) and the 10th November 2015 (minutes 15/285.2). 2.9 Subsequent to this, the Cabinet Secretary for Health, Well-being and Sport announced on the 31st January 2017 the appointment of an external oversight panel. Its key tasks are to: 5
2.9.1 Review the scope, methodology and process including completion of the work in a timely manner for the HASCAS Investigation and Ockenden Governance Review. 2.9.2 Ensure the appropriate and timely sharing of information between the HASCAS, Ockenden and separate but related POVA investigations being taken forward under the local safeguarding arrangements. 2.9.3 Set out and agree the roles and responsibilities of each of the key parties – i.e. the LHB, regional safeguarding board, HASCAS and Donna Ockenden with all parties to avoid confusion or conflict. 2.9.4 Agree a process and timetable for the conclusion of the work and publication of related reports. 2.9.5 Ensure the LHB has the mechanisms and effective plan in place to communicate with all stakeholders. 2.9.6 Ensure stakeholders are clear on the role and independence of the Panel. 2.10 The panel consists of three external independent members, Jack Straw (Chair); Helen Bennett (Panel Member) and Phil Hodgson (Panel Member). 2.11 The panel has met on ten occasions in North Wales to continue its work on progressing the Ockenden review of Governance and the HASCAS independent investigation.
3. Previous updates to the Board: 3.1 This report follows on from a number of previous reports to the Health Board and its Committees which have included: 3.1.1 In Committee Board paper 21/01/16 - Item 16/6. 3.1.2 Quality, Safety & Experience Committee paper- 13/09/16 - Item QS 16- 131/132. 3.1.3 Public Board paper 22/09/16 - Item 16/176. 3.1.4 Public Board paper 19/01/17 - Item 17/14. 3.1.5 In-Committee Board paper 16/02/17 - Item 17/30. 3.1.6 Public Board paper 18/05/17 - Item 17/105 (a) & (b). 3.1.7 Board briefing - 17/08/17.
4. Progress with Ockenden review of Governance: 4.1 The Ockenden review of governance has engaged, interviewed and completed its investigative phase and has moved to the writing of the report. 4.2 In terms of scale, the investigative process has involved: 6
4.2.1 Interviews with 76 representatives of the older person’s Mental Health service. 4.2.2 Interviews with 86 members of staff. 4.2.3 Receipt and review of over 9400 documents. 4.2.3 User engagement and listening events in each of the 6 local authority areas in conjunction with the Community Health Council.
5. Progress with HASCAS investigation and products: 5.1 The Health Board acknowledges the importance of a thorough investigation whilst also seeking to complete the work as soon as possible. It also recognises that both patients, family representatives and staff are eagerly awaiting the completion of this work. 5.2 The scope of the HASCAS investigation has grown significantly since the initial commission which has increased the extent of documentation collection and interviews. Whilst the initial scope reflected 25 complaints, subsequent investigative processes have increased the number of patient cases being reviewed to 108. 5.3 HASCAS have engaged, interviewed and completed their investigative phase. This has involved a review of clinical records, policy and procedural documentation and the interviewing of staff. 5.4 They are currently writing the individual patient reports that will be prepared for the BCUHB complaints and Putting Things Right process.
5.5 In terms of scale, the investigative process has involved:
5.5.1 The review and subsequent pagination of approximately 400,000 pages of clinical records. 5.5.2 The review and subsequent pagination of approximately 300,000 pages of corporate records. 5.5.3 Interviews with 73 staff or team interviews. 5.5.4 Interviews with approximately 40 families.
6 Future timescales and arrangements: Ockenden review of governance and HASCAS thematic report 6.1 Following processes of drafting, checking factual accuracy, consideration of amendments and printing the Ockenden Review and HASCAS thematic report will be published on the 8th of March 2018. Note, as happens now with reports from for example Healthcare Inspectorate Wales and the Welsh Audit Office the Health Board will be consulted purely on matters of factual accuracy. The authors and Independent Oversight Panel will ensure the integrity of the overall process. 7
6.2 The Health Board will receive an In-committee briefing on the findings of the Ockenden review of governance and the HASCAS thematic report during end of February 2018/early March so as to prepare its response to the reports.
6.3 Prior to the release of the reports arrangements will be made to brief: 6.4.1 The Tawel Fan Families 6.4.2 Trade Unions and Professional Organisations representing staff 6.4.3 Key public sectors partners e.g. Local Authorities and North Wales Police 6.4.4 Assembly Members/MPs
6.4 A special meeting of the Health Board will be held on the 15th March 2018 to formally receive the Ockenden review of Governance and the HASCAS thematic reports and consider the actions arising.
6.5 As per agreed Health Board policy the reports will be written in the language of the author. The Health Board will arrange for the Executive Summary of the reports to be translated into Welsh and will make these available separately.
HASCAS – Individual patient reports
6.6 The individual patient specific reports have been commissioned by the Health Board to ensure that a definitive account of what happened to their loved one is provided to each family. The reports will also be used to support the Putting Things Right process. As per agreed Health Board policy the reports will be written in the language of the author, however the Health Board will of course provide a translation into Welsh where requested.
6.7 The period between November and Christmas will be used to discuss with families their preferences about how they would like to receive the overall reports and their individual report and how they would wish to engage with HASCAS & the Health Board. A paper will come to the Board meeting in January 2018 giving a high level summary of the progress made at that time. Some family members have already chosen to receive support arranged by or provided by the Health Board. As part of the discussions regarding receipt of the reports the opportunities that are available for counselling and other forms of support will also be discussed.
6.8 Following the special meeting of the Health Board on the 15th March 2018, individual patient reports will be shared/considered with each family as per the agreement reached, and formal Putting Things Right processes will progress including an assessment of any requirements for redress.
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Staff reports
6.9 A number of staff are subject to employment restrictions and alterations following the first Ockenden report and subsequent risk assessments, whilst a wider group have been referred to the regulatory bodies such as the Nursing & Midwifery Council and General Medical Council either by the Health Board or by complainants. A series of meetings have been held between HASCAS, BCUHB and Trade Unions representing staff affected. Throughout the process, staff have been able to access the Health Board’s Occupational Health Service who have been a conduit to counselling services as necessary.
6.10 Following the special meeting of the Health Board on the 15th March 2018, the Health Board will take forward matters relating to individual staff. As per agreed Health Board policy the reports will be written in the language of the author, however the Health Board will of course provide a translation into Welsh where requested. HASCAS will have assigned staff to one of three categories:
6.10.1 Those where they have identified issues of misconduct, where the Health Board will need to move forward to disciplinary processes. 6.10.2 Those where they have identified minor conduct issues or issues of capability, where further training and support is necessary. 6.10.3 Those staff who do not fall into the above two categories
6.11 A separate, confidential report will be prepared for the Health Board on those staff within the wider group who have been referred to professional regulatory bodies. This report will support the offices of the Medical and Nursing Directors, who hold responsibility for matters of professional regulation, in their liaison role with the Nursing and Midwifery Council and General Medical Council.
6.12 The Health Board has previously decided that Human Resource advice to any disciplinary panels will be external to the Health Board. External support has been secured. There has also been a previous undertaking that disciplinary proceedings will have an external reviewer who will provide a further level of assurance that proceedings have been undertaken in accordance with Health Board policy and expected norms of practice. ACAS have been approached to undertake this role.
7. Recommendations:
7.1 The Board is asked to: 7.1.1 Note the progress of both the Ockenden review of Governance and the HASCAS investigations. 7.1.2 Note the forthcoming timescales for the products of the investigation and governance review. 5.2 17.258 Summary of In Committee Board business to be reported in public 1 17.258 In committee items reported in public.docx
1
Health Board
16.11.17
To improve health and provide excellent care
Title: Summary of In Committee Board business to be reported in public
Author: Mrs Kate Dunn, Head of Corporate Affairs
Responsible Mrs Grace Lewis-Parry, Board Secretary 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’ 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 issues listed below were considered by the Board at its private in Scrutiny Route committee meetings on 19.10.17 and 2.11.17.
Purpose: Standing Order 6.5.3 requires the Board to formally report any decisions taken in private session to the next meeting of the Board in public session.
Significant issues Issues were considered as follows: and risks 19.10.17 • Final amended internal audit report into Ysbyty Glan Clwyd redevelopment project • Lease arrangement with Fron Heulog, Bangor University.
2.11.17 • Timeframe for publication of external governance review reports Special Measures Leadership and Governance Improvement 2
Framework Theme/ Expectation addressed by this paper Equality Impact No equality impact assessment is considered necessary for this paper. Assessment
Recommendation/ The Board is asked to note this paper. Action required by the Board Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board
5.3 17.259 Vascular Update - Dr Evan Moore 1 17.259 Vascular Update_amended 7.11.17.docx
1
Health Board
16.11.17
To improve health and provide excellent care
Title: Progress Report on the North Wales Vascular Service
Author: Mr Robyn Williams, Project Manager
Responsible Dr Evan Moore, Executive Medical Director 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’ 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 / Scrutiny Executive Medical Director Route Purpose: To update the Board on the provision of a Hub and Spoke model for the provision of vascular services across North Wales. Following the setting up of the Vascular Implementation Task & Finish Group by the Executive Management Group, this quarterly report is provided to update the Board as to the progress this implementation group is making.
Significant issues All risks identified by the Task & Finish Group will be included on the and risks Corporate Risk Register
Special Measures Strategic and Service Planning Framework addressed Equality Impact No equality impact assessment is considered necessary for this Assessment update paper.
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Recommendation/ The Board is 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
Board Coversheet v8.0 June 2016
3
Betsi Cadwaladr University Health Board
Update on North Wales Vascular Service – July to September 2017
1. Network Vascular Consultant Posts
Five candidates attended for interview on 25th August 2017 four of which were offered and have accepted appointment.
• Mr Hans Desmarowitz will commence January 2018 • Mr Sean Matheiken will commence April 2018 • Mr Soroush Sohrabi will commence April 2018 • Mr Edward Brown will commence September 2018
Ysbyty Glan Clwyd continues to be covered by Agency Locum Consultant Vascular Surgeons, however difficulties have arisen with the retention of these doctors, therefore it has been agreed with the consultant body that two locum posts will provide service to Ysbyty Glan Clwyd until the newly appointed consultants take up post. One locum post will be linked to Bangor and the other linked to Ysbyty Maelor Wrexham. Both locums who will commence in late October 2017 will have sessions at Ysbyty Glan Clwyd.
2. Interventional Radiology
Following confirmation of College approval for the Job Description and Person Specification by the Royal College of Radiologists, three posts will be advertised nationally during late October. In addition to providing a general interventional radiology cover these posts will support the Vascular Network and will have sessions in the Hybrid Theatre at Ysbyty Glan Clwyd.
Whilst there is a known national shortage of trained Consultant Interventional Radiologists it is hoped that a similar recruiting method, supported by Social Media as utilised for the Consultant Vascular Surgeon posts will attract an appointable field of candidates. Consultant Interventional Radiology posts are vacant at Ysbyty Glan Clwyd and Ysbyty Maelor, Wrexham and the third post is an additional post.
Interviews are scheduled for 5th February 2018.
3. Business Justification Case
The Business Justification Case approved by the Health Board at its August 2017 meeting has been submitted to Welsh Government and a response is awaited.
4. Management Control Plan
As the Project has now entered its’ Implementation Phase, the Vascular Implementation Task & Finish Group dedicated its September 2017 meeting to reviewing the work required to deliver the Project.
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Operational arrangements are in place to progress the procurement of the Hybrid Theatre Radiology equipment the Hybrid Theatre at Ysbyty Glan Clwyd which would become operational in October 2018. The Vascular Implementation Task & Finish Group will be exploring, what vascular surgery could be undertaken during Quarter 1 of 2018/19 at Ysbyty Glan Clwyd. This would be the subject of full Risk Assessment and Impact Assessment on existing surgical services.
5. Welsh Abdominal Aortic Aneurysm Screening Programme (WAAASP)
The WAASP Quality Assurance Report has been received by the Chairman and Chief Executive Officer. WAAASP QA Team and Dr Quentin Sandifer Executive Director of Public Health and Medical Director, have confirmed that they are reassured, that progress was being made for the centralisation of arterial services at Ysbyty Glan Clwyd. Three main risk areas identified by BCU were:
• Clinical risk to include enough staff across the Board • Infrastructure to include the hybrid theatre • Clinical space to include the bed capacity
WAAASP were encouraged by:
• Positive clinical engagement • Recruitment process for vascular surgeons • Progress with all work streams, e.g. hybrid theatre business case
6. Leadership of Vascular Services
At present the budget and line management for the vascular service sits in the three hospital site teams. This is currently being bypassed by the direct management of the Vascular Implementation Task & Finish Group (VITFG) and the lead operational manager appointed for the vascular implementation. The VITFG is also overseeing clinical governance and reviewing the safety of the service on a day to day basis.
The service will be developing business plans in line with the Health Board’s governance arrangements. The service will work as a North Wales network with a single service lead to ensure consistency in approach and access.
7. Recommendation
The Board is requested to note the work which has been undertaken to date. 5.4 17.260 Welsh Health Specialised Services Committee - Joint Committee Approved Minutes of Meeting Held 25.7.17 1 17.260 WHSSC Joint Committee Approved Minutes 25.7.17.pdf
Minutes of the Welsh Health Specialised Services Committee Meeting of the Joint Committee held on 25 July 2017 at Health and Care Research, Castlebridge 4, Cowbridge Road East, Cardiff
Members Present Ann Lloyd (AL) Chair Lyn Meadows (LM) Vice Chair (via Videoconference) Marcus Longley (ML) Independent Member Chris Turner (CT) Independent Member/ Audit Lead Alexandra Howells (AH) Acting Chief Executive, Abertawe Bro Morgannwg UHB Gary Doherty (GD) Chief Executive, Betsi Cadwaladr UHB Steve Moore (SM) Chief Executive, Hywel Dda UHB (via Videoconference) Judith Paget (JP) Chief Executive, Aneurin Bevan UHB Len Richards (LR) Chief Executive, Cardiff and Vale UHB Allison Williams (AW) Chief Executive, Cwm Taf UHB Stuart Davies (SD) Acting Managing Director of Specialised and Tertiary Services Commissioning, WHSSC Carole Bell (CB) Director of Nursing and Quality, WHSSC Sian Lewis (SL) Acting Medical Director, WHSSC Chris Koehli (CK) Interim Chair of Quality and Patient Safety Committee
Apologies: Carol Shillabeer (CS) Chief Executive, Powys THB John Williams (JW) Chair of Welsh Renal Clinical Network Tracey Cooper (TC) Chief Executive, Public Health Wales Steve Ham (SH) Chief Executive, Velindre NHS Trust
In Attendance Claire Nelson (IL) Acting Assistant Director of Planning, WHSSC Kevin Smith (KS) Committee Secretary & Head of Corporate Services, WHSSC
Minutes: Juliana Field (JF) Corporate Governance Officer, WHSSC
The Meeting opened at 9.30am
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JC17/027 Welcome, Introductions and Apologies The Chair formally opened the meeting and welcomed members and the public.
JC17/028 Declarations of Interest There were no declarations to note.
The Chair informed members that this would be her last meeting at WHSSC as she had commenced her role as Chair of Aneurin Bevan University Health Board and noted that she would withdraw should any conflict be identified during the meeting.
JC17/029 Accuracy of Minutes of the meeting held 27 June 2017 Members reviewed and approved the minutes of the meeting held on 27 June 2017 as a true and accurate record.
JC17/030 Action Log and Matters Arising
Action Log
JC002 – WHSSC Integrated Commissioning Plan 2017-20 Members noted that the All Wales NHS Chairs’ meeting had been cancelled. It was confirmed that the Chair had written to the Individual Health Board Chairs to provide clarity regarding services included within the ICP.
JC006 – CB had provided input on engagement to the 2017-20 ICP.
JC009 – Provision of Specialised Neurosciences in NHS Wales Work was ongoing. It was anticipated that a final paper would be presented to Members in March 2018.
JC17/031 Report from the Chair Members received a report from the Chair; the following areas were highlighted:
Meeting with Cabinet Secretary Members noted that the Cabinet Secretary was keen for the timely delivery of a sustainable and efficient thoracic surgery model. A meeting had been scheduled for early August 2017 in relation to the Gender Pathway work to finalise arrangements and a written statement on this was to be produced; the Chair extended her thanks to CB and representatives from the Health Boards for their work on this project. The Chair had been asked to get WHSSC to look further at the revenue funding for the proposed new Cystic Fibrosis unit.
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The Chair had raised concerns with the Cabinet Secretary relating to the latest All Wales Medicines Strategy Group (AWMSG) decision on Ivacaftor. WHSSC officers had been liaising with AWMSG in relation to this matter.
Appointment of New Chair Professor Vivienne Harpwood had been appointed as the Chair of WHSSC for a period of 12 months succeeding AL. It was noted that Professor Harpwood would retain her position as Chair of Powys Teaching Health Board and that conflicts of interest would be fully considered. It was confirmed that Professor Harpwood officially commenced her role on 26 June 2017 and that this would be AL’s last meeting as Chair of WHSSC.
Members resolved to Note the content of the report
JC17/032 Report from the Acting Managing Director Members received a report from the Acting Managing Director; the following areas were highlighted:
Genomics for Precision Medicine Welsh Government launched its strategy in June 2017. Members noted that WHSSC retained a commissioning role via the hosting and commissioning group which was responsible for the development of a Commissioning Strategy. Whilst a £6.8m five year budget had been outlined within the strategy, it was unclear what the implications were for recurrent and non-recurrent funding. Members noted that WHSSC would be working closely with the All Wales Medical Genetics Service and Welsh Government.
Members discussed the funding situation further and whether this would be from Health Boards via the ICP or direct from Welsh Government and noted their concerns regarding the current financial position within NHS Wales. It was agreed that WHSSC would seek clarification on the funding arrangements from Welsh Government.
Action: SD to write to Welsh Government to seek clarification of the funding arrangements for the Genomics Strategy
Interventional Neuroradiology Since the report had been written, the first locum had resigned and left. A second locum would be joining the service shortly and a substantive consultant was expected to return to active duty shortly. It was noted that the Walton Centre might be able to take emergency cases in addition to its commitment to take ten elective cases.
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Members enquired as to the level of confidence in the service being able to continue in the current position and the financial implications relating to the arrangements with the Walton Centre. It was noted that any charges would initially be paid by WHSSC but recharged to CVUHB. as ultimate responsibility for continuity of the service remained with CVUHB.
Gary Doherty joined the meeting at approximately 9.50am
A question was raised as to the likelihood of any outsourcing costs going beyond those planned in the WHSSC ICP. It was explained that this was unlikely and there was ample opportunity for CVUHB to absorb additional costs. Members received assurances that should there be any changes to this, a paper would be presented to Management Group for scrutiny and to the Joint Committee for a decision.
Transcatheter Aortic Valve Implantation (TAVI) Members noted that the number of patients on a previously undeclared waiting list at ABMUHB was still being validated. Concern was noted around the mortality risks for these patients whilst on the waiting list. It was noted that TAVIs were subject to prior approval in line with Policy and that this process had recently been reinforced. A query was raised around application of thresholds within the policy and overall impact across cardiac waiting lists. A discussion followed around waiting list management, concerns around surgical operability and lessons that could be learned relating to management of waiting lists.
Posture and Mobility Members noted that more information was awaited from CVUHB regarding its proposal for increased investment to replace obsolete wheelchairs. A question was raised regarding the wider impact of replacement of obsolete wheelchairs and it was agreed that a note would be provided on the current position for north Wales but it was explained that this was less of an issue that for south Wales.
Paediatric Rheumatology Members noted that Welsh Government had asked WHSSC to review the provision of paediatric rheumatology services for Wales. An initial scoping report was available for the meeting.
Cardiac Ablation Work had begun on developing the case for investment on economic grounds as a curative treatment for certain indications. It was noted that waiting lists had started to build up and that referral to treatment issues were anticipated within the next six months.
Members resolved to Note the content of the report
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JC17/033 Patient Story (video) Members watched a video in which members of PMH Cymru shared their experience of Perinatal Mental Health and services in Wales.
JC17/034 Perinatal Mental Health CB presented an overview of the report which considered the national context of perinatal services including investments in both England and Wales. The appended options paper, which had been considered by the All Wales Perinatal Mental Health Steering Group, outlined a shortlist of three preferred options for the future configuration of tier 4 specialised perinatal mental health services in Wales. The three options were broadly (1) build upon IPFR process through a secured contract; (2) establish a single regional Mother and Baby Unit (MBU) for the whole of Wales; and (3) establish a regional MBU for south Wales and contract for an English provider for a north Wales service.
A query was raised regarding the governance and scrutiny of the report presented. It was noted that the All Wales Perinatal Mental Health Steering Group reported directly to the Child and Adolescent Mental Health Services and Eating Disorders Network Steering Group, who report directly to the Joint Committee and therefore the report had not been considered by the WHSSC Management Group. It was further noted that the Welsh Government had commissioned the All Wales Perinatal Mental Health Steering Group to undertake this work.
Members suggested that consideration was required as to the rationale for decommissioning the Cardiff service in 2013, the wider work being around early intervention in Mental Health Services, what the evidence suggested regarding centralised treatment versus local services and patient outcome and service sustainability given current workforce pressures in mental Health Services. It was noted that further detail was required in order for a decision regarding investment to be made.
It was noted that evidence had been presented to the National Assembly for Wales’ Children, Young People and Education Committee relating to the current Perinatal Mental Health inquiry.
A discussion was held around the work undertaken by the All Wales Perinatal Mental Health Steering Group, the potential required investment, and opportunity to improve commissioning arrangements and the requirement to understand the competency and demand of the existing pathway and underpinning detail before moving forward to a decision.
It was suggested that consideration could be given to a review of
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available evidence on the impact of service proximity to patient outcomes and levels of activity. Further to this, it was suggested that there was a need for leadership and coordination of IT systems across Wales to ensure consistency of coding and data capture, and provide a cohesive and joined up approach across Wales.
It was agreed that Members comments would be fed back to C Shillabeer as Chief Executive lead for Mental Health and Chair of the Child and Adolescent Mental Health Services and Eating Disorders Network Steering Group for further consideration and a clear recommendation on how to proceed. Members recognised the sensitivities in relation to the service and the need to ensure that expectations were appropriately managed.
Members resolved to Note the information presented within the report; Provide C Shillabeer as Chief Executive Lead for Mental Health, and Chair of the Child and Adolescent Mental Health Services and Eating Disorders Network Steering Group, with feedback from the discussions.
JC17/035 Integrated Commissioning Plan 2017-20: Risk Management Framework Members received a paper describing the implementation of the ICP Risk Management Framework to date and the progress made to date on the population of it from both a WHSSC and Health Board perspective. The paper also sought approval of the commissioning of three service areas.
Members noted that the Management Group Workshop had undertaken considerable work to review baseline scores and had supported the recommendation for funding the schemes detailed within the paper.
A query was raised in relation to the 2017-20 ICP and provision for the three services. It was noted that these were not specifically identified in the ICP; however it was explained that if the procedure and drugs were not commissioned it was highly likely that patients would proceed through the individual patient funding request (IPFR) route. Members noted that the Management Group workshop had considered the financial implications and that provision had been sourced from the IPFR; consequently the financial impact would effectively be neutral.
Assurance was sought that there would not be a significant increase in demand for the services once commissioned. It was noted that given the rarity of the conditions it was unlikely that there would be an increase in demand. Members noted that NICE had undertaken detailed policy work in relation to volume and budget impact and held further discussions around financial implications. It was acknowledged that there needed to be a robust policy with clear access criteria.
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Clairty was requested as to what the Joint Committee was being asked to approve and whether this was to: adopt a new commissioning policy aligned to English policy, recognising that there may be minimal cost implications with some services cost neutral.
Members were advised that WHSSC endeavoured to follow correct governance process and that rigorous scrutiny had been undertaken of the services during the Management Group workshop session which supported the recommendations as detailed within the report.
Members approved the commissioning of the three services and requested that a future evaluation be undertaken of the impact of changing from the IPFR approval process to a Commissioning Policy.
Members resolved to Note the progress made to date on implementing the ICP Risk Management Framework and the next steps for completion; and Approve the commissioning of: - Complex Obesity Surgery for Paediatrics - The use of Plerixafor for Stem Cell mobilisation - The use of Pasireotide for Cushings Disease
Commissioning Arrangement for Positron Emission Tomography (PET) Scans Members noted that all Health Board CEOs had received a letter from the Director General regarding commissioning arrangements for PET scans. Members were advised that the Management Group had held recent discussions and identified areas of risk to implementing a commissioning policy. It was noted that a paper had been provided to Management Group for consideration at its next meeting, scheduled for 27 July 2017. The paper set out a potential basis to mitigate the lack of agreed funding in the 2017-20 ICP for PET scans in respect of new indications. This was based on projections for lower demand than had been budgeted for PET scans on existing approved indications.
Chief Executives were reminded that the prioritisation process utilised in the ICP was evidence based, although new schemes were restricted by an overall lack of funding. A discussion was held around the decision making process and challenge presented by the Welsh Government in relation to the decision to continue to manage through IPFR. It was agreed that a single response would be drafted to the Director General regarding the matter.
Action: Single response to be drafted on behalf of all Health Boards and WHSSC regarding the commissioning arrangements for PET Scans (Chair/JP)
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JC17/036 Value Based Commissioning: Progress Report Members received the report which provided an update on progress in the development of WHSSC’s approach to value based commissioning as part of the 2017-20 ICP.
The paper considered value based healthcare from a commissioning perspective that than the more familiar provider perspective, using a systematic approach with three components: technical efficiency, allocative efficiency and patient value.
Members were advised that the WHSS team would be undertaking work to review commissioned services against the Framework, some of which had already commenced within the finance and planning teams. It was noted that this work would be expanded upon following the appointment of the new associate medical directors, establishment of programme teams to support the working closely with the Management Group to identify and test opportunities.
It was suggested that consideration be given as to how Public Health Wales (PHW) may be included in supporting the process and how to engage with Health Boards to avoid duplication of work. Members were advised that the service level agreement between WHSSC and PHW had been terminated and that WHSSC was recruiting a 0.2WTE Associate Medical Director for Public Health and work was being carried out with Cwm Taf University Health Board (CTUHB) in relation to informatics. It was noted that concerns had been raised with Welsh Government around strategic issues and the gap in provision of services from PHW. It was also noted that a discussions were ongoing with Welsh Government and that the Chair had raised concerns with the new Chair of PHW.
A discussion followed around the analytical capability of PHW, importance of the value based work, the necessity to consider the whole pathway rather than simply the specialised services element and the need to commence identification of specific services. Members noted that a Right Value Commissioning Group had been formed that had already met several times and started looking at high cost low volume areas.
A further discussion was held around harnessing clinical engagement and leadership within this work and how value based commissioning linked with the principles of the prudent healthcare agenda.
Members resolved to Note the content of the report.
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JC17/037 Inherited Bleeding Disorders Members received a paper which described a proposal outlining the management resource requirements and potential offsetting efficiency savings to facilitate the development of an all Wales commissioning strategy for Inherited Bleeding Disorders (IBD).
Members were reminded of previous discussion on IBD and noted the current request for an additional 0.5WTE resource for a period of 12 months to support the development of an all Wales commissioning strategy. It was noted that the estimated savings from repatriation of IBD services from Liverpool to BCUHB, through reduced administration charges alone, would more than cover the additional resource requirement in WHSSC but that the saving would not be achieved without pursuing this initiative.
Members held a discussion around the work being carried forward in north Wales in relation to repatriation of services, the ability to achieve savings without the need for investment, and the additional resource being used to accelerate the achievement of saving and allow reinvestment in other local services.
The discussion continued around the proposal for an all Wales Commissioning strategy for IBD which would be brought under WHSSC as a single commissioner. Members requested that more detail was required in relation to the benefits/dis-benefits and gains made though a single commissioning lead. Greater clarity was required around the problem to be addressed. It was noted that the current arrangements were fragmented and the aim was to commission a more coherent model. Members suggested that further scrutiny was required though Management Group.
Members resolved to Note the potential savings which would offset the resource required to increase WHSSC’s commissioning capacity; and Support the outline proposal for repatriation of IBD services from Liverpool to BCUHB and referred the outline proposal to bring commissioner responsibility and funding under WHSSC as a single commissioner of IBD services across Wales to Management Group for further review.
JC17/038 Paediatric Rheumatology Services in South Wales Members received a paper which described the current service provision and referral process for paediatric rheumatology services in Wales. It also described the services around the United Kingdom, the standards of care and provided benchmarking with particular regard to composition of tertiary multi disciplinary teams (MDT). It also made recommendations regarding future actions required to progress commissioning of the
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service.
Members noted that WHSSC had been approached by Welsh Government to review the current service provision and make recommendations. It was identified that Wales was the only country within the UK that did not have a specific paediatric rheumatology service. Services for Welsh patients were commissioned currently commissioned from Alderhey, Bristol and Bath and managed through a gatekeeper, funded by the individual Health Boards.
Members were presented with an overview of the detail provided within the paper including benchmarking against larger English centres, outline scope of the review and recommendations of the British Society for Rheumatology and the National Rheumatoid Arthritis Society.
Following a discussion regarding the information provided and funding arrangements, it was agreed that the paper should be shared with Welsh Government and the matter referred back to Welsh Government requesting its guidance on what was required next and noting that an improved service would require additional funding.
Members resolved to Note the paediatric rheumatology service provision for the population of south Wales, the position around the UK and the recommendation of The British Society for Rheumatology (BSPAR) and the National Rheumatoid Arthritis Society (NRAS); and Agree for the paper to be referred to Welsh Government requesting guidance on what was required next and noting that an improved service would require additional funding.
JC17/039 Integrated Commissioning Plan (ICP) 2016-17 Closure Report Members received a report that set out the progress and outcomes against the delivery of the 2016-17 ICP schemes approved during 2016- 17, highlighted where further action was required for schemes that had not been completed, and summarised the key lessons learned.
It was noted that 62 schemes had been delivered and 75 schemes were recorded as ‘In progress’ or ‘Not commenced’, a summary of which was provided within the report. Members were informed that a number of services had not been completed, including Proton Beam Therapy and other policies that were being evaluated by NICE, due to limited resources. These schemes were to be managed via the 2017-20 ICP Risk Management Framework.
The full year financial effect of 2016-17 developments was £1.5m lower than the 2016-19 year 2 provision. Providers would be challenged as to whether they have spent the approved investment and on achieved
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outcomes.
Members resolved to Note the work completed in the WHSSC 2016-17 ICP; Note the lessons learned; and Note the closure of the Integrated Commissioning Plan (ICP) 2016- 17.
JC17/040 Annual Performance Report 2016-17 Members received the report for 2016-17, which provided a summary of the performance of providers throughout the year and details of the actions undertaken to address areas of non-compliance. Cardiac, Plastic, Paediatric, Neuro and Bariatric surgery failed to achieve 100% compliance with the 36 week RTT targets and Thoracic surgery only achieved its 36 week RTT target once during the year. However Plastic, Paediatric and Bariatric surgery improved their performance during the course of the year. Lung cancer data previously provided by the Cancer Network ceased during Q4. It was noted that additional investment had been provided for Cardiac, Neuro and Thoracic surgery during the year and it was therefore particularly disappointing that they had not achieved their targets.
Members resolved to Note the performance over 2016/17
JC17/041 Financial Performance Report Members received the report which set out the estimated financial position for WHSSC for the third month of 2017/18. No corrective action was required at this point. The financial position was reported against the 2017/18 baselines following provisional approval of the 2017/18 Technical Plan by the Joint Committee in March 2017.
Members noted a year to date over spend of £988k and a forecast under spend to year-end of £236k. The largest in year movement was a deterioration of £1.273m against NHS England contracts; this was due to previously disclosed HRG4+ PbR rates dispute.
A discussion was held around the HRG4+ concerns and members noted that a working group had been established to review the Health Boards’ positions. The Directors of Finance were now making judgements and providing for the impact of the increased rates. Discussions continued around financial risks, related provider performance and patient experience. It was noted that discussions had been held with Welsh Government and that the main risk on HRG4+ was for BCUHB and PTHB because of their heavy reliance on English providers.
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It was agreed that a letter from WHSSC would be sent the Welsh Government setting out the concerns as discussed and the potential risks as identified by the Joint Committee. It was noted that an update would be presented to the Joint Committee in September 2017.
Action: Letter to be sent to Welsh Government highlighting the Joint Committee concerns. Update paper to be provided at the September 2017 meeting
Members discussed the requirement for a consistent approach to payment of HRG4+ contracts and requested that the WHSS Team agree an approach with Management Group colleagues at their next meeting scheduled for 27 July 2017.
Action: Management Group members to agree a consistent approach to payment of HRG4+ contracts.
Members resolved to Note the current financial position and forecast year-end position.
JC17/042 Reports from the Joint Sub-committees and Advisory Group Chairs Members received the following report from the Joint Sub-committees and Advisory Group chairs:
Sub Committees
Child and Adolescent Mental Health Service and Eating Disorders Network Steering Group Members noted the update from the meeting held 23 June 2017.
JC17/043 Items of Any Other Business
Neonatal Workforce SL advised that a letter had been received from the South Wales Programme Neonatal Task & Finish Group explaining that Chairs and CEOs were currently looking at how the regional planning committee arrangements would work and that this might have some impact on whether or not the current South Wales Programme had the appropriate governance arrangements in place. In turn this might impact on the responsibilities that the Joint Committee delegated to the Task & Finish Group in March 2017 in relation to implementation of the Neonatal Alliance workforce model. At present the Task & Finish Group was continuing its work and it would keep the Joint Committee informed of
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any developments.
JC17/044 Date and Time of Next Meeting It was confirmed that the next meeting of the Joint Committee would be held on 26 September 2017.
The public meeting concluded at approximately 12.05pm
Chair’s Signature: ......
Date: ......
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5.5 17.261 Welsh Health Specialised Committee - Joint Committee Core Briefing Meeting Held 26.9.17 1 17.261 WHSCC Joint Committee Core Briefing 26.9.17.pdf
WELSH HEALTH SPECIALISED SERVICES COMMITTEE JOINT COMMITTEE – SEPTEMBER 2017
The Welsh Health Specialised Services Committee held its latest public meeting on 26 September 2017. This briefing sets out the key areas of discussion and aims to ensure everyone is kept up to date with what’s happening in Welsh Health Specialised Services.
The papers for the meeting are available here
Action Log Members noted the action log. Members received an update on: JC011/012/013 – It was noted that these actions would be rolled into the output on the Neurosciences Strategy that was due to be issued in March 2018. JC014 – Single response from LHBs to Welsh Government on PET scans completed. JC015/016/017 – Letter to Welsh Government regarding HRG4+, update on HRG4+ position and agreement of Management Group members to consistent approach on HRG4+ - to be addressed in agenda item 19 Financial Performance Report.
Perinatal Mental Health A workshop convened for 13 October 2017 will consider the issues raised in relation to the paper presented at the previous meeting (JC17/034) and wider factors. The next paper to the Joint Committee will be brought back in January 2018.
Chair’s Report The Chair explained that she had met with many stakeholders since her appointment and was on a steep learning curve.
Acting Managing Director’s Report Members noted the Acting Managing Director’s report and in particular: SL intends to focus on two work streams during the first three months of her tenure (1) internal structure and processes at WHSSC, and (2) development of the strategy for WHSSC. A ‘temperature check’ had recently been undertaken to assess progress against recommendations made in the November 2016 Culture Review – the result had been encouraging.
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Neonatal transport – The need to understand what was currently in place for south Wales, how this compared to the standard being prepared by the Neonatal Network, the risks associated with any shortfall of service and the potential funding implications had been identified as issues to be addressed. Any requirement for additional funding would be factored into the 2018-19 Integrated Commissioning Plan (ICP). All Wales Blood Service Programme – the programme closure report had been received by WHSSC and was circulated with the meeting papers for information.
Thoracic Surgery Review Members received a paper which (1) provided an update on the progress to date of the project, (2) confirmed the timeline for a decision regarding the number and location of future services in south Wales, and (3) sought approval for the processes and documentation underpinning the Joint Committee’s decision.
Members noted the update and approved the process and documentation, including the latest proposed timeline that culminated in a decision by the Joint Committee by the end of January 2018.
PET Scan Policy Development Members received a paper that presented a business case which mitigated the financial risk associated with proposed changes to the PET policy as recommended by the All Wales PET Advisory Group. The proposal was principally based on funding the PET expansion for new indications from the predicted over provision for PET scans in the 2017-20 ICP.
Members were advised that there was a strong evidence base that the expansion of the PET policy for new indications would result in clinical and cost benefits within health boards for patients who were more appropriately managed following successful PET scans but it was difficult to achieve visibility of this (NICE had modelled this for some indications – e.g. head and neck - but the modelling was resource heavy and took considerable time to develop).
The Management Group had considered and supported the proposal but subject to receipt of assurances from Welsh Government regarding financial underwriting. A formal response was awaited from Welsh Government but informal indications suggested there would be support for the proposal but that financial underwriting might not be forthcoming.
There was some concern that growth in demand might result in an over spend against the ICP provision in either 2017-18 or the following year.
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It was noted that the proposal included a substantial margin for error in this regard.
Members wished to see clinical evidence that an increase in PET scans for new indications would result in clinical and cost benefits elsewhere in the patient pathway prior to approving the proposal and asked for this to be channelled through Management Group in the first instance.
Alternative Augmentative Communication (AAC) Members received a paper summarising the current position of the All Wales AAC service, including the risk to patients (essentially the lack of funding for AAC equipment) and potential mitigations identified through the Risk Management Framework approach.
A letter of support from the Wales Neurological Alliance had been received that recommended arrangements be made for further non pay funding for AAC.
An informal indication had been received from Welsh Government that non pay funding was likely to be made available for the remainder of the current financial year.
It was agreed that a collective approach to Welsh Government would be co-ordinated to request continued non pay funding through the Joint Equipment Fund (jointly funded by Health, Social Care and Education).
Adult Cystic Fibrosis (CF) Service Members received an update summarising the current position regarding adult CF services for mid and south Wales, the risks to sustainability of the services and the potential for a commissioning decision regarding the revenue requirements to address these.
Members supported the case for change and agreed that Welsh Government should be briefed on the prospective need for new revenue funding in support of the capital business case being developed by CVUHB. The business case for change would consider alternative models for delivering the service including outpatient and/ or community services.
Risk Sharing Members received a paper which provided an update on implementing proposals to move the neutralisation date from the end of 2011-12 to 2013-14 and set out the latest modelling together with the issues and questions raised by the Finance Group. The financial impact had materially shifted. It was noted that running the numbers at any point in time led to huge volatility in the financial impact based on relatively small numbers of high cost services/episodes of care. Members of the Finance Group continued to have a preference for an activity based share but
WHSSC Joint Committee Briefing Page 3 of 6 Meeting held 26 September 2017 Version: 1.0 were concerned about the challenge for individual health boards on the financial outcome.
It was agreed that an activity based share was desirable but might be unachievable if the financial impact was excessive on a small number of health boards and that the Finance Group should have a final attempt to resolve this, also that advice should be sought from Welsh Government on the final option.
Cardiac Magnetic Resonance Imaging (CMRI) Members received an update on the collective commissioning work completed by WHSSC in respect of CMRI and a recommendation to transfer the responsibility for further planning and implementation to health boards/ Regional Planning Boards with support from the All Wales Cardiac Network.
Members noted the update, approved the adoption of the CMRI Service Specification by health boards and approved the transfer of responsibility for further planning and implementation from WHSSC to health boards/ Regional Planning Boards supported by the All Wales Cardiac Network.
Development of the WHSSC ICP 2018-21 Members received a paper that outlined the commissioning intentions that had been drafted to inform the development of the three year ICP 2018- 21. It was noted that although value based commissioning was not expressly mentioned it was part of WHSSC’s assessment process; also that WHSSC would be working with health boards to look through their IMTPs to inform both the IMTPs and the ICP in relation to specialised services.
Members approved the WHSSC commissioning intentions.
Restructuring of Staffing Models Members received a paper that informed members of a planned staffing restructure within the WHSSC Team that included the establishment of a Quality Assurance Team on a cost neutral basis.
Members approved the cost neutral staffing restructure without the need to seek approval for specific changes.
Governance for Clinical Networks Members received a paper that made recommendations to facilitate regularisation of the governance and accountability arrangements for the CAMHS/ ED and Neonatal clinical networks that transferred to the NHS Wales Health Collaborative (the Collaborative), hosted by Public Health Wales, on 1 October 2016 and to formalise the ongoing relationship
WHSSC Joint Committee Briefing Page 4 of 6 Meeting held 26 September 2017 Version: 1.0 between the five clinical networks managed by the Collaborative and WHSSC.
Members noted the information presented in the paper and approved the recommendations with a target implementation date of 1 January 2018.
ICP Risk Management Framework (RMF) Members received a report that provided an update on the implementation of the ICP RMF and highlighted schemes that required further review, risk mitigation and escalation and noted the ‘extreme’ and ‘high’ risk rated schemes.
Members were advised that WHSSC had submitted a letter to Welsh Government seeking additional funding from the £50m identified as available. The WHSSC request was targeted toward funding to reduce waiting times for various specialised services.
Integrated Performance Report Members received the report for June 2017, which provided a summary of the key issues arising and detailed the actions being undertaken to address areas of non-compliance.
The most significant change related to CAMHS OoA placements due to reduced capacity at the north Wales facility which was now in stage 3 escalation, together with Paediatric Surgery and Neurosurgery at CVUHB.
Financial Performance Report Members received the finance report for Month 5 2017-18 noting a year to date over spend of £1,109k with a forecast under spend to year-end of £2,082k, which primarily related to a release of £2,000k of Balance Sheet reserves. The year to date position included around £2,500k of HRG4+ costs for English contracts; however, the year-end forecast included a partial adjustment to HRG4+ costs due to some positive conversations with NHS Improvement. Welsh Government was now fully engaged on the HRG4+ position.
Joint Committee Annual Self Assessment Members received a paper that provided information relating to the Joint Committee’s annual self assessment.
Members noted the information provided in the report and supported consideration by the Chair and Committee Secretary of a ‘development day’ and/ or an induction programme.
Joint Sub Committees and Advisory Groups Members noted the update reports from the following joint sub committees and advisory groups:
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Audit Committee All Wales Individual Patient Funding Request Panel Integrated Governance Committee Quality & Patient Safety Committee . Revised Committee Terms of Reference were approved. Welsh Renal Clinical Network WHSSC Management Group NHS Wales Gender Identity Partnership Group . An update was presented on recent developments, in particular, regarding Welsh Government’s announcement of the planned development of a Welsh Gender Identity Team. Wales Child and Adolescent Mental Health service and Eating Disorders Network.
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5.6 17.262 Mid Wales Healthcare Collaborative Progress Report October 2017 : Mr Geoff Lang 1 17.262 MWHC Report Oct 2017 v2 24 10 17.pdf
PROGRESS REPORT ON THE WORK OF THE MID WALES HEALTHCARE COLLABORATIVE (MWHC)
OCTOBER 2017 (Version 2 – 24/10/17)
1. INTRODUCTION The Mid Wales Healthcare Collaborative (MWHC), established in March 2015, is a joint Committee comprising the Chair and Chief Executive of Betsi Cadwaladr University Health Board (BCUHB), Hywel Dda University Health Board (HDdUHB), Powys Teaching Health Board (PTHB), Welsh Ambulance Services NHS Trust (WAST) and the Leaders and Chief Executives of Ceredigion County Council, Gwynedd County Council and Powys County Council. The MWHC is led by two independent co-chairs Dr Ruth Hall and Mr Jack Evershed. The MWHC is accountable to Welsh Government, to the three Health Boards, WAST and to the scrutiny mechanisms for local government.
The following report provides an update on the work undertaken by the MWHC and the areas of work that are being progressed and achievements that are being made to implement the recommendations of the Mid Wales Healthcare Study.
This report is intended to ensure that the collaborative healthcare organisations of the MWHC are kept up to date on the progress of the work of the MWHC and provides an opportunity to highlight future planned areas of work for reporting to the collaborative healthcare organisations of the MWHC.
2. KEY ACHIEVEMENTS
2.1 Recommendation 1 – Mid Wales Healthcare Collaborative The Mid Wales Healthcare Collaborative was initially established for a period of 2 years, and then extended by Welsh Government for a further 12 month period. The successor arrangements are outlined in the Terms of Reference and Operating Framework which seek to both reflect the changes in the requirements of NHS bodies for collaborative and regional working and build upon the strengths and successes of the MWHC arrangements.
The proposed arrangements, which recommend the establishment of a Mid Wales Joint Committee for Health & Social Care (MWJC), were presented for endorsement by the MWHC Board (following engagement with Welsh Government) on 5 th September 2017 with these being approved subject to the respective Local Authorities strengthening their governance position for inclusion within the terms of reference. The final version of the Terms of Reference and Operating Framework, which will include feedback from the Local Authorities, will be presented to the MWJC Shadow Board meeting for ratification at its meeting on 5th December 2017.
Work is now being undertaken, in conjunction with the four Collaborative healthcare organisations, to:
1 i. Confirm and agree the resource requirement to undertake the coordination work of the Joint Committee. ii. Discuss and agree the MWJC’s work programme (workshop arranged for Tuesday 19 th December 2017). iii. Discuss and agree the key leadership roles for the MWJC for 2018/19 onwards including Lead Chair, Lead Chief Executive and Programme Director.
2.2 Recommendation 2 - Improved Public Engagement The MWHC Board has agreed that the Mid Wales Engagement Plan for 2017/18 will focus around the following engagement activities: a) Engagement events held by healthcare organisations across Mid Wales The four collaborative healthcare organisations already hold engagement events within their own communities across Mid Wales and it is important to utilise these wherever possible. Existing community engagement events planned for Mid Wales 2017/18 have been co-ordinated into one overarching Mid Wales community engagement event schedule. Working together in a more co-ordinated way will make better use of existing resources, knowledge and networks. This work is being led by the Communications and Engagement sub-group. b) MWHC Board / Mid Wales Planning Forum meetings The MWHC Board has introduced a question and answer session ‘Listening to You’ during their meetings to allow members of the public the opportunity to provide feedback and ask questions about presentations/papers provided to the Board. In addition time has been set aside before and after each Board meeting to allow the public to meet with MWHC colleagues to allow the public to share issues of importance to them and to discuss how to continue to communicate with local communities. This has proved to be a successful method of engaging with the public and this format will continue for planned meetings of the MWHC Board and the MWJC over the next 12 months. c) Local groups and Health forums During the course of the last 2 years, the Independent co-chairs have met with local groups and health forums to listen to the views of local people and this has also proven to be a successful method for engaging with our local communities. These groups have well-established, influential and comprehensive membership and networks and present an important opportunity to engage with communities across Mid Wales. This mechanism for engaging with local communities has continued over 2017/18. A review is being undertaken to ensure that all relevant groups have been identified and the schedule of meetings will be co-ordinated alongside the Mid Wales community engagement event schedule. This work is being led by the Communications and Engagement sub-group.
2.3 Recommendation 3 - Local Action on Primary Care Physician Associates The work to develop Physician Associate roles across Mid Wales has resulted in a number of successes. One student graduating in early 2017 now currently works at Borth surgery, North Ceredigion. A second student who graduated in May 2017 was immediately offered a position in a practice in North Powys. A third student due to graduate in the early part of 2018 has spent part of their placement working in
2 practices across North Powys and Bronglais General Hospital. A further fourth student who qualifies in summer 2018 will be working in Powys for two years. Looking forward work is being undertaken to identify another couple of students for placement in North Powys and a cohort of students starting on the October 2016 scheme with Swansea University will be placed in South Powys in 2018.
Widening access to dental services Following the establishment of a dental clinic at Newtown dental services have been provided to 240 patients from HDdUHB, significantly in excess of the original target of 100 patients, for which the majority would have had to travel a longer distance for the same service in South West Wales.
Work is in progress on developing a broad range of dental services at Bronglais General Hospital.
2.4 Recommendation 4 - National Primary Care Plan There are many challenges facing the current model of general practice across Mid Wales which include the recruitment and retention of GPs and practice nurses, the changing nature of delivering medical care, an ageing frail population with multiple chronic conditions and the current financial pressures facing public sector organisation in Wales. The seven GP practices that are part of the North Ceredigion GP Cluster established a federation on 1st April 2017 in order to develop innovative ways of working which are appropriate for a rural area. The federation is keen to work with the MWHC to include their patients in helping co- design future services. Going forward we would wish the collaborative to learn the lessons from this federated arrangement for rolling out across Mid Wales.
2.5 Recommendation 5 - Bronglais General Hospital Recommendation 6 - Clinical Engagement Recommendation 7 - Bronglais General Hospital Cardiology Services Recommendation 8 - Bronglais General Hospital General Surgery and Obstetrics and Gynaecology Services
A Surgical and Oncology Pathways group has been established for Mid Wales to progress the work on the development of Surgical and Oncology pathways across Mid Wales. A series of meetings have been held with specific discussions held around the following: • Oncology pathways; • Colorectal surgical pathways; • Upper GI and Bariatric surgery; • Vascular Surgery pathways; • Establishment of videoconference links; • Concept of a Clinical Advisory Group for Mid Wales. This partnership approach will significantly benefit the residents of Mid Wales.
A number of other key developments being progressed within secondary care services include: • Refurbishment of theatres at Bronglais General Hospital which upon completion will provide a modern service when completed.
3 • Plans in progress for installing a new MRI scanner for which this new diagnostic facility will allow for more patients to be seen at Bronglais General Hospital. • Introduction of discharge planning integrated without borders which will enable patients to move through the hospital at an increased pace. • Establishment of the Mid Wales operational forum which will facilitate better joint working across the Mid Wales border. • Introduction of a 6 bedded escalation area in Bronglais General Hospital. • Introduction of a new MDT suite to allow MDTs to link with specialist services. • Nurse led discharge which will enable patients to be discharged at weekends.
2.6 Recommendation 9 - Access and Transport Community First Responders Community First Responders (CFR) provide a vital role supporting and caring for patients in the community. This initiative, which is now ‘live’ is focused upon increasing the number and availability of CFRs across Powys. Recent developments include: • Expanding the role of the Mid and West Wales Fire & Rescue Service (MWWFRS) in Machynlleth and Llanidloes; • All MWWFRS staff trained and available to respond to cardiac arrests (de-fib only); • Armed Forces at Dering Lines responding as a CFR team.
ISCLE pilot in Powys ISCLE is a clinical tool to support the effective peer review of Paramedic clinical practice. The toolkit enables Clinical Team leaders (CTLs) to undertake a clinical review and provide Paramedics with feedback to support clinical learning, identify opportunities for continued development and improve the quality of care delivered. This work is in-going and all Paramedic clinicians have been reviewed and provided with feedback
Improving access to CPADS in Nursing Homes This project is focused upon improving the access and availability of PADS (public access de-fibs) in nursing homes across Powys experiencing high levels of 999 calls requesting an ambulance response. To improve survival rates WAST is engaging with the ‘top 10’nursing homes to train the nursing staff to use public access de-fibs and place one at each site. To date 3 PADs have been established in South Powys nursing homes. This work continues to progress with an additional 8 nursing home sites identified for placement in South Powys and 4 sites in North Powys. Training is being arranged and rolled out to staff.
Enhanced Falls Pathway WAST is continuing dialogue with PTHB to enable Paramedics to access an enhanced falls pathway for patients residing in Montgomeryshire. The pathway will work in parallel to the current all Wales non-injured falls pathway and will focus upon patients that have fallen and require enhanced ongoing care but do not require admission to hospital. Enhanced care includes access to GPs, PTHB therapy teams and the PURSH team (Patient urgent response services at home) to ensure the correct care is provided at the time of referral.
4 2.7 Recommendation 10 - Advanced Paramedic Practitioners In Ceredigion, the WAST is working with GP clusters to provide a more multi- disciplinary approach to primary care. This includes a more joined up/cross boundary roster with advanced practice practitioners.
Community Paramedics Work is being undertaken to develop a model where up to 4 community paramedics will be attached to Llandrindod Community Hospital. This innovation is based upon testing a new integrated way of joint working linking a Rapid Response Vehicle (RRV) paramedic directly to the community hospital. The community paramedic is attending patients on behalf of the GP that may otherwise have entered the 999 system. This is planned to go live in quarter 4 of 2017/18.
2.8 Recommendation 11 – Telehealth, Telemedicine and Telecare A draft Telemedicine Strategy for Mid Wales has been developed which will concentrate on the following key areas: i. Development of specialist consultant in-reach services to Bronglais General Hospital from patient to clinician and clinician to clinician. ii. Development of clinician outreach into rural communities. iii. Supporting Primary and Secondary care joint working. iv. Establishing Mid Wales as an exemplar for the deployment of telemedicine .
This draft strategy supports the Mid Wales Healthcare Collaborative’s (MWHC) key objective of delivering care as close to home as possible and will allow care to be delivered through a number of settings including, at a local GP surgery, local community hospital or another appropriate venue in the community
The final version the Strategy and the implementation plan to support its delivery will be completed by late November 2017. The MWHC’s Telehealth Innovation sub- group (TISG) will oversee the delivery of the Telemedicine strategy and will be the driving force for the strategy, planning and co-ordination for all telemedicine services across Mid Wales. The sub-group will report to the MWHC which will transition into the MWJC over the course of 2017/18.
Membership of the TISG will be reviewed to ensure that it includes relevant representatives of the collaborative organisations across Mid Wales who are in a position to facilitate delivery of this strategy.
2.9 Recommendation 12 – Centre for Excellence in Rural Health and Social Care (CfERH) Following extensive discussion at the MWHC Board meeting in March 2017, it was agreed that the CfERH sub-committee be asked to explore further options for a suitable alternative name for the CfERH in order to ensure it reflected both health and social care with the name agreed as Rural Health and Care Wales (RHCW. Key areas of work being progressed by RHCW include: • A new recruitment brochure for Mid Wales (health and social care) has been produced and is being circulated (“Train, Work, Live in Mid Wales – Health and Social Care careers in Ceredigion, Powys and south Gwynedd”). • The official launch of the RHCW website was held at the Royal Welsh show on Monday 24 th July.
5 • Research project currently in progress include i) Recruitment and Retention of Nurses in Rural Areas ii) Recruitment and Retention of Health and Social Care professionals in Rural areas iii) The Education, Training and Professional Development of Health and Social Care Professionals in Rural areas. The RHCW is also working in partnership with Public Health Wales and WARU (Aberystwyth University) on a proposed Social Prescribing Project. • The Rural Health and Care Conference ‘Sustainable Health and Social Care Services in Rural and Remote Places’ will be held on Tuesday 14 th November 2017 at the Montgomery and International Pavilions on the Royal Welsh showground in Builth Wells. The conference is being promoted as “a conference for health and social care professionals, academics and practitioners with a particular interest in rural and remote issues”.
The Independent co-chairs have met with Dr Chris Jones, Chair of Health Education and Improvement Wales, and Bernardine Rees, Chair of HDdUHB and Lead Chair for the MWHC, to explore the potential opportunities for RHCW to work alongside Health Education and Improvement Wales.
Discussions have also been held with Professor Elizabeth Treasure, the newly appointed Vice-Chancellor for Aberystwyth University, to discuss research opportunities around rural healthcare.
Close working relationships with Social Care Wales will need to be established to enable a joined up approach across the care system. Carol Shillabeer, the MWHC’s Lead Chief Executive, is leading on this work in conjunction with the Chief Executive of Social Care Wales.
2.10 Mental Health & Learning Disabilities sub-group Mental Health Pathway WAST are currently working jointly with PTHB to implement a dedicated Mental Health Pathway. The pathways will enable WAST crews to directly refer to Community Mental Health Teams for advice. This will reduce WAST conveyances and provide more appropriate care for service users.
2.11 Palliative Care and End of Life Innovation sub-group The Palliative Care and End of Life Innovation Sub Group has developed a report with recommendations on how services can be modified, improved or developed to meet the specific needs of the Mid Wales population. Specific recommendations were made for Ceredigion, Meirionnydd, Powys and WAST as well as overarching recommendations which would seek to benefit the entire region. Work continues on exploring the most appropriate approach for implementing the report’s recommendations.
2.12 Health and Wellbeing Innovation sub-group The report produced following the ‘Green Health in Practice’ conference held in March 2017, organised by the MWHC with Welsh Government support, outlined key messages and a proposed set of actions. The report identifies work for MWHC and other organisations represented at the event to address, either singly or in partnership with others. Proposals are now being developed for incorporating wider approaches to preventive health and social care into routine practice, including
6 discussion with GP clusters on progressing ‘social prescribing’ in Mid Wales. The group originally established to arrange the conference, chaired by Teresa Owen, Director of Public Health for BCUHB, will take this work forward in conjunction with Diana Reynolds, Welsh Government.
3. RECOMMENDATION For information – Collaborative organisations are asked to note the progress on the work undertaken by the MWHC and the areas of work that are being progressed and achievements that are being made.
7